Chapter 2 The Liver Flashcards
_____ describes the transverse image taken of the porta hepatis
Mickey sign
The ____ carries oxygenated blood to the liver from the abdominal aorta
Common hepatic artery
The porta hepatis may also be referred to as
Liver Hilum
Scanning after a meal will often demonstrate an increase in
Portal vein flow
Normal flow within the portal veins should be:
Hepatopetal and monophasic
Enlargement of the portal veins is often indicative of
Portal hypertension
The blood within the portal vein is partially oxygenated because it is derived from the:
Intestines
The ______ provides the liver with approximately 75% of its total blood supply
Portal vein
The main portal vein is created by the union of the
SMV & Splenic vein
The main portal vein enters the liver at the _______
Porta hepatis (liver hilum)
The ______ has its own separate blood supply and venous drainage, it’s the smallest hepatic lobe
Caudate lobe
The ______ is used to separate the liver into eight surgical segments
Couinaud system
The liver is covered by _____, a thin fibrous casing
Glisson capsule
The left lobe of the liver is located;
Within the epigastrium and may transverse the midline and extend into the left hypochondrium
The right lobe of the liver is located
RUQ
______ is the largest parenchymal organ in the body
Liver
In early embryonic life, the liver is responsible for:
Hemopoiesis
E. Granulosus is associated with
Hydatid liver cyst
The childhood syndrome beckwith-weidermann is associated with an increased risk for developing:
Hepatoblastoma
Clinical findings of hepatocellular carcinoma (3):
- Elevated AFP
- Abnormal liver function test (LFTs)
- Cirrhosis
______ is considered the most common benign childhood hepatic mass
Infantile Hemangioendothelioma
_____ is often associated with the use of oral contraceptives
Hepatic adenoma
_____ is the most common form of liver cancer
Metastatic liver disease
Normal flow toward the liver in the portal veins is termed
Hepatopetal
Common sequela of cirrhosis includes:
- Portal hypertension
- Varicosities in abdomen
- Portal vein thrombosis
- Splenomegaly
- HCC
What form of hepatic abnormality are immunocompromised patients more prone to develop?
Candidiasis
Clinical findings of hepatitis (9):
- Chills
- Dark urine
- Elevated LFTs
- Fatigue
- Fever
- Hepatosplenomegaly
- Jaundice
- Nausea
- Vomiting
The most common cause of cirrhosis:
Cirrhosis
Sonographically, when the liver is difficult to penetrate and diffusely echogenic, this is indicative of?
Fatty liver disease
Shortly after birth, the ductus venosus collapse and becomes the:
Ligamentum venosum
Clinical findings of fatty liver disease;
Elevated LFTs
(No symptoms)
____ is the leading indication for liver transplantation in the U.S.A
Hepatitis C
The inferior extension of the caudate lobe is referred to as:
Papillary process
Normal flow within the hepatic veins is said to be:
Triphasic
The left umbilical vein after birth becomes the:
Ligamentum teres
The left portal vein divides into:
Medial and lateral branches
A tongue like extension of the right lobe of the liver is termed:
Riedel lobe
Buds-chiari syndrome leads to a reduction in the size of:
Hepatic veins
Normal flow within the hepatic artery should demonstrate a:
Low-resistance wave form pattern, with a quick upstroke and gradual deceleration with diastole
_______ have brighter walls that the hepatic veins
Portal veins
The right lobe of the liver can be divided into:
Anterior and posterior segments
The diameter of the portal vein should not exceed:
13mm
The right portal vein divides into:
Anterior and posterior branches
The TIPS shunt is placed:
Between a portal vein and hepatic vein
The right lobe of the liver is divided into segments by the:
Right hepatic vein
The right Intersegmental fissure contains the:
Right hepatic vein
The main portal vein divides into:
Left and right branches
The Ligamentum teres can be used to separate the:
