Liver Disease Flashcards
What is fatty infiltration?
Acquired, reversible disorder of metabolism. An accumulation of triglycerides within hepatocytes. No harmful effect on liver function.
What is hepatocellular disease?
Defined as a disease process that affects the hepatocytes and interferes with liver function
Causes of fatty liver
- Obesity
- Alcoholism
- Diabetes mellitus- hyperglycemia
- Pregnancy- rapid weight gain
- Severe hepatitis
Diffuse fatty infiltration
Will cause increased liver echogenicity and increased attenuation of the ultrasound beam.
Focal fatty infiltration
May mimic neoplastic involvement. Regions of increased echogenicity are present within background of normal liver parenchyma. Will have a lack of mass effect. Fatty infiltration may resolve as early as within 6 days. The extent of fatty infiltration is variable but commonly seen at the ports hepatis.
Focal fatty sparing
Entire liver is fatty except one spot of normal tissue. Small focal areas of normal liver surrounded by fatty tissue. Appear as hypoechoic masses within a dense fatty infiltrated liver. Commonly seen adjacent to gb fossa.
Cavernous malformation
Multiple serpinginous channels at the porta hepatis as a result of recanalization of the thrombosed vein. Usually happens with portal vein thrombosis. Hepatic artery tries to work harder.
Clinical presentation of cavernous malformation
Abdominal pain, hematemesis (blood in stomach acids), encephalopathy
What is the sonographic appearance of cavernous malformation?
Non visualization of portal vein.
Multiple serpinginous channels within a distorted porta hepatis
What is Budd Chiari Syndrome?
It is an obstruction of the hepatic venous outflow tract
What is Budd Chiari Syndrome etiology?
Intrinsic thrombus of hepatic vein
Rumors, Extrinsic compression by HCC or RCC
IVC thrombus
Membrane or Webb is present in the IVC or atrium
Hematologist disorders such as polycythemia rubes Vera, and coagulopathies
Signs and symptoms of Budd Chiari Syndrome
Abdominal pain Jaundice associated with hepatocellular disease Ascites Hepatomegaly Splenomegaly
What are the sonographic features of Budd Chiari?
Depending on degree from of obstruction
Enlarged hepatic veins (prox to obstruction)
Non visualization of hepatic veins dist to obstruction
Abnormal flow pattern
What may cause a cyst?
They may be congenital, traumatic, parasitic or inflammatory in origin.
Single or Policystic disease of the liver
A gradual dilation of interlobar bile duct
Commonly associated with polycystic disease of the kidneys, spleen, ovaries and lungs
Characteristics of simple cysts
Anechoic Thin walled Round well-defined borders Posterior acoustic enhancement Smooth margin No internal echoes
If only one organ is affected with multiple cysts what is it called?
Multicystic
If multiple organs are involved with multiple cysts what is it called?
Polycystic
*1:1000 incidence. Affects females more than males 4:1 ratio. Usually through 5th and 6th decade of life.
What is a hematoma
Localized collection of blood caused by trauma to the liver
Ultrasound appearance of hematoma
Day 1-2: blood is an school or hypoechoic
Day 3-5: more echoes due to clotting
Day 6: hypoechoic to anechoic due to resolving clot
What are the names of cystic structures found in or around liver?
Perivascular: near or around vessels
Subcapsular: between glissons capsule and liver
Perihepatic : outside or surrounding the liver
Clinical manifestation of hematoma
RUQ pain Hepatomegaly And distention Decreased hematocrit Increased leukocytes Hypotension
What is another name for Hydatid Cyst?
Echinococcal Cyst
Etiology of Echinococcus
Tapeworm larvae ingestion from contaminated vegetables.
Human becomes intermediate host
The eggs invade the intestinal wall and travel through the portal system where they develop into cystic mass
What are the clinical signs of Hydatid cyst?
RUQ pain
Nausea
Vomiting
Positive serological testing
Sonographic appearance of Hydatid cyst?
1 stage: simple cyst
Later stages:
May develop a daughter cyst (cyst within a cyst)
Cysts with thick septa between the fluid collections
Has a “honeycomb” appearance
Calcified cysts
When Hydatid cyst is healing. Surgery removal may be necessary
What is the water lily sign?
When echinococcal cyst germinal layer has either collapsed or become detached
What is an amoebic cyst caused by?
The amoeba named entamoeba hystolytica
What is the route of transmission of entamoeba hystolytica?
Fecal/oral route
Contaminated water
Lives in GI tract
Travels through portal system
Clinical signs and symptoms of amoebic cyst
Abdominal pain Dysentery (blood and mucus in diarrhea) Vomiting Fever/chills Black stools
Lab values of amoebic cyst?
Increased wbc and lft
What is the ultrasound appearance of an amoebic cyst?
Variable appearance
Largest cyst of liver
Internal echoes
May look like abscess- complex cyst (amoebic abcess)
What is schistosomiasis?
