Abd (outcome 1) Flashcards
1
Q
Viral Hepatitis
A
- inflammation of the liver
- common (occurs worldwide)
2
Q
How many distinct hepatitis viruses are there?
A
- 6
- A through E or G
3
Q
Serosurvey
A
-study of blood serum to find antibodies when exposed to hepatitis
4
Q
Can viral hepatitis be fatal?
A
Yes, if not treated.
5
Q
What can viral hepatitis lead to?
A
- portal hypertension
- cirrhosis
- hepatocellular carcinoma (HCC)
6
Q
Hepatitis A
A
- worldwide
- spread through fecal, oral. route
- endemic in developing countries (affects the young)
- acute infection
- can cause death (liver failure)
7
Q
Hepatitis B
A
- worldwide
- transmitted parenterally (not oral), blood transfusions, needle punctures, sexual contact and at birth
- mostly in Asia, Africa and Greenland
8
Q
Hepatitis C
A
- major problem in Italy and the Mediterranean
- spread through blood (sharing needles)
- presence of antibodies in blood
9
Q
Hepatitis D
A
- dependant on B
- geographically the same as B
- uncommon in North America
- common in IV drug users
10
Q
How soon does acute hepatitis imply recovery?
A
-within 4 months
11
Q
What is the sonographic appearance of acute hepatitis?
A
- hypoechoic liver parenchyma
- bright periportal walls
- starry night sign
12
Q
How long does hepatitis last to be chronic?
A
-biochemical abnormalities persist beyond 6 months
13
Q
If there are not antibodies present, what will the result be for chronic hepatitis?
A
-negative
14
Q
How can we detect different hepatitis virus’?
A
-antibody and antigen tests
15
Q
What does chronic hepatitis look like on US?
A
- hepatomegaly
- thickening of GB wall
- liver may appear normal sometimes
16
Q
What can be harmful to the liver?
A
- alcohol
- prescription drugs
- poor diet
17
Q
Disorders of Metabolism
A
- steatosis (fatty liver)
- glycogen storage (neonatal)
- cirrhosis (chronic liver disease)
- NASH (non alcoholic steatohepatitis)
18
Q
Can steatosis (fatty liver) be reversed?
A
Yes. If the cause is corrected.
19
Q
What is the most common cause of steatosis?
A
- obesity
- triglycerides (fat) in the hepatocytes
20
Q
Causes of Steatosis (fatty liver)
A
- excessive alcohol consumption (stimulates lipolysis)
- severe hepatitis
- hyperlipidemia (cholesterol)
- diabetes
- excess corticosteroids
- pregnancy
- hyperalimentation
- obesity bypass surgery
- cystic fibrosis
- toxins
21
Q
What is steatosis a precursor for?
A
-chronic liver disease
22
Q
What can steatosis lead to?
A
-hepatocellular carcinoma (HCC)
23
Q
How do the deposits of steatosis look like?
A
-focal or diffuse
24
Q
What does sonography of fatty infiltration look like?
A
-varies depending gon amount of fat
25
Characterization of Mild Steatosis
-minimal diffuse increase in hepatic echogenicity
26
Characterization of Moderate Steatosis
- moderate diffuse increase in hepatic achogenicity
| - slightly impaired visualization of intrahepatic vessels and diaphragm
27
Characterization of Severe Steatosis
- marked increase in echogenicity
- poor penetration of posterior liver
- poor or no visualization of hepatic vessels and diaphragm
- hepatomegaly often present
28
Sonographic Appearance of Fatty Liver
- focal fatty infiltration
- fatty sparing
- focal fat
29
Focal Infiltration
- regions of increased echogenicity, with a background of normal liver
- can mimic a mass
30
Fatty Sparing
-islands of normal liver parenchyma appear as hypoechoic masses within a dense fatty infiltrated liver (no mass effect)
31
Does steatosis have a mass effect?
No.
32
How rapidly does steatosis change in appearance and resolution?
6 days
33
Sonographic Appearances of Steatosis
- no liver contour abnormality
| - focal fat may appear rounded, nodular or interspersed with normal tissue
34
Where is the preferred site for focal fat in steatosis?
-anterior to PV at porta hepatis
35
Where is the preferred site for focal fatty sparing or infiltration in steatosis?
-anterior to PV at porta hepatis, GB fossa and liver margins
36
Other Testing for Liver Disease
- CT can show regions of low attenuation
- CEUS (contrast enhanced US) differentiates fatty change from neoplasia
- MRI can distinguish diffuse from focal fatty infiltration
- nuclear medicine scintigraphy
37
When does glycogen storage disease occur and where?