Medial and lateral segments of the left lobe
The main lobar tissue contains the:
Middle hepatic vein
What are the three structures located within the porta hepatis
•main portal vein
•CBD
•hepatic artery
Right sided heart failure often leads to enlargement of the:
IVC and hepatic veins
The right lobe can be divided into an anterior and posterior segment by the:
Right hepatic vein
Where does the right hepatic vein lie:
Within the right intersegmental fissure
The right lobe can be separated from the left lobe by the:
Middle hepatic vein
Where does the middle hepatic vein lie:
Within the main lobar fissure
The caudate lobe can be separated from the left lobe by the:
Ligamentum venosum
As the main portal vein enters the liver it splits into the:
Right and left portal veins
The hepatic veins drain into the:
IVC
The _____ veins increase in size as they approach the diaphragm
Hepatic
______ have a triphasic blood flow pattern
Hepatic veins
Occlusion or narrowing of the hepatic veins is seen with:
Budd-chiari syndrome
In utero, the umbilical vein supplies the fetus with:
Oxygenated blood
The umbilical vein travels to the liver and bifurcates into a:
Left and right branche
_____ shunts blood directly into the fetal IVC
Ductus venosum (right branch)
The Ligamentum teres ascends along the:
Falciforme ligament
The Ligamentum venosum can be seen:
Anterior to the caudate lobe
The falciform ligament in transverse can be seen between the:
Left and right hepatic lobes
Riedel lobe is most often seen in:
Women
Riedel lobe may extend inferiorly as far as the:
Iliac crest
The normal liver is:
Homogeneous
The liver is slightly less echogenic than the:
Spleen
When compared with the pancreas, the liver is slightly
Less echogenic
The liver measures approximately
13 - 15cm
Fatty liver disease is also known as:
Hepatic steatosis
_____ is acquired and reversible
Nonalcoholic fatty liver disease
The cause of nonalcoholic fatty liver disease include (6):
- starvation
- obesity
- chemotherapy
- diabetes mellitus
- hyperlipidemia
- pregnancy
Metabolic syndrome can lead to:
Steatohepatitis
Focal fatty infiltration and focal fatty sparing can occur in:
The same place
The signs of sparing and infiltration are seen:
near the porta hepatis and the left medial segment
____ is said to resolve within 4 months
Acute hepatitis
_____ persists beyond 6 months
Chronic hepatitis
The left lobe of the liver can be divided into
Medial and lateral segments
The thin fibrous casing of the liver is the
Glisson capsule
The hepatic veins are considered intersegmental and interlobar because they are:
Located between the segments and the lobes
Shortly after birth, the ductus venosus collapses and becomes the:
Ligamentum venosum
The left umbilical vein connects directly to the:
Left portal vein
After birth the left umbilical vein becomes a fibrous cord known as the:
Ligamentum Teres (round ligament)
Ligamentum Teres is potentially identifiable with sonography within the:
Lower margins of the falciform ligament
_____ can be described as a tongue like extension of the right hepatic lobe
Riedel lobe
To differentiate Riedel lobe from hepatomegaly, one could exam the:
Left lobe for coexisting enlargement
The patient should fast for a period of _____ if the entire RUQ is to be evaluated
8 hours
The echogencity of the liver is either equal to or slightly greater than the parenchyma of the:
Right kidney
Hepatomegaly is often suspected if the liver measures greater than _____ in the midhepatic line
15.5cm
______is a disorder characterized by fatty deposits (triglycerides) within the hepatocytes
Fatty liver
______ has been cited as the most common liver disorder in the western world
Nonalcoholic fatty liver disease
Fatty liver disease is also the hepatic manifestation of a disorder known as
Metabolic syndrome
______ is inflammation of the liver disease leading to FIBROSIS, cirrhosis, and hepatocellular carcinoma
Steatohepatitis
