Chapter 2: The Liver Flashcards
What is the gold standard imaging for the liver
CT first, then MRI
What liver structures are not covered by the peritoneum
Bare area, falciform ligament, gallbladder fossa, porta hepatis, and area adjacent to IVC
The liver is covered by the _____ capsule
Glisson
What does the Couinaud classification do
Separates the love into 8 surgical segments
The medial segment of the left lobe is also referred to as the _______ lobe
Quadrate
What is the splanchnic circulation
Blood flow to the majority of GI organs.
Composed of celiac artery, SMA, IMA
Which vessel provides the majority of flow to the liver
Main portal vein
The main portal vein is created by the union of which two veins
SMV and splenic vein
What is the portal splenic confluence
The place where the smv and splenic vein merge
The portal vein provides the liver with what percentage of blood supply
75%
Portal veins are considered ________ because they course within liver segments
Intrasegmental
The main portal vein should measure less than ____ mm
13
Hepatic veins are considered _________ and ________ because they are located between the segments and the lobes
Intersegmental and interlobar
The hepatic veins are used to distinguish hepatic ______
Segments
The hepatic veins ________ in size as they approach the diaphragm
Increase
The hepatic artery has a ______ resistance blood blow
Low
The Mickey sign is a transverse image of the
Porta hepatis
The porta hepatis is composed of what three structures
MPV, CBD, and hepatic artery
Enlargement of hepatic veins and IVC is seen with
Right sided heart failure
Occlusion/ narrowing of the hepatic veins is seen with
Budd Chiari syndrome
The right branch of the umbilical vein becomes
The ligamentum venosum
The left branch of the umbilical vein becomes
The ligamentum teres
Recanalization of the ligamentum teres indicates
Portal hypertension
What is a diaphragmatic slip
Pseudomass of the liver resulting from hypertrophied diaphragmatic muscle bundles
What does a diaphragmatic slip look like on ultrasound
Hyperechoic strand extending from diaphragm into liver
What is the anatomic variant Riedel lobe
Tongue like extension of the right lobe
Most often seen in women
The anatomic variant “papillary process of the caudate lobe” can resemble a _____
Mass
And adult liver should measure between _____ and ____ cm
13-15
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
Jaundice is caused by
Hyperbilirubinemia
Describe Unconjugated (indirect) bilirubin
Non water soluble bilirubin, Travels to the liver via bloodstream, then gets converted into conjugated bilirubin there
Describe conjugated (direct) bilirubin
Water soluble bilirubin, that exits the liver and its excreted into the intestines with bile
An increase in conjugated bilirubin is usually associated with
Gallstones or pancreatic mass
An increase in unconjugated bilirubin is usually associated with
Hepaticellular disease (hepatitis, cirrhosis)
Describe prehepatic jaundice
The liver cannot process the amount of hemolysis of RBCs, resulting in buildup of unconjugated bilirubin
Describe hepatic jaundice
The liver is not able to conjugate bilirubin or secrete it.
Describe posthepatic jaundice
Caused by an obstruction of bile flow, will cause elevated conjugated bilirubin
Posthepatic jaundice is also called
Obstructive jaundice
What does CEUS stand for
Contrast enhanced ultrasound
What is contrast enhanced ultrasound
Used to identify if a mass is benign by injecting contrast agent to identify lesions
(95% specifity)
What is a hepatoblastoma
Malignant pediatric liver tumor seen usually before age 5.
