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Everything you need to know about Computed Tomography (CT) & CT Scanning

Liver: Iron Overload Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Liver ❯ Iron Overload

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  • Iron overload (hemosiderosis) in Thalassemia
    Iron overload secondary to repeated transfusions (such as in beta-thalassaemia major) and increased intestinal absorption (such as in beta-thalassaemia intermedia), is a major cause of morbidity and mortality. Although multiorgan siderosis occurs, the liver is the main storage organ. Sequential liver iron quantification provides the best estimate of total body iron stores, hence can be used to tailor chelation therapy.
  • “Iron overload secondary to repeated transfusions (such as in beta-thalassaemia major) and increased intestinal absorption (such as in beta-thalassaemia intermedia), is a major cause of morbidity and mortality. Although multiorgan siderosis occurs, the liver is the main storage organ. Sequential liver iron quantification provides the best estimate of total body iron stores, hence can be used to tailor chelation therapy.”
    Imaging features of thalassaemia.  
    Gosselin M, Maharaj P, Balkaransingh P, et al.  
    Br J Radiol. 2019;92(1095):20180658. doi:10.1259/bjr.20180658
  • “The clinical management of Cooley anemia depends on repeated blood transfusions to prevent cardiac morbidity and mortality and on chelation therapy to alleviate the total body iron burden which results from the transfusions. While the CT findings of hemochromatosis of the liver, spleen, and other organs have recently been described in the literature, deposition of iron in upper abdominal lymph nodes has not been emphasized. We observed this and other CT findings in a series of nine patients with Cooley anemia who received transfusions and chelation therapy. Opportunity to relate CT density to iron deposition was provided in three individuals who underwent splenectomy and hepatic and lymph node biopsy.”
    CT in B-Thalassemia: Iron Deposition in the Liver, Spleen, and Lymph Nodes
    Julie S. Mitnick, Morton A. Bosniak, Alec J. Megibow et al.
    AJR136:1191-1194,June1981
  • “Computed tomography on the other hand, because of its sensitivity to tissue densities, clearly demonstrates the increased attenuation of the iron pigment in the reticuloendothelial system. Lymph node attenuation coefficients measured 145-205H in our series. Since the atomic number of calcium is close to that of iron,  the lymph nodes do appear calcified. However, absorption spectrophotometry data showed iron as the only significant element present in the excised nodes.”
    CT in B-Thalassemia: Iron Deposition in the Liver, Spleen, and Lymph Nodes
    Julie S. Mitnick, Morton A. Bosniak, Alec J. Megibow et al.
    AJR136:1191-1194,June1981
  • “CT examination  revealed increased density of lymph nodes in all patients . This was determined by visual evaluation of the scans and was confirmed by tissue attentuation measurements in Hounsfield units (H). The youngest patient in the series (age 6) had only faintly in creased density in periportal nodes. Attenuation coefficients of liver, spleen, and lymph nodes for the nine patients are recorded in table 1.”
    CT in B-Thalassemia: Iron Deposition in the Liver, Spleen, and Lymph Nodes
    Julie S. Mitnick, Morton A. Bosniak, Alec J. Megibow et al.
    AJR136:1191-1194,June1981
  • “An unenhanced CT liver attenuation threshold of 75 HU was sensitive (83.3%) for hereditary hemochromatosis while maintaining an acceptably low screening test positive rate (1.2%). An unexplained liver attenuation of 75 HU or more on unenhanced CT should trigger appropriate laboratory investigation for iron overload; early intervention with phlebotomy can limit or prevent organ damage in patients with hemochromatosis.”
    Opportunistic Screening for Hereditary Hemochromatosis With Unenhanced CT: Determination of an Optimal Liver Attenuation Threshold
    Edward M. Lawrence et al.
    AJR 2018; 211:1206–1211
  • “In conclusion, an unenhanced CT liver attenuation threshold of 75 HU (scanned at 120 kV) was reasonably sensitive (83%) in a cohort of patients with HH, was associated with elevated serum ferritin, and had an acceptably low test-positive rate in a screening cohort (1.2%). Therefore, an unexplained liver attenuation of 75 HU or more should be considered an opportunistic screening threshold that can provide added value by triggering appropriate laboratory investigation and lead to early intervention with phlebotomy that could limit or prevent organ damage.”
