Liver Flashcards
- A 48-year-old presents with a right upper quadrant mass. He has a history of episodes of constipation with no weight loss. CT shows a 6cm mass in the left lobe of the liver, with peripheral globular cloud-like enhancement. Delayed phase images show the mass ‘has filled in’ with contrast, with minimal low attenuation central remaining. T2 MRI shows a well-defined high signal mass in the left lobe of the liver. Which is the most likely diagnosis?
A. Hypervascular liver metastasis
B. Focal Nodular Hyperplasia (FNH)
C. Hepatocellular Carcinoma (HCC)
D. Cavernous haemangioma
E. Metastatic colon cancer
D. Cavernous haemangioma
Peripheral nodular enhancement with central fill-in is characteristic.
- A 40-year-old woman presents with some poorly localizing abdominal pain and is investigated with CT. A non-contrast study shows a 4cm isoattenuated mass in the left lobe. Arterial phase images show the mass to enhance with a small lower attenuation focus centrally. On the PV phase, the mass is isoattenuating but the central low attenuated focus persists. What is the diagnosis?
A. Regional nodule
B. FNH
C. HCC
D. Hypervascular metastasis
E. Cavernous haemangioma
B. FNH
Typically, iso on non-contrast, hyperdense on arterial phase and isodense on portovenous phase. Presence of a central low attenuation scar can be seen in 50% but can also present in adeno and hepatocellular carcinoma.
- Which of following causes of diffuse hepatic surface nodularity can be difficult to distinguish from cirrhosis?
A. Chronic Budd-Chiari syndrome
B. Chronic portal vein thrombosis
C. Treated breast cancer metastases to the liver
D. Pseudomyxomaperitonei
E. Miliary metastases
C. Treated breast cancer metastases to the liver
Post-chemotherapy changes to hepatic metastases from breast cancer can cause fine diffuse nodularity resembling cirrhosis known as ‘pseudocirrhosis.’
B-D cause coarse nodularity rather than fine and diffuse nodules in cirrhosis. Mets is unlikely to mimic cirrhosis.
- US of a 44-year-old man shows a 7cm cystic lesion in segment 8 of the liver. There is some dependent debris and an apparent cyst within cyst appearance. Which is the most likely diagnosis?
A. Haemangioma
B. Abscess
C. Hydatid disease
D. Hepatic cyst
E. Cystic metastasis
C. Hydatid disease
The cyst within cyst appearance represents daughter cyst. Other features include wall calcification.
- A 40-year-old woman has an ultrasound for investigation of gallstones. She is otherwise fit and well. A large lesion is found in the left lobe of the liver. CT is performed for further characterisation pre-contrast, arterial and porto venous phases. The 8cm lesion appears isointense to liver parenchyma on the non-contrast CT uniformly avidly enhancing in the arterial phase and again isointense to liver parenchyma on the portal phase. A low attenuated central scar is noted within the lesion. Which is the most likely diagnosis?
A. Hepatic adenoma
B. FNH
C. Atypical haemangioma
D. Focal fat
E. Fibrolamella carcinoma (FLC)
B. FNH
FLC is usually a solidly lobulated well-defined turn, usually low attenuation on unenhanced CT and an even lower attenuation central scar, often with punctate calcification. Delayed enhancement of the scar can occur in both FNH and FLC. However, the scar does not calcify in FNH.
- During discussion with a patient due for Radio-frequency Ablation (RFA) treatment of HCC, she asks you about potential increased risk of tumour seeding along needle track, which she has read about on the internet. Which of the following statements is most true?
A. Lesions with a subscapular location are at lower risk
B. Mortality rates range from 1.5-2%
C. Major complication rates range from 5-10%
D. Minor complication rates typically 10-15%
E. 0.5% risk of tumour seeding down needle track
E. 0.5% risk of tumour seeding down needle track
Uncommon and late complication of RFA. In patients with HCC, tumour seeding occurred in 8/1610 cases in a multicenter study and 1/187 in a single series lesions with Subcapsular location. Invasive tumour pattern/poorly differentiated are at higher risk. Mortality rates are typically 0.1-0.5%, major complications 2.2-3.1%, and minor complications 5-8.9%.
- A 40-year-old male presents with an indeterminate liver lesion. He is Hep C positive with previous history of Intravenous Drug Use (IVDU) and was successfully treated for T2NO colorectal cancer last year. Ultrasound demonstrates a 1.5cm slightly hypoechoic lesion in segment 8. This lesion takes up contrast in homogenously in the arterial phase and demonstrates washout in the portovenous and delayed phases, becoming hypoechoic with regards to surrounding liver parenchyma. Which is the most likely diagnosis?
A. Metastasis
B. Focal fatty sparing
C. Capillary haemangioma
D. Hepatic abscess
E. Regenerate nodule
A. Metastasis
Rapid washout and residual hypoechoic lesions are features of metastatic deposit.
- Which is the most common MR feature of autoimmune hepatitis?
A. MR is diagnostic test for AIH
B. Surface nodules rarely present
C. PV thrombosis is frequently present
D. Fibrosis better evaluated on CT than MR
E. Enlarged preportal space is a recognised finding
E. Enlarged preportal space is a recognised finding
Although AIH has a wide variability in imaging appearances, from normal to end-stage chronic liver disease, the most common feature on CT and MR in one series is surface nodularity.