- neonatal period
| - lg amounts of glycogen are deposited in liver and kidneys
38
Can neonates with glycogen storage disease survive?
-until childhood or early adulthood with enzyme therapy
39
What may develop from glycogen storage disease?
- benign adenomas
| - hepatocellular carcinoma
40
How does glycogen storage disease appear compared to diffuse fatty infiltration?
-appears the same, but affects a different age group
41
Cirrhosis
-diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules (coarse texture)
42
What 3 major pathological mechanisms combine to create cirrhosis?
1) cell death
2) fibrosis
3) regeneration
43
What is the most common cause of micro nodular form (<1cm)?
-alcohol consumption
44
What is the most frequent cause of macro nodular form (1-5cm)?
-chronic viral hepatitis
45
What may happen to patients with cirrhosis if they continue to abuse alcohol?
-end stage liver disease
46
Clinical Presentation of Cirrhosis
- heptomegaly
- jaundice
- ascites
47
Other Etiologies/Causes of Cirrhosis
- biliary cirrhosis
- wilson's disease
- primary sclerosis cholangitis
- hemochromatosis
48
What is the most common cause/etiology of portal hypertension?
-cirrhosis
49
Sonographic Appearance of Cirrhosis
- volume redistribution
- coarse ehotexture
- nodular surface
- nodules (regenerative and dysplastic)
- portal hypertension (ascites, splenomegaly and varcies)
50
Early Stages of Cirrhosis
- liver may be enlarged
- may be difficult to distinguish from fatty liver
- look for irregular contour (higher frequency)
51
Advanced Stages of Cirrhosis
- liver is often small/shrinking
| - ascites
52
What does a coarse echotexture look like?
- increase echogenicity
| - loss of smooth texture
53
Nodular Surfface
- irregularity of liver surface
- due to presence of regenerating nodules and fibrosis
- ascites helps outline edges
- linear probe delineates contour wall
54
Regenerating Nodules
- hepatocytes surrounded by fibrotic septae
| - may be isoechoic or hypoechoic with thin echogenic border (fibrofatty CT)
55
Dysplastic Nodules
- adenomatous hyperplastic nodules
| - well differentiated hepatocytes, portal venous blood supply, atypical or frankly malignant cells
56
How large do dysplastic nodules have to be to be considered premalignant?
-larger than 10mm
57
Is colour doppler helpful with dysplastic nodules?
Yes.
58
Why might a biopsy be ordered with dysplastic nodules?
-to r/o HCC (cancerous mass)
59
NASH (non-alcoholic steatohepatitis)
- common, silent liver disease
| - resembles alcoholic liver disease, in people who do not consume much alcohol
60
What are the main features of NASH?
- fat in the liver
- inflammation
- damage
61
What can NASH lead to?
-cirrhosis
62
What is NASH related to?
-obesity
63
What has happened to the rate of obesity in the past 10 years?
- x2 in adults
| - x3 in children
64
What does obesity contribute to?
- diabetes
| - high blood cholesterol (can further complicate the health of someone with NASH)
65
Signs and Symptoms of NASH?
- fatigue
- weight loss
- weakness
66
What does NASH cause an increase in?
-LFT's
67
What is NASH I diagnosed by?
-biopsy
68
Treatment for NASH
- reduced weight
- balanced diet
- physical activity
- avoid alcohol and unnecessary medications
69
How does NASH appear sonographically?
-dense fatty infiltration or cirrhosis
70
Hepatic Failure
-inability of the liver to perform it's normal synthetic and metabolic function as part of normal physiology
71
2 Forms of Hepatic Failure
- acute
| - chronic
72
Acute Liver Failure
-rapid development of hepatocellular dysfunction, specifically coagulopathy and mental status changes (encephalopathy) in a patient without known prior liver disease
73
When does chronic liver failure occur?
-usually in context with cirrhosis
74
What could chronic liver failure be the result of?
- excessive alcohol intake
- hep B or C
- autoimmune, hereditary and metabolic causes such as iron or copper overload
- steatohepatitis or non alcoholic fatty liver disease
75
Ascites
- uncomplicated portal hypertension does not cause ascites
| - ascites usually occurs secondary to liver cell failure
76
Other Causes of Hepatic Failure
- worsening jaundice
- coagulopathy
- hepatic encephalopathy
- drug toxicity
- death occurs if loss of hepatic parenchyma by necrosis is >40%
77
Coagulopathy
- aka clotting/bleeding disorder
- bloods ability to clot is impaired
- may occur spontaneously or following a medical condition (cirrhosis)
78
What is hepatic encephalopathy brought on by?