    Opportunistic Screening for Hereditary Hemochromatosis With Unenhanced CT: Determination of an Optimal Liver Attenuation Threshold
    Edward M. Lawrence et al.
    AJR 2018; 211:1206–1211
  • Hemochromatosis: Causes
    - primary hemochromatosis (hereditary)
    - Anemia 
    - Blood transfusions.
    - Iron pills or injections.
    - Kidney dialysis over a long period of time.
    - Liver disease, such as hepatitis C infection or fatty liver disease.
  • “However, high liver density seen on CT scans, which is secondary to increased iodine content of amiodarone and reflects the tissue level of amiodarone, may be useful to detect the toxicity .In this regard, it is important to evaluate elevations of liver enzymes, liver CT imaging (high attenuation of the liver parenchyma), and histology, and discontinuation should be considered when amiodarone induced hepatotoxicity is suspected.”  
    Amiodarone-induced reversible and irreversible hepatotoxicity: two case reports
    Toyonobu Tsuda et al.
    Journal of Medical Case Reports (2018) 12:95 
  • “Amiodarone is an amphiphilic iodinated compound that is used as a treatment for refractory ventricular arrhythmias. During evaluation for possible pulmonary toxicity, a patient receiving amiodarone was noted to have an increase in the density of his liver as seen on computed tomographic (CT) scanning of the abdomen. Six additional patients who were receiving amiodarone were subsequently evaluated to ascertain the frequency of this finding. The CT density of the liver was increased in all patients. Values obtained varied from 95 to 145 H, with a mean of 117 +/- 8.9 (normal, 30-70). The alkaline phosphatase was elevated in four patients, but only one had an elevation of either the alanine or aspartate aminotransferase.”
    Increased hepatic density and phospholipidosis due to amiodarone.  
    Goldman IS et al.  
    AJR Am J Roentgenol. 1985 Mar;144(3):541-6.
  • Iron overload (hemosiderosis) in Thalassemia
    Iron overload secondary to repeated transfusions (such as in beta-thalassaemia major) and increased intestinal absorption (such as in beta-thalassaemia intermedia), is a major cause of morbidity and mortality. Although multiorgan siderosis occurs, the liver is the main storage organ. Sequential liver iron quantification provides the best estimate of total body iron stores, hence can be used to tailor chelation therapy.
  • “Iron overload secondary to repeated transfusions (such as in beta-thalassaemia major) and increased intestinal absorption (such as in beta-thalassaemia intermedia), is a major cause of morbidity and mortality. Although multiorgan siderosis occurs, the liver is the main storage organ. Sequential liver iron quantification provides the best estimate of total body iron stores, hence can be used to tailor chelation therapy.”
    Imaging features of thalassaemia.  
    Gosselin M, Maharaj P, Balkaransingh P, et al.  
    Br J Radiol. 2019;92(1095):20180658. doi:10.1259/bjr.20180658
  • “The clinical management of Cooley anemia depends on repeated blood transfusions to prevent cardiac morbidity and mortality and on chelation therapy to alleviate the total body iron burden which results from the transfusions. While the CT findings of hemochromatosis of the liver, spleen, and other organs have recently been described in the literature, deposition of iron in upper abdominal lymph nodes has not been emphasized. We observed this and other CT findings in a series of nine patients with Cooley anemia who received transfusions and chelation therapy. Opportunity to relate CT density to iron deposition was provided in three individuals who underwent splenectomy and hepatic and lymph node biopsy.”
    CT in B-Thalassemia: Iron Deposition in the Liver, Spleen, and Lymph Nodes
    Julie S. Mitnick, Morton A. Bosniak, Alec J. Megibow et al.
