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Gastrointestinal Imaging (Beri) > Liver (for PBR 2) > Flashcards

Liver (for PBR 2) Flashcards

1
Q

Term used for transient enhancement differences seen during either arterial phase imaging or portal venous imaging on MDCT or dynamic MRI

A

Transient hepatic attenuation differences (THAD) or
Transient hepatic intensity differences (THID) or
Transient hepatic enhancement differences (THED)

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2
Q

Findings in hepatic perfusion abnormalities

A
  1. Hyperenhancement in the arterial phase
  2. Isoenhancement in portal venous and delayed phase
  3. Isoattenuation on unenhanced CT
  4. Isointensity on MR unenhanced T1, T2, and DWI
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3
Q

Evidence of hepatomegaly

A

Round of the inferior border of the liver

Extension of the right lobe of the liver inferior to the lower pole of the right kidney

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4
Q

Liver length of how many centimeters is considered enlarged?

A

Greater than 15.5 cm

Measures in the midclavicular line

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5
Q

It is an elongated inferior tip of the right lobe of the liver

A

Reidel lobe

Normal variant - when present the left lobe of the liver is correspondingly smaller in size

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6
Q

Most common abnormality by hepatic imaging

A

Hepatic steatosis

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7
Q

Two most common cause of hepatic steatosis

A

Alcoholic liver disease

Nonalcoholic fatty liver related to metabolic syndrome

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8
Q

Reliable ultrasound finding of nonalcoholic steatohepatitis (NASH)

A
  1. Liver echogenicity is greater than the renal cortex
  2. Loss of visualization of normal echogenic portal triads
  3. Poor sound penetration with loss of definition of diaphragm

All three findings must be present to make an unquivocal US diagnosis

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9
Q

Unenhanced CT finding of NASH

A
  1. Liver attenuation is 10 HU less than spleen attenuation
    OR
    Liver attenuation is less than 40 HU
  2. Blood vessels appear brighter than the dark liver on unenhanced CT
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10
Q

Sign seen with fatty liver being dark on unenhanced CT and bright on US

A

“Flip-flop” sign

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11
Q

Characteristic feature of fatty deposition on all modalities

A
  1. Lack of mass effect (no bulging of the liver contour or displacement of intrahepatic vessels)
  2. Angulated geometric boundaries between involved and uninvolved parenchyma
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12
Q

Most common pattern of fatty liver

a. Diffuse fatty liver
b. Focal fatty liver
c. Focal sparing
d. Multifocal fatty liver
e. Perivascular fatty liver
f. Subcapsular fatty liver

A

A. Diffuse fatty liver

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13
Q

MC locations of focal fat

A

Adjacent to the:

Falciform ligament
Gallbladder fossa
Porta hepatis

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14
Q

MC location of fat-spared area in fatty liver

A

Segment 4

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15
Q

Pattern of fatty liver which is only seen in patients with renal failure on peritoneal dialysis and only when insulin is added to the dialysate

A

Subcapsular fatty liver

High concentrations of insulin in the subcapsular lier lead to fat deposition

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16
Q

Liver disease that is characterized pathologically by:

  1. Diffuse parenchymal destruction
  2. Fibrosis with alteration of hepatic architecture
  3. Innumerable regenerative nodules (RN) that replace normal liver parenchyma
A

Cirrhosis

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17
Q

Imaging findings of cirrhosis (7)

A
  1. Hepatomegaly (early)
  2. Atrophy or hypertrophy of hepatic segments
  3. Coarsening of hepatic parenchymal texture
  4. Nodularity of the parenchyma, often most noticeable on the liver surface
  5. Hypertrophy of the caudate lobe and left lobe with shrinkage of the right lobe
  6. Regenerating nodules
  7. Enlargement of the hilar periportal space (>10mm)
Creator's notes:
Early enlargement
Atrophy
Coarsening
Nodularity 
Caudate lobe hypertrophy
Enlargement of the hilar periportal space (1 cm)
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18
Q