- Regarding Wilson’s disease:
A. Is autosomal dominant in inheritance
B. Hyperdense nodules on non-enhanced CT is the most common finding
C. Honeycomb pattern is most evident on the pre-contrast study
D. The honeycomb pattern is more evident on T1 than T2
E. Occurs due to overproduction of copper
B. Hyperdense nodules on non-enhanced CT is the most common finding
Most cases demonstrate hyperdense nodules on the non-contrast study, some of which became isodense with contrast. A honeycomb appearance is seen in portal and parenchymal phases and on T2 sequences on MR.
- Which of the following is a cause of generalised increase in density pre-iv contrast on CT?
A. Fatty infiltration
B. Malignant infiltration
C. Budd-Chiari
D. Amyloidosis
E. Amiodarone treatment
E. Amiodarone treatment
Fatty infiltration, malignant infiltration, Budd-Chiari and amyloidosis all demonstrate generalized low density on pre-contrast CT.
- A 42-year-old woman is being investigated following a new diagnosis of hepatitis C. Which of the following would have the highest accuracy in the characterization of a focal liver lesion in this patient?
A. Ultrasound
B. Doppler ultrasound
C. Microbubble contrast enhanced ultrasound (Ceus )
D. Combined US and AFP
E. Combined US and Doppler US
C. Microbubble contrast enhanced ultrasound (Ceus )
CEUS can be used to characterise focal liver lesions with 96.6% accuracy. Small HCC (1-2cm) can be diagnosed due to arterial phase hypervascularity and washout characteristics.
- A 45-year-old man 3 weeks post-op for liver transplantation, develops non-specific abdominal pain with a slight rise in liver function tests. A Doppler ultrasound is requested. Which is the most common vascular complication of orthoptic liver transplantation?
A. Hepatic vein thrombosis
B. Portal vein thrombosis
C. IVC thrombosis
D. Hepatic artery thrombosis
E. Hepatic artery stenosis
D. Hepatic artery thrombosis
Hepatic artery thrombosis occurs in 2-12% of cases, usually between 15-132 days post-operatively. The donor celiac axis is anastmosed to the recipient hepatic artery in orthoptic liver transplants. This can be either at the bifurcation of the hepatic into the right and left hepatic arteries, or at the takeoff of the gastroduodenal artery. As the hepatic artery is the only vascular supply to the bile ducts, hepatic artery thrombosis and stenosis can lead to biliary ischemia
- A 34-year-old male visitor to the United Kingdom under the care of the medical team has abnormal liver function tests. US reveals periportal hyperechogenicity and gallbladder wall thickening but no biliary dilatation. The patient has a liver MRI study. T2 images show high signal intensity bands along the portal tracts and note is made of splenomegaly with siderotic nodules. Gadolinium enhanced T1 images confirm enhanced periportal bands. Which of the following is the most likely causative organism?
A. Strongyloides
B. Shistosomiasis
C. Fasciola hepatica flatworm
D. Ascariasis
E. Echinococcus
B. Shistosomiasis
Schistosomiasis is the most likely cause. Periportal fibrosis with signs of portal hypertension, splenomegaly and siderotic nodules are typical features of hepatosplenic schistosomiasis
- A 44-year-old man undergoes ultrasound of the abdomen during which the liver is incidentally noted to be of diffusely increased echogenicity, with attenuation of the ultrasound beam and poor visualization of the intrahepatic architecture. Which of the following imaging features is most likely in this condition?
A. liver echogenicity less than that of renal cortex on ultrasound scan
B. relatively hypoattenuated intrahepatic vessels on unenhanced CT
C. liver attenuation 10 HU greater than that of the spleen on unenhanced CT
D. absolute liver attenuation of >40 HU on contrast-enhanced CT
E. loss of liver signal intensity on out-of-phase gradient echo MR images
E. loss of liver signal intensity on out-of-phase gradient echo MR images
Fatty liver describes a spectrum of conditions characterized by triglyceride accumulation within hepatocytes. It is common, affecting around 15% of the general population, but is more prevalent among those with obesity, hyperlipidaemia and high alcohol consumption. Fatty liver may be diagnosed on ultrasound scan if liver echogenicity exceeds that of renal cortex, with attenuation of the ultrasound beam, loss of definition of the diaphragm and poor visualization of the intrahepatic architecture. CT featuresinclude absolute attenuation of less than 40 HU on contrast-enhanced CT and, onunenhanced CT, liver attenuation at least 10 HU less than that of spleen, and relativelyhyperattenuating liver vasculature. Chemical shift gradient echo imaging is the mostwidely used MR technique for assessment of fatty liver, demonstrating signal intensityloss on out-of-phase images compared with in-phase images.
- Which venous structure divides the liver into the right and left lobes?
A. right hepatic vein
B. middle hepatic vein
C. left hepatic vein
D. left portal vein
E. right portal vein
B. middle hepatic vein
The functional segmental anatomy of the liver is based on the distribution of the three major hepatic veins. The middle hepatic vein divides the liver into left and right lobes. The left hepatic vein divides the left lobe into medial and lateral segments. The right hepatic vein divides the right lobe into anterior and posterior segments. In addition, the four sections are further subdivided in a transverse plane by an imaginary line drawn between the right and left portal veins. Segments run in a clockwise fashion, with segments III, IV(b), V and VI lying below the portal veins and segments VII, VIII, IV(a) and II lying above. The caudate lobe (segment I) lies posterior and to the right of the inferiorvena cava.
- A previously well, 28-year-old man recently returned from the Far East becomes acutely unwell with fever and right upper quadrant pain. Ultrasound scan demonstrates a well-defined, rounded, 7 cm hypoechoic lesion in the right lobe of the liver contiguous with the liver capsule, with fine homogeneous, low-level internal echoes and acoustic enhancement. What is the most likely diagnosis?