-disorders that affect the liver
79
What is hepatic encephalopathy also known as?
- portosystemic encephalopathy
| - hepatic coma
80
What may a patient with hepatic encephalopathy exhibit?
- confusin
- altered level of consciousness
- coma
81
What is hepatic encephalopathy a result of?
-liver failure
82
What % of hepatic failure do drugs account for?
20-40%
83
What is the outcome of drug toxicity?
-liver transplantation or death
84
Why are alcoholic persons more susceptible to drug toxicity?
-alcohol induces liver injury and cirrhotic changes that alter drug metabolism
85
Malignant Hepatic Neoplasms
- hepatocellular carcinoma (HCC)
- fibrolamellar carcinoma
- hemangiosarcoma (angiosarcoma)
- hepatic epithelial hemangioendothelioma
86
HCC/Hepatoma
-one of the most common malignant tumors
| mostly in men (5x more common)
87
Cause of HCC/Hepatoma
- alcoholic cirrhosis (west)
- viral hep B and C (worldwide)
- fatty liver, steatohepatitis, cirrhosis (west)
- fungi, toxins in food (developing countries)
88
Symptoms of HCC
- RUQ pain
- weight loss
- abd swelling (ascites)
89
Clinical Presentation of HCC
-often delated until tumor reaches an advanced stage
90
3 Pathological Forms of HCC
- solitary tumor
- multiple nodules
- diffuse infiltration
91
What % of HCC cases cause invasion of PV?
30 to 60%
92
Budd Chiari Syndrome
-HCC invading the hepatic venous system
93
Sonographic Appearance of HCC
- variable appearance
- hypoechoic, complex or echogenic
- thin, peripheral, hypoechoic halo fibrous capsule
94
Appearance of Nodules with HCC
- small (<5cm)
| - hypoechoic solid tumor, without necrosis
95
Is calcification common in HCC?
No.
96
What is HCC indistinguishable from?
- focal fat
- hemangiomas
- lipomas
97
Other Testing for HCC
- CEUS
- CT
- MRI
- dopper
98
Why might US not be the best for HCC?
-cannot distinguish between steatosis and hemangiomas
99
What is fibrolamellar carcinoma a subtype of?
-HCC
100
Who is fibrolamellar carcinoma found in?
-adolescents and young adults
101
Fibrolamellar Carcinoma
- without coexisting liver disease
- advanced disease at diagnosis
- alphafetoprotein levels are normal
- surgical resection of tumor is recommended
102
Echogenicity of Fibrolamella Carcinoma
-variable
103
What distinguishes calcification of a fibrolamellar carcinoma from a hepatoma of HCC?
-central echogenic scar
104
Hemangiosarcoma
-extremely rare malignant tumor
105
Hepatic Epitheliod
-rare malignant tumor of vascular origin
106
What age is hemangiosarcoma seen in?
-adults 60 to 70 years old
107
Echogenicity of Hemangiosarcoma
-lg mass of mixed echogenicity
108
What is hemangiosarcoma associated with?
-specific carcinogens
109
Who does hepatic epithelial occur in?
-adults
110
Where does hepatic epithelial occur and what does it create?
- soft tissues (lung and liver)
| - multiple hypoechoic nodules (lg masses)
111
What the are the most common primary tumors resulting in liver metastases results of?
- GB
- colon
- stomach
- pancreas
- breast
- lung
112
Blood Borne Routes for Metastatic Liver Disease
- hepatic artery
| - portal vein
113
Lymphatic Spread of Metastatic Liver Disease
- stomach
- pancreas
- ovary
- uterus
114
Where are tumor cells from the GI tract drained through?
-the portal system to the liver
115
Sonographic Appearance of Mets
- single or multifocal liver lesions
- identical sonographic morphology
- diffuse iver involvement, varied sized lesions
- geographic infiltration rarely
- hypoechoic halo (malignancy)
- prior knowledge of malignancy aids interpretation
116
What metastatic diseases are echogenic?
- tend to arise from GI tract or HCC
- generally hypervascular
- may mimic hemangioma on sonography
- GI tract
- HCC
- vascular primaries
- islet cell carcinoma
- carcinoid
- choriocarcinoma
- renal cell carcinoma
117
What metastatic diseases are hypoechoic?