Most common malignant childhood tumor
There is a high incidence of hepatoblastoma in children with _____________ syndrome
Beckwith-wiedemann
What are the symptoms of hepatoblastoma
Asymptomatic a veces
Palpable abdominal mass and pain
Weight loss
Anorexia
Elevated AFP
Jaundice
Hepatomegaly
What does a hepatoblastoma look like in ultrasound
Solid hyperechoic or heterogenous mass that may contain calcifications
What is an infantile hemangioendothelioma
Most common benign liver childhood tumor, identified in the first few weeks or months of life
List the clinical and sonographic findings of hemangioendothelioma
Hepatomegaly, hemangiomas of the skin
Homogenous or complex mass that may contain calcifications or cysts
What is the most common vascular complication of a liver transplant
Hepatic artery thrombosis
Hepatic veins show ______ flow
Triphasic
Assessment of flow should be done at the _____ of respiration
End
The hepatic artery should have what type of waveform
Continuous low resistance waveform
What is the normal resistive index of hepatic artery
0.5 - 0.8
A TIPS stent is typically located between the __________and the ___________
Right portal vein, right hepatic vein
What patients usually need a TIPS stent
Pts with advanced cirrhosis and portal hypertension
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
What is the primary goal of a TIPS stent
Prevent rupture and hemorrhage of gastroesophageal and other varices
What is the normal flow velocity within the stent
90-190 cm/s
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
Flow in the right and left portal vein typically _______ after TIPS placement
Reverses
What primary cancers metastasize to the liver more often
Gallbladder, colon, stomach, pancreas, breast and lung
What is the most common liver cancer
Hepatocellular carcinoma (HCC)
What are the clinical findings of hepatic metastasis
Abnormal liver function tests,
Weight loss
Jaundice
RUQ pain
Hepatomegaly
Abdominal swelling with ascites
What are the sonographic findings of hepatic metastasis
Heterogenous liver, hyperechoic, hypoechoic, calcified, cystic or heterogenous masses
Hepatocellular carcinoma is most common in what gender
Men
What is a hepatoma
The malignant mass in Hepatocellular carcinoma
What is the tumor marker for Hepatocellular carcinoma
Alpha-fetoprotein (AFP)
What does Hepatocellular carcinoma look like
Solitary hypoechoic mass or
Heterogenous masses throughout the liver
Ascites
Mass with hyperechoic center
What are the clinical findings of Hepatocellular carcinoma
Elevated AFP
Abnormal liver function test
Cirrhosis
Chronic hepatitis
Weight loss
Hepatomegaly
Fever
Palpable mass
Hepatic steatosis is also called
Fatty liver disease
Describe fatty liver disease
Disorder characterized by fatty deposits (triglycerides) within the hepatocytes
Fatty liver disease can be alcoholic or ________
Non alcoholic
What are some causes of nonalcoholic fatty liver disease
Starvation, obesity, chemotherapy, diabetes, pregnancy, con fuerte disease, total parental hyperalimentation, severe hepatitis
Fatty liver disease is the hepatic manifestation of what disorder that can lead to steatohepatitis
Metabolic syndrome
What is steatohepatitis
Inflammation of the liver secondary to fatty liver disease
What are the symptoms of fatty liver disease
Often asymptomatic
Elevated liver function tests
Fatty liver can be diffuse or
Focal
Describe diffuse fatty infiltration
Liver will be diffusely echogenic and difficult to penetrate
No se puede ver bien the vessels and diaphragm
What does focal fatty infiltration look like
Area of increased echogenicity that can appear like a mass
What is focal fatty sparing
Diffuse fatty infiltration except for some areas that will look hypoechoic
Signs of sparing and fatty infiltration are often seen adjacent to ______
Gallbladder
Acute hepatitis is said to resolve within _______ months
4
Chronic hepatitis persists beyond _____ months
6
The two most common forms of hepatitis are
Hepatitis A and B
Briefly describe hepatitis A
Spread by fecal-oral route in contaminated food and water
Describe hepatitis B
Spread by contact with body fluids, mother to infant, blood contact
Describe hepatitis C
Spread by contact with body fluids
Leading indication of liver transplant in the US
Hepatitis may be triggered by systemic viruses like herpes or ______ virus
Epstein Barr
Chronic hepatitis can be caused by autoimmune disorders, Wilson disease, hemochromatosis or it can be _________ induced
Drug
What is Wilson disease
excessive accumulation of copper in the liver, brain and other tissues
What is hemochromatosis
Excessive iron
What are some symptoms of hepatitis
Fever, nausea, fatigue, hepatosplenomegaly, dark urine, HEPATIC (nonobstructive) jaundice, elevated liver function tests
Alanine aminotransferase (ALT) is a more specific indicator of _____
Hepatic injury
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
What is Kernicterus in newborns
Brain damage that occurs with sever jaundice
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
What is the starry sky sign
Increased echogenicity of the walls of the portal triads (Periportal cuffing)
Define hepatic cirrhosis
Liver disorder defined as Hepatocyte death, liver fibrosis and necrosis that will cause regenerating nodules
What are common sequelas of cirrhosis
Portal hypertension, development of varocosities in the abdomen, portal vein thrombosis, splenomegaly, Hepatocellular carcinoma and hepatorenal syndrome
What is the most common cause of cirrhosis
Alcoholism (alcoholic liver disease)
How many grams of alcohol per week is considered significant consumption
210g in men
140g in women
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
Cirrhosis caused by alcohol abuse will show micronodules measuring less than ____cm.
