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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
What is the right and left triangular ligament?
Peritoneal reflections of the far right and left of the bare area
26
Where is the liver size measured?
Sup-inf dimension on the mid-clavicular sagittal or coronal mid-axial plane
27
When is hepatomegaly indicated?
Greater than 15.5 cm
28
What is Reidel's lobe?
Inferior projection of the right lobe, commonly seen in women
29
What causes hepatic granulomas?
Histoplasmosis or TB
30
What is a hepatic granuloma?
Small organized collection of macrophages that appear as calcifications in the liver and spleen
31
What does acute hepatitis look like on ultrasound?
"Starry Night" (periportal cuffing) Hypoechoic liver parenchyma Liver enlargement Hyperechoic portal vein walls
32
What does chronic hepatitis look like on ultrasound?
Hyperechoic liver parenchyma Small liver Decreased echogenicity of portal vein walls
33
Where is the most common source of pyogenic abscesses?
Biliary tract disease
34
Which lobe is affected more often with pyogenic abscesses?
Right > Left (2:1)
35
What are the 3 major forms of liver abscesses?
Pyogenic (polymicrobial) 80% Amebic (Entamoeba histolytica) travel out of US Fungal (Candida)
36
What do amebic abscesses look like on ultrasound?
Round hypoechoic/complex mass Right lobe (dome) Contiguous with liver capsule
37
What do fungal abscesses look like on ultrasound?
Course changes: 1. "Wheel within a wheel" 2. "Bull's eye" 3. "Uniformly hypoecoic focus" < most common 4. "Echogenic focus"
38
What does a echinococcal cyst look like on ultrasound?
``` "Cyst within a cyst" Simple cyst Cyst w detached endocyst Cyst with multiple daughter cysts Calcified mass ```
39
What lab tests are used to dx Hydatid disease?
Casoni skin test Echinococcal Arc 5 Indirect hemagglutination
40
Should echinococcal cysts be aspirated?
NO - rupture or aspiration can lead to anaphylactic shock!
41
What infection is a major cause of portal HTN?
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
What does schistosomiasis look like on ultrasound?
Occluded intrahepatic portal veins | Thickening of portal vein walls
43
What are sonographic findings of PCP involvement of the liver?
Diffuse, non shadowing, hyperechoic foci
44
How are lymphoma and Kaposi's sarcoma seen on ultrasound?
Intrahepatic mass or possibly diffuse infiltration without visualization of a sonographic abnormality
45
What is fatty liver disease?
Steatosis - accumulation of triglycerides within the hepatocytes
46
What does fatty infiltration look like on ultrasound?
Increased echogenicity and decreased acoustic penetration
47
What is focal fatty infiltration?
Focal regions of increased echogenicity within normal liver parenchyma most commonly seen at portal hepatis
48
What is focal fatty sparing?
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
What are sonographic findings of cirrhosis?
``` Hepatomegaly (acute) Liver atrophy (chronic) Caudate lobe enlargement Surface nodularity Fatty infiltration ```
50
What is normal portal pressure?
5-10 mmHg
51
What is a major cause of portal HTN?
Cirrhosis
52
At what diameter of the portal vein suggests HTN?
>13 mm
53
List 4 types of portal HTN.
Extrahepatic presinusoidal Intrahepatic presinusoidal Intrahepatic (most common) Intrahepatic postsinusoidal
54
What are sonographic findings of portal HTN?
Secondary signs of splenomegaly, ascites, portal systemic venous collaterals
55
What are some surgical techniques to lower portal pressure?
Portacaval shunt Splenorenal shunt/Linton shunt Distal splenorenal shunt/Warren shunt TIPS
56
What are some portal system collaterals?
``` Gastroesophageal varices Recanalized umbilical vein Splenorenal varices Intestinal varices Rectal varices (hemorrhoids) ```
57
Where is a TIPS placed?
By jugular access, placed between a hepatic vein and a portal vein (typically RHV and RPV)
58
What flow is evident in a patent TIPS?
Hepatofugal (away from liver)
59
What are indications for transplantation in children?
Biliary atresia
60
Is a TIPS shunt visible on ultrasound within the first 3-5 days after placement?
No - it is made of a wire reinforced with PTFE covered conduit - porous material that retains air after placement
61
What are indications for transplantation in children?
Biliary atresia
62
What is MELD?
Model for End-Stage Liver Disease- assesses severity of chronic liver disease (bilirubin, creatinine, INR)
63
What are sonographic findings of a portal vein thrombosis?
Hypoechoic thrombus within portal vein Increased portal vein caliber Cavernous transformation Portal systemic collaterals
64
What are non-tumor causes of portal vein thrombosis?
``` Cirrhosis/hepatitis (most common) Pancreatitis IBD Trauma Splenectomy Hypercoagulation Portal lymphadenopathy ```
65
What is cavernous transformation?
Numerous worm-like venous collaterals that parallel the chronically thrombosed portal vein (usually in benign causes)
66
What is Budd-Chiari Syndrome?
Hepatic vein obstruction | Patients present with signs associated with portal HTN
67
What causes Budd-Chiari Syndrome?
``` Idiopathic (50%) Congenital Hypercoagulable states Infections Pregnancy/Postpartum Tumors ```
68
Which lobe is spared in Budd-Chiari Syndrome?
Caudate lobe - because of emissary veins that drain into the IVC; thus it enlarges and can compress the IVC
69
What causes portal vein gas in infants?
Necrotizing enterocolitis
70
Define a liver cyst.
Fluid-filled space lined by biliary epithelium | Appears in 5th decade of life
71
How does a hemorrhagic liver cyst appear on ultrasound?
Cyst with internal echoes accompanied by RUQ pain and a decreasing Hct
72
What is a cavernous hemangioma?
Most common benign tumor of the liver
73
What does a cavernous hemangioma look like on US?
Hyperechoic | Posterior enhancement
74
Can you see flow within a cavernous hemangioma?
No
75
What is focal nodular hyperplasia?
Benign solid liver mass that is believed to be a developmental hyperplastic lesion, not true neoplasm
76
What does focal nodular hyperplasia look like on US?
Central fibrous scar Solid mass with varying echogenicity Solitary lesion (80-95%) Stellate vascularity
77
What does the mass in FNH contain?
Proliferating bile ducts Kupffer cells Connective tissue Central stellate scar
78
What is a Stealth Lesion?
FNH's that have an echogenicity equal to the surrounding liver parenchyma
79
What are hepatic adenomas commonly associated with?
Use of OCPs | Glycogen storage disease
80
How do pt's present with a hepatic adenoma?
Pain from tumor hemorrhage
81
What are sonographic findings of hepatic adenoma?
Nonspecific echogenicity | Tumor hemorrhage
82
What are hepatic lipomas?
Extremely rare fatty tumors
83
What are hepatic lipomas associated with?
Tuberous sclerosis (congenital familial disease)
84
List hyperechoic hepatic masses.
Hepatic lipoma Hemangioma Echogenic mets Focal fatty infiltration
85
What is propagation speed artifact?
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
What is the most common primary malignancy of the liver?
HCC - hepatocellular carcinoma | occurs in 10-25% of pts with cirrhosis
87
What does HCC look like on US?
Variable appearance | Most are hypoechoic
88
What lab abnormalities are associated with HCC?
Increased AFP, AST, ALT
89
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
``` Hyperechoic mets Hypoechoic mets Bulls-eye or target mets Calcified mets Cystic mets ```
90
What is the most common malignant liver tumor in early childhood?
Hepatoblastoma
91
When is AFP elevated?
HCC Germ cell tumors Metastatic liver CA Hepatoblastoma
92
What lab tests are monitored prior to an invasive procedure to insure proper clotting?
PT, PTT and platelets

Abdominal Sonography (12 decks)

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