A. pyogenic abscess
B. amoebic abscess
C. fungal abscess
D. hydatid disease
E. incidental simple hepatic cyst
B. amoebic abscess
Pyogenic abscesses are the commonest type of liver abscess in developed countries, and are most frequently due to ascending cholangitis from benign or malignant obstructive biliary disease. They are often poorly defined with irregular walls on ultrasound scan,and may contain debris or demonstrate intense hyperechogenicity when containing gas. Amoebic abscesses tend to occur in younger, more acutely unwell patients from high prevalence areas or with a history of recent travel. They are treated medically whereas pyogenic abscesses usually require percutaneous or surgical drainage. Fungal abscesses are usually multiple and occur in immunosuppressed individuals. Hydatid disease tends to be asymptomatic or present with biliary colic. Characteristic ultrasound scan features include daughter cysts and detachment of the endocyst, giving rise to ‘floating membranes’ within the cyst cavity.
- A 43-year-old woman is incidentally found to have a well-defined, rounded, low-density, 2 cm lesion in the liver on unenhanced CT. Contrast-enhanced CT demonstrates peripheral nodular arterial enhancement with complete fill-in on delayed images. What is the most likely diagnosis?
A. hepatic haemangioma
B. hepatocellular carcinoma
C. simple hepatic cyst
D. focal fatty infiltration
E. focal nodular hyperplasia
A. hepatic haemangioma
Haemangiomas are the most common benign liver tumour. They are often asymptomatic but may present with hepatomegaly or rarely spontaneous haemorrhage. Typical CT features of a hepatic haemangioma are of a well-defined hypodense mass on unenhanced CT, with early peripheral enhancement after intravenous contrast followed by complete fill-in on delayed images. Hepatocellular carcinoma is seen as a hypodense mass and usually demonstrates contrast enhancement during the arterial phase, but enhancement decreases on delayed images. Focal fatty infiltration usually has ageographic distribution, and, like simple hepatic cysts, does not demonstrate contrast enhancement. Focal nodular hyperplasia is usually isodense on unenhanced CT and, although it tends to show intense transient arterial phase enhancement, is often isodense during the portal phase. A central scar, if present, may demonstrateenhancement on delayed images.
- A 68-year-old man presents with acute abdominal pain. As well as other pathology, CT of the abdomen reveals multiple linear branching structures with an attenuation value of –1000 HU in the liver extending to the periphery. What are these appearances most likely to represent?
A. gas in the portal venous system
B. gas in the biliary tree
C. portal venous thrombosis
D. intrahepatic biliary dilatation
E. fatty infiltration of the liver
A. gas in the portal venous system
Portal venous gas is identified on CT as linear branching structures of air density extending to the periphery of the liver, presumably due to the direction of portal venous flow. The commonest cause in adults is mesenteric infarction, when it is a poor prognostic sign. In infants the commonest cause is necrotizing enterocolitis, when it does not necessarily imply a poor outcome. In contrast, gas within the biliary tree is central and does not extend into the peripheral 2 cm of the liver. In portal venous thrombosis, a focal hypodensity is seen within the portal vein on contrast-enhanced CT. Intrahepatic biliary dilatation appears as dilated branching ductal structures of fluid density. In fatty infiltration of the liver, vessels may appear hyperattenuating on unenhanced CT in contrast to the hypodense liver.
- A 30-year-old woman on the oral contraceptive pill undergoes unenhanced CT of the abdomen, which demonstrates a well-circumscribed, slightly hypoattenuating mass in the liver. Which additional radiological finding would favour a diagnosis of hepatic adenoma rather than focal nodular hyperplasia?
A. measured lesion size of 3 cm
B. accompanying acute subcapsular haematoma
C. transient arterial-phase enhancement
D. normal uptake on 99mTc-labelled sulphur colloid scan
E. hypodense central stellate scar
B. accompanying acute subcapsular haematoma
Focal nodular hyperplasia (FNH) is a benign hamartomatous malformation commonest in young women. Lesions are usually smaller than 5 cm, and contain a central stellate scar in up to one-third of cases. Hepatic adenomas are benign tumours averaging 8–10 cm in size, seen predominantly in young women and related to oral contraceptive use. Lesions have a propensity for spontaneous haemorrhage, presenting as subcapsular haematoma or haemoperitoneum. FNH, though highly vascular, rarely undergoes spontaneous haemorrhage. FNH usually contains sufficient functioning Kupffer cells to demonstrate normal or increased uptake on 99 mTc-labelled sulphur colloid scan, whereas hepatic adenoma, composed of hepatocytes and non-functioning Kupffer cells, appears as a focal photopenic lesion. Both lesions demonstrate transient arterial enhancement following intravenous contrast.
- A 45-year-old patient with cirrhosis is found to have a focal liver lesion on ultrasound scan, clinically suspected to be hepatocellular carcinoma. What would be the expected appearances of the lesion on T2W MR images following infusion of superparamagnetic iron oxide particles?
A. increased signal intensity compared with rest of liver
B. decreased signal intensity compared with rest of liver
C. lesion signal intensity unchanged; rest of liver increased signal intensity
D. lesion signal intensity unchanged; rest of liver decreased signal intensity
E. no effect on appearances on T2W images
D. lesion signal intensity unchanged; rest of liver decreased signal intensity
Superparamagnetic iron oxide (SPIO) particles are iron-based particles of 30–150 nm, which, when administered as an infusion 1–4 hours prior to imaging, act as a negative MR contrast agent. They target the reticuloendothelial system, being taken up by macrophages throughout the body, but are preferentially accumulated by the Kupffer cells of the liver. Their superparamagnetic properties result in T2 and T2shortening of the tissues that accumulate the particles, which show reduced signal intensity on T2W, T2W and, to a lesser extent, T1W images. Most liver tumours do not exhibit uptake, as they are deficient in Kupffer cells. However, as the rest of the liver accumulates SPIO and darkens preferentially, the tumour appears of increased conspicuity. SPIO particles are particularly used, in combination with gadolinium, to improve detection of hepatocellular carcinoma in cirrhotic patients, in whom the parenchymal changes of fibrosis and regenerative nodules make detection with gadolinium alone difficult.
