Chapter 2: The Liver Flashcards
1
Q
What is the gold standard imaging for the liver
A
CT first, then MRI
2
Q
What liver structures are not covered by the peritoneum
A
Bare area, falciform ligament, gallbladder fossa, porta hepatis, and area adjacent to IVC
3
Q
The liver is covered by the _____ capsule
A
Glisson
4
Q
What does the Couinaud classification do
A
Separates the love into 8 surgical segments
5
Q
The medial segment of the left lobe is also referred to as the _______ lobe
A
Quadrate
6
Q
What is the splanchnic circulation
A
Blood flow to the majority of GI organs.
Composed of celiac artery, SMA, IMA
7
Q
Which vessel provides the majority of flow to the liver
A
Main portal vein
8
Q
The main portal vein is created by the union of which two veins
A
SMV and splenic vein
9
Q
What is the portal splenic confluence
A
The place where the smv and splenic vein merge
10
Q
The portal vein provides the liver with what percentage of blood supply
A
75%
11
Q
Portal veins are considered ________ because they course within liver segments
A
Intrasegmental
12
Q
The main portal vein should measure less than ____ mm
A
13
13
Q
Hepatic veins are considered _________ and ________ because they are located between the segments and the lobes
A
Intersegmental and interlobar
14
Q
The hepatic veins are used to distinguish hepatic ______
A
Segments
15
Q
The hepatic veins ________ in size as they approach the diaphragm
A
Increase
16
Q
The hepatic artery has a ______ resistance blood blow
A
Low
17
Q
The Mickey sign is a transverse image of the
A
Porta hepatis
18
Q
The porta hepatis is composed of what three structures
A
MPV, CBD, and hepatic artery
19
Q
Enlargement of hepatic veins and IVC is seen with
A
Right sided heart failure
20
Q
Occlusion/ narrowing of the hepatic veins is seen with
A
Budd Chiari syndrome
21
Q
The right branch of the umbilical vein becomes
A
The ligamentum venosum
22
Q
The left branch of the umbilical vein becomes
A
The ligamentum teres
23
Q
Recanalization of the ligamentum teres indicates
A
Portal hypertension
24
Q
What is a diaphragmatic slip
A
Pseudomass of the liver resulting from hypertrophied diaphragmatic muscle bundles
25
What does a diaphragmatic slip look like on ultrasound
Hyperechoic strand extending from diaphragm into liver
26
What is the anatomic variant Riedel lobe
Tongue like extension of the right lobe
Most often seen in women
27
The anatomic variant “papillary process of the caudate lobe” can resemble a _____
Mass
28
And adult liver should measure between _____ and ____ cm
13-15
29
What are three indirect signs of hepatomegaly
Extension of right lobe below lower pole of kidney
Rounding of inferior tip of Rt lobe
Extension of left lobe into LUQ
30
Jaundice is caused by
Hyperbilirubinemia
31
Describe Unconjugated (indirect) bilirubin
Non water soluble bilirubin, Travels to the liver via bloodstream, then gets converted into conjugated bilirubin there
32
Describe conjugated (direct) bilirubin
Water soluble bilirubin, that exits the liver and its excreted into the intestines with bile
33
An increase in conjugated bilirubin is usually associated with
Gallstones or pancreatic mass
34
An increase in unconjugated bilirubin is usually associated with
Hepaticellular disease (hepatitis, cirrhosis)
35
Describe prehepatic jaundice
The liver cannot process the amount of hemolysis of RBCs, resulting in buildup of unconjugated bilirubin
36
Describe hepatic jaundice
The liver is not able to conjugate bilirubin or secrete it.
37
Describe posthepatic jaundice
Caused by an obstruction of bile flow, will cause elevated conjugated bilirubin
38
Posthepatic jaundice is also called
Obstructive jaundice
39
What does CEUS stand for
Contrast enhanced ultrasound
40
What is contrast enhanced ultrasound
Used to identify if a mass is benign by injecting contrast agent to identify lesions
(95% specifity)
41
What is a hepatoblastoma
Malignant pediatric liver tumor seen usually before age 5.
