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Abdominal Sonography > Liver > Flashcards

Liver Flashcards

1
Q

What are the main 5 jobs of the Liver ?

A

Filter blood from the digestive tract
Detoxifies chemicals
Metabolizes drugs
Secretes Bile to the intestines
Makes proteins for clotting blood

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2
Q

What are the 3 lobs of the liver

A

Right, Left, and caudate.

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3
Q

What use to be referred to as the quadrate lobe and where is it located?

A

Misnomer. Medial aspect of the Left lobe.

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4
Q

The liver is divided based on what distribution?

A

Portal and hepatic.

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5
Q

What are the 3 order of PV branching

A

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)

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6
Q

In the 1st order of PV branching the RT and LT hepatic lobes are divided by a plane between what?

A

IVC and GB. MHV, MPV

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7
Q

What are the names of the 4 sectors in the 2 order of PV branching?

A

Lateral, Medial, Anterior, and Posterior.

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8
Q

What segments are in the following sectors?
LT Lat, LT Med, RT Ant, RT Post?

A

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)

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9
Q

What PV supplies the RT, Lt and Caudate lobe?

A

RT lobe is RT PV
LT lobe is LT PV
caudate lobe is both RT and LT PV

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10
Q

Where is the caudate located?

A

Posterior-superior surface of the liver b/t the IVC and the med LT lobe of the liver.

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11
Q

Where is the caudate lobe located specifically to the following. Ligamentum venosum, porta hepatis, IVC, and lesser sac?

A

Posterior Ligamentum venosum
Posterior to porta hepatis
Anterior and Medial to IVC
Lateral to lesser sac

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12
Q

What may be compressed if the caudate gets to be enlarged?

A

IVC

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13
Q

What is segment I

A

Caudate Lobe

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14
Q

What is segment II

A

LT Lat Superior

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15
Q

What is segment III

A

Lt Lat Inferior

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16
Q

What is segment IVa

A

LT Med Superior

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17
Q

What is segment IVb

A

LT Med Inferior

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18
Q

What is segment V

A

RT Ant Inferior

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19
Q

What is segment VI

A

RT Post Inferior

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20
Q

What is segment VII

A

RT Post Superior

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21
Q

What is segment VIII

A

RT Ant Superior

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22
Q

When imaging the liver and viewing the superior part of the liver (3 order branching) what segments would you see?

A

7,8,4a, 2
PICTURE

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23
Q

When imaging the liver and viewing the inforior part of the liver (3 order branching) what segments would you see?

A

6,5,4b, 3
PICTURE

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24
Q

Which order of liver division is the following

A

1st order
PICTURE

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25
Q

Which order of liver division is the following

A

2nd Order
PICTURE

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26
Q

Which order of liver division is the following

A

3rd Order
PICTURE

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27
Q

what view of the liver is this ?

A

Anterior view
PICTURE

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28
Q

What view of the liver is this ?

A

Inferior view
PICTURE

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29
Q

What are the INTERsegmental vessels?

A

Hepatic veins

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30
Q

What are the INTRAsegmental Vessels?

A

The vessels of the portal triad.

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31
Q

What are the difference between intersegmenal and intrasegmental vessels?

A

inter course between the lobes and segments
intra course to the center of each segment

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32
Q

What vessels of the liver have non-echogenic walls?

A

Hepatic veins

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33
Q

What vessels have hyperechoic walls?

A

Vessels of the portal triad

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34
Q

What makes the Portal triad have and hyperechoic wall?

A

They are encased by a fibrofatty sheath (Glisson’s capsule)

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35
Q

What are the portal triad vessles?

A

MPV, PHV,CBD.

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36
Q

Where is the main lobar fissure located?

A

Divides the RT and LT lobes of the liver, at the MHV and between the IVC and the GB fossa.

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37
Q

The main lobar fissure is located between what segments?

A

divides the anterior segment of the RT lobe and the medial segment of the LT lobe.