- A 35-year-old woman on the oral contraceptive pill presents with right upper quadrant pain, shortness of breath and leg oedema. Ultrasound scan of the abdomen demonstrates hepatosplenomegaly and ascites. The hepatic veins are not visualized on Doppler ultrasound scan. What is the most likely diagnosis?
A. acute Budd–Chiari syndrome
B. primary biliary cirrhosis
C. passive hepatic congestion
D. hepatic veno-occlusive disease
E. viral hepatitis
The answer is: A
Budd–Chiari syndrome is caused by obstruction of hepatic venous outflow, which may, in turn, be caused by membranous obstruction of the suprahepatic IVC by a congenital web, or hepatic venous thrombosis due to hypercoagulable state, tumour or trauma. Patients develop hepatosplenomegaly and intractable ascites. Doppler ultrasound scan demonstrates non-visualization of, or thrombus within, one or more hepatic veins. CT findings reflect severely impaired blood flow to the liver, with a ‘flip-flop’ enhancement pattern after contrast administration. Early images show prominent central liver enhancement with poor peripheral enhancement, whereas delayed images show central washout with peripheral enhancement. The caudate lobe is typically spared because of its separate venous drainage directly into the IVC, and enhances normally. Passive hepatic congestion complicates heart failure, and results in distended hepatic veins and IVC. Hepatic veno-occlusive disease refers to occlusion of small centrilobular hepatic veins following radio- and chemotherapy in bone-marrow transplant recipients, or related to alkaloid consumption. The main hepatic veins and IVC are normal. Hepaticvenous involvement is not a feature of viral hepatitis or primary biliary cirrhosis.
- An 86-year-old, otherwise well woman is admitted with abdominal pain and undergoes plain abdominal radiography. This demonstrates a normal bowel gas pattern, but the liver and spleen are noted to be of increased density with a stippled appearance. What is the most likely cause?
A. haemochromatosis
B. thorotrastosis
C. amiodarone therapy
D. sickle cell anaemia
E. glycogen storage disease
B. thorotrastosis
Thorotrast (thorium dioxide), an alpha-emitting radioactive isotope of atomic number 90and long half-life, was used as a contrast agent until the mid-1950s, predominantly for cerebral angiography and reticuloendothelial imaging. It is retained indefinitely by the reticuloendothelial system, and results in increased density of the liver, spleen and lymph nodes with a characteristic stippled appearance. It is associated with delayed malignancies, including angiosarcoma, cholangiocarcinoma and hepatocellular carcinoma. Haemochromatosis may result in diffusely increased density of the liver and spleen, but usually presents earlier in life. Amiodarone may result in increased liver attenuation of 95–145 HU (normal 30–70 HU), but splenic involvement is not usually a feature. Sickle cell anaemia can result in a shrunken calcified spleen, but again is unlikely in this age group. Glycogen storage disease can result in a generalized increase or decrease in hepatic density on CT, but increased splenic density is not a feature.
- A 51-year-old man with alcoholic cirrhosis presents with jaundice. CT of the abdomen reveals an encapsulated, 20 mm focal area of low density in the liver, which demonstrates arterial-phase enhancement and rapid washout on delayed imaging. What is the most likely diagnosis?
A. regenerative nodule
B. dysplastic nodule
C. hepatocellular carcinoma
D. hepatic haemangioma
E. focal fatty sparing
C. hepatocellular carcinoma
Nodules are a common finding in cirrhosis, and differentiation of benign nodules from hepatocellular carcinoma (occurring in 7–12% of patients) is vital. Most nodules are regenerative nodules, representing reparative attempts by hepatocytes in response to liver injury. These are typically under 10 mm in size and appear isodense to liver parenchyma on CT, unless they contain iron deposits (siderotic nodules), in which case they may be slightly hyperdense. Dysplastic nodules are proliferative premalignant lesions found in 15–25% of cirrhotic livers. They resemble regenerative nodules on CT but are usually larger than 10 mm. Hepatocellular carcinomas usually appear as encapsulated hypodense masses that demonstrate rapid arterial enhancement and early washout of contrast on delayed images. Hepatic haemangioma usually appears as a low density mass, but has different enhancement characteristics, demonstrating peripheral enhancement with complete fill-in on delayed images. Focal fatty sparing appears as an area of normal density in a generally hypodense liver and does not demonstrate contrast enhancement.
- A 27-year-old woman presents with upper abdominal pain and is found to have a palpable right upper quadrant mass on examination. CT demonstrates a low attenuation lesion in the right lobe of the liver. Which imaging feature would favour a diagnosis of fibrolamellar carcinoma of the liver rather than focal nodular hyperplasia?
