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Abdominal Sonography > Liver > Flashcards

Liver Flashcards

1
Q

What divides the right and left hepatic lobes?

A

Plane between the GB and IVC

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2
Q

What are the right and left lobes divided by?

A

The hepatic veins

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3
Q

What are the right and left lobes further divided into?

A

Right posterior, Right anterior, Left lateral, Left medial

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4
Q

What vein is supplied by which lobe?

A

Right lobe - Right portal vein
Left lobe - Left portal vein
Caudate lobe - Both portal veins

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5
Q

Where is the caudate lobe specifically located?

A

Posterior to the ligamentum venosum and porta hepatis
Anterior and medial to the IVC
Lateral to the lesser sac

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6
Q

Where do the hepatic veins course?

A

Between the lobes and segments (interlobar and intersegmental)

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7
Q

Where do portal vessels course?

A

Center of each segment (intrasegmental)

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8
Q

What are the vessels of the portal triad?

A

Main portal vein, Proper hepatic artery, Common hepatic (bile) duct

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9
Q

What does the MLF divide?

A

The right and left hepatic lobes between the IVC and gallbladder fossa
Landmarks: GB, IVC, middle hepatic vein

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10
Q

What does the right intersegmental fissure divide?

A

The right lobe into anterior and posterior segments

Landmark: Right hepatic vein

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11
Q

What does the left intersegmental fissure divide?

A

The left lobe into medial and lateral segments

Landmarks: Left hepatic vein, asc left portal vein, falciform ligament, ligamentum teres

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12
Q

What does the ligamentum venosum divide?

A

Separates the left lobe from the caudate lobe

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13
Q

What are the remnants from fetal circulation?

A

Umbilical vein - ligamentum teres
Ductus venosus - ligamentum venosum
(Umbilical vein > LPV > Ductus venosus > IVC)

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14
Q

Describe the direction of bloodflow for the portal veins.

A

Hepatopetal - flow TOWARD liver

Hepatofugal - flow AWAY from liver

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15
Q

What is hepatic blood flow comprised of?

A

1500mL/min
25% Proper hepatic artery
75% Portal vein

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16
Q

What supplies hepatic oxygenation?

A

50% Proper hepatic artery

50% Portal vein (PV O2 Sat=85%)

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17
Q

What is the upper limit of the portal vein diameter?

A

13mm

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18
Q

Describe hepatic vein waveforms?

A

Triphasic - right atrial filling, contraction, and relaxation

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19
Q

What does the main hepatic artery run parallel to?

A

Main portal vein

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20
Q

Where does a replaced right hepatic artery originate from and where is it located?

A

SMA (11%)

Posterior to the head of the pancreas and main portal vein

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21
Q

What waveforms can be seen in the hepatic artery in a post-op liver transplant?

A

High-resistance hepatic artery waveform (venous congestion of liver or possible organ rejection)
Parvus tardus hepatic artery waveform (prox anastomotic stenosis)

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22
Q

What is the ligamentum teres a remnant of?

A

Umbilical vein from the umbilicus to the left portal vein

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23
Q

What is the falciform ligament?

A

Peritoneal reflection or fold from the passage of the embryonic umbilical vein from the umbilicus to the left branch of the portal vein

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24
Q

What is the coronary ligament?

A

Peritoneal reflections which suspend the liver from the diaphragm

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25
Q

What is the right and left triangular ligament?

A

Peritoneal reflections of the far right and left of the bare area

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26
Q

Where is the liver size measured?

A

Sup-inf dimension on the mid-clavicular sagittal or coronal mid-axial plane

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27
Q

When is hepatomegaly indicated?

A

Greater than 15.5 cm

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28
Q

What is Reidel’s lobe?

A

Inferior projection of the right lobe, commonly seen in women

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29
Q

What causes hepatic granulomas?

A

Histoplasmosis or TB

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30
Q

What is a hepatic granuloma?

A

Small organized collection of macrophages that appear as calcifications in the liver and spleen

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31
Q

What does acute hepatitis look like on ultrasound?

A

“Starry Night” (periportal cuffing)
Hypoechoic liver parenchyma
Liver enlargement
Hyperechoic portal vein walls

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32
Q

What does chronic hepatitis look like on ultrasound?

