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Term 2 > Abd (outcome 1) > Flashcards

Abd (outcome 1) Flashcards

1
Q

Viral Hepatitis

A
  • inflammation of the liver

- common (occurs worldwide)

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2
Q

How many distinct hepatitis viruses are there?

A
  • 6

- A through E or G

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3
Q

Serosurvey

A

-study of blood serum to find antibodies when exposed to hepatitis

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4
Q

Can viral hepatitis be fatal?

A

Yes, if not treated.

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5
Q

What can viral hepatitis lead to?

A
  • portal hypertension
  • cirrhosis
  • hepatocellular carcinoma (HCC)
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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)
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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
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8
Q

Hepatitis C

A
  • major problem in Italy and the Mediterranean
  • spread through blood (sharing needles)
  • presence of antibodies in blood
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9
Q

Hepatitis D

A
  • dependant on B
  • geographically the same as B
  • uncommon in North America
  • common in IV drug users
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10
Q

How soon does acute hepatitis imply recovery?

A

-within 4 months

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11
Q

What is the sonographic appearance of acute hepatitis?

A
  • hypoechoic liver parenchyma
  • bright periportal walls
  • starry night sign
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12
Q

How long does hepatitis last to be chronic?

A

-biochemical abnormalities persist beyond 6 months

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13
Q

If there are not antibodies present, what will the result be for chronic hepatitis?

A

-negative

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14
Q

How can we detect different hepatitis virus’?

A

-antibody and antigen tests

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15
Q

What does chronic hepatitis look like on US?

A
  • hepatomegaly
  • thickening of GB wall
  • liver may appear normal sometimes
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16
Q

What can be harmful to the liver?

A
  • alcohol
  • prescription drugs
  • poor diet
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17
Q

Disorders of Metabolism

A
  • steatosis (fatty liver)
  • glycogen storage (neonatal)
  • cirrhosis (chronic liver disease)
  • NASH (non alcoholic steatohepatitis)
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18
Q

Can steatosis (fatty liver) be reversed?

A

Yes. If the cause is corrected.

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19
Q

What is the most common cause of steatosis?

A
  • obesity

- triglycerides (fat) in the hepatocytes

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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
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21
Q

What is steatosis a precursor for?

A

-chronic liver disease

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22
Q

What can steatosis lead to?

A

-hepatocellular carcinoma (HCC)

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23
Q

How do the deposits of steatosis look like?

A

-focal or diffuse

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24
Q

What does sonography of fatty infiltration look like?

A

-varies depending gon amount of fat

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25
Q

Characterization of Mild Steatosis

A

-minimal diffuse increase in hepatic echogenicity

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26
Q

Characterization of Moderate Steatosis

A
  • moderate diffuse increase in hepatic achogenicity

- slightly impaired visualization of intrahepatic vessels and diaphragm

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27
Q

Characterization of Severe Steatosis

A
  • marked increase in echogenicity
  • poor penetration of posterior liver
  • poor or no visualization of hepatic vessels and diaphragm
  • hepatomegaly often present
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28
Q

Sonographic Appearance of Fatty Liver

A
  • focal fatty infiltration
  • fatty sparing
  • focal fat
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29
Q

Focal Infiltration

A
  • regions of increased echogenicity, with a background of normal liver
  • can mimic a mass
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30
Q

Fatty Sparing

A

-islands of normal liver parenchyma appear as hypoechoic masses within a dense fatty infiltrated liver (no mass effect)

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31
Q

Does steatosis have a mass effect?

A

No.

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32
Q

How rapidly does steatosis change in appearance and resolution?

A

6 days

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33
Q

Sonographic Appearances of Steatosis

A
  • no liver contour abnormality

- focal fat may appear rounded, nodular or interspersed with normal tissue

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34
Q

Where is the preferred site for focal fat in steatosis?

A

-anterior to PV at porta hepatis

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35
Q

Where is the preferred site for focal fatty sparing or infiltration in steatosis?

A

-anterior to PV at porta hepatis, GB fossa and liver margins

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36
Q

Other Testing for Liver Disease

A
  • 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
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37
Q

When does glycogen storage disease occur and where?

A
  • neonatal period

- lg amounts of glycogen are deposited in liver and kidneys

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38
Q

Can neonates with glycogen storage disease survive?

A

-until childhood or early adulthood with enzyme therapy

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39
Q

What may develop from glycogen storage disease?

A
  • benign adenomas

- hepatocellular carcinoma

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40
Q

How does glycogen storage disease appear compared to diffuse fatty infiltration?