1cm
Cirrhosis caused by hepatitis will show macronodules that measure between ____ and ____ cm
1-5 cm
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
Pathway of liver disease:
Alcoholism -> ___________ ->steatohepatitis -> ________ -> portal hypertension -> _____________ -> HCC
Alcoholism, hepatic steatosis (fatty liver), steatohepatitis, cirrhosis, portal hypertension, portal vein thrombosis, HCC
What is liver fibrosis
Development of scar tissue within the liver as it attempts to repair itself
The stiffer the liver tissue the more ______ is present
Fibrosis
Stiffness is evaluated with what technique
Elastography
What type of elastography we use
Shear wave elastography
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
What is the most common cause of portal hypertension
Cirrhosis
With portal hypertension the hepatic artery will ______ and the flow in the portal vein will be ______
Enlarge
Hepatofugal
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
What is one of the most common collaterals found in portal hypertension
Recanalization of the paraumbilical vein
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
What are some clinical findings of portal hypertension
Abdominal varicosities near splenic and renal hilum, and gastroesophageal junction
Cirrhosis symptoms
Hematemesis is often present with portal hypertension and it’s a sign of rupture of ___________
Esophageal varices
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
What does TIPS stand for
Transjugular intrahepatic portosystemic shunt
Describe TIPS
Placement of a stent between the portal veins and hepatic veins to shunt blood and reduce portal systemic pressure
If cirrhosis is suspected, the tech should analyze the _______ vein for evidence of paraumbilical vein Recanalization
Left portal
Portal compression leads to portal vein obstruction and it’s caused by
Tumors from adjacent organs or lymphadenopathy
Portal vein thrombosis is seen in conditions such as
Hepatocellular carcinoma
Portal hypertension
Pancreatitis
Cholecystitis
Pregnancy
Surgery
When a thrombus completely occlude the portal vein, the development of ______ may occur
Collaterals
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
What are the clinical findings of portal vein thrombosis
Pain, fever, leukocytosis, hypovolemia, elevated liver function tests, vomiting
Gas within the portal or mesenteric veins that results from ischemic bowel disease is typically ____
Fatal
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
What does portal venous gas look like
Small bright reflectors noted within the circulating blood inside portal vein
What is budd chiari syndrome
Occlusion of the hepatic veins with possibly coexisting occlusion of IVC
Budd chiari syndrome can be seen secondary to IVC web which is what
Obstruction of hepatic segment of IVC
What are the clinical findings of Budd chiari syndrome
Oral contraception
Ascites, RUQ Pain, hepatomegaly, splenomegaly, elevated liver function tests
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
What is hepatorenal syndrome
Renal impairment and failure as a result of chronic liver disease and liver failure
What is a common cause for hepatorenal syndrome
Cirrhosis
What are the clinical findings of hepatorenal syndrome
Reduced glomerular filtration rate
Increased serum creatinine
Decrease urine output
What does hepatorenal syndrome look like
Normal kidneys
Liver findings are consistent with cirrhosis
True hepatic cysts are usually not encountered until middle age and they may be solitary and ____
Idiopathic
Hepatic cysts may be associated with what disease
autosomal dominant polycystic kidney disease (ADPKD)
Hepatic cysts associated with ADPKD have what characteristics
Asymptomatic, multiple irregular shape
Hepatic cysts may also be noted in patients with what disease
Von hippel Lindau disease
A hydatid liver cyst may also be called
Echinococcal cyst