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38
Q

Where is the Right intersegment fissure located?
- landmarks

A

Divides the RT lobe into anterior and posterior
- RT HV

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39
Q

Where is the Left intersegment fissure located?
- landmarks

A

Divides the LT lobe into medial and lateral segments
- LT HV, ascending LPV, falciform ligament, ligament teres

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40
Q

Where is the ligamentum venosum fissure located?

A

Remnant of the ductus venosus
Separates the LT lobe and the Caudate lobe.

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41
Q

What is the Ligamentum Teres?

A

Remnant of the umbilical vein

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42
Q

What happens to the ligamentum Teres when a patient has hyertension?

A

The ligament recanalizes to form a portosystemic venous collateralat

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43
Q

What is the ligament venosum?

A

Remnant of the ductus venosus

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44
Q

What is is the direction of fetal circulation?

A

umbilical v ( liga Teres) -> LPV -> ductus venosus (Lliga venosum) -> IVC

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45
Q

What does hepatopetal and hepatofugal mean?

A

Hepatopetal flowing towards from the liver
Hepatofugal flowing away from the liver

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46
Q

What is the approx ml/min of hepatic blood flow?
-% of PHA
-% of PV

A

1500ml/min
25% PHA
75% PV

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47
Q

what is the % of of hepatic oxgyenation?

A

50% PHA
50% PV (PV o2 sat = 85%)

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48
Q

What is the upper limit of the MPV diameter?

A

13mm

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49
Q

What does a lager MPV diameter suggest?

A

Portal hypertension

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50
Q

What type of flow does the portal V have?

A

low velocity continuous flow

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51
Q

What type of flow does the hepatic V have?

A

Phasic: above and below baseline.
sometimes described as triphasic (reflecting atrial filling, contraction, and relaxation)

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52
Q

Where is the PHA located?

A

Runs parallel to the MPV
located anterior and to the left of the MPV 55%

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53
Q

What is a replaced RHA?
What is a replaced LHA?

A

RHA originates from the SMA. 11%
LHA originates from the gastric artery. 10%

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54
Q

Where is a replaced RHA seen?

A

Seen posterior to The head of the panc abd MPV

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55
Q

What is the PHA waveform

A

flow throughout diastolic flow. Low resistance

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56
Q

What does a high resistance PHA waveform suggest after a liver TX?

A

venous congestion of the liver or possible organ rejection

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57
Q

What does parvus tarus mean if seen in the PHA after a liver TX

A

Suggest proximal anastomotic stenosis

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58
Q

What is the falciform ligament

A

peritoneal reflection/fold created by the embryonic umbilc v from the umbilicus to the LPV

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59
Q

What is the coronary ligament
- is it apart of the peritoneal space?

A

peritoneal reflections which suspend the liver from the diaphragm
-No, not seen with ascites

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60
Q

What is the right and left triangular ligament

A

peritoneal reflections to the far right and left of the bare area

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61
Q

How big is a normal liver ?

A

15.5cm superior-inferior dimension

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62
Q

What is Riedels lobe?

A

inferior projection of the RT lobe
- commonly seen in women
- can be mistaken as hepatomegaly

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63
Q

Rank the following from HYPER to HYPO
- panc, spleen/liver, renal sinus, renal cortex

A

Renal sinus, panc, spleen/liver, renal cortex

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64
Q

What are small organized collection of macrophages that appear as calcifications in the liver and spleen?

A

granulomas

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65
Q

What are granulomas caused by?

A

Histoplasmosis and Tuberculosis

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66
Q

What is Histoplasmosis caused by

A

spores/fungus that float in the air from bird/bat droppings
- common in chicken coops, barns, and caves

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67
Q

What is Hepatitis?

A

Liver inflammation from an infection/noninfecting
- viral, bacterial, fungal, parasite
- medications, toxins, autoimmune disorders

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68
Q

What lab is elevated with Hepatitis?

A

Elevated ALT, AST conjugated and unconjugated bilirubin

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69
Q

How are the following hepatitis transmitted
- hepatitis A, hepatitis B, hepatitis C

A

hepatitis A (HAV) - fecal/oral
hepatitis B (HBV) - Blood/Body fluids
hepatitis C (HCV) - Blood/Body fluids - sharing needles

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70
Q

What does acute hepatitis look like ?