Parasitic infection acquired from contaminated water where worms can penetrate the skin or enter GI tract and travel through portal system into liver and causing periportal fibrosis
Clinical signs and symptoms of schistosomiasis
Portal hypertension
Cirrhosis is possible
What is the ultrasound appearance of schistosomiasis?
Increased echogenicity of periportal region
PV dilation and thickened portal walls
What causes an abscess in the liver?
Bacterial infection,
Commonly from biliary infection
What is the ultrasound appearance of an abscess?
Thick walls Round or oval shaped Irregular, poorly defined borders Multiple septations Internal echoes Size is variable 80% located in Rt lobe Comet tail artifact from micro bubbles
What is cavernous hemangioma?
Most common benign tumor of the liver
Not a true neoplasm but more of a vascular abnormality
Arterio-venous malformation
Lined with endothelial tissue filled with wbc
More common in women
Typically < 5cm
What are the complications of cavernous hemangioma?
Enlargement can occur during pregnancy and hormone therapy
Clinical signs and symptoms of cavernous hemangioma
Usually asymptomatic
Large hemangioma can cause abdominal distention and pain
What are the lab values of cavernous hemangioma?
Normal
What is the ultrasound appearance of cavernous hemangioma?
Hyperechoic Round Homogenous Well circumscribed mass Usually in art lobe May be multiple As the mass degenerates the center will become anechoic Post enhancement seen within >2.5 cm Extremely low flow, may or may not be visualized w Doppler
What is focal modular hyperplasia (FNH)?
Second most common benign tumor
Excess growth and accumulation of liver lobule components
Occurring most commonly in women of reproductive age
Linked to birth control
Usually <8cm
What is the ultrasound appearance of FNH?
Variable Typically <5 cm Hypo-hyperechoic Even isle choice to the liver Frequently identified by mass effect Non capsulated
What is liver cell adenoma (LCA)?
A true encapsulated neoplasm consisting of atypical cells
Less common than FNH
more common in women and associated with birth control
Women/men ratio incidence 4:1
Variable sonographic appearance
What are the clinical signs and symptoms of LCA?
Palpable abdominal mass
RUQ pain
Abdominal pressure
Normal labs
What is the most common primary liver malignancy?
Hepatocellular carcinoma HCC - adult
Hepatoblastoma, germ cell tumor - pediatric under 3 yrs of age
Etiology of HCC
Alcohol abuse Hep B & C Toxins - hepatocarcinoges in food Metabolic disorders More common in men
Clinical signs and symptoms of HCC
RUQ pain
Palpable mass, rapid liver enlargement
Fever of unknown origin
Rapid weight loss
Sonographic appearance of HCC
Single or multiple tumor
Variable in echogenicity, usually hypoechoic w irregular borders
Hyper vascular
A distinct tendency to destroy the portal venous wall with invasion into the vessel lumen
Hepatoma gay if mass is large
Related findings of HCC
Ascites in advanced stages
Portal HTN
jaundice
Splenomegaly
What are the lab values of HCC?
Increased AFP
Most accurate 70%
Complications of HCC
Hepatomegaly
Invasion of hepatic vein producing Budd Chiari syndrome
Thrombosis or tumor invasion of portal system occurs in 68% of HCC
What is Metastatic disease in liver?
Cancer that spreads to liver causing ,ultisols tumor invasion
Can be from lungs, breast, colon, panc
Ultrasound appearance of METS
Non specific. Depends on primary target lesions
Mets from lung or breast cancer- echogenic w hyperechoic rim
Mets from lymphoma- multiple hypoechoic lesions
Mets from GI tract- echogenic lesions
Mets from mucinous or serous cyst or adenocarcinoma of the ovary- cystic
What is Bouveret’s syndrome?
Gastric outlet obstruction caused duodenal impaction of large gallstone that has migrated
What is double barrel shot gut sign?
Dilated bile ducts are caused by obstructed gall stones.
It can also result from neoplasm
What is another name for double barrel shot gun sign?
Parallel channel sign
Sizes do dilated ducts
Extrahepatic >5 mm
Intrahepatic >2 mm
Complications of gall stones
Cholecystitis Cholangitis Jaundice Gangrene Ulcer Perforation Fistula Pancreatitis Peritonitis Paralytic ileus (obstruction of small intestine) Sepsis
Bouveret’s Syndrome
Gastric outlet obstruction caused by duodenal impaction of a large gallstone that has migrated through a cholecystoduodenal fistula
What kind of treatments for gall stones are there?
ESWL
Laproscopic cholecystectomy
Sphincterotomy and extraction of stones
Oral dilution therapy
What is ESWL?
Stands for extracorporal shock-wave lithotripsy
The shock wave shatters the small stones into smaller pieces. Limited success
What is porcelain GB?
Porcelain GB is complete or patchy calcification of the GB wall.
