Liver Flashcards
What are the main 5 jobs of the Liver ?
Filter blood from the digestive tract
Detoxifies chemicals
Metabolizes drugs
Secretes Bile to the intestines
Makes proteins for clotting blood
What are the 3 lobs of the liver
Right, Left, and caudate.
What use to be referred to as the quadrate lobe and where is it located?
Misnomer. Medial aspect of the Left lobe.
The liver is divided based on what distribution?
Portal and hepatic.
What are the 3 order of PV branching
1 order: Right and Left portal branching
2 order: 4 parts (sectors) divided by 3 HV (longitudinally)
3 order: 8 segments (longitudinally and then transversely)
In the 1st order of PV branching the RT and LT hepatic lobes are divided by a plane between what?
IVC and GB. MHV, MPV
What are the names of the 4 sectors in the 2 order of PV branching?
Lateral, Medial, Anterior, and Posterior.
What segments are in the following sectors?
LT Lat, LT Med, RT Ant, RT Post?
Lt Lat: segment 2 (II) and 3 (III)
Lt Med: segment 4a (IV) and 4b (IV)
Rt Ant: segment 5 (V) and 8 (VIII)
RT post: segment 7 (VI) and 6 (VII)
What PV supplies the RT, Lt and Caudate lobe?
RT lobe is RT PV
LT lobe is LT PV
caudate lobe is both RT and LT PV
Where is the caudate located?
Posterior-superior surface of the liver b/t the IVC and the med LT lobe of the liver.
Where is the caudate lobe located specifically to the following. Ligamentum venosum, porta hepatis, IVC, and lesser sac?
Posterior Ligamentum venosum
Posterior to porta hepatis
Anterior and Medial to IVC
Lateral to lesser sac
What may be compressed if the caudate gets to be enlarged?
IVC
What is segment I
Caudate Lobe
What is segment II
LT Lat Superior
What is segment III
Lt Lat Inferior
What is segment IVa
LT Med Superior
What is segment IVb
LT Med Inferior
What is segment V
RT Ant Inferior
What is segment VI
RT Post Inferior
What is segment VII
RT Post Superior
What is segment VIII
RT Ant Superior
When imaging the liver and viewing the superior part of the liver (3 order branching) what segments would you see?
7,8,4a, 2
PICTURE
When imaging the liver and viewing the inforior part of the liver (3 order branching) what segments would you see?
6,5,4b, 3
PICTURE
Which order of liver division is the following
1st order
PICTURE
Which order of liver division is the following
2nd Order
PICTURE
Which order of liver division is the following
3rd Order
PICTURE
what view of the liver is this ?
Anterior view
PICTURE
What view of the liver is this ?
Inferior view
PICTURE
What are the INTERsegmental vessels?
Hepatic veins
What are the INTRAsegmental Vessels?
The vessels of the portal triad.
What are the difference between intersegmenal and intrasegmental vessels?
inter course between the lobes and segments
intra course to the center of each segment
What vessels of the liver have non-echogenic walls?
Hepatic veins
What vessels have hyperechoic walls?
Vessels of the portal triad
What makes the Portal triad have and hyperechoic wall?
They are encased by a fibrofatty sheath (Glisson’s capsule)
What are the portal triad vessles?
MPV, PHV,CBD.
Where is the main lobar fissure located?
Divides the RT and LT lobes of the liver, at the MHV and between the IVC and the GB fossa.
The main lobar fissure is located between what segments?
divides the anterior segment of the RT lobe and the medial segment of the LT lobe.
Where is the Right intersegment fissure located?
- landmarks
Divides the RT lobe into anterior and posterior
- RT HV
Where is the Left intersegment fissure located?
- landmarks
Divides the LT lobe into medial and lateral segments
- LT HV, ascending LPV, falciform ligament, ligament teres
Where is the ligamentum venosum fissure located?
Remnant of the ductus venosus
Separates the LT lobe and the Caudate lobe.
What is the Ligamentum Teres?
Remnant of the umbilical vein
What happens to the ligamentum Teres when a patient has hyertension?
The ligament recanalizes to form a portosystemic venous collateralat
What is the ligament venosum?