A

HYPO liver
Enlarge liver
HYPER PV walls

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71
Q

What does chronic hepatitis look like?

A

HYPER liver
Small liver
Decrease ECHO of PV walls

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72
Q

How does bacteria reach the liver

A

Bile ducts, PV, HA, or Lymphatics

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73
Q

What is the most common source of a pyogenic liver abscess?

A

Biliary tract disease

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74
Q

pyogenic liver abscess affected which lobe of the liver more?

A

Right more than left
2.1 factor

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75
Q

Sonographic findings:
complex mass, gas, reverberation artifact (air).

A

pyogenic abscess

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76
Q

Symptoms of a pyogenic abscess?

A

RUQ pain, leukocytosis (increase WBC), fever, elevated LFT

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77
Q

How would you confirm pyogenic abscess?

A

aspiration

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78
Q

What are the 3 major liver abscesses?

A

Pyogenic, amebic, fungal

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79
Q

What is amebic abscess due to ?

A

Entamoeba histolytica

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80
Q

What is fungal abscess due to ?

A

Candida species

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81
Q

How do you differentiate the difference between the pyogenic and amebic abscess

A

If travelled out of the USA more likely to be amebic
- almost exclusively in immigrants and travelers

82
Q

How does amebic abscess form?

A

Parasite from the intestines reach the PV.

83
Q

Which liver abscess is the most common extra intestinal complication?

A

Amoebic dysentery

84
Q

Sonographic findings:
Round HYPO/ complex mass, RT dome of liver, and contiguous with the liver capsule?

A

Amebic abscess

85
Q

Symptoms of Amebic abscess ?

A

RUQ pain, leukocytosis, fever, elevated LFT, Diarrhea

86
Q

How can you get a fungal abscess?

A

Mycotic fungal infection of the blood that results in small abscesses

87
Q

What are the type of appearances of fungal abscess?

A

Wheel within a wheel- early and most recognizable
bulls eye- center calcifies
uniformly hypoechoic focus- most common
echogenic focus- late process

88
Q

What is echinococcal cyst from

A

Adult tapeworms

89
Q

Sonographic findings:
cyst within a cyst or water-lily sign

A

Echinococcal cyst

90
Q

What are laboratory studies for echinococcal cysts

A

Casoni skin test, detection of antibodies : indirect hemagglutination, enzyme-linked immunosorbent assay

91
Q

What happens if a echinococcal cyst ruptures?

A

Rupture or aspiration is associated with anaphylactic shock

92
Q

What is schistosomiasis?

A

Most common parasitic infection in humans

93
Q

What does schistosomiasis cause?
- why

A

Portal hypertension
- eggs reach the liver via PV causing a granulomatous reaction resulting periportal fibrosis

94
Q

What happens to the PV with schistosomiasis?

A

PV become occluded resulting in PV HTN

95
Q

Sonographic findings:
occluded intrahepatic PV, Thicken PV walls

A

Schistosomiasis

96
Q

What are secondary signs of Portal Hypertension?

A

Splenomegaly, Ascites, Esophageal variceal bleeding, portosystemic collaterals.

97
Q

___ is the most common opportunistic infection associated with HIV

A

Tuberculosis TB

98
Q

____ is a common herpes virus that is transmitted in body fluids: saliva, blood, urine, semen, breast milk

A

Cytomegalovirus

99
Q

____ 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

A

Candidiasis

100
Q

____ is a common central nervous system infection associated with HIV caused by fungus in the soil

A

Cryptococcal meningitis

101
Q

____ is a infection caused by a parasite spread by mainly cats from their stool

A

Toxoplasmosis

102
Q

___ is a infection caused by an intestinal parasite found in animals

A

Cryptosporidiosis

103
Q

___ 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

A

Kaposi’s sarcoma

104
Q

___ is an early sign of pain and swelling of the noes in your neck, armpit, and groin

A

Lymphomas

105
Q

___ HIV associated nephropathy is an inflammation of the glomerulus

A

Kidney disease

106
Q

What is the accumulation of triglycerides within the hepaticocytes

A

Fatty liver (steatosis)

107
Q

Sonographic findings:
increase echogenicity of liver and decrease acoustic penetration

A

Fatty liver

108
Q

What are the two patterns of fatty inflitration?