A

-appears the same, but affects a different age group

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41
Q

Cirrhosis

A

-diffuse process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules (coarse texture)

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42
Q

What 3 major pathological mechanisms combine to create cirrhosis?

A

1) cell death
2) fibrosis
3) regeneration

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43
Q

What is the most common cause of micro nodular form (<1cm)?

A

-alcohol consumption

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44
Q

What is the most frequent cause of macro nodular form (1-5cm)?

A

-chronic viral hepatitis

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45
Q

What may happen to patients with cirrhosis if they continue to abuse alcohol?

A

-end stage liver disease

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46
Q

Clinical Presentation of Cirrhosis

A
  • heptomegaly
  • jaundice
  • ascites
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47
Q

Other Etiologies/Causes of Cirrhosis

A
  • biliary cirrhosis
  • wilson’s disease
  • primary sclerosis cholangitis
  • hemochromatosis
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48
Q

What is the most common cause/etiology of portal hypertension?

A

-cirrhosis

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49
Q

Sonographic Appearance of Cirrhosis

A
  • volume redistribution
  • coarse ehotexture
  • nodular surface
  • nodules (regenerative and dysplastic)
  • portal hypertension (ascites, splenomegaly and varcies)
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50
Q

Early Stages of Cirrhosis

A
  • liver may be enlarged
  • may be difficult to distinguish from fatty liver
  • look for irregular contour (higher frequency)
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51
Q

Advanced Stages of Cirrhosis

A
  • liver is often small/shrinking

- ascites

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52
Q

What does a coarse echotexture look like?

A
  • increase echogenicity

- loss of smooth texture

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53
Q

Nodular Surfface

A
  • irregularity of liver surface
  • due to presence of regenerating nodules and fibrosis
  • ascites helps outline edges
  • linear probe delineates contour wall
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54
Q

Regenerating Nodules

A
  • hepatocytes surrounded by fibrotic septae

- may be isoechoic or hypoechoic with thin echogenic border (fibrofatty CT)

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55
Q

Dysplastic Nodules

A
  • adenomatous hyperplastic nodules

- well differentiated hepatocytes, portal venous blood supply, atypical or frankly malignant cells

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56
Q

How large do dysplastic nodules have to be to be considered premalignant?

A

-larger than 10mm

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57
Q

Is colour doppler helpful with dysplastic nodules?

A

Yes.

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58
Q

Why might a biopsy be ordered with dysplastic nodules?

A

-to r/o HCC (cancerous mass)

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59
Q

NASH (non-alcoholic steatohepatitis)

A
  • common, silent liver disease

- resembles alcoholic liver disease, in people who do not consume much alcohol

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60
Q

What are the main features of NASH?

A
  • fat in the liver
  • inflammation
  • damage
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61
Q

What can NASH lead to?

A

-cirrhosis

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62
Q

What is NASH related to?

A

-obesity

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63
Q

What has happened to the rate of obesity in the past 10 years?

A
  • x2 in adults

- x3 in children

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64
Q

What does obesity contribute to?

A
  • diabetes

- high blood cholesterol (can further complicate the health of someone with NASH)

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65
Q

Signs and Symptoms of NASH?

A
  • fatigue
  • weight loss
  • weakness
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66
Q

What does NASH cause an increase in?

A

-LFT’s

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67
Q

What is NASH I diagnosed by?

A

-biopsy

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68
Q

Treatment for NASH

A
  • reduced weight
  • balanced diet
  • physical activity
  • avoid alcohol and unnecessary medications
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69
Q

How does NASH appear sonographically?

A

-dense fatty infiltration or cirrhosis

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70
Q

Hepatic Failure

A

-inability of the liver to perform it’s normal synthetic and metabolic function as part of normal physiology

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71
Q

2 Forms of Hepatic Failure

A
  • acute

- chronic

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72
Q

Acute Liver Failure

A

-rapid development of hepatocellular dysfunction, specifically coagulopathy and mental status changes (encephalopathy) in a patient without known prior liver disease

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73
Q

When does chronic liver failure occur?

A

-usually in context with cirrhosis

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74
Q

What could chronic liver failure be the result of?

A
  • 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
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75
Q

Ascites

A
  • uncomplicated portal hypertension does not cause ascites

- ascites usually occurs secondary to liver cell failure

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76
Q

Other Causes of Hepatic Failure

A
  • worsening jaundice
  • coagulopathy
  • hepatic encephalopathy
  • drug toxicity
  • death occurs if loss of hepatic parenchyma by necrosis is >40%
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77
Q

Coagulopathy

A
  • aka clotting/bleeding disorder
  • bloods ability to clot is impaired
  • may occur spontaneously or following a medical condition (cirrhosis)
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78
Q

What is hepatic encephalopathy brought on by?