Remnant of the ductus venosus
What is is the direction of fetal circulation?
umbilical v ( liga Teres) -> LPV -> ductus venosus (Lliga venosum) -> IVC
What does hepatopetal and hepatofugal mean?
Hepatopetal flowing towards from the liver
Hepatofugal flowing away from the liver
What is the approx ml/min of hepatic blood flow?
-% of PHA
-% of PV
1500ml/min
25% PHA
75% PV
what is the % of of hepatic oxgyenation?
50% PHA
50% PV (PV o2 sat = 85%)
What is the upper limit of the MPV diameter?
13mm
What does a lager MPV diameter suggest?
Portal hypertension
What type of flow does the portal V have?
low velocity continuous flow
What type of flow does the hepatic V have?
Phasic: above and below baseline.
sometimes described as triphasic (reflecting atrial filling, contraction, and relaxation)
Where is the PHA located?
Runs parallel to the MPV
located anterior and to the left of the MPV 55%
What is a replaced RHA?
What is a replaced LHA?
RHA originates from the SMA. 11%
LHA originates from the gastric artery. 10%
Where is a replaced RHA seen?
Seen posterior to The head of the panc abd MPV
What is the PHA waveform
flow throughout diastolic flow. Low resistance
What does a high resistance PHA waveform suggest after a liver TX?
venous congestion of the liver or possible organ rejection
What does parvus tarus mean if seen in the PHA after a liver TX
Suggest proximal anastomotic stenosis
What is the falciform ligament
peritoneal reflection/fold created by the embryonic umbilc v from the umbilicus to the LPV
What is the coronary ligament
- is it apart of the peritoneal space?
peritoneal reflections which suspend the liver from the diaphragm
-No, not seen with ascites
What is the right and left triangular ligament
peritoneal reflections to the far right and left of the bare area
How big is a normal liver ?
15.5cm superior-inferior dimension
What is Riedels lobe?
inferior projection of the RT lobe
- commonly seen in women
- can be mistaken as hepatomegaly
Rank the following from HYPER to HYPO
- panc, spleen/liver, renal sinus, renal cortex
Renal sinus, panc, spleen/liver, renal cortex
What are small organized collection of macrophages that appear as calcifications in the liver and spleen?
granulomas
What are granulomas caused by?
Histoplasmosis and Tuberculosis
What is Histoplasmosis caused by
spores/fungus that float in the air from bird/bat droppings
- common in chicken coops, barns, and caves
What is Hepatitis?
Liver inflammation from an infection/noninfecting
- viral, bacterial, fungal, parasite
- medications, toxins, autoimmune disorders
What lab is elevated with Hepatitis?
Elevated ALT, AST conjugated and unconjugated bilirubin
How are the following hepatitis transmitted
- hepatitis A, hepatitis B, hepatitis C
hepatitis A (HAV) - fecal/oral
hepatitis B (HBV) - Blood/Body fluids
hepatitis C (HCV) - Blood/Body fluids - sharing needles
What does acute hepatitis look like ?
HYPO liver
Enlarge liver
HYPER PV walls
What does chronic hepatitis look like?
HYPER liver
Small liver
Decrease ECHO of PV walls
How does bacteria reach the liver
Bile ducts, PV, HA, or Lymphatics
What is the most common source of a pyogenic liver abscess?
Biliary tract disease
pyogenic liver abscess affected which lobe of the liver more?
Right more than left
2.1 factor
Sonographic findings:
complex mass, gas, reverberation artifact (air).
pyogenic abscess
Symptoms of a pyogenic abscess?
RUQ pain, leukocytosis (increase WBC), fever, elevated LFT
How would you confirm pyogenic abscess?
aspiration
What are the 3 major liver abscesses?
Pyogenic, amebic, fungal
What is amebic abscess due to ?
Entamoeba histolytica
What is fungal abscess due to ?
Candida species
How do you differentiate the difference between the pyogenic and amebic abscess
If travelled out of the USA more likely to be amebic
- almost exclusively in immigrants and travelers
How does amebic abscess form?
Parasite from the intestines reach the PV.
Which liver abscess is the most common extra intestinal complication?
Amoebic dysentery
Sonographic findings:
Round HYPO/ complex mass, RT dome of liver, and contiguous with the liver capsule?
Amebic abscess
Symptoms of Amebic abscess ?