Most common malignant childhood tumor
42
There is a high incidence of hepatoblastoma in children with _____________ syndrome
Beckwith-wiedemann
43
What are the symptoms of hepatoblastoma
Asymptomatic a veces
Palpable abdominal mass and pain
Weight loss
Anorexia
Elevated AFP
Jaundice
Hepatomegaly
44
What does a hepatoblastoma look like in ultrasound
Solid hyperechoic or heterogenous mass that may contain calcifications
45
What is an infantile hemangioendothelioma
Most common benign liver childhood tumor, identified in the first few weeks or months of life
46
List the clinical and sonographic findings of hemangioendothelioma
Hepatomegaly, hemangiomas of the skin
Homogenous or complex mass that may contain calcifications or cysts
47
What is the most common vascular complication of a liver transplant
Hepatic artery thrombosis
48
Hepatic veins show ______ flow
Triphasic
49
Assessment of flow should be done at the _____ of respiration
End
50
The hepatic artery should have what type of waveform
Continuous low resistance waveform
51
What is the normal resistive index of hepatic artery
0.5 - 0.8
52
A TIPS stent is typically located between the __________and the ___________
Right portal vein, right hepatic vein
53
What patients usually need a TIPS stent
Pts with advanced cirrhosis and portal hypertension
54
Describe the function of a TIPS stent
Reduces the amount of flow to the liver by rerouting the blood coming from the portal vein to the hepatic vein
55
What is the primary goal of a TIPS stent
Prevent rupture and hemorrhage of gastroesophageal and other varices
56
What is the normal flow velocity within the stent
90-190 cm/s
57
What are some signs of TIPS failure
Thrombus, stenosis or stent, stenosis of hepatic veins, reversal flow and the hepatic veins, flow void, drop in stent velocity or too high of a flow
58
Flow in the right and left portal vein typically _______ after TIPS placement
Reverses
59
What primary cancers metastasize to the liver more often
Gallbladder, colon, stomach, pancreas, breast and lung
60
What is the most common liver cancer
Hepatocellular carcinoma (HCC)
61
What are the clinical findings of hepatic metastasis
Abnormal liver function tests,
Weight loss
Jaundice
RUQ pain
Hepatomegaly
Abdominal swelling with ascites
62
What are the sonographic findings of hepatic metastasis
Heterogenous liver, hyperechoic, hypoechoic, calcified, cystic or heterogenous masses
63
Hepatocellular carcinoma is most common in what gender
Men
64
What is a hepatoma
The malignant mass in Hepatocellular carcinoma
65
What is the tumor marker for Hepatocellular carcinoma
Alpha-fetoprotein (AFP)
66
What does Hepatocellular carcinoma look like
Solitary hypoechoic mass or
Heterogenous masses throughout the liver
Ascites
Mass with hyperechoic center
67
What are the clinical findings of Hepatocellular carcinoma
Elevated AFP
Abnormal liver function test
Cirrhosis
Chronic hepatitis
Weight loss
Hepatomegaly
Fever
Palpable mass
68
Hepatic steatosis is also called
Fatty liver disease
69
Describe fatty liver disease
Disorder characterized by fatty deposits (triglycerides) within the hepatocytes
70
Fatty liver disease can be alcoholic or ________
Non alcoholic
71
What are some causes of nonalcoholic fatty liver disease
Starvation, obesity, chemotherapy, diabetes, pregnancy, con fuerte disease, total parental hyperalimentation, severe hepatitis
72
Fatty liver disease is the hepatic manifestation of what disorder that can lead to steatohepatitis
Metabolic syndrome
73
What is steatohepatitis
Inflammation of the liver secondary to fatty liver disease
74
What are the symptoms of fatty liver disease
Often asymptomatic
Elevated liver function tests
75
Fatty liver can be diffuse or
Focal
76
Describe diffuse fatty infiltration
Liver will be diffusely echogenic and difficult to penetrate
No se puede ver bien the vessels and diaphragm
77
What does focal fatty infiltration look like
Area of increased echogenicity that can appear like a mass
78
What is focal fatty sparing
Diffuse fatty infiltration except for some areas that will look hypoechoic
79
Signs of sparing and fatty infiltration are often seen adjacent to ______
Gallbladder
80
Acute hepatitis is said to resolve within _______ months
4
81
Chronic hepatitis persists beyond _____ months