_____ will cause the liver to appear diffusely echogenic and it will be more difficult to penetrate
Diffuse infiltration
Clinical findings of fatty liver disease:
Elevated LFTs
____ is inflammation of the liver, which can ultimately lead to cirrhosis, portal hypertension and HCC
Hepatitis
A benign liver mass composed of a combination of hepatocytes and fibrous tissue that typically contains a central scar
Focal nodular hyperplasia
The left lobe of the liver can be separated from the right lobe by the
Middle hepatic vein
______ is typically transmitted through contaminated water found in places such as Mexico, Central America, South America, Asia, India, and Africa
Amebic liver abscess
An abscess that develops from a parasite that grows in the colon and invades the liver via the portal vein
Amebic hepatic abscess
____ is the largest lobe in the liver
Right hepatic lobe
The only part of the liver not covered by peritoneum
Bare area
Where is the liver measurement taken at:
Right mid clavicular line
The liver measurement is done:
Cranial to caudal
The left lobe of the liver is best imaged:
Midline inferior to the xiphoid
Cirrhosis caused by hepatitis will lead to the development of
Macronodule (>1cm)
Cirrhosis caused by alcoholism will lead to the development of:
Larger nodules that measure less than 1cm
Sonographic findings of cirrhosis include (4):
- Echogenic, small right lobe
- Enlarged caudate
- Nodular surface irregularity
- Ascites
Cirrhosis can also be caused by
•Wilson disease
•primary biliary cirrhosis
•hepatitis
•cholangitis
•hemochromatosis
Common sequela of cirrhosis includes (3):
- Portal hypertension
- Portal vein thrombosis
- HCC
_____ is a liver disorder that is defined as hepatocyte death, fibrosis and necrosis of the liver and the subsequent development of regenerating nodules
Cirrhosis
In the presence of hepatitis the gallbladder wall may be
Thickened
Sonographically the periportal cuffing is known as:
“Starry sky” sign
_____ is an increase in the echogencity of the walls of the portal triads
Periportal cuffing
As the liver enlarges, it tends to become
More hypoechoic
Bilirubin exposure in newborns is also known as
Kernicterus
In newborns, brain damage can occur with severe jaundice as a result of:
Bilirubin exposure
Jaundice related hepatitis is known as
Nonobstructive Jaundice
_____ relates to hepatitis is on a cellular level and is not associated with biliary obstruction
Jaundice
_____ is characterized by disproportionate absorption of dietary iron
Hemochromatosis
Chronic hepatitis can be caused by (4):
- Wilson disease
- Hemochromatosis
- Autoimmune disorder
- Drug induced
Hepatitis may be triggered by reactions to systemic viruses such as:
•HSV
•Epstein-Barr virus
_____ is the leading indication for liver transplantation in the United States
Hepatitis C
Hepatitis C is spread by contact with
•blood
•body fluid
Hepatitis B is spread by contact with:
•contaminated body fluid
•mother to infant
•inadvertent blood contact
Hepatitis A is spread by
Fecal-oral route in contaminated water or food
The two most common forms are hepatitis:
•A
•B
List all the forms of hepatitis:
•A
•B
•C
•D
•E
•G
_____ causes the body to accumulate excess copper
Wilson disease
The posterior surface of the right lobe of the liver are marked by three fossae:
•the porta hepatis
•the gallbladder
•IVC
The right lobe of the liver occupies the
Right hypochondrium
With portal hypertension the coronary vein will demonstrate abnormal flow toward the ________ and will measure ________
*Esophagus
*Greater than 6mm
In some individuals, the normal coronary vein can be seen arising from:
Splenic vein and extending superiorly toward the left
Coronary vein AKA:
Left gastric vein
Sonographic evidence of enlargement and reversed flow within the ________ may be seen with portal hypertension
Coronary vein