A

Focal fatty infiltration
focal fatty sparing

109
Q

What is focal fatty infiltration ?

A

Focal areas of increase echogenicity within NL liver parenchyma commonly around Porta hepatis

110
Q

What is focal fatty sparing?

A

Focal area of NL liver parenchyma within a fatty liver
commonly around GB**, Porta hepatis, caudate, and liver margins

111
Q

What is Glycogen Storage Disease (GSD)

A

Genetically acquired disorder that results in excess deposition of glycogen in the liver

112
Q

What is von gierke’s disease

A

GSD type 1A a defected in the enzyme glucose 6 phosphate

113
Q

___ is a diffuse process of fibrosis and distortion of normal liver architecture

A

Cirrhosis

114
Q

What can cause cirrhosis ?

A

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

115
Q

ABNL LFT include

A

AST, ALT, GGT, LDH, conjugated bilirubin

116
Q

Sonographic finding:
Enlarge caudate lobe, surface nodularity, fatty infiltration, change to PV hypertension

A

Cirrhosis

117
Q

What is normal Portal hypertension?

A

5 to 10 mmhg

118
Q

What is the major cause of portal hypertension?

A

cirrhosis

119
Q

What arties rupture with esophageal varices

A

RT and LT gastric (coronary) veins that are branches of the Portal veins

120
Q

What are clinical signs of cirrhosis

A

hematemeis, encephalopathy, caput medusa ( dilated abd wall veins)

121
Q

How do you lower portal pressure

A

SHUNTS
portacaval, spelnorenal/linton, dist splenorenal/ warren, TIPS

122
Q

What are the portal systemic collaterals

A

Gastroesophageal varices
Splenorenal varices
Intestinal varices
Rectal Varices
Recanalized umbilical vein

123
Q

What are gastroesophageal varices and where does it drain into?

A

Left gastric vein (AKA coron. ary vein) that drains both gastric walls
portal vein and communicates with the lower esophageal veins

124
Q

What is the recanalized umbilical vein and where does it drain?

A

re opening of the umbilical v. (liga teres)
LPV to epigastric to IVC

125
Q

What are splenorenal varices ?

A

tortuous veins around the spleen and left renal hilum

126
Q

What are intestinal varices?

A

retroperitoneal veins from the colon, duodenum, and panc.

127
Q

What are rectal varices (hemorrhoids)

A

IMV drains into rectal veins

128
Q

What are signs of collaterals?

A

Dilated veins on Ant ABD wall
Caput Medusa
Hemorrhoids
Ascites

129
Q

What does Caput Medusa mean?

A

Tortuous collaterals around the umbilicus

130
Q

What does TIPS mean

A

Transjugular Intrahepatic Portal systemic Shunting

131
Q

How often should you evaluate a TIPS?

A

6m intervals

132
Q

With a TIPS which direction should the following be
RPV, LPV, MPV

A

RPV and LPV hepatofugal flow
MPV hepatopetal flow

133
Q

What is a low and high velocity of a TIPS?

A

low <50cm/sec
high >190cm/sec

134
Q

With a TIPS what would the flow direction be of the LPV if the patient has a patent umbilical vein?

A

either hepatofugal or hepatopetal

135
Q

What does a TIPS look like after the first 3-5 days after placement and why?

A

shadow with no flow
the PTFE retains air after placement

136
Q

What is a TIPS made of ?

A

GORE Viatorr endoprothesis - wire PTFE or polytetrafluorethylene

137
Q

What is an indication for a liver TX in adults and children ?