RUQ pain, leukocytosis, fever, elevated LFT, Diarrhea
How can you get a fungal abscess?
Mycotic fungal infection of the blood that results in small abscesses
What are the type of appearances of fungal abscess?
Wheel within a wheel- early and most recognizable
bulls eye- center calcifies
uniformly hypoechoic focus- most common
echogenic focus- late process
What is echinococcal cyst from
Adult tapeworms
Sonographic findings:
cyst within a cyst or water-lily sign
Echinococcal cyst
What are laboratory studies for echinococcal cysts
Casoni skin test, detection of antibodies : indirect hemagglutination, enzyme-linked immunosorbent assay
What happens if a echinococcal cyst ruptures?
Rupture or aspiration is associated with anaphylactic shock
What is schistosomiasis?
Most common parasitic infection in humans
What does schistosomiasis cause?
- why
Portal hypertension
- eggs reach the liver via PV causing a granulomatous reaction resulting periportal fibrosis
What happens to the PV with schistosomiasis?
PV become occluded resulting in PV HTN
Sonographic findings:
occluded intrahepatic PV, Thicken PV walls
Schistosomiasis
What are secondary signs of Portal Hypertension?
Splenomegaly, Ascites, Esophageal variceal bleeding, portosystemic collaterals.
___ is the most common opportunistic infection associated with HIV
Tuberculosis TB
____ is a common herpes virus that is transmitted in body fluids: saliva, blood, urine, semen, breast milk
Cytomegalovirus
____ is common in HIV related fungal infection
it causes inflammation and a thick white coating on the mucus membranes of the mouth, tongue, esophagus, or vagina
Candidiasis
____ is a common central nervous system infection associated with HIV caused by fungus in the soil
Cryptococcal meningitis
____ is a infection caused by a parasite spread by mainly cats from their stool
Toxoplasmosis
___ is a infection caused by an intestinal parasite found in animals
Cryptosporidiosis
___ is a tumor of the blood vessels wall. appears pink, red, or purple lesions around the skin and mouth. it can also affect the digestive tract and lungs
Kaposi’s sarcoma
___ is an early sign of pain and swelling of the noes in your neck, armpit, and groin
Lymphomas
___ HIV associated nephropathy is an inflammation of the glomerulus
Kidney disease
What is the accumulation of triglycerides within the hepaticocytes
Fatty liver (steatosis)
Sonographic findings:
increase echogenicity of liver and decrease acoustic penetration
Fatty liver
What are the two patterns of fatty inflitration?
Focal fatty infiltration
focal fatty sparing
What is focal fatty infiltration ?
Focal areas of increase echogenicity within NL liver parenchyma commonly around Porta hepatis
What is focal fatty sparing?
Focal area of NL liver parenchyma within a fatty liver
commonly around GB**, Porta hepatis, caudate, and liver margins
What is Glycogen Storage Disease (GSD)
Genetically acquired disorder that results in excess deposition of glycogen in the liver
What is von gierke’s disease
GSD type 1A a defected in the enzyme glucose 6 phosphate
___ is a diffuse process of fibrosis and distortion of normal liver architecture
Cirrhosis
What can cause cirrhosis ?
Hep B, Hep c, Alcoholic liver dz, NAFLD, NASH,
Autoimmune hep
Prim Billiary cirrhosis
Prim Sclerosing cholangitis
Hemochromatosis
Wilson dz***
drug liver dz
Budd-chaiari
RT heart failure
ABNL LFT include
AST, ALT, GGT, LDH, conjugated bilirubin
Sonographic finding:
Enlarge caudate lobe, surface nodularity, fatty infiltration, change to PV hypertension
Cirrhosis
What is normal Portal hypertension?
5 to 10 mmhg
What is the major cause of portal hypertension?
cirrhosis
What arties rupture with esophageal varices
RT and LT gastric (coronary) veins that are branches of the Portal veins
What are clinical signs of cirrhosis
hematemeis, encephalopathy, caput medusa ( dilated abd wall veins)
How do you lower portal pressure
SHUNTS
portacaval, spelnorenal/linton, dist splenorenal/ warren, TIPS
What are the portal systemic collaterals
Gastroesophageal varices
Splenorenal varices
Intestinal varices
Rectal Varices
Recanalized umbilical vein
What are gastroesophageal varices and where does it drain into?