With portal hypertension, the umbilical vein becomes open again and shunts blood away from the liver and into:
epigastric veins
Abdominal varicosities may be noted near the (3):
- Splenic hilum
- Renal hilum
- Gastroesophageal junction
The umbilical vein is associated with :
•left portal vein
•Ligamentum Teres
•falciform ligament
The stiffer the liver the more _____
Fibrosis present
Possible Doppler findings in patients with cirrhosis include (2):
- Monophasic flow within the hepatic veins
- Hepatofungal flow within the portal veins
_____ is the elevation of blood pressure within the portal venous system
Portal hypertension
The most common cause of portal hypertension is:
Cirrhosis
Normal flow towards the liver within the portal veins is termed ______
Hepatopetal
With ______ the liver becomes fibrotic or scarred and more difficult to perfuse
Cirrhosis
With cirrhosis, the blood traveling into the main portal vein meets ______
Greater vascular resistance
Thrombus can completely _____ the portal vein
Occlude
Portal vein thrombosis is seen in conditions such as (7):
- HCC
- Portal hypertension
- Pancreatitis
- Cholecystitis
- Pregnancy
- Oral contraceptives
- Surgery
______ is the development of clots within the portal vein
Portal vein thrombosis
_____ is most commonly caused by tumors from adjacent organs or lymphadenopathy
Portal vein compression
Portal vein compression, which subsequently leads to ______
Portal vein obstruction
Surgically placed shunts include
• Portocaval shunt
•splenorenal shunts
•mesocaval shunt
______ may be placed to reduce the likelihood of complications resulting from portal hypertension
Surgical shunts
_____ is an ominous sign of ruptured esophageal varices because it markedly increased mortality and morbidity
Hematemesis
Budd-chiari syndrome will cause _____ of the IVC
Narrowing
______ may also appear as a cyst within a cyst
Hydatid cyst
Hydatid cyst debris is referred to as
Hydatid sand
Hydatid cyst may appear as an
Anechoic mass containing some debris
______ moves from the bowel through the portal vein to enter the liver
Echinococcus grandulosus
_____ is a tapeworm that lives in dog feces
Echinococcus grandulosus
Hydatid liver cysts develop most commonly from a parasite referred to as
Echinococcus grandulosus
A Hydatid liver cyst is also known as
Echinococcal cyst
Clinical findings of hepatic cysts (4):
- Asymptomatic
- Possible normal LFTs
- ADPKD
- Hemorrhagic or large cysts may cause RUQ pain
When pain occurs because of hepatic cysts, it may be due to
•hemorrhage
•infection
•secondary to mass effect
Hepatic cysts are often associated with
Autosomal dominant polycystic kidney disease (ADPKD)
True hepatic cysts are usually not encountered until
Middle age
Sonographic findings of Budd-Chianti syndrome (5):
- Nonvisualization/reduce visualization of the hepatic vein
- Thrombus within the hepatic veins
- Enlarged caudate lobe
- Narrowing of the IVC
- Lack of flow in the hepatic veins
Sonographic findings of hepatic cysts (3):
- Anechoic mass(es) with posterior enhancement
- May have irregular shape
- Clusters of cysts May be noted
Sonographic findings of hydatid liver cysts (4):
- Anechoic mass containing some debris (hydatid sand)
- ”Water lily” sign
- Mass May contain calcifications
- “Mother/daughter” cyst
Amebic abscesses are mostly found in the:
Right lobes of the liver near the capsule
With time, thrombus will become more _______ and_______within the portal vein
•echogenic
•noticeable
The ______of the portal veins will appear as wormlike or serpiginous vessels within the region of the portal vein
Cavernous transformation
______ can also be the result of tumor invasion within the portal vein
Portal occlusion
_____within the portal veins or mesenteric veins that result from ischemic bowel disease is typically fatal
Gas
Portal venous gas Can be confused with ______
Pneumobilia
_____ is air located within the biliary ducts
Pneumobilia