6
82
The two most common forms of hepatitis are
Hepatitis A and B
83
Briefly describe hepatitis A
Spread by fecal-oral route in contaminated food and water
84
Describe hepatitis B
Spread by contact with body fluids, mother to infant, blood contact
85
Describe hepatitis C
Spread by contact with body fluids
Leading indication of liver transplant in the US
86
Hepatitis may be triggered by systemic viruses like herpes or ______ virus
Epstein Barr
87
Chronic hepatitis can be caused by autoimmune disorders, Wilson disease, hemochromatosis or it can be _________ induced
Drug
88
What is Wilson disease
excessive accumulation of copper in the liver, brain and other tissues
89
What is hemochromatosis
Excessive iron
90
What are some symptoms of hepatitis
Fever, nausea, fatigue, hepatosplenomegaly, dark urine, HEPATIC (nonobstructive) jaundice, elevated liver function tests
91
Alanine aminotransferase (ALT) is a more specific indicator of _____
Hepatic injury
92
What is hepatic encephalopathy
A condition in which a patient becomes confused or suffers from loss of consciousness secondary to the brain being exposed to chemicals the liver would normally remove from the body
93
What is Kernicterus in newborns
Brain damage that occurs with sever jaundice
94
What does hepatitis look like on ultrasound
Might look normal at first. Then it shows hepatosplenomegaly.
Liver tends to become hypoechoic, periportal cuffing may be seen
95
What is the starry sky sign
Increased echogenicity of the walls of the portal triads (Periportal cuffing)
96
Define hepatic cirrhosis
Liver disorder defined as Hepatocyte death, liver fibrosis and necrosis that will cause regenerating nodules
97
What are common sequelas of cirrhosis
Portal hypertension, development of varocosities in the abdomen, portal vein thrombosis, splenomegaly, Hepatocellular carcinoma and hepatorenal syndrome
98
What is the most common cause of cirrhosis
Alcoholism (alcoholic liver disease)
99
How many grams of alcohol per week is considered significant consumption
210g in men
140g in women
100
What are some sonographic findings of cirrhosis
Echogenic small right love
Enlarged caudate and left love
Surface irregularity
Ascites
Splenomegaly
Monophasic hepatic veins
Hepatofugal portal veins
101
Cirrhosis caused by alcohol abuse will show micronodules measuring less than ____cm.
1cm
102
Cirrhosis caused by hepatitis will show macronodules that measure between ____ and ____ cm
1-5 cm
103
List clinical findings of cirrhosis and make sure you understand what they are
Son una PILA
Elevated AST, LDH, ALT and bilirubin
Jaundice
Fatigue
Weight loss
Diarrhea
Spider nevi
Púrpura
Palmar erythema
Gynecomastia
Fetor hepaticus
Facial telangiectasia
Hepatic encephalopathy
Caput Medusae
Muscle wasting
Testicular atrophy
Hemorrhoids
104
Pathway of liver disease:
Alcoholism -> ___________ ->steatohepatitis -> ________ -> portal hypertension -> _____________ -> HCC
Alcoholism, hepatic steatosis (fatty liver), steatohepatitis, cirrhosis, portal hypertension, portal vein thrombosis, HCC
105
What is liver fibrosis
Development of scar tissue within the liver as it attempts to repair itself
106
The stiffer the liver tissue the more ______ is present
Fibrosis
107
Stiffness is evaluated with what technique
Elastography
108
What type of elastography we use
Shear wave elastography
109
Define portal hypertension
Elevation of blood pressure within the portal venous system because el hígado se pone tan duro que la sangre pasa trabajo pa entrar
110
What is the most common cause of portal hypertension
Cirrhosis
111
With portal hypertension the hepatic artery will ______ and the flow in the portal vein will be ______
Enlarge
Hepatofugal
112
What can consequently develop within the abdomen as a result of the body’s attempt to repair itself by channeling blood away from the damaged liver
Portosystemic collaterals and varicosities
113
What is one of the most common collaterals found in portal hypertension
Recanalization of the paraumbilical vein
114
Define Cruveilhier Baumgarten syndrome
The umbilical vein (which is associated with left portal vein) reopens and shunts blood away from the liver into the inferior or superior epigastric veins
115
What are some clinical findings of portal hypertension