A

Adults - Cirrhosis Hep C
Children- Biliary atresia

138
Q

What do you evaluate in a liver TX

A

Biliary tree
PV, HA, HV, IVC
collaterals
Fluid collection (Hematoma/Biloma)

139
Q

What is MELD used for and what is included ?

A

Model for End-Stage Liver Disease
bilirubin, creatine, INR

140
Q

What is cavernous transformation of the portal vein?

A

Wormlike venous collaterals that run along the PV
(d/t PV thrombosis)

141
Q

Sonographic Findings:
HYPO area in PV
increase PV diameter
cavernous transformation
PV collaterals

A

PV thrombosis

142
Q

What are the tumoral causes of PV thrombosis ?

A

HCC
METS
Panc Carcinoma

143
Q

What are the non tumoral causes of PV thrombosis?

A

Pancreatitis
Cirrhosis
Inflammatory bowel dz
Trauma
Splenoectomy
Hypercoagulation
Portal lymphadenopathy

144
Q

What is Budd-chiarai syndrome?

A

HV outflow obstruction with possible IVC involvement

145
Q

With Budd-Chiari with happens to the RT, LT and caudate lobes of the liver?

A

RT and LT become atrophy
Caudate lobe becomes enlarged d/t emissary veins

146
Q

What intrahepatic portal vein gas due to in infants?

A

necrotizing entercolitis

147
Q

What is portal vein gas/ pneumatosis intestinalis?

A

air is noted within the intrahepatic portal veins

148
Q

Sonographic Findings:
Anechoic, thin walled, acoustic enhancment

A

Simple cyst

149
Q

What is a cyst with internal echos accompanied by RUQ and decrease hematocrit?

A

Hemorrhagic cyst

150
Q

What is the most common benign tumor of the liver

A

Cavernous hemangioma

151
Q

Sonographic Findings:
In the Liver a hyperechoic area with posterior enhancement
can enlarge with pregnancy/ admin of estrogen

A

hemangioma

152
Q

What is a benign solid liver mass and to believed to be a hyperplastic lesion rather than a true neoplasm ?

A

Focal Nodular Hyperplasia

153
Q

Sonographic Findings:
In the Liver solid mass with varying echogenicity, solitary lesion, CENTRAL FIBROUS SCAR

A

Focal Nodular Hyperplasia

154
Q

What is known as a Stealth lesion?

A

Focal Nodular Hyperplasia

155
Q

What liver mass is strongly associated with women using oral contraceptive pills or on estrogen?

A

Hepatic Adenoma

156
Q

Hepatic Adenoma are associated with what disease?

A

Glycogen storage disease

157
Q

What is the recommended treatment for Hepatic Adenoma ?

A

Surgical resection D/t risk of malignant transformation

158
Q

What are extremely rare fatty tumors

A

Hepatic Lipoma

159
Q

Sonographic Findings:
In the liver a Hyperechoic mass is seen with propagation speed artifact

A

Hepatic Lipoma

160
Q

What is propagation speed artifact?
- what happens to the ultrasound image?

A

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.

161
Q

What are a list of Hyperechoic hepatic masses?

A

Hepatic Lipoma
Hemangioma
Echogenic Mets
Focal Fatty Infiltration

162
Q

What is the most common primary malignancy of the liver

A

Hepatocellular Carcinoma HCC

163
Q

HCC occurs in ___% of patients with Cirrhosis?

A

10-15%

164
Q

Sonographic Findings:
In the liver a HYPOechoic mass seen around PV, HV, or IVC.

A

HCC

165
Q

What lab values are increase with HCC ?

A

Alpha fetoprotein
AST (SGOT)
ALT (SGPT)

166
Q

Why do Mets like to live in the liver ?

A

Dual blood supply and the sinusoidal endothelium allows met cells to be trapped

167
Q

What are the sonographic patterns of the following Mets
Gastrointestinal Tract
Lymphoma
Lung
Mucinous Adenocarcinoma of the colon
Leiomyosarcoma

A

Gastrointestinal Tract- Hyper mets
Lymphoma- Hypo mets
Lung- Bulls eye or target mets
Mucinous Adenocarcinoma of the colon- Calcified mets
Leiomyosarcoma- Cystic mets

168
Q

What is needed to diagnosis metastaic lover disease ?