A. calcifications within a central scar
B. lesion size of 3 cm
C. multiple lesions
D. increased uptake on sulphur colloid scan
E. central scar hyperintense on T2W images
A. calcifications within a central scar
Fibrolamellar carcinoma of the liver is an uncommon variant of hepatocellular carcinoma, typically presenting as a large, 5-20 cm liver mass in a young patient with no risk factors. Typical features are of an encapsulated mass with a prominent central fibrous scar. The scar often contains areas of calcification, and appears hypointense on T1- and T2-weighted images. Focal nodular hyperplasia (FNH) is a hamartomatous malformation also most commonly seen in young woman. However, lesion size is usually <5 cm and, although a central fibrous scar is also a common feature, this usually appears hyperintense on T2-weighted images due to vascular channels and oedema, and calcifications within it are extremely rare. Both pathologies may result in multiple lesions, with FNH being multiple in 20% and fibrolamellar carcinoma demonstrating satellite lesions in 10–15%. FNH is the only liver lesion with sufficient Kupffer cells to cause normal or increased uptake on sulphur colloid scan.
- 45-year-old man undergoes ultrasound scan of the abdomen 2 days following orthotopic liver transplantation, which demonstrates periportal oedema and a small fluid collection at the hilum of the liver. What is the most likely diagnosis?
A. graft rejection
B. hepatic arterial thrombosis
C. portal vein stenosis
D. bile leak
E. normal post-transplantation findings
E. normal post-transplantation findings
Orthotopic liver transplantation is the treatment of choice for patients with end-stage liver disease for which no other therapy is available. Surgery involves one arterial anastomosis (hepatic artery), at least two venous anastomoses (portal vein and IVC) and a biliary anastomosis, and complications may occur at any of these sites. Vascular complications are the most frequent cause of graft loss, and most commonly involve the hepatic artery, with portal venous and IVC complications being relatively infrequent. Biliary complications occur in up to 34% of cases, and are the second most common cause of liver dysfunction after graft rejection. They include leak, stricture and obstruction. Other complications include fluid collections, infection and malignancy. Normal findings following liver transplantation include a small amount of free intraperitoneal fluid in the perihepatic region, especially at the hilum, or in the fissure for the ligamentum teres, which usually resolves within a few weeks. Other normal findings are a right fluid pleural effusion, and periportal oedema, attributed to lymphatic cchannel dilatation due to lack of normal lymphatic drainage.
- A 40-year-old man with hyperpigmentation, arthalgia and diabetes mellitus is clinically suspected to have primary haemochromatosis. What are the most likely findings on liver MRI in this condition?
A. normal appearances of the liver
B. decreased signal intensity on T1W and T2Wimages
C. decreased signal intensity on T1W and increased signal intensity on T2W images
D. increased signal intensity on T1W and decreased signal intensity on T2W images
E. increased signal intensity on T1W and T2WImages
B. decreased signal intensity on T1W and T2Wimages
In primary haemochromatosis, there is increased duodenal absorption and parenchymal retention of dietary iron, which is accumulated within the liver, pancreas, heart and pituitary gland. Intracellular iron deposits within hepatocytes result in a paramagnetic susceptibility effect, leading to marked shortening of T1 and T2 relaxation times of adjacent protons. This manifests as a marked reduction in liver signal intensity on T2Wand T2*W images, and a moderate loss of signal intensity on T1W images.
- A 54-year-old woman undergoes CT of the abdomen and pelvis for weight loss and is found to have multiple, irregular, calcified, low-attenuation lesions in the liver, suggestive of metastases. What is the most likely primary lesion?
A. invasive ductal carcinoma of the breast
B. mucinous adenocarcinoma of the gastrointestinal tract
C. osteosarcoma
D. non-small-cell lung carcinoma
E. carcinoid
B. mucinous adenocarcinoma of the gastrointestinal tract
Calcified liver metastases represent up to 3% of liver metastases, and are most commonly seen with mucinous carcinomas of the gastrointestinal tract. They are also seen in osteosarcoma, breast cancer, lung cancer and carcinoid, but these are less common.
- A 45-year-old woman undergoes abdominal ultrasound scan. The portal vein measures 16 mm in diameter and demonstrates continuous monophasic flow without respiratory variation. Portal vein flow velocity is hepatopetal and is measured to be 7 cm/s. What is the most likely diagnosis?
A. normal findings
B. Budd–Chiari syndrome
C. portal hypertension
D. cavernous transformation of the portal vein
E. portal vein thrombosis
C. portal hypertension
The normal portal vein measures up to 13 mm in diameter when measured in the AP direction where the portal vein crosses the inferior vena cava during quiet respiration in a supine patient. Portal venous flow is normally 12–30 cm/s and demonstrates respiratory variation but little or no pulsatility, though this may be seen in thin patients. Normal flow is hepatopetal (anterograde flow into the liver). Portal hypertension is defined as an increase in portal venous pressure above10 mmHg, and is most commonly caused by cirrhosis in the western world. As portal pressure increases, portal vein diameter increases, and portal flow loses its respiratory fluctuation and becomes slow and turbulent. Reversed (hepatofugal) flow may occur in 8% of patients and is generally associated with a reduced portal vein diameter. Other findings include portosystemic collaterals, splenomegaly and ascites. In portal vein thrombosis, portal vein diameter increases, but no flow is seen on Doppler ultrasound scan. Echogenic thrombus may be seen within the lumen. Cavernoustrans formation of the portal vein may occur with chronic portal vein thrombosis, representing a conglomerate of collateral veins. Budd–Chiari syndrome affects the hepatic veins.
- A 26-year-old man with AIDS presents with weight loss. He is noted to have multiple raised purple skin lesions on examination. Contrast-enhanced CT of the abdomen and pelvis demonstrates multiple, subcentimetre, low-attenuation nodules within the liver, as well as high attenuation lymphadenopathy at the porta hepatis, retrocaval and aortocaval regions. What is the most likely diagnosis?
A. fungal infection
B. multiple haemangiomas
C. lymphoma
D. Kaposi’s sarcoma
E. mycobacterial disease
D. Kaposi’s sarcoma
Kaposi’s sarcoma is a low-grade tumour of the blood and lymphatic vessels that primarily affects the skin but may cause disseminated disease in other organs. It is an AIDS-defining illness and is the most common AIDS-related neoplasm. The commonest manifestation is of multiple raised purplish skin lesions, but lymphadenopathy is the second commonest feature in AIDS-related Kaposi’s sarcoma. Typical appearances are of abdominopelvic lymph nodes that enhance after intravenous contrast due to high vascularity, appearing to be of higher attenuation than skeletal muscle. Liver involvement occurs in 34% of cases at autopsy, and typically causes multiple 5–12 mm nodules that are hyperechoic on ultrasound scan and of low attenuation on CT. Skin lesions are present in most cases, and help to distinguish Kaposi’s sarcoma from other conditions such as fungal microabscesses and multiple haemangiomas, which may have similar appearances on CT. Mycobacterial disease is characteristically associated with low-attenuation lymphadenopathy. Non-Hodgkin’s lymphoma is the second commonest AIDS-related neoplasm, and may cause multiple low-attenuation liver lesions, but it is not associated with skin lesions or high-attenuation lymphadenopathy.
- A 45-year-old woman undergoes a follow-up staging CT of the chest, abdomen and pelvis after treatment for metastatic breast cancer. Compared with her initial staging scan, there is a generalized decrease in the attenuation value of the liver. No focal liver lesion or other new feature is seen. What is the most likely cause?
A. diffuse metastatic disease
B. fatty liver related to chemotherapy
C. hepatic venous congestion
D. amyloidosis
E. Budd–Chiari syndrome
B. fatty liver related to chemotherapy
Chemotherapeutic agents are commonly associated with fatty liver. Diffuse fat deposition (the commonest pattern) causes a generalized decrease in the attenuation value of the liver on CT, and may be diagnosed with an absolute liver attenuation value of less than 40 HU on contrast-enhanced CT. It may also be diagnosed at unenhanced CT if the liver attenuation value is at least 10 HU less than that of the spleen. Liver metastases usually present as focal, low-attenuation lesions on portal phase imaging. Hepatic venous congestion causes a diffuse decrease in attenuation but is associated with enlargement of the inferior vena cava and hepatic veins due to elevated central venous pressure. Amyloidosis can cause a generalized decrease in liver attenuation, but more commonly appears as discrete areas of low attenuation with reduced contrast enhancement. Budd–Chiari syndrome may also result in a diffuse decrease in liver attenuation, but there is usually patchy liver enhancement and poor visualization of the hepatic veins.
6 A 61-year-old has alcohol-related chronic liver disease. Which of the conditions is he not at increased risk of developing compared the general population?
(a) Non-specific interstitial pneumonitis
(b) Bacterial pneumonia
(c) Hydrothorax
(d) Pulmonary hypertension
(e) Acute respiratory distress syndrome
(a) Non-specific interstitial pneumonitis
There is no increased risk of NSIP or any other interstitial lung disease as a result of cirrhosis. Patients with cirrhosis have altered immunity and undergo changes to the vascular bed both the liver and the lungs.
17 An unenhanced CT of the liver is performed. The liver has density of 60 HU and the spleen has a density of 50 HU. How might you account for these findings?
(a) Normal findings
(b) Diffuse fatty infiltration
(c) Haemochrornatosis
(d) Wilson’s disease
(e) Budd-Chiari syndrome
(a) Normal findings
The normal liver has a density of 50-70 HU. Fatty infiltration will reduce this as the atomic numbers of the elements C, H and O. Iron and copper deposition can raise the density, as they have high atomic numbers.
19 A 50-year-old man undergoes liver transplantation. A routine liver US comments that the intra-hepatic arterial Doppler has a low resistance index (0.48) and a prolonged systolic acceleration time. What diagnosis does this suggest?
(a) Hepatic artery stenosis
(b) Portal vein occlusion
(c) Hepatic artery pseudoaneurysm
(d) Graft rejection
(e) Hepatic artery thrombosis
(a) Hepatic artery stenosis
The tardus et parvus waveform described here is seen distal to a stenosis. At the stenosis, a jet phenomenon may be seen with greatly increased flow.
Hepatocellular adenomas are not associated with which of the following?
(a) Spontaneous rupture
(b) Oral contraceptive pill
(c) Hepatocellular carcinoma
(d) Androgenic steroids
(e) Cholangiocarcinoma
(e) Cholangiocarcinoma
Hepatocellular adenomas are uncommon benign tumours which comprise hepatocytes with no portal tracts or bile ducts. They are associated with the oral contraceptive pill and androgenic steroids. On imaging, they may have a scar or a pseudocapsule and enhance avidly in the arterial phase which can make differentiation from FNH difficult. There is a tendency to bleed or rupture, 1 % are thought to transform in to malignant lesions (HCC).
A 28-year-old man with cystic fibrosis and abnormal liver function is referred to you for liver imaging by his clinical team. Which of the following are not associated with cystic fibrosis?
(a) Nodular regenerative hyperplasia
(b) Steatosis
(c) Sclerosing cholangitis
(d) Cirrhosis
(e) Cholelithiasis
(a) Nodular regenerative hyperplasia
Cystic fibrosis produces a range of abnormalities, which may lead to fibrosis, cirrhosis and portal hypertension. A micro-gallbladder is also seen commonly.
2 A 42-year-old presents acute right upper quadrant pain and abdominal distension. She has a 1-week history of dark urine, particularly in the mornings, and is found to have pancytopenia. What is the most likely diagnosis?
(a) Acute cholecystitis
(b) Acute pyelonephritis
(c) Bud-Chiari syndrome
(d) Ruptured renal cell carcinoma
(e) Infectious mononucleosis
2 (c)
The patient has classical features of underlying paroxysmal nocturnal haemoglobinuria (PHH), which predisposes to Budd-Chiari syndrorme. Budd-Chiari syndrome presents with these symptoms; the severity of the initial liver disease is variable depending upon the extent of venous occlusion.
3 An MRI liver report reads: ‘There is a hyperintense lesion on T2-weighted imaging, which is hypointense on TI -weighted images. administration of i.v. Gadolinium, there is peripheral nodular enhancement in the arterial phase progressive enhancement on the portal venous and delayed phases.” What is the most likely diagnosis?
(a) Hemangioma
(b) Cyst
(c) Focal nodular hyperplasia
(d) Hepatocellular adenoma
(e) Hepatocellular carcinoma
(a) Hemangioma
These are characteristic findings of a haemangioma. A cyst will enhance; and adenoma are benign hyper vascular lesions that equilibrate in the portal phase. HCC is hypervascular with washout on delayed imaging; the liver is usually cirrhotic.
5 You are asked to review a CT for a patient with a metastatic melanoma in a clinical trial. There is a single deposit within the liver which measured 10 cm on the initial study and now measures 6 cm. How should you classify the response by RECIST criteria?
(a) Complete Response
(b) Complete Response Unconfirmed
(c) Partial Response
(d) Stable Disease
(e) Progressive Disease
(c) Partial Response
A reduction of > 30%, falling short of a complete response, constitutes a partial response.
13 A 33-year-old woman undergoes an MRI study to characterise a 4 cm focal liver lesion found incidentally on US. The lesion is isointense to liver on TI and T2 weighted images, enhances homogeneously and avidly in the arterial phase and is isointense in the portal and delayed phases. 1 hour after the administration of contrast mediun (Gd-Bopta), the lesion is hyperintense to liver. What is the most likely diagnosis?
(a) Hemangioma
(b) Focal nodular hyperplasia
(c) Hepatocellular adenoma
(d) Fibrolamellar hepatocellular carcinoma
(e) Metastasis
(b) Focal nodular hyperplasia
These imaging features are characteristic of FNH. FNH is a tumour thought to represent a hyperplastic response to a pre-existing arterial malformation. It is most commonly seen in women and has no malignant potential. A central scar may be seen which shows delayed enhancement.
14 A 52-year woman with a history of atrial fibrillation and rheumatoid arthritis presents with right-sided renal colic. On the unenhanced CT study there is diffuse low density in the liver. Which of the following right account for this appearance?
(a) Amyloidosis
(b) Amiodarone therapy
(c) Haemochromatosis
(d) Haemosiderosis
(e) Wilson’s disease
(a) Amyloidosis
The most common cause of diffuse low attenuation is fatty infiltration; amyloidosis is another due to amyloid deposition. Amyloidosis can be a primary condition, or secondary to chronic infectious, chronic inflammatory disease (e.g. rheumatoid arthritis), or multiple myeloma. Answers (b) - (d) increase copper/iron deposition within the liver, which will lead to increased liver density on a pre-contrast CT.
16 A 47-year old man presents with atypical RIF pain; a CT abdomen is requested to rule out appendicitis. No cause for abdominal pain is identified. The only finding of note is 8 mm low-attenuation lesion within the left lobe of the liver. The lesion lies inferior to the portal vein and lateral to the left hepatic vein. What segment of the liver is the lesion in?
(a) Segment I
(b) Segment II
(c) Segment III
(d) Segment IV-A
(e) Segment IV-B
(c) Segment III
The Couinaud classification divides the liver into 8 functionally independent segments, each with its own blood supply and biliary drainage. The portal vein divides the liver into superior and inferior segments. The middle hepatic vein divides the left (segments I-IV ) and right lobes (segments V-VIII). The right hepatic vein divides the right lobe into anterior (V and VIII) and posterior (VI and VII) segments. The left hepatic vein divides the left lobe into medial (segments IV-A and IV-B) and lateral part (segments II and III); segment I is the caudate lobe, situated posteriorly.
24 A 52-year-old lady undergoes liver transplantation for autoimmune liver disease. 6 months later, she presents with deranged liver function and an MRCP demonstrates an anastomotic stricture. What is the most common aetiology of non-anastomotic strictures in this group?
(a) Ischaemia
(b) Rejection
(c) Recurrent autoimmune liver disease
(d) Biliary cast syndrome
(e) Post-transplantation lymphoproliferative disease
(a) Ischaemia
Ischaemia is the underlying cause in approximately 50% of cases; the bile ducts are supplied by the hepatic artery and their blood supply is inevitably disrupted to some extent during transplantation. Evaluation of the hepatic arterial supply to the graft is crucial as thrombosis usually requires re-transplantation in the adult population.
26 A 56-year-old woman is referred for an US of the liver which shows a solitary 3 cm hypoechoic lesion. US contrast is given which demonstrates the lesion to be hyporeflective with rim enhancement. The rim enhancement fades in the portal venous phase and the lesion becomes increasingly hyporeflective and well-defined. What is the most likely diagnosis?
(a) Cyst
(b) Hemangioma
(c) Focal nodular hyperplasia
(d) Hepatocellular carcinoma
(e) Metastasis
(e) Metastasis
These are the characteristic features of a hypovascular metastasis. Lesions enhance in a fashion similar to that seen on CT or MRI.