A

-disorders that affect the liver

79
Q

What is hepatic encephalopathy also known as?

A
  • portosystemic encephalopathy

- hepatic coma

80
Q

What may a patient with hepatic encephalopathy exhibit?

A
  • confusin
  • altered level of consciousness
  • coma
81
Q

What is hepatic encephalopathy a result of?

A

-liver failure

82
Q

What % of hepatic failure do drugs account for?

A

20-40%

83
Q

What is the outcome of drug toxicity?

A

-liver transplantation or death

84
Q

Why are alcoholic persons more susceptible to drug toxicity?

A

-alcohol induces liver injury and cirrhotic changes that alter drug metabolism

85
Q

Malignant Hepatic Neoplasms

A
  • hepatocellular carcinoma (HCC)
  • fibrolamellar carcinoma
  • hemangiosarcoma (angiosarcoma)
  • hepatic epithelial hemangioendothelioma
86
Q

HCC/Hepatoma

A

-one of the most common malignant tumors

mostly in men (5x more common)

87
Q

Cause of HCC/Hepatoma

A
  • alcoholic cirrhosis (west)
  • viral hep B and C (worldwide)
  • fatty liver, steatohepatitis, cirrhosis (west)
  • fungi, toxins in food (developing countries)
88
Q

Symptoms of HCC

A
  • RUQ pain
  • weight loss
  • abd swelling (ascites)
89
Q

Clinical Presentation of HCC

A

-often delated until tumor reaches an advanced stage

90
Q

3 Pathological Forms of HCC

A
  • solitary tumor
  • multiple nodules
  • diffuse infiltration
91
Q

What % of HCC cases cause invasion of PV?

A

30 to 60%

92
Q

Budd Chiari Syndrome

A

-HCC invading the hepatic venous system

93
Q

Sonographic Appearance of HCC

A
  • variable appearance
  • hypoechoic, complex or echogenic
  • thin, peripheral, hypoechoic halo fibrous capsule
94
Q

Appearance of Nodules with HCC

A
  • small (<5cm)

- hypoechoic solid tumor, without necrosis

95
Q

Is calcification common in HCC?

A

No.

96
Q

What is HCC indistinguishable from?

A
  • focal fat
  • hemangiomas
  • lipomas
97
Q

Other Testing for HCC

A
  • CEUS
  • CT
  • MRI
  • dopper
98
Q

Why might US not be the best for HCC?

A

-cannot distinguish between steatosis and hemangiomas

99
Q

What is fibrolamellar carcinoma a subtype of?

A

-HCC

100
Q

Who is fibrolamellar carcinoma found in?

A

-adolescents and young adults

101
Q

Fibrolamellar Carcinoma

A
  • without coexisting liver disease
  • advanced disease at diagnosis
  • alphafetoprotein levels are normal
  • surgical resection of tumor is recommended
102
Q

Echogenicity of Fibrolamella Carcinoma

A

-variable

103
Q

What distinguishes calcification of a fibrolamellar carcinoma from a hepatoma of HCC?

A

-central echogenic scar

104
Q

Hemangiosarcoma

A

-extremely rare malignant tumor

105
Q

Hepatic Epitheliod

A

-rare malignant tumor of vascular origin

106
Q

What age is hemangiosarcoma seen in?

A

-adults 60 to 70 years old

107
Q

Echogenicity of Hemangiosarcoma

A

-lg mass of mixed echogenicity

108
Q

What is hemangiosarcoma associated with?

A

-specific carcinogens

109
Q

Who does hepatic epithelial occur in?

A

-adults

110
Q

Where does hepatic epithelial occur and what does it create?

A
  • soft tissues (lung and liver)

- multiple hypoechoic nodules (lg masses)

111
Q

What the are the most common primary tumors resulting in liver metastases results of?

A
  • GB
  • colon
  • stomach
  • pancreas
  • breast
  • lung
112
Q

Blood Borne Routes for Metastatic Liver Disease

A
  • hepatic artery

- portal vein

113
Q

Lymphatic Spread of Metastatic Liver Disease

A
  • stomach
  • pancreas
  • ovary
  • uterus
114
Q

Where are tumor cells from the GI tract drained through?