A

Ultrasound guided biopsy

169
Q

What is the most popular metastaic cancer?

A

Lung with 156,000

170
Q

What malignant liver neoplasm occurs in infants and children (the first 2 years of age)

A

Hepatoblastoma

171
Q

Hepatoblastoma is associated with what genetic conditions?

A

Beckwith-Wiedemann syndrome
Familial Adenomatous Polyposis

172
Q

What is a benign INFANTILE vascular tumor that is located on the liver and is usually diagnosed in the 1st few months of life?

A

Infantile hemangioendothelioma

173
Q

Infantile hemangioendothelioma can become life threatening due to

A

CHF, and or consumptive thrombocytopenia and coagulopathy

174
Q

What is elastography assessment of liver fibrosis?

A

METAVIR Meta analysis of histological data in viral hepatitis

175
Q

The liver uses ____ to metabolize amino acids and to make protein.

A

Aminotransferases (transaminases)

176
Q

When the liver is damage it does what to enzymes?

A

Spill AST and ALT into the blood stream

177
Q

What is AST and what is it AKA?

A

Asparate Aminotransferases
SGOT: Serum glutamic oxaloacetic transaminases

178
Q

Where is AST found?

A

brain, skeletal muscle, heart, liver, kidney

179
Q

AN increase in AST withOUT ALT is seen with what?

A

myocardial infarction**
heart failure, muscle injury, CNS dz

180
Q

What is ALT and what is its AKA

A

Alanine Aminotransferases
SGPT: serm glutamic pyruvic transaminases

181
Q

Is AST or ALT more specific for liver disease?

A

ALT

182
Q

If AST and LDH are increased but ALT is normal what does that mean for liver disease?

A

It rules out liver disease

183
Q

What is GGT?

A

Gamma Glutamyl Transpeptidase

184
Q

What does elevated GGT mean ?

A

Hepatocellular disease and Biliary Obstruction

185
Q

What does the following mean
Increase GGT + increase ALP= ?
Increase GGT + increase ALT=?

A

Biliary Obstruction
Hepatocelluar disease

186
Q

What does LDH mean ?

A

Lactic Dehydrogenase

187
Q

LDH is mostly assessed with what cancer?

A

Testicular cancer

188
Q

What is AFP
- when does it decrease ?

A

Alpha fetoprotein
- 1st year of life

189
Q

What is an elevated AFP mean ?

A

HCC
Germ cell tumors
Mets liver cancer
Hepatoblastoma

190
Q

Platelets contribute to _____

A

Hemostatsis

191
Q

Low platelet concentration is _____

A

Thrombocytopenia

192
Q

Elevated platelet concentration is _____

A

Thrombocytosis

193
Q

____ and ___ are used to help diagnose the cause of unexplained bleeding or inappropriate blood clots

A

Prothrombin time (PT)
Partial thromboplastin time PPT)

194
Q

What is the reference rang for PT ?

A

12-13 seconds

195
Q

what is the INR in absence of anticoagulant therapy range?

A

0.8-1.2

196
Q

What is the INR in anticoagulant use range?

A

2 -3

197
Q

What is monitored prior to an invasive procedure to insure proper clotting ?

A

PT (INR) and PTT

198
Q

What is tumor marker CA 19-9

A

Lung
Pancreatic
Cholangiocarcinoma
Gastrointestinal
Colorectal

199
Q

What is tumor marker HCG?

A

Germcell tumor and testicular

200
Q

What is tumor marker PSA?

A

Prostate specific antigen
prostate cancer

201
Q

What is tumor marker CEA?

A

Carcinoembryonic antigen

Thyroid, Esophageal, Lung
Breast, Bile, bladder
Gastrointestinal, Colorectal, Uterine

Abdominal Sonography (9 decks)

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