- generally hypovascular
- untreated breast, ling, gastric, pancreatic and esophageal cancer
- breast
- lung
- lymphoma
- esophagus
- stomach
- pancreas
118
Lymphoma of Liver
-multiple hypoechoic masses
119
Bull's Eye or Target
- typically seen with lung cancer
- hypoechoic peripheral halo
- non specific and common appearance
120
Calcified Metastases
- mucinous adenocarcinoma
- osteogenic sarcoma
- chomdrosarcoma
- tetracarcinoma
- neuroblastoma
121
What is shadowing in the liver most often due to?
-calcifications, air, stones and fat containing lesions
122
What is a clean shadow caused by?
-calcifications
123
What is a dirty shadow caused by?
-air
124
What is the most common cause of a calcified liver tumor?
-metastases
125
Does FNH have calcifications?
-rarely
126
Cystic Mets
- necrosis sarcomas
- cystadenocarcinoma of ovary and pancreas
- mucinous carcinoma of colon
127
What makes cystic metastases distinguishable from simple cysts?
- mural nodules
- thick walls
- fluid
- internal septations
- extensive necrosis
128
Are cystic metastases common?
No.
129
What are infiltrative mets seen with?
- breast
- lung
- malignant melanoma
130
Infiltrative Metastatic Disease
- diffuse disorganization of parenchyma
- difficult to see on US (may be confused with cirrhosis or fatty liver)
- chemotherapy may make liver fatty (nodules difficult to appreciate)
- CEUS, CT or MRI can be used
131
Metastatic- Kaposi Sarcomas
- neuroendocrine and carcinoid tumors
- primary cystadenocarcinoma
- mucinous carcinoma
132
CEUS
- involves the use of micro bubble contrast agents and specialized imaging techniques
- tiny bubbles in an injectable gas
133
What does CEUS play a major role in?
-detection of mets
134
What does CEUS show?
- sensitive blood flow
| - tissue perfusion
135
What determines vascularity in metastases?
CEUS
136
What helps in a biopsy to establish the primary tissue site?
CEUS
137
What does CEUS have similar results to?
- CT
| - MRI
138
Benefits of CEUS
- no ionizing radiation
| - not nephrotoxic
139
Causes of Hepatomegaly
- liver trauma
- passive liver congestion
- hepatomegaly
140
Aurora Sign (ring down artifact)
- not in liver
- caused by lung parenchymal disease
- may be seen when scanning liver
141
Hepatomegaly
- enlargement of the liver
| - frequent indication for sonography of liver
142
With hepatomegaly, where can the physician feel the patients liver?
-can feel edge below rib cage
143
Reidel's Lobe
- often mistaken for enlarged liver
- found more often in women
- tongue shaped process of the liver
- normal varient
144
Causes of Hepatomegaly
- fatty liver
- viral infections (hep A, B and C)
- mononucleosis
- hemochromatosis
- primary liver cancer
- leukemia
- lymphoma
145
Symptoms of Hepatomegaly
- abd pain
- swelling
- feeling of fullness
- jaundice
146
Diagnostic Tests for Hepatomegaly
- US
- xray
- CT
- LFT's
- biopsy
**underlying cause must be treated
147
What is initially performed after hepatic trauma (enlargement)?
- abd CT
| - US may be used fr serial monitoring
148
Where in the liver does trauma usually occur?
-Rt lobe
149
How does a fresh hemorrhage appear on US?
-echogenic
150
After 1 week, how does a hemorrhage occur?
-hypoechoic
151
After 2 to 3 weeks, how does a hemorrhage occur?
-indistict due to fluid resorption and granulation
152
What is passive liver congestion caused by?
-stasis of the blood within liver parenchyma
153
What does stasis of blood within liver parenchyma result in?
- hepatic venous drainage is compromised
| - common complication of congestive heart failure
154
With passive liver congestion, where is central venous pressure transmitted from to go to the HV's?
-Rt atrium
155
How does the liver appear with passive liver congestion?
- tensely swollen
| - sinusoids dilate to accomodate back flow of blood
156
Miscellaneous
- portal venous gas
| - lung parenchymal disease causing artifact seen when scanning liver
157
Portal Venous Gas
-accumulation of gas in the peripheral portal venous system
158
What is portal venous gas similar in appearance to?
-pnemobilia (air in bile ducts)
159
What is portal venous gas in adults caused by?