A

-the portal system to the liver

115
Q

Sonographic Appearance of Mets

A
  • 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
Q

What metastatic diseases are echogenic?

A
  • 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
Q

What metastatic diseases are hypoechoic?

A
  • generally hypovascular
  • untreated breast, ling, gastric, pancreatic and esophageal cancer
  • breast
  • lung
  • lymphoma
  • esophagus
  • stomach
  • pancreas
118
Q

Lymphoma of Liver

A

-multiple hypoechoic masses

119
Q

Bull’s Eye or Target

A
  • typically seen with lung cancer
  • hypoechoic peripheral halo
  • non specific and common appearance
120
Q

Calcified Metastases

A
  • mucinous adenocarcinoma
  • osteogenic sarcoma
  • chomdrosarcoma
  • tetracarcinoma
  • neuroblastoma
121
Q

What is shadowing in the liver most often due to?

A

-calcifications, air, stones and fat containing lesions

122
Q

What is a clean shadow caused by?

A

-calcifications

123
Q

What is a dirty shadow caused by?

A

-air

124
Q

What is the most common cause of a calcified liver tumor?

A

-metastases

125
Q

Does FNH have calcifications?

A

-rarely

126
Q

Cystic Mets

A
  • necrosis sarcomas
  • cystadenocarcinoma of ovary and pancreas
  • mucinous carcinoma of colon
127
Q

What makes cystic metastases distinguishable from simple cysts?

A
  • mural nodules
  • thick walls
  • fluid
  • internal septations
  • extensive necrosis
128
Q

Are cystic metastases common?

A

No.

129
Q

What are infiltrative mets seen with?

A
  • breast
  • lung
  • malignant melanoma
130
Q

Infiltrative Metastatic Disease

A
  • 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
Q

Metastatic- Kaposi Sarcomas

A
  • neuroendocrine and carcinoid tumors
  • primary cystadenocarcinoma
  • mucinous carcinoma
132
Q

CEUS

A
  • involves the use of micro bubble contrast agents and specialized imaging techniques
  • tiny bubbles in an injectable gas
133
Q

What does CEUS play a major role in?

A

-detection of mets

134
Q

What does CEUS show?

A
  • sensitive blood flow

- tissue perfusion

135
Q

What determines vascularity in metastases?

A

CEUS

136
Q

What helps in a biopsy to establish the primary tissue site?

A

CEUS

137
Q

What does CEUS have similar results to?

A
  • CT

- MRI

138
Q

Benefits of CEUS

A
  • no ionizing radiation

- not nephrotoxic

139
Q

Causes of Hepatomegaly

A
  • liver trauma
  • passive liver congestion
  • hepatomegaly
140
Q

Aurora Sign (ring down artifact)

A
  • not in liver
  • caused by lung parenchymal disease
  • may be seen when scanning liver
141
Q

Hepatomegaly

A
  • enlargement of the liver

- frequent indication for sonography of liver

142
Q

With hepatomegaly, where can the physician feel the patients liver?

A

-can feel edge below rib cage

143
Q

Reidel’s Lobe

A
  • often mistaken for enlarged liver
  • found more often in women
  • tongue shaped process of the liver
  • normal varient
144
Q

Causes of Hepatomegaly

A
  • fatty liver
  • viral infections (hep A, B and C)
  • mononucleosis
  • hemochromatosis
  • primary liver cancer
  • leukemia
  • lymphoma
145
Q

Symptoms of Hepatomegaly

A
  • abd pain
  • swelling
  • feeling of fullness
  • jaundice
146
Q

Diagnostic Tests for Hepatomegaly

A
  • US
  • xray
  • CT
  • LFT’s
  • biopsy

**underlying cause must be treated

147
Q

What is initially performed after hepatic trauma (enlargement)?

A
  • abd CT

- US may be used fr serial monitoring

148
Q

Where in the liver does trauma usually occur?

A

-Rt lobe

149
Q

How does a fresh hemorrhage appear on US?

A

-echogenic

150
Q

After 1 week, how does a hemorrhage occur?

A

-hypoechoic

151
Q

After 2 to 3 weeks, how does a hemorrhage occur?

A

-indistict due to fluid resorption and granulation

152
Q

What is passive liver congestion caused by?

A

-stasis of the blood within liver parenchyma

153
Q

What does stasis of blood within liver parenchyma result in?

A
  • hepatic venous drainage is compromised

- common complication of congestive heart failure

154
Q

With passive liver congestion, where is central venous pressure transmitted from to go to the HV’s?

A

-Rt atrium

155
Q

How does the liver appear with passive liver congestion?