Left gastric vein (AKA coron. ary vein) that drains both gastric walls
portal vein and communicates with the lower esophageal veins
What is the recanalized umbilical vein and where does it drain?
re opening of the umbilical v. (liga teres)
LPV to epigastric to IVC
What are splenorenal varices ?
tortuous veins around the spleen and left renal hilum
What are intestinal varices?
retroperitoneal veins from the colon, duodenum, and panc.
What are rectal varices (hemorrhoids)
IMV drains into rectal veins
What are signs of collaterals?
Dilated veins on Ant ABD wall
Caput Medusa
Hemorrhoids
Ascites
What does Caput Medusa mean?
Tortuous collaterals around the umbilicus
What does TIPS mean
Transjugular Intrahepatic Portal systemic Shunting
How often should you evaluate a TIPS?
6m intervals
With a TIPS which direction should the following be
RPV, LPV, MPV
RPV and LPV hepatofugal flow
MPV hepatopetal flow
What is a low and high velocity of a TIPS?
low <50cm/sec
high >190cm/sec
With a TIPS what would the flow direction be of the LPV if the patient has a patent umbilical vein?
either hepatofugal or hepatopetal
What does a TIPS look like after the first 3-5 days after placement and why?
shadow with no flow
the PTFE retains air after placement
What is a TIPS made of ?
GORE Viatorr endoprothesis - wire PTFE or polytetrafluorethylene
What is an indication for a liver TX in adults and children ?
Adults - Cirrhosis Hep C
Children- Biliary atresia
What do you evaluate in a liver TX
Biliary tree
PV, HA, HV, IVC
collaterals
Fluid collection (Hematoma/Biloma)
What is MELD used for and what is included ?
Model for End-Stage Liver Disease
bilirubin, creatine, INR
What is cavernous transformation of the portal vein?
Wormlike venous collaterals that run along the PV
(d/t PV thrombosis)
Sonographic Findings:
HYPO area in PV
increase PV diameter
cavernous transformation
PV collaterals
PV thrombosis
What are the tumoral causes of PV thrombosis ?
HCC
METS
Panc Carcinoma
What are the non tumoral causes of PV thrombosis?
Pancreatitis
Cirrhosis
Inflammatory bowel dz
Trauma
Splenoectomy
Hypercoagulation
Portal lymphadenopathy
What is Budd-chiarai syndrome?
HV outflow obstruction with possible IVC involvement
With Budd-Chiari with happens to the RT, LT and caudate lobes of the liver?
RT and LT become atrophy
Caudate lobe becomes enlarged d/t emissary veins
What intrahepatic portal vein gas due to in infants?
necrotizing entercolitis
What is portal vein gas/ pneumatosis intestinalis?
air is noted within the intrahepatic portal veins
Sonographic Findings:
Anechoic, thin walled, acoustic enhancment
Simple cyst
What is a cyst with internal echos accompanied by RUQ and decrease hematocrit?
Hemorrhagic cyst
What is the most common benign tumor of the liver
Cavernous hemangioma
Sonographic Findings:
In the Liver a hyperechoic area with posterior enhancement
can enlarge with pregnancy/ admin of estrogen
hemangioma
What is a benign solid liver mass and to believed to be a hyperplastic lesion rather than a true neoplasm ?
Focal Nodular Hyperplasia
Sonographic Findings:
In the Liver solid mass with varying echogenicity, solitary lesion, CENTRAL FIBROUS SCAR
Focal Nodular Hyperplasia
What is known as a Stealth lesion?
Focal Nodular Hyperplasia
What liver mass is strongly associated with women using oral contraceptive pills or on estrogen?
Hepatic Adenoma
Hepatic Adenoma are associated with what disease?
Glycogen storage disease
What is the recommended treatment for Hepatic Adenoma ?
Surgical resection D/t risk of malignant transformation
What are extremely rare fatty tumors
Hepatic Lipoma
Sonographic Findings:
In the liver a Hyperechoic mass is seen with propagation speed artifact
Hepatic Lipoma
What is propagation speed artifact?
- what happens to the ultrasound image?
Decrease speed of sound in fat (1450 m/s)
- objects posterior to the fatty mass will be displaced further away. Can look like a broken diaphragm.