Abdominal varicosities near splenic and renal hilum, and gastroesophageal junction
Cirrhosis symptoms
116
Hematemesis is often present with portal hypertension and it’s a sign of rupture of ___________
Esophageal varices
117
With portal hypertension, the coronary vein (left gastric) will demonstrate what kind of flow and what does it measure
Flow toward the esophagus and measures greater than 6mm
118
What does TIPS stand for
Transjugular intrahepatic portosystemic shunt
119
Describe TIPS
Placement of a stent between the portal veins and hepatic veins to shunt blood and reduce portal systemic pressure
120
If cirrhosis is suspected, the tech should analyze the _______ vein for evidence of paraumbilical vein Recanalization
Left portal
121
Portal compression leads to portal vein obstruction and it’s caused by
Tumors from adjacent organs or lymphadenopathy
122
Portal vein thrombosis is seen in conditions such as
Hepatocellular carcinoma
Portal hypertension
Pancreatitis
Cholecystitis
Pregnancy
Surgery
123
When a thrombus completely occlude the portal vein, the development of ______ may occur
Collaterals
124
What is cavernous transformation of the portal vein when thrombosis is present
Mesh of tiny blood vessels in the area of the portal vein trying to shunt blood around the clot
125
What are the clinical findings of portal vein thrombosis
Pain, fever, leukocytosis, hypovolemia, elevated liver function tests, vomiting
126
Gas within the portal or mesenteric veins that results from ischemic bowel disease is typically ____
Fatal
127
Portal venous gas can be associated with bowel diseases and what kind of procedures
Invasive procedures that involve stent placement or endoscopic analysis of bowel
128
What does portal venous gas look like
Small bright reflectors noted within the circulating blood inside portal vein
129
What is budd chiari syndrome
Occlusion of the hepatic veins with possibly coexisting occlusion of IVC
130
Budd chiari syndrome can be seen secondary to IVC web which is what
Obstruction of hepatic segment of IVC
131
What are the clinical findings of Budd chiari syndrome
Oral contraception
Ascites, RUQ Pain, hepatomegaly, splenomegaly, elevated liver function tests
132
What are the sonographic findings of Budd chiari syndrome
Nonvizualization or reduced visualization of hepatic veins
Thrombus may be seen within them.
Enlarged caudate lobe
Absent flow in hepatic veins
Narrowed IVC
133
What is hepatorenal syndrome
Renal impairment and failure as a result of chronic liver disease and liver failure
134
What is a common cause for hepatorenal syndrome
Cirrhosis
135
What are the clinical findings of hepatorenal syndrome
Reduced glomerular filtration rate
Increased serum creatinine
Decrease urine output
136
What does hepatorenal syndrome look like
Normal kidneys
Liver findings are consistent with cirrhosis
137
True hepatic cysts are usually not encountered until middle age and they may be solitary and ____
Idiopathic
138
Hepatic cysts may be associated with what disease
autosomal dominant polycystic kidney disease (ADPKD)
139
Hepatic cysts associated with ADPKD have what characteristics
Asymptomatic, multiple irregular shape
140
Hepatic cysts may also be noted in patients with what disease
Von hippel Lindau disease
141
A hydatid liver cyst may also be called
Echinococcal cyst
142
Describe how hydatid cysts are developed
From a tapeworm parasite that lives in dog feces, si una oveja se come la caca de un perro y después te comes la oveja that’s how you get it
The parasite gets to the liver from the bowel through the portal vein
143
What are the clinical findings of hydatid cyst
Fever, RUQ tenderness, nausea, jaundice, leukocytosis and raise in alkaline phosphatase
144
What is the debris contained in a hydatid cyst called
Hydatid sand
145
What is the water lily sign (hydatid cyst)
Endocyst floating within the pericyst
146
A hydatid cyst may also look like one or more little cysts within a cyst, this is called
Mother and daughter cyst
147
What is an amebic hepatic abscess
Comes from a parasite that is in contaminated waters that grows in the colon and invades the liver via portal vein
148
Patients who present with amebic abscesses most likely did what recently
Traveled out of the country
149