Portosystemic collaterals and varicosities can develop within the abdomen as a result of body’s attempt to repair itself by:
channeling blood away from the damaged liver
With greater vascular resistance the pressure within the_______increases resulting in portal hypertension
Portal veins
The flow within the portal vein can eventually become reversed this is termed
Hepatofugal
Shunting of the blood toward the esophagus increases the risk for ______
Esophageal hemorrhage and death
Hepatofugal flow is _____ and _____
•irregular
•Stagnant
Along with hepatofugal flow, the portal vein diameter will exceed ______in the anterior dimension and the SMV will exceed ______
•13mm
•10mm
Hepatofugal flow increases the patients likelihood of developing:
Portal vein thrombosis
Clinical features of portal hypertension often mimic_____
Cirrhosis
Clinical findings of focal nodular hyperplasia
Asymptomatic
Focal nodular hyperplasia is composed of a combination of:
Hepatocytes and fibrous tissue
Clinical findings of a cavernous hemangioma (1);
Asymptomatic
Sonographic findings of a cavernous hemangioma (2):
- Small, hyperechoic mass
- In the right lobe
The most common benign liver tumor is the
Cavernous hemangioma
Cavernous hemangioma measures
Less than 3cm but some are larger
______can result from the spread of infection from inflammatory conditions
Pyogenic hepatic abscess
_____ results from the spread of fungus, namely Candida albicans, in the blood to the liver
Hepatic candidiasis
Clinical findings of hepatic candidiasis (5):
- Immunocompromised patients
- RUQ pain
- Fever
- Leukocytosis
- Infection symptoms
Sonographic findings of a hepatocellular adenoma (2):
- HYPOECHOIC
- May be hyperechoic, isoechoic, or be comprised of mixed echogenicities
Clinical findings of a hepatocellular adenoma (3):
- Asymptomatic
- Oral contraceptives use
- Pain occurs with hemorrhage
Sonographic findings of hepatic lipoma
Hyperechoic mass
Clinical findings of hepatic lipoma (1):
- Asymptomatic
Sonographic findings of hepatic hematoma (liver bruise) 3:
- Fresh clot may appear hyperechoic
- Older hemorrhage can appear anechoic or complex
- May be intrahepatic or subcapsular
The 8 ligaments of the liver are:
• coronary ligament
•right triangular ligament
•left triangular ligament
•falciform ligament
•Ligamentum Teres
•Ligamentum venosum
•gastrohepatic ligament
•hepatoduodebal ligament
_____ can appear solid or complex depending on their age
Hematomas
Clinical findings of hepatic hematoma (4):
- Trauma
- Recent surgery
- Pain
- Decreased hematocrit
The _____ will yield a hypoechoic rim, with the center of the mass often isoechoic to normal liver tissue
Target lesion
Sonographic findings of hepatocellular carcinoma (3):
- Solitary, hypoechoic mass
- Heterogeneous masses scattered throughout the liver
- ”Target” or “bulls-eye” ascites
HCC is most often seen in?
Men and frequently accompanied by cirrhosis or chronic hepatitis
Diffuse metastasis Can produce an appearance of a nodular liver termed
Pseudocirrhosis
Clinical findings of hepatic metastasis (6):
- Abnormal LFTs
- Weight loss
- Jaundice
- RUQ pain
- Hepatomegaly
- Abdominal swelling with ascites
Metastatic cancer from the gastrointestinal tract and pancreas tends to be _____
Calcified tumors
Clinical findings hepatocellular carcinoma (9):
- Elevated AFP
- Abnormal LFTs
- Cirrhosis
- Chronic hepatitis
- weight loss
- Hepatomegaly
- Fever
- Palpable mass
- Ascites
Sonographic findings of hepatic metastasis (4):
- Hyperechoic, hypoechoic calcified cystic or heterogeneous masses
- Mass demonstrating a hypoechoic rim and central echogenic region
- Diffusely heterogeneous liver
- Possible ascites
_____ is the most common form of liver cancer
Metastatic liver disease
What is the most common vascular complication of a liver transplantation
Hepatic artery thrombosis
Sonographic findings of infantile hemangioendothelioma (2):
- Homogeneous or complex hepatic mass