What are a list of Hyperechoic hepatic masses?
Hepatic Lipoma
Hemangioma
Echogenic Mets
Focal Fatty Infiltration
What is the most common primary malignancy of the liver
Hepatocellular Carcinoma HCC
HCC occurs in ___% of patients with Cirrhosis?
10-15%
Sonographic Findings:
In the liver a HYPOechoic mass seen around PV, HV, or IVC.
HCC
What lab values are increase with HCC ?
Alpha fetoprotein
AST (SGOT)
ALT (SGPT)
Why do Mets like to live in the liver ?
Dual blood supply and the sinusoidal endothelium allows met cells to be trapped
What are the sonographic patterns of the following Mets
Gastrointestinal Tract
Lymphoma
Lung
Mucinous Adenocarcinoma of the colon
Leiomyosarcoma
Gastrointestinal Tract- Hyper mets
Lymphoma- Hypo mets
Lung- Bulls eye or target mets
Mucinous Adenocarcinoma of the colon- Calcified mets
Leiomyosarcoma- Cystic mets
What is needed to diagnosis metastaic lover disease ?
Ultrasound guided biopsy
What is the most popular metastaic cancer?
Lung with 156,000
What malignant liver neoplasm occurs in infants and children (the first 2 years of age)
Hepatoblastoma
Hepatoblastoma is associated with what genetic conditions?
Beckwith-Wiedemann syndrome
Familial Adenomatous Polyposis
What is a benign INFANTILE vascular tumor that is located on the liver and is usually diagnosed in the 1st few months of life?
Infantile hemangioendothelioma
Infantile hemangioendothelioma can become life threatening due to
CHF, and or consumptive thrombocytopenia and coagulopathy
What is elastography assessment of liver fibrosis?
METAVIR Meta analysis of histological data in viral hepatitis
The liver uses ____ to metabolize amino acids and to make protein.
Aminotransferases (transaminases)
When the liver is damage it does what to enzymes?
Spill AST and ALT into the blood stream
What is AST and what is it AKA?
Asparate Aminotransferases
SGOT: Serum glutamic oxaloacetic transaminases
Where is AST found?
brain, skeletal muscle, heart, liver, kidney
AN increase in AST withOUT ALT is seen with what?
myocardial infarction**
heart failure, muscle injury, CNS dz
What is ALT and what is its AKA
Alanine Aminotransferases
SGPT: serm glutamic pyruvic transaminases
Is AST or ALT more specific for liver disease?
ALT
If AST and LDH are increased but ALT is normal what does that mean for liver disease?
It rules out liver disease
What is GGT?
Gamma Glutamyl Transpeptidase
What does elevated GGT mean ?
Hepatocellular disease and Biliary Obstruction
What does the following mean
Increase GGT + increase ALP= ?
Increase GGT + increase ALT=?
Biliary Obstruction
Hepatocelluar disease
What does LDH mean ?
Lactic Dehydrogenase
LDH is mostly assessed with what cancer?
Testicular cancer
What is AFP
- when does it decrease ?
Alpha fetoprotein
- 1st year of life
What is an elevated AFP mean ?
HCC
Germ cell tumors
Mets liver cancer
Hepatoblastoma
Platelets contribute to _____
Hemostatsis
Low platelet concentration is _____
Thrombocytopenia
Elevated platelet concentration is _____
Thrombocytosis
____ and ___ are used to help diagnose the cause of unexplained bleeding or inappropriate blood clots
Prothrombin time (PT)
Partial thromboplastin time PPT)
What is the reference rang for PT ?
12-13 seconds
what is the INR in absence of anticoagulant therapy range?
0.8-1.2
What is the INR in anticoagulant use range?
2 -3
What is monitored prior to an invasive procedure to insure proper clotting ?
PT (INR) and PTT
What is tumor marker CA 19-9
Lung
Pancreatic
Cholangiocarcinoma
Gastrointestinal
Colorectal
What is tumor marker HCG?
Germcell tumor and testicular
What is tumor marker PSA?
Prostate specific antigen
prostate cancer
What is tumor marker CEA?
Carcinoembryonic antigen
Thyroid, Esophageal, Lung
Breast, Bile, bladder
Gastrointestinal, Colorectal, Uterine