Imaging finding of cirrhosis that reflects parenchymal atrophy

A

Enlargement of the hilar periportal space

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19
Q

Extrahepatic signs of cirrhosis

A
  1. Portosystemic collaterals (as evidence of portal hypertension)
  2. Splenomegaly
  3. Ascites
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20
Q

Different causes of nodules in a cirrhotic liver

A
  1. Regenerative nodules
  2. Dysplastic nodules
  3. Hepatocellular carcinoma
  4. Confluent fibrosis
  5. Focal fat infiltration
  6. Focal fat sparing
  7. Metastases (rare in cirrhosis)
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21
Q

Most common nodules of cirrhosis

A

Regenerative nodules

Regular pathologic feature of cirrhosis due to attempted repair of hepatocyte injury

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22
Q

Difference of low-grade dysplastic nodules and high-grade dysplastic nodules

A

Low-grade DN

  • Minimal atypia, no mitosis, not premalignant
  • Supplied by portain vein
  • No arterial phase enhancement
  • Progresses to high-grade

High-grade DN

  • Moderate atypia, occasional mitosis, secrete AFP
  • Not frankly malignant
  • Blood supply by hepatic artery
  • Show arterial phase enhancement
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23
Q

Siderotic nodules may be regenerative or dysplastic but are seldom benign.

What imaging finding would consider a benign siderotic nodule on MRI?

A

< 20 mm
Homogeneous on all sequences (low signal)
Isoenhance compared to background cirrhotic nodules in all phases

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24
Q

Major criteria for diagnosis of hepatocellular carcinoma (LIRADS)

A
  1. Hyperenhancement in arterial phase definitely greater than background liver
  2. “Washout”
  3. Threshold growth
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25
Q

Definition of “washout” of HCC

A

During contrast-enhanced study:

Visual hypointensity/ hypodensity of the lesion compared with background liver on portal venous and delayed phases

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26
Q

Definition of Threshold Growth in HCC

A

Diameter increase of the mass by 5 mm or more

50% increase in diameter compared to prior examination ≤6 months

100% increase in diameter compared to prior examination at >6 months

New 10-mm lesion regardless of time interval

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27
Q

Ancillary sings of HCC by LI-RADS criteria

*Low yield

A
  1. Mild to moderate hyperintensity on T2WI
  2. Restricted diffusion on MR
  3. Rim of perilesional enhancement (corona enhancement)
  4. Mosaic architecture
  5. “nodule within a nodule” (HCC developing within a DN)
  6. Intralesional fat
  7. Intralesional iron sparing
  8. Intralesional fat sparing
  9. Diameter increase less than that defined as threshold growth
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28
Q

LI-RADS criteria favoring benign nodule

*Low yield

A

5 and 6 - indicates no growth

  1. Homogeneous marked hyperintensity on T2
  2. Homogeneous marked hypointensity on T2 or T2*
  3. Intralesional vessels without distortion
  4. Nodule enhancement parallels blood pool
  5. Decrease diameter
  6. Stable diameter for > 2 years
*Creator's note simplify:
#1 is a cyst
#2 is probably a siderotic nodule
#3 is a focal fat
# 4 is probably a hemangioma
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29
Q

This refers to a bulging hypertrophied expanse of the liver surrounded by atrophic fibrotic liver parenchyma

A

Hypertrophic pseudomass

Imaging features that favor pseudomass over tumor include preservation of hepatic architectures and presence of undistorted vessels traversing the lesion

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30
Q

This refers to mass-like areas of fibrosis found in livers with advance cirrhosis

A

Confluent fibrosis

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31
Q

This is a pathologic increase in portal venous pressure that results in the formation of portosystemic collateral vessels that divert blood flow away from the liver and into the systemic circulation

A

Portal hypertension

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32
Q

Signs of portal hypertension

A
  1. Visualization of portosystemic collaterals
  2. Increased portal vein diameter (>13 mm)
  3. Increased superior mesenteric and splenic vein diameters (>10 mm)
  4. Portal vein thrombosis
  5. Calcifications in the portal and mesenteric veins
  6. Splenomegaly due to vascular congestion
  7. Ascites
  8. Reversal of flow in any portion of the portal venous system (hepatofugal flow)
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33
Q

What are the portosystemic collaterals affected in portal hypertension?