A
  • tensely swollen

- sinusoids dilate to accomodate back flow of blood

156
Q

Miscellaneous

A
  • portal venous gas

- lung parenchymal disease causing artifact seen when scanning liver

157
Q

Portal Venous Gas

A

-accumulation of gas in the peripheral portal venous system

158
Q

What is portal venous gas similar in appearance to?

A

-pnemobilia (air in bile ducts)

159
Q

What is portal venous gas in adults caused by?

A

GI Issues:

  • ischemic, necrotic, ulcerated bowel
  • colorectal carcinoma
  • inflammatory bowel disease
  • perforated peptic ulcer
160
Q

What are the 4 most common ways that pyogenic bacteria reaches the liver?

A

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
Q

What causes hepatic abscesses?

A
  • no cause in 50% of cases

- anaerobic (bacterial) infection

162
Q

What are the presenting features of a pyogenic liver abscess?

A
  • fever
  • malaise
  • anorexia
  • RUQ pain
  • jaundice
  • leukocytosis
163
Q

Is sonography helpful in detection of a hepatic abscess?

A

Yes.

164
Q

Sonographic Signs of Liver Abscess

A
  • 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
Q

Which fungal disease is usually common in patients who are immunosuppressed?

A

-candidiasis

166
Q

Which patients are immunosuppressed?

A
  • transplant pre and post
  • cancer
  • chemotherapy/radiation therapy
  • AIDS/HIV
  • inherited disease (blood disorders)
  • underlying systemic infection
  • poor nutrition
167
Q

What is amebiasis?

A

-hepatic infection

168
Q

What causes amebiasis?

A

-parasite (entamoeba histolytica)

169
Q

How is amebiasis transmitted?

A
  • fecal oral route

- penetrates through the colon via mesenteric venues, then to the portal vein and to liver

170
Q

Symptoms of Amebiasis

A
  • pain

- diarrhea (15%)

171
Q

Sono Appearance of Amebiasis

A
  • 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
Q

Treatment of Hydatid Disease

A
  • surgery

- US is used to monitor

173
Q

What is the most common parasitic infection in humans?

A

-schistosomiasis

174
Q

Schistosomiasis

A
  • most common parasite in humans
  • 4 different parasites
  • ova reach liver via PV
  • terminal PV branches become occluded
175
Q

What can schistosomiasis lead to?

A
  • portal hypertension
  • splenomegaly
  • varices
  • ascites ensues
176
Q

Sonographic Appearance of Schistosomiasis

A
  • 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
Q

Pneumocystis Carinii

A
  • most common organism causing opportunistic infection in patients with AIDS
  • patients undergoing bone marrow and organ transplants are at risk
178
Q

Pneumonia

A

-most common cause of life threatening infection

179
Q

Sono Appearance of Pneumocytstis Carinii

A

-tiny, diffuse, non shadowing, echogenic foci
OR
-extensive replacement of normal hepatic parenchyma by echogenic clumps of dense calcifications

180
Q

5 Incidentaloma’s

A
  • granulomas
  • cavernous hemangioma
  • FNH
  • adenoma
  • simple cyst
181
Q

Most Common Benign Tumor

A

-cavernous hemangioma

182
Q

2 Tumors Occurring with Hormone Influence

A
  • FNH

- adenoma

183
Q

Which benign tumor is a broken diaphragm a sign of?

A

-fatty tumor

184
Q

4 Complications of Viral Hepatitis

A
  • portal hypertension
  • cirrhosis
  • HCC
  • liver failure
185
Q

What is starry night sign associated with?

A

-acute viral hepatitis

186
Q

2 Complications of Chronic Hepatitis

A
  • hepatomegaly

- GB wall thickening

187
Q

What are 2 common causes of bacterial disease via the biliary tract?

A
  • cholangitis

- cholecystitis

188
Q

What is the most common complication of bacterial disease associated with fever and leukocytosis?

A

-abscess

189
Q

What sonographic sign could differentiate between hematoma and an abscess?

A
  • gas

- echogenic foci with ring down artifact OR posterior reverberation artifact

190
Q

Which fungal disease is most commonly associated with patients who are immunosuppressed?

A

-candidiasis

191
Q

Which parasitic infection is prevalent in sheep and cattle raising countries?

A

-hydatid disease

192
Q

What is the most common parasitic infection in humans?

A

-schistomiasis

193
Q

What is the distinguishing feature of schistosomiasis on US?

A

-widening and echogenic portal tracts

Term 2 (19 decks)

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