GI Issues:
- ischemic, necrotic, ulcerated bowel
- colorectal carcinoma
- inflammatory bowel disease
- perforated peptic ulcer
160
What are the 4 most common ways that pyogenic bacteria reaches the liver?
1) via the biliary tract in patients with suppurative (pus) cholangitis (inflammation of biliary system) or cholecystitis (inflammation of GB)
2) through portal venous system (diverticulitis and appendicitis)
3) through HA (osteomyelitis and bacterial endocarditis)
4) trauma to liver (turns into abscess)
161
What causes hepatic abscesses?
- no cause in 50% of cases
| - anaerobic (bacterial) infection
162
What are the presenting features of a pyogenic liver abscess?
- fever
- malaise
- anorexia
- RUQ pain
- jaundice
- leukocytosis
163
Is sonography helpful in detection of a hepatic abscess?
Yes.
164
Sonographic Signs of Liver Abscess
- frankly purulent (cystic with fluid ranging from echo free to highly echogenic)
- early suppuration (solid with altered echogenicity, usually hypoechoic due to necrotic hepatocytes)
- gas producing organisms give rise to echogenic foci with posterior reverberation artifacts
- fluid, internal septations and debris
- walls can be thick, irregular or well defined
165
Which fungal disease is usually common in patients who are immunosuppressed?
-candidiasis
166
Which patients are immunosuppressed?
- transplant pre and post
- cancer
- chemotherapy/radiation therapy
- AIDS/HIV
- inherited disease (blood disorders)
- underlying systemic infection
- poor nutrition
167
What is amebiasis?
-hepatic infection
168
What causes amebiasis?
-parasite (entamoeba histolytica)
169
How is amebiasis transmitted?
- fecal oral route
| - penetrates through the colon via mesenteric venues, then to the portal vein and to liver
170
Symptoms of Amebiasis
- pain
| - diarrhea (15%)
171
Sono Appearance of Amebiasis
- round/oval lesion
- absense of prominent wall
- hypoechoic
- low level echoes
- distal enhancement
- simple cysts
- cysts with detached endocyst (secondary to rupture)
- cyst with daughter cysts
- densely calcified masses
172
Treatment of Hydatid Disease
- surgery
| - US is used to monitor
173
What is the most common parasitic infection in humans?
-schistosomiasis
174
Schistosomiasis
- most common parasite in humans
- 4 different parasites
- ova reach liver via PV
- terminal PV branches become occluded
175
What can schistosomiasis lead to?
- portal hypertension
- splenomegaly
- varices
- ascites ensues
176
Sonographic Appearance of Schistosomiasis
- widened echogenic portal tracts (up to 2cm)
- dilated biliary ducts
- porta hepatis region most affected
- initially hepatomegaly, then periportal fibrosis occurs
- liver then shrinks
- portal hypertension prevails
177
Pneumocystis Carinii
- most common organism causing opportunistic infection in patients with AIDS
- patients undergoing bone marrow and organ transplants are at risk
178
Pneumonia
-most common cause of life threatening infection
179
Sono Appearance of Pneumocytstis Carinii
-tiny, diffuse, non shadowing, echogenic foci
OR
-extensive replacement of normal hepatic parenchyma by echogenic clumps of dense calcifications
180
5 Incidentaloma's
- granulomas
- cavernous hemangioma
- FNH
- adenoma
- simple cyst
181
Most Common Benign Tumor
-cavernous hemangioma
182
2 Tumors Occurring with Hormone Influence
- FNH
| - adenoma
183
Which benign tumor is a broken diaphragm a sign of?
-fatty tumor
184
4 Complications of Viral Hepatitis
- portal hypertension
- cirrhosis
- HCC
- liver failure
185
What is starry night sign associated with?
-acute viral hepatitis
186
2 Complications of Chronic Hepatitis
- hepatomegaly
| - GB wall thickening
187
What are 2 common causes of bacterial disease via the biliary tract?
- cholangitis
| - cholecystitis
188
What is the most common complication of bacterial disease associated with fever and leukocytosis?
-abscess
189
What sonographic sign could differentiate between hematoma and an abscess?
- gas
| - echogenic foci with ring down artifact OR posterior reverberation artifact
190
Which fungal disease is most commonly associated with patients who are immunosuppressed?
-candidiasis
191
Which parasitic infection is prevalent in sheep and cattle raising countries?
-hydatid disease
192
What is the most common parasitic infection in humans?
-schistomiasis
193
What is the distinguishing feature of schistosomiasis on US?
-widening and echogenic portal tracts