Rare. More common in female 5:1
What is the sonographic appearance of porcelain GB?
Biconvex, curvilinear, hyperechoic structure with variable acoustic shadowing
May simulate stone-filled GB devoid of bile, but lacks WES sign
Low level echoes with the GB wall are not identifiable due to calcification infiltration
What is courvoisier gallbladder?
An enlarged, hydropic gallbladder Painless distention of the GB Patients may have palpable mass in RUQ Usually due to obstruction of cbd Pancreatic head mass may obstruct cbd Clinical Obstructive jaundice, increased DB, increased ALP
GB polyp?
Benign growth within GB Projects into GB lumen on a stalk which is rarely visible Soft tissue mass Non-mobile, non-shadowing Less echogenic compared to stone
What is cholesterolosis?
Cholesterol deposit in the GB wall.
Another name for cholesterolosis
Strawberry GB
What is adenomyomatosis?
Hyperplastic cholecystosis or diverticulosis of GB
Diffuse type involves all mucosal walls of the GB
It is characterized by epithelial proliferation, muscle hypertrophy, intramural diverticula (rokitansky aschoff sinuses) which may be segmental or diffuse
Benign condition that requires no specific treatment, found as an accidental finding in up to 9% of cholecystectomy specimen
Other names for adenomyomatosis
Hyperplastic cholecystosis
Diverticulosis of GB
Sonographic appearance of adenomyomatosis?
Mural thickening with calcification and comet tail reverberation artifact due to small cholesterol crystals within rokitansky aschoff sinuses
What is Rokitansky Aschoff Sinuses?
Diverticula within the wall of GB
The pathology associated with them is adenomyomatosis
Sludge and stones accumulate within the sinuses and present as focal wall thickening. Echogenic foci are visible within the thickened wall.
The accumulation causes a characteristic V-shaped or comet tail reverberation artifact
What imaging modality can differentiate adenomyomatosis from GB carcinoma?
MRI, by depicting Rokitansky aschoff sinuses.
MRI is the modality of choice.
What is Adenoma?
Rare, bening epithelial tumor, representing as an overgrowth of the epithelial lining of GB. Protrudes into the GB lumen. Non mobile, adhere to GB wall.
What is the sonographic appearance of adenoma?
Solitary, homogenously hyperechoic mass which becomes heterogenous with increasing size. Single or multiple Usually larger than polyps No shadow, no movement to dependent part Usually less than 1 cm
What is emphysematous GB?
An infection associated with gas-forming bacteria within the wall of the GB. Differs from the usual type of acute cholecystitis as cholelithiasis is absent
Incidence: male>female
Men >60 yo
What is the predisposing factor of emphysematous GB?
Diabetes mellitus
Vascular compromise of cystic area may play role in etiology
Gas may occur in the wall and/or lumen of GB
Gas may spread to peri-cholecystitis tissue
Gas rarely escapes into bile ducts because usually occluded by cholelithiasis
Sonographic features of emphysematous GB
Indistinct shadowing emanating from the wall or lumen of GB
Ring Down artifact or comet tail artifact from shadowing from air in GB lumen
What is pneumobilia?
Air in biliary tract
Most commonly seen after ERCP
And can also occur due to surgically created biliary-enteric anastomosis, incompetence of the sphincter of oddi, wall erosion by the gallstone or ulcer into cbd.
Where is pneumobilia most commonly seen?
In the hilum of liver.
What is Mirizzi’s Syndrome?
Extrinsic biliary obstruction caused by compression of the stone within the cystic duct. The stone causes extrinsic mechanical compression of the cbd
Sonographic features of Mirizzi’s Syndrome
Intrinsic hepatic bile dilation, a normal size cbd.
A large stone in the cystic duct of GB
What is Caroli’s Desease?
Congenital communicating cavernous ectasis of the intrahepatic bile ducts.
It is a segmental, non-obstructive, saccular dilation of intrahepatic bile ducts
What is choledochal cyst
Congenital cyst in the bile duct
Sonographic appearance of choledochal cyst
A presence of cyst-like mass in the porta hepatis area
Dilated intrahepatic biliary tree
Biliary carcinoma clinical and lab
More common in women 60-70% white women Stones will be present in almost 95% of cases May be asymptomatic Increased direct bilirubin, WBC and ALP CEA- carceno embrionic antigen
Etiology of biliary carcinoma
70-80% of cases the neoplasm is adenocarcinoma
15% is papillary carcinoma
What 3 other areas should be investigated to confirm the diagnosis of GB carcinoma?
Liver METS
Periaortic lymphadenopathy
Bile duct dilation
What is Klatskin Tumor?
Is a specific type of cholangiocarcinoma
Causes intrahepatic biliary dilation without extrahepatic dilation.
Located at the hepatic hilum, at the junction of the right and left hepatic ducts.
Signs and symptoms are weight loss, jaundice, RUQ pain, digestive disturbances
