Korean J Radiol.  2014 Apr;15(2):218-225. 10.3348/kjr.2014.15.2.218.

Hepatic Sinusoidal Obstruction Syndrome Caused by Herbal Medicine: CT and MRI Features

• Zhou H
• Wang YX
• Lou HY
• Xu XJ
• Zhang MM

• KMID: 1705576
• DOI: http://doi.org/10.3348/kjr.2014.15.2.218

Abstract

OBJECTIVE
To describe the CT and MRI features of hepatic sinusoidal obstruction syndrome (HSOS) caused by herbal medicine Gynura segetum.
MATERIALS AND METHODS
The CT and MRI features of 16 consecutive Gynura segetum induced HSOS cases (12 men, 4 women) were analyzed. Eight patients had CT; three patients had MRI, and the remaining five patients had both CT and MRI examinations. Based on their clinical presentations and outcomes, the patients were classified into three categories: mild, moderate, and severe. The severity of the disease was also evaluated radiologically based on the abnormal hepatic patchy enhancement in post-contrast CT or MRI images.
RESULTS
Ascites, patchy liver enhancement, and main right hepatic vein narrowing or occlusion were present in all 16 cases. Hepatomegaly and gallbladder wall thickening were present in 14 cases (87.5%, 14/16). Periportal high intensity on T2-weighted images was present in 6 cases (75%, 6/8). Normal liver parenchymal enhancement surrounding the main hepatic vein forming a clover-like sign was observed in 4 cases (25%, 4/16). The extent of patchy liver enhancement was statistically associated with clinical severity classification (kappa = 0.565).
CONCLUSION
Ascites, patchy liver enhancement, and the main hepatic veins narrowing were the most frequent signs of herbal medicine induced HSOS. The grade of abnormal patchy liver enhancement was associated with the clinical severity.

Keyword

Hepatic sinusoidal obstruction syndrome; Herbal medicine; Pyrrolizidine alkaloid; Computed tomography; Magnetic resonance imaging

MeSH Terms

Adult
Aged
Ascites/diagnosis
Asteraceae/chemistry
Cholecystography
Female
Gallbladder/pathology
Hepatic Veins/pathology/radiography
Hepatic Veno-Occlusive Disease/chemically induced/*diagnosis
Hepatomegaly/diagnosis
Humans
*Magnetic Resonance Imaging
Male
Middle Aged
Phytotherapy/*adverse effects
Pyrrolizidine Alkaloids/adverse effects
Severity of Illness Index
*Tomography, X-Ray Computed
Young Adult
Pyrrolizidine Alkaloids

Figure

• 

  Fig. 1 Post contrast-enhanced MR images show severity of patchy liver enhancement in hepatic sinusoidal obstruction syndrome. A. Grade 1. Arrow denotes mild patchy enhancement. B. Grade 2. Arrows denote moderate confluent patchy enhancement. C. Grade 3. Severe case with diffuse confluent patchy enhancement. Note all three cases demonstrate ascites.

• 

  Fig. 2 57-year-old man diagnosed with hepatic sinusoidal obstruction syndrome two months after ingestion of Gynura segetum. A. Periportal cuffing (black arrow) and subtle parenchymal heterogeneity (white arrow) are demonstrated on fat-suppressed T2-weighted MRI. B. Gallbladder wall thickening (arrow) is also demonstrated. C-E. Patchy enhancement is well demonstrated on T1-weighted gadolinium-enhanced MRI (C: artery phase, D: portal phase, E: hepatic venous phase), especially on portal and hepatic venous phase. Note middle and left main hepatic vein are narrowed, while right main hepatic vein is unenhanced (arrow). F. Hepatic venous phase CT from same patient also demonstrates patchy liver enhancement.

• 

  Fig. 3 49-year-old man diagnosed with hepatic sinusoidal obstruction syndrome two months after ingestion of Gynura segetum. A-C. Arterial, portal and hepatic venous phase CT scans demonstrate patchy liver enhancement. D. Clover-like enhancement surrounding hepatic veins is well demonstrated at hepatic venous phase on slice through hepatic vein level (arrows). E. Multiple planar reconstruction CT angiogram shows that inferior vena cava is slightly compressed by swelling liver while still remain patent. F. Pathologic hematoxylin and eosin staining (×100) from liver transplantation demonstrates sinusoidal congestion, centrilobular hepatocytes necrosis and slight fibrous hyperplasia in portal area.

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