A 
Coronary
Gastroesophageal
Splenorenal
Paraumbilical
Hemorrhoidal
Retroperitoneal
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34
Q

Causes of portal vein thrombosis

A

Complication of cirrhosis
Portal vein invasion or compression by tumor
Hypercoagulable states
Inflammation (pancreatitis)

*Creator;s notes:
Cirrhosis, neoplasm, inflammation, blood problem

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35
Q

Characteristic of a malignant thrombus in the portal vein

A

It is contiguous with and extends from the primary tumor

Portal vein is expanded, filled with tumor in vein of the same imaging characteristics, including enhancement, as the primary tumor

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36
Q

Characteristic of a bland thrombus in the portal vein

A

It fills a portal vein of near-normal size

On MR bland thrombus is of low signal because of its hemosiderin content
Bland thrombus does not enhance

The thrombus is hyperintense on T1WI when acute and isointense when chronic

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37
Q

This develops when small collateral veins adjacent to the portal vein expand and replace the obliterated portal vein

A

Cavernous transformation of the portal vein

These collateral veins appear as a tangle of small vessels surrounding the thrombosed portal vein

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38
Q

This refers to a group of disorders characterized by obstruction to hepatic venous outflow involving one or more hepatic veins

A

Budd-Chiari syndrome

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39
Q

Causes of Budd-Chiari syndrome

A

Coagulation disorder
Membranous webs obstructing hepatic veins or IVC
Malignant tumor invasion

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40
Q

CE CT scan finding of Budd-Chiari syndrome

A

Early images - central liver enhancement prominently while the peripheral liver enhances weakly

Delayed images - the periphery of the liver is enhanced, while the contrast has washed out of the central liver

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41
Q

What is the “comma” sign?

A

It is a comma-shaped intrahepatic collateral vessels that may be seen on CT or MR in Budd-Chiari syndrome

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42
Q

Diffuse liver disease that is a common complication of congestive heart failure and constrictive pericarditis

A

Passive hepatic congestion

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43
Q

Imaging finding of passive hepatic congestion

A

Distention of hepatic veins and IVC
Reflux of intravenous contrast into hepatic veins and IVC
Increased pulsatility of the portal vein
Inhomogeneous contrast enhancement of the liver

Note: More of vessel findings

44
Q

Hereditary disorder that increases dietary iron absorption, or secondary due to excessive iron intake usually from multiple blood transfusions or chronic diseases including cirrhosis, myelodysplastic syndrome, and certain anemias

A

Hemochromatosis

45
Q

Imaging modality of choice for hemochromatosis

A

MRI

Susceptibility effect of iron, best appreciated on T2* images, causes loss of signal in tissues with excessive iron accumulation

46
Q

What are the different patterns of hemochromatosis

A

Parenchymal pattern
Reticuloendothelial pattern
Renal pattern

47
Q

Pattern of iron deposition seen with increased iron absorption of primary hemochromatosis and with secondary hemochromatosis caused by chronic anemias (thalessemia, congenital dyserythropoietic anemias, sideroblastic anemia)

A

Parenchymal pattern

This pattern shows decreased MR signal in the liver, pancreas, and heart

The spleen and bone marrow are spared

48
Q

Pattern of iron deposition is seen in secondary hemochromatosis with iron overload caused by blood transfusions

A

Reticuloendothelial pattern

The excess iron accumulation occurs in reticuloendothelial cells in the liver, spleen, and bone marrow

MR shows diffuse decreased signal in all three areas

49
Q

Pattern of iron deposition is rare but dramatic, occurring only in patients with intravascular hemolysis caused by mechanical heart valves

A

Renal pattern

Excess iron deposition occurs in the proximal convoluted tubules of the renal cortex causing loss of cortical signal on T1WI and T2WI, reversing the normal corticomedullary differentiation pattern