What are clinical findings of amebic hepatic abscess
Hepatomegaly
RUQ pain
General malaise
Bloody diarrhea
Fever
150
What are laboratory findings related to amebic hepatic abscess
Leukocytosis, elevated liver function tests and mild anemia
151
What do amebic abscesses look like on ultrasound
Typically round, hypoechoic, anechoic, with debris and some posterior enhancement
152
Amebic abscesses are often noted in what part of the liver
Right lobe, near the capsule
153
What is schistosomiasis
Hematocrit infestation of schistoma (flatworm parasite)
154
Schistosomiasis is also called what two names
Snail fever
Bilharzia
155
____________ is said to be one of the most common causes of hepatic fibrosis
Schistosomiasis
156
How is Schistosomiasis transmitted
Though contaminated waters that contain snail parasite, then if you shower with that water te penetra el bicho en la piel
157
What are the symptoms of schistosomiasis
Fever
Hepatomegaly
Abdominal pain and bloody diarrhea
158
What does schistosomiasis look like on ultrasound
Bulls eye lesions that have anechoic center and hyperechoic rim
Periportal thickening
Turtle back sign can be seen in chronic cases. This is calcified septa and fibrosis resembling the turtles shell
159
Describe a pyogenic hepatic abscess
Results from infections like appendicitis diverticulitis etc spreading to the liver through portal triads
160
What are the symptoms of pyogenic abscesses
Fever, leukocytosis, abnormal liver function tests, RUQ pain, hepatomegaly
161
What does a pyogenic abscess look like on ultrasound
May appear as a complex cyst with thick walls, debris, septstions and or gas
162
What is hepatic candidiasis
The spread of Cándida fungus in the blood to the liver
Most common in immunocompromised people
163
What are the symptoms for hepatic candidiasis
RUQ pain, fever, hepatomegaly
164
What are the sonographic findings of candidiasis
Multiple hyperechoic masses with hypoechoic borders (bulls eye), less than 1cm big
165
What is the most common benign liver tumor
Cavernous hemangioma
166
Cavernous hemangiomas are most commonly seen in what gender
Female
167
What is the most common location for cavernous hemangioma
Right lobe of the liver
168
What does a cavernous hemangioma looks like
Small hyperechoic mass measuring less than 3cm. Posterior enhancement may be seen.
If they’re large they are called Giant hemangiomas
169
Cavernous hemangiomas are comprised of blood vessels, but what will color Doppler show?
No flow ni nada because the flow in those vessels is extremely slow
170
Hemangiomas can also look _______, which can be confused for metastatic liver disease
Hypoechoic
171
Focal nodular hyperplasia is most commonly seen in what gender
Female
172
Describe focal nodular hyperplasia
Second most common benign liver tumor composed of hepatocytes and fibrous tissue
173
What are the symptoms with focal nodular hyperplasia
Asymptomatic
174
Focal nodular hyperplasia is not caused by contraceptives but the use of it can make it worse. Why
The mass tends to be estrogen dependent so it grows with contraceptives
175
What does focal nodular hyperplasia look like on ultrasound
Could be hypo, hyper or isoechoic
Contains a central stellate (star like) scar that could be hypo or hyperechoic and hypervascular
176
Focal nodular hyperplasia is also called___________ because it’s difficult to see it most of the time
Stealth lesion
177
Hepatic adenomas are rare and benign. And they may be caused by ________ use
Contraceptive
178
What are other names for Hepatocellular adenoma
Hepatic adenoma or liver cell adenoma
179
What are the symptoms of Hepatocellular adenoma
Asymptomatic
Pain if hemorrhage occurs
180
What does a Hepatocellular adenoma look like
Mostly hypoechoic
It can also be hyper or isoechoic or mixed echogenicities
181
Describe hepatic lipoma quick
Rare, asymptomatic, hyperechoic mass
Ojalá todo fueran así nojoda
182
Describe a hepatic hematoma
Consequence of trauma or surgery. Can be intrahepatic or subcapsular
183
Describe the echogenicity of the hematoma as it ages
Echogenic at first
Then cystic or complex
184
When a subcapsular hematoma is anechoic it can be confused with
Ascites
185
Following trauma to the liver, what other connection can form
An arteriovenous fistula