A

Hyperechoic liver parenchyma
Small liver
Decreased echogenicity of portal vein walls

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33
Q

Where is the most common source of pyogenic abscesses?

A

Biliary tract disease

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34
Q

Which lobe is affected more often with pyogenic abscesses?

A

Right > Left (2:1)

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35
Q

What are the 3 major forms of liver abscesses?

A

Pyogenic (polymicrobial) 80%
Amebic (Entamoeba histolytica) travel out of US
Fungal (Candida)

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36
Q

What do amebic abscesses look like on ultrasound?

A

Round hypoechoic/complex mass
Right lobe (dome)
Contiguous with liver capsule

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37
Q

What do fungal abscesses look like on ultrasound?

A

Course changes:

  1. “Wheel within a wheel”
  2. “Bull’s eye”
  3. “Uniformly hypoecoic focus” < most common
  4. “Echogenic focus”
38
Q

What does a echinococcal cyst look like on ultrasound?

A 
"Cyst within a cyst"
Simple cyst
Cyst w detached endocyst
Cyst with multiple daughter cysts
Calcified mass
39
Q

What lab tests are used to dx Hydatid disease?

A

Casoni skin test
Echinococcal Arc 5
Indirect hemagglutination

40
Q

Should echinococcal cysts be aspirated?

A

NO - rupture or aspiration can lead to anaphylactic shock!

41
Q

What infection is a major cause of portal HTN?

A

Schistosomiasis
Eggs reach liver through the portal vein causing a granulomatous reaction resulting in periportal fibrosis. The portal veins become occluded resulting in portal HTN

42
Q

What does schistosomiasis look like on ultrasound?

A

Occluded intrahepatic portal veins

Thickening of portal vein walls

43
Q

What are sonographic findings of PCP involvement of the liver?

A

Diffuse, non shadowing, hyperechoic foci

44
Q

How are lymphoma and Kaposi’s sarcoma seen on ultrasound?

A

Intrahepatic mass or possibly diffuse infiltration without visualization of a sonographic abnormality

45
Q

What is fatty liver disease?

A

Steatosis - accumulation of triglycerides within the hepatocytes

46
Q

What does fatty infiltration look like on ultrasound?

A

Increased echogenicity and decreased acoustic penetration

47
Q

What is focal fatty infiltration?

A

Focal regions of increased echogenicity within normal liver parenchyma most commonly seen at portal hepatis

48
Q

What is focal fatty sparing?

A

Focal regions of normal liver parenchyma within a fatty infiltrated liver commonly seen next to the GB, porta hepatic, in caudate lobe and at liver margins

49
Q

What are sonographic findings of cirrhosis?

A 
Hepatomegaly (acute)
Liver atrophy (chronic)
Caudate lobe enlargement
Surface nodularity
Fatty infiltration
50
Q

What is normal portal pressure?

A

5-10 mmHg

51
Q

What is a major cause of portal HTN?

A

Cirrhosis

52
Q

At what diameter of the portal vein suggests HTN?

A

> 13 mm

53
Q

List 4 types of portal HTN.

A

Extrahepatic presinusoidal
Intrahepatic presinusoidal
Intrahepatic (most common)
Intrahepatic postsinusoidal

54
Q

What are sonographic findings of portal HTN?

A

Secondary signs of splenomegaly, ascites, portal systemic venous collaterals

55
Q

What are some surgical techniques to lower portal pressure?

A

Portacaval shunt
Splenorenal shunt/Linton shunt
Distal splenorenal shunt/Warren shunt
TIPS

56
Q

What are some portal system collaterals?

A 
Gastroesophageal varices
Recanalized umbilical vein
Splenorenal varices
Intestinal varices
Rectal varices (hemorrhoids)
57
Q

Where is a TIPS placed?

A

By jugular access, placed between a hepatic vein and a portal vein (typically RHV and RPV)

58
Q

What flow is evident in a patent TIPS?

A

Hepatofugal (away from liver)

59
Q

What are indications for transplantation in children?

A

Biliary atresia

60
Q

Is a TIPS shunt visible on ultrasound within the first 3-5 days after placement?

A

No - it is made of a wire reinforced with PTFE covered conduit - porous material that retains air after placement

61
Q

What are indications for transplantation in children?

A

Biliary atresia

62
Q

What is MELD?

A

Model for End-Stage Liver Disease- assesses severity of chronic liver disease (bilirubin, creatinine, INR)

63
Q

What are sonographic findings of a portal vein thrombosis?

A

Hypoechoic thrombus within portal vein
Increased portal vein caliber
Cavernous transformation
Portal systemic collaterals

64
Q

What are non-tumor causes of portal vein thrombosis?

A 
Cirrhosis/hepatitis (most common)
Pancreatitis
IBD
Trauma
Splenectomy
Hypercoagulation
Portal lymphadenopathy
65
Q

What is cavernous transformation?

A

Numerous worm-like venous collaterals that parallel the chronically thrombosed portal vein (usually in benign causes)

66
Q

What is Budd-Chiari Syndrome?

A

Hepatic vein obstruction

Patients present with signs associated with portal HTN

67
Q

What causes Budd-Chiari Syndrome?

A 
Idiopathic (50%)
Congenital
Hypercoagulable states
Infections
Pregnancy/Postpartum
Tumors
68
Q

Which lobe is spared in Budd-Chiari Syndrome?

A

Caudate lobe - because of emissary veins that drain into the IVC; thus it enlarges and can compress the IVC

69
Q

What causes portal vein gas in infants?

A

Necrotizing enterocolitis

70
Q

Define a liver cyst.

A

Fluid-filled space lined by biliary epithelium

Appears in 5th decade of life

71
Q

How does a hemorrhagic liver cyst appear on ultrasound?

A

Cyst with internal echoes accompanied by RUQ pain and a decreasing Hct

72
Q

What is a cavernous hemangioma?

A

Most common benign tumor of the liver

73
Q

What does a cavernous hemangioma look like on US?

A

Hyperechoic

Posterior enhancement

74
Q

Can you see flow within a cavernous hemangioma?

A

No

75
Q

What is focal nodular hyperplasia?

A

Benign solid liver mass that is believed to be a developmental hyperplastic lesion, not true neoplasm

76
Q

What does focal nodular hyperplasia look like on US?

A

Central fibrous scar
Solid mass with varying echogenicity
Solitary lesion (80-95%)
Stellate vascularity

77
Q

What does the mass in FNH contain?

A

Proliferating bile ducts
Kupffer cells
Connective tissue
Central stellate scar

78
Q

What is a Stealth Lesion?

A

FNH’s that have an echogenicity equal to the surrounding liver parenchyma

79
Q

What are hepatic adenomas commonly associated with?

A

Use of OCPs

Glycogen storage disease

80
Q

How do pt’s present with a hepatic adenoma?

A

Pain from tumor hemorrhage

81
Q

What are sonographic findings of hepatic adenoma?

A

Nonspecific echogenicity

Tumor hemorrhage

82
Q

What are hepatic lipomas?

A

Extremely rare fatty tumors

83
Q

What are hepatic lipomas associated with?

A

Tuberous sclerosis (congenital familial disease)

84
Q

List hyperechoic hepatic masses.

A

Hepatic lipoma
Hemangioma
Echogenic mets
Focal fatty infiltration

85
Q

What is propagation speed artifact?

A

Decreased speed of sound in fat (1450 m/s) resulting in a prolonged sound return time - objects posterior to the fatty mass will be placed farther away from the transducer

86
Q

What is the most common primary malignancy of the liver?

A

HCC - hepatocellular carcinoma

occurs in 10-25% of pts with cirrhosis

87
Q

What does HCC look like on US?

A

Variable appearance

Most are hypoechoic

88
Q

What lab abnormalities are associated with HCC?

A

Increased AFP, AST, ALT

89
Q

What are the associated sonographic patterns for the following mets in the liver?
GI Tract
Lymphoma
Lung
Mucinous adenoma of the colon
Leiomyosarcoma/Mucinous cystadenoCA/Squamous cell CA

A 
Hyperechoic mets
Hypoechoic mets
Bulls-eye or target mets
Calcified mets
Cystic mets
90
Q

What is the most common malignant liver tumor in early childhood?

A

Hepatoblastoma

91
Q

When is AFP elevated?

A

HCC
Germ cell tumors
Metastatic liver CA
Hepatoblastoma

92
Q

What lab tests are monitored prior to an invasive procedure to insure proper clotting?

A

PT, PTT and platelets

Abdominal Sonography (12 decks)

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