50
Q

Attenuation value plain CT can detect when there is excess iron in the liver

A

72 HU

51
Q

Other causes that can increased hepatic parenchymal attenuation (such as hemochromatosis)

A 
Wilson diseases (copper deposition)
Amiodarone treatment (iodine deposition)
Colloidal gold
52
Q

This may be an ominous imaging sign associated with bowel ischemia in adults and necrotizing entrocolilis in infants

A

Gas in the portal venous system

Less ominous, causes include recent colonoscopy, enema administration, gastrostomy tube placement, abdominal trauma, inflammatory bowel disease, perforated gastric ulcer, necrotizing pancreatitis, diverticulitis, and abdominal abscess

53
Q

What are the most common hypervascular lesions in the normal liver parenchyma?

A

Hemangioma
Hepatic adenoma
Hypervascular metastases

54
Q

What are the most common hypervascular lesions in the fibrotic liver and cirrhosis?

A

Hepatocellular carcinoma

Dysplastic nodules

55
Q

Most common malignant mass in the liver

A

Metastases

56
Q

Metastases in the liver most commonly originates where?

A

GI tract
Breast
Lung

57
Q

Characteristic imaging finding of liver metastases on postcontrast CT and MR images

A

Band-like peripheral enhancement creating a “target lesion”

58
Q

This mass is second only to metastases as a common cause of a liver mass

It is the most common benign liver neoplasm

A

Cavernous hemangioma

Consist of large, thin-walled, blood-filled vascular spaces separated by fibrous septa

59
Q

Characteristic pattern of enhancement of hepatic cavernous hemangioma

A

Discontinuous nodular enhancement from the periphery of the lesion that gradually becomes isodense or hyperdense compared to the liver parenchyma

20 to 30 minutes following injection

60
Q

Most common primary malignancy of the liver

A

Hepatocellular carcinoma

61
Q

Three major patterns of large HCC (>2 cm)

A

Solitary massive
Multinodular
Diffuse infiltrative

62
Q

Pattern of large HCC that has a single large mass with or without satellite nodules

A

Solitary massive HCC

63
Q

Pattern of large HCC that appears as multiple discrete nodules involving larger area of the liver

A

Multinodular HCC

64
Q

Pattern of large HCC that has innumerable tiny distinct nodules throughout the liver distorting the parenchyma but not causing a discrete mass

A

Diffuse HCC

65
Q

Imaging characteristic of large HCC:

Hallmark finding on CE MDCT

A

Heterogeneous enhancement during arterial phase with RAPID WASHOUT of contrast during portal venous and delayed phase

66
Q

Imaging characteristic of large HCC:

Related to portal vein compression or occlusion by the tumor with compensatory increase in hepatic arterial supply appearing wedge shaped and confined to the segment of the liver with compromised portal venous supply

A

Peritumoral arterial phase enhancment

67
Q

Imaging characteristic of large HCC:

A pattern of confluent small nodules separated by thin septations and necrotic areas

A

Mosaic pattern

Best seen in T2

*Creators notes: Seems like a typical heterogeneous mass

68
Q

Imaging characteristic of large HCC:

This is seen on CT, T1WI, and T2WI as a hypointense rind up to 4 mm thick consisting of an inner fibrous layer and an outer tissue layer of compressed bile ducts and blood vessels

A

Distinct tumor capsule

69
Q

Imaging characteristic of large HCC:

Tumor projection through the capsule

A

Extracapsular extension of tumor with satellite lesions

70
Q

Imaging characteristic of large HCC:

Portal vein or hepatic vein involvement seen as enhancing tumor and lack of flow within the blood vessels

A

Vascular invasion

71
Q

Imaging characteristic of large HCC:

Occluded veins have expanded lumens, ill-defined walls

What DWI finding is seen?

A

Restricted diffusion

72
Q

Imaging characteristic of large HCC:

What is the pattern of calcifications seen?

A

Punctate, stippled or rim-like

10% of caes

73
Q

Imaging characteristic of large HCC:

Fatty metamorphosis within the tumor - This is best seen in what MR sequence?

A

Chemical shift MR

74
Q

Imaging characteristