Liver Flashcards
This structure marked by the arrow in the image separates the left and right lobes of the liver on ultrasound.
Main lobar fissure
What are the three vessels seen in this ultrasound image?
Right, Middle and Left Hepatic Veins
What is the portal triad composed of?
- Branch of the portal vein
- Hepatic artery
- Bile duct
On ultrasound, how can you tell a portal vein from a hepatic vein?
The portal vein has a sheath around it to house the portal vein branch, hepatic artery, and bile duct. This sheath is echogenic, so a portal venous vessel will have an echogenic wall, and a hepatic vein will not.
What is the normal echogenicity of the liver compared to renal cortex?
Isoechoic or SLIGHTLY Hyperechoic
Diagnosis?
Hepatic Steatosis
What distinguishes mild, moderate, and severe hepatic steatosis on ultrasound?
Mild: diffuse increased echogenicity, beam penetrates liver evenly, diaphragm clearly seen
Moderate: beam more attenuated posteriorly -> bright to dark gradient, triads become a little harder to see, and diaphragm isn’t as clear
Severe: can’t see diaphragm
Rare, but on questions usually seen as a innumerable hyperechoic hepatic nodules with “ringdown” artifact. Often confused for metastatic disease.
Biliary Hamartomas
(von Meyenburg Complexes)
These are small, focal developomental lesions in the liver composed of groups of dilated intrahepatic bile ducts set within a dense collagenous stroma.
In most patients with acute hepatitis, the liver appears normal. If it isn’t normal, name four common findings you could see on ultrasound with acute hepatitis?
Hepatomegaly
Decreased echogenicity diffusely
Periportal cuffing: thick echogenic tissue around portal triads
Gallbladder wall thickening (big time)
“Starry night liver” is a buzzword for what?
Acute hepatitis (the increased echogenicity of the portal triad walls makes it look like a bunch of bright things like stars)
Diagnosis?
Acute hepatitis.
Note how hypoechoic the liver is and how thickened the gallbladder wall is with hypoechoic pocket of edema fluid.
What utrasound artifact is this?
Reverberation artifact
What is this finding in the liver and how can you tell?
Pyogenic liver abscess.
Numerous echogenic foci are gas from gas-producing organisms AND you can see posterior reverberation artifact (the bright streaks).
Liver abscesses can look super different at different times depending on maturity, so if they’re going to give you an image of one, it has to be this unique appearance to come down hard on it.
What is the most common finding of early fungal hepatic infection?
“Wheel within a wheel” or “Bull’s eye” lesion(s).
What is the appearance of hepatic candidiasis when the infection’s been around a while?
When the infection first starts, you get the bull’s eye lesions (“wheel within a wheel”), but then it progresses to innumerable diffuse tiny hypoechoic lesions.
Note: when it advances even further, it progresses from a hypoechoic liver to an echogenic one with calcification representing scar formation
Diagnosis?
Hydatid liver disease
Cysts with “daughter cysts”
Diagnosis
Hydatid cyst
Cyst with detached endocyst secondary to rupture
What is the diagnosis in this immunocompromised patient’s liver with innumerable tiny, bright echogenic foci without shadowing throughout the liver?
Pneumocystis carinii
Note: don’t confuse this for the “starry sky” appearance of acute hepatitis, those echogenicities are around the portal triads
Diagnosis?
Cirrhosis
Note the coarse echotexture, numerous tiny hyperechoic nodules, and surface nodularity
List the two abnormal patterns of hepatic vein doppler ultrasound characteristics in patients with cirrhosis?
- Decreased amplitude of phasic oscillations with loss of reversed flow
- Flattened waveform
In patients with cirrhosis and chronic liver disease, what happens to the postprandial resistive index?
In normal people it’s supposed to increase as a response to increased portal venous flow stimulated by eating, but in cirrhotics this response is blunted and RI is decreased (in hepatic artery).
List the five major sites of portosystemic venous collaterals visualized by ultrasound in cirrhotics?
- GE junction
- Paraumbilical vein
- Splenorenal and gastrorenal
- Intestinal
- Hemorrhoidal
Diagnosis?
Cavernous Transformation of the Portal Vein:
Numerous wormlike vessels at the porta hepatis that occur secondary to long-standing portal vein thrombosis. They’re basically collaterals.
What is the diagnosis in this patient? What other findings could they show you on ultrasound?
Budd Chiari Syndrome
Hepatic vein thrombus, tight stricturing, and overall difficulty visualizing all three veins.
Other findings include: bulbous enlarged caudate lobe, high hepatic vein velocities, and intrahepatic collaterals (looks like cavernous transformation of the portal vein but these wormlike collaterals are actually in the liver not just the porta hepatis)
Although a histologic diagnosis, if they tell you a patient either recently got a renal or liver transplant, or that they use anabolic steroids and show you an image of a liver with masses containing innumerable tiny punctate calcifications, what is the likely diagnosis?
Peliosis hepatis
What is the diagnosis in this liver and what kind of study is this?
This is the classic stellate appearance of an FNH on microbubble contrast enhanced ultrasound of the liver.
Likely diagnosis of this liver lesion?
Hemangioma
Classic morphologies:
- Multiple small echogenic masses
- Single, large, lobulated echogenic mass
- Echogenic lobulated mass with a hypoechoic area centrally secondary to thrombosis/scarring
Most common benign tumor of the liver?
Cavernous hemangioma
Diagnosis?
Stellate mass on doppler classic for FNH
What can look just like a liver hemangioma that should always be included in the differential?
Hepatic adenoma, just a nonspecific echogenic mass, though can also be hypo or isoechoic.
Best way to identify bleeding hepatic adenomas?
Noncontrast CT will show the different ages of blood, unlike contrasted studies.
If you see a highly echogenic solid focal mass in the liver, what would also noticing a discontinuity of the diaphragm echo point you to?
Lipoma and angiomyolipoma
(the fat messes with the physics of the beam and you get what looks like a step off deformity in the diaphragm)
Any new mass in a cirrhotic liver?
HCC until proven otherwise.
Echogenic metastasis to the liver are usually from which primaries?
- GI
- HCC
- Carcinoid
- RCC
Hypoechoic metastasis to the liver are usually from which primaries?
- Breast
- Lung
What should a hypoechoic halo around a liver mass on ultrasound make you think?
Cancer. It is strongly associated with malignancy, particularly metastatic disease but also HCC.
What liver finding can you see in patient’s with treated hepatic metastasis from another primary cancer, especially breast cancer?
Pseudocirrhosis
Looks just like cirrhosis
In liver trauma, what is the echogenicity of acute vs. older blood?
Acute blood: hyperechoic
Old blood: hypoechoic
What are secondary (not direct) sonographic signs that a hepatic TIP shunt is malfunctioning?
- Reaccumulation of ascites
- Reappearance of varices
- Reappearance of recanalized paraumbilical vein