- Calcifications or cystic spaces
Sonographic findings of Hepatoblastoma (2):
- Solid, hyperechoic or heterogeneous mass
- Mass may contain some calcifications
Clinical findings of Hepatoblastoma (malignant) 8:
- May be asymptomatic
- Palpable abdominal mass
- Hepatomegaly
- Abdominal pain
- Weight loss
- Anorexia
- Elevated AFP
- Jaundice
There is a high incidence of Hepatoblastoma in children who have
Beckwith-wie-demann syndrome
_____are most often discovered before age 5, with half of the cases identified in children less than 2 years old
Hepatoblastoma
Sonographic findings of a pyogenic hepatic abscess (3):
- Complex cyst with thick walls
- Debris, septations and/or gas
- Air may produce dirty shadowing/ring down artifact
Clinical findings of a pyogenic hepatic abscess (5):
- Fever
- Hepatomegaly
- Leukocytosis
- Abnormal LFTs
- RUQ pain
Clinical findings of hydatid liver cysts (6):
- Leukocytosis
- fever
- jaundice
- Pain
- Infection symptoms
- Recently traveled abroad
Lab findings of amebic hepatic abscess (3):
- Leukocytosis
- Elevated LFTs
- Mild anemia
Clinical findings of an amebic hepatic abscess
- Hepatomegaly
- Pain
- General malaise
- Diarrhea
- Fever
- Leukocytosis
- Elevated LFTs
- Traveled abroad
Cyst rupture could lead to:
Anaphylactic shock
_____ comes from the parasite entamoeba histolytica that grows in the colon and invades the liver via the portal vein
Amebic hepatic abscess
_____ is described as the occlusion of the hepatic veins, with possible coexisting occlusion of the IVC
Budd-chiari syndrome
_____ involves the placement of a stent between the portal veins and hepatic veins to shunt blood and reduce portal systemic pressure
TIPS
_____ correlates with cirrhosis complications including variceal hemorrhage, ascites and HCC. All signs of advance cirrhosis and portal hypertension
Liver stiffness
One of the most common sonographically identifiable collaterals in portal hypertension is the recanalization of the
Paraumbilical vein
If ascites is not present with cirrhosis, a _______ can be used to analyze the liver surface for surface nodularity or lumps
High-frequency linear transducer
Focal nodular hyperplasia has been referred to as a?
“Stealth lesion” because it may be difficult to identify
Focal nodular hyperplasia typically contains a _______ that is not always detected with sonography but is readily identified with CT and MRI
Central stellate (star-like) scar
Budd-chiari syndrome can be seen secondary to (7):
- Congenital webbing disorder
- Coagulation abnormalities
- Tumor invasion from HCC
- Thrombosis
- Oral contraceptives
- Pregnancy
- Trauma
Clinical symptoms of budd-chiari syndrome when found in females on oral contraceptives include (4):
- Ascites
- RUQ pain
- Hepatomegaly
- Splenomegaly
Clinical findings of budd-chiari syndrome (5):
- Ascites
- Elevated LFTs
- Hepatomegaly
- Splenomegaly
- Upper abdominal pain
Patients with portal hypertension will have many of the same sonographic findings as cirrhosis including
•ascites
•splenomegaly
•portal vascular and shunting abnormalities
•development of collaterals channels
Sonographic findings of focal nodular hyperplasia (2):
- Isoechoic to liver
- Central scar will have hypervascularity
Sonographic findings of hepatic candidiasis (3):
- Multiple masses with hyperechoic central portions and hypoechoic boarders “target”, “halo”, or “bullseye”
- Typically 1cm or smaller
- Older lesions may calcify
Sonographic findings of an amebic hepatic abscess (3):
- Round, hypoechoic / anechoic mass
- May contain debris (with fluid debris layering)
- Anechoic enhancement
_____ are typically identified in the first few weeks or months of life
Infantile hemangioendothelioma
Clinical findings of infantile hemangioendothelioma (3):
- Pediatric patient
- May cause hepatomegaly
- May be accompanied by hemangiomas
_____ is the most common benign liver childhood tumor
Infantile hemangioendothelioma