27 A 47-year-old man with multifocal hepatocellular carcinoma and chronic liver disease is referred for consideration of liver transplantation. Which of the following would be considered for transplantation in the UK?
(a) 2 lesions measuring 5 cm or less
(b) 2 lesions measuring 4 cm or less
(c) 3 lesions measuring 3 cm or less
(d) 4 lesions measuring 2 cm or less
(e) 5 lesions measuring 2 cm or less
(c) 3 lesions measuring 3 cm or less
Transplantation is considered in patients with 1 lesion <5 cm or up to 3 lesions measuring 3 cm or less, the ‘Milan Criteria’.
41 You are referred a patient with a history of previous left hepatectomy. What liver segments will have been resected?
(a) I &II
(b) II &III
(c) I, II &III
(d) II, III &IV
(e) I, II, III, IV
(b) II &III
These segments are also referred to as the left lateral lobe. Resection of segment IV also is termed an extended left hepatectomy. Resection of V, VI, VII and VIII is a right hepatectomy. An extended right hepatectomy includes segment IV also. The caudate lobe is usually only resected during liver transplantation.
46 With regard to non-alcoholic steato-hepatitis (NASH), which of the statements is not true?
(a) It is seen in up to 30 % of the population
(b) Diabetes mellitus is a risk factor
(c) up to 15% of patient’s progress
(d) Is associated with hepatic fibrosis
(e) May resolve with dietary modifications alone
(a) It is seen in up to 30 % of the population
Hepatic steatosis is seen in this proportion of the population; of these, 6-8% progress to NASH, where there is inflammation of the hepatocytes and abnormal liver function.
58 A 48-year-old man with diabetes mellitus and abnormal liver function undergoes an MRI of the liver. The liver parenchyma has a smooth contour and is relatively hypointense on the TI -weighted image and hypointense to muscle on the T 2- weighted image. What is the most likely diagnosis?
(a) Acute hepatitis
(b) Fatty liver
(c) Haemochromatosis
(d) Autoimmune liver disease
(e) Wilson’s disease
(c) Haemochromatosis
The low signal within the liver parenchyma on T2-weighted images is due to the susceptibility artefact from iron overload. Patients with haemochromatosis deposit iron within the skin, heart, liver and pancreas. This degree of iron within the liver can be quantified using MRI
A previously well 56-year-old man presents with right upper quadrant pain and tenderness associated with nausea and vomiting. A liver US demonstrates the presence of a large cyst containing a number of smaller cysts with a honeycomb appearance. What is the most likely diagnosis?
(a) Cystadenoma
(b) Cholangiocarcinoma
(c) Hydatid cyst
(d) Hepatocellular carcinoma
(e) Caroli disease
(c) Hydatid cyst
Hydatid infection is caused by Echinococcus multilocularis, and may give rise to a number of appearances at US with cysts being uni- or multi-loculated, thin or thick-walled, with or without calcification. The appearance described here is referred to as daughter cysts. Cystadenoma gives rise to a large unilocular cyst or septated cyst. Caroli disease is due to duct abnormalities. Hepatocellular carcinoma and cholangiocarcinoma are solid lesions.
60 Which of the following is not a recognised association of polycystic liver disease?
(a) Non-Hodgkin lymphoma
(b) Hemorrhage
(c) Portal hypertension
(d) Infection
(e) Polycystic kidney disease
(a) Non-Hodgkin lymphoma
Polycystic liver disease is a hereditary condition that may or may be associated with polycystic kidney disease. There is malignant potential within the cysts but complications may arise from the sheer size of the cysts, and therapeutic interventions. Aspiration, fenestration and enucleation may provide short term relief, but some cases will require repeated therapy or transplantation.
Which of the following conditions is not associated with nodular regenerative hyperplasia?
(a) Polycythaemia rubravera
(b) Rheumatoid arthritis
(c) Cirrhosis
(d) Systemic lupus erythematosus
(e) Non-Hodgkin’s lymphoma
(c) Cirrhosis
NRH is diffuse nodularity of the liver produced by regenerative nodules in the absence of hepatic fibrosis. Although a rare entity, it is commonly associated with portal hypertension (50% cases).
Following solid organ transplantation, post-transplantation lymphoproliferative disorder most commonly affects which of the following organs?
(a) Lungs
(b) Liver
(c) Spleen
(d) Kidney
(e) Bowel
66 (b)
The liver is affected most frequently, with involvement in up to
45% of liver transplant PTLDs,
40% of pancreas transplant PTLDs
23% of heart transplant PTLDs
0% of lung transplant PTLDs
- An 83 year old woman is investigated for weight loss, and undergoes contrast enhanced CT scan of the chest, abdomen and pelvis. Multiple hypervascular metastases are found in the liver. Which one of the following is most likely to be the primary tumour?
a. Adenocarcinoma of the stomach
b. Invasive ductal carcinoma of the breast
c. Carcinoid tumour
d. Adenocarcinoma of the sigmoid
e. Pancreatic ductal adenocarcinoma
- c. Carcinoid tumour
Of the options listed, carcinoid tumour is the only primary tumour that typically causes hypervascular liver metastases. Other causes of hypervascular liver metastases are pancreatic islet cell tumours, phaeochromocytoma and renal cell carcinoma. Stomach, breast, lung and colon cancers are associated with hypovascular liver metastases. Liver metastases from carcinoid tumours are more common with increasing size of the primary tumour. The incidence of metastases depends on the location of the primary tumour, where approximately 30% of carcinoids of the ileum metastasise compared to less than 5% of carcinoids of the appendix.