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
What are the clinical findings of hydatid cyst
Fever, RUQ tenderness, nausea, jaundice, leukocytosis and raise in alkaline phosphatase
What is the debris contained in a hydatid cyst called
Hydatid sand
What is the water lily sign (hydatid cyst)
Endocyst floating within the pericyst
A hydatid cyst may also look like one or more little cysts within a cyst, this is called
Mother and daughter cyst
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
Patients who present with amebic abscesses most likely did what recently
Traveled out of the country
What are clinical findings of amebic hepatic abscess
Hepatomegaly
RUQ pain
General malaise
Bloody diarrhea
Fever
What are laboratory findings related to amebic hepatic abscess
Leukocytosis, elevated liver function tests and mild anemia
What do amebic abscesses look like on ultrasound
Typically round, hypoechoic, anechoic, with debris and some posterior enhancement
Amebic abscesses are often noted in what part of the liver
Right lobe, near the capsule
What is schistosomiasis
Hematocrit infestation of schistoma (flatworm parasite)
Schistosomiasis is also called what two names
Snail fever
Bilharzia
____________ is said to be one of the most common causes of hepatic fibrosis
Schistosomiasis
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
What are the symptoms of schistosomiasis
Fever
Hepatomegaly
Abdominal pain and bloody diarrhea
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
Describe a pyogenic hepatic abscess
Results from infections like appendicitis diverticulitis etc spreading to the liver through portal triads
What are the symptoms of pyogenic abscesses
Fever, leukocytosis, abnormal liver function tests, RUQ pain, hepatomegaly
What does a pyogenic abscess look like on ultrasound
May appear as a complex cyst with thick walls, debris, septstions and or gas
What is hepatic candidiasis
The spread of Cándida fungus in the blood to the liver
Most common in immunocompromised people
What are the symptoms for hepatic candidiasis
RUQ pain, fever, hepatomegaly
What are the sonographic findings of candidiasis
Multiple hyperechoic masses with hypoechoic borders (bulls eye), less than 1cm big
What is the most common benign liver tumor
Cavernous hemangioma
Cavernous hemangiomas are most commonly seen in what gender
Female
What is the most common location for cavernous hemangioma
Right lobe of the liver
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
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
Hemangiomas can also look _______, which can be confused for metastatic liver disease
Hypoechoic
Focal nodular hyperplasia is most commonly seen in what gender
Female
Describe focal nodular hyperplasia
Second most common benign liver tumor composed of hepatocytes and fibrous tissue
What are the symptoms with focal nodular hyperplasia
Asymptomatic
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
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
Focal nodular hyperplasia is also called___________ because it’s difficult to see it most of the time
Stealth lesion
Hepatic adenomas are rare and benign. And they may be caused by ________ use
Contraceptive
What are other names for Hepatocellular adenoma
Hepatic adenoma or liver cell adenoma
What are the symptoms of Hepatocellular adenoma
Asymptomatic
Pain if hemorrhage occurs
What does a Hepatocellular adenoma look like
Mostly hypoechoic
It can also be hyper or isoechoic or mixed echogenicities
Describe hepatic lipoma quick
Rare, asymptomatic, hyperechoic mass
Ojalá todo fueran así nojoda
Describe a hepatic hematoma
Consequence of trauma or surgery. Can be intrahepatic or subcapsular
Describe the echogenicity of the hematoma as it ages
Echogenic at first
Then cystic or complex
When a subcapsular hematoma is anechoic it can be confused with
Ascites
Following trauma to the liver, what other connection can form
An arteriovenous fistula