    AJR136:1191-1194,June1981
  • “Computed tomography on the other hand, because of its sensitivity to tissue densities, clearly demonstrates the increased attenuation of the iron pigment in the reticuloendothelial system. Lymph node attenuation coefficients measured 145-205H in our series. Since the atomic number of calcium is close to that of iron,  the lymph nodes do appear calcified. However, absorption spectrophotometry data showed iron as the only significant element present in the excised nodes.”
    CT in B-Thalassemia: Iron Deposition in the Liver, Spleen, and Lymph Nodes
    Julie S. Mitnick, Morton A. Bosniak, Alec J. Megibow et al.
    AJR136:1191-1194,June1981
  • “CT examination  revealed increased density of lymph nodes in all patients . This was determined by visual evaluation of the scans and was confirmed by tissue attentuation measurements in Hounsfield units (H). The youngest patient in the series (age 6) had only faintly in creased density in periportal nodes. Attenuation coefficients of liver, spleen, and lymph nodes for the nine patients are recorded in table 1.”
    CT in B-Thalassemia: Iron Deposition in the Liver, Spleen, and Lymph Nodes
    Julie S. Mitnick, Morton A. Bosniak, Alec J. Megibow et al.
    AJR136:1191-1194,June1981
  • “An unenhanced CT liver attenuation threshold of 75 HU was sensitive (83.3%) for hereditary hemochromatosis while maintaining an acceptably low screening test positive rate (1.2%). An unexplained liver attenuation of 75 HU or more on unenhanced CT should trigger appropriate laboratory investigation for iron overload; early intervention with phlebotomy can limit or prevent organ damage in patients with hemochromatosis.”
    Opportunistic Screening for Hereditary Hemochromatosis With Unenhanced CT: Determination of an Optimal Liver Attenuation Threshold
    Edward M. Lawrence et al.
    AJR 2018; 211:1206–1211
  • “In conclusion, an unenhanced CT liver attenuation threshold of 75 HU (scanned at 120 kV) was reasonably sensitive (83%) in a cohort of patients with HH, was associated with elevated serum ferritin, and had an acceptably low test-positive rate in a screening cohort (1.2%). Therefore, an unexplained liver attenuation of 75 HU or more should be considered an opportunistic screening threshold that can provide added value by triggering appropriate laboratory investigation and lead to early intervention with phlebotomy that could limit or prevent organ damage.”
    Opportunistic Screening for Hereditary Hemochromatosis With Unenhanced CT: Determination of an Optimal Liver Attenuation Threshold
    Edward M. Lawrence et al.
    AJR 2018; 211:1206–1211
  • Hemochromatosis: Causes
    - primary hemochromatosis (hereditary)
    - Anemia 
    - Blood transfusions.
    - Iron pills or injections.
    - Kidney dialysis over a long period of time.
    - Liver disease, such as hepatitis C infection or fatty liver disease.
  • “However, high liver density seen on CT scans, which is secondary to increased iodine content of amiodarone and reflects the tissue level of amiodarone, may be useful to detect the toxicity .In this regard, it is important to evaluate elevations of liver enzymes, liver CT imaging (high attenuation of the liver parenchyma), and histology, and discontinuation should be considered when amiodarone induced hepatotoxicity is suspected.”  
    Amiodarone-induced reversible and irreversible hepatotoxicity: two case reports
    Toyonobu Tsuda et al.
    Journal of Medical Case Reports (2018) 12:95 
  • “Amiodarone is an amphiphilic iodinated compound that is used as a treatment for refractory ventricular arrhythmias. During evaluation for possible pulmonary toxicity, a patient receiving amiodarone was noted to have an increase in the density of his liver as seen on computed tomographic (CT) scanning of the abdomen. Six additional patients who were receiving amiodarone were subsequently evaluated to ascertain the frequency of this finding. The CT density of the liver was increased in all patients. Values obtained varied from 95 to 145 H, with a mean of 117 +/- 8.9 (normal, 30-70). The alkaline phosphatase was elevated in four patients, but only one had an elevation of either the alanine or aspartate aminotransferase.”
    Increased hepatic density and phospholipidosis due to amiodarone.  
    Goldman IS et al.  
    AJR Am J Roentgenol. 1985 Mar;144(3):541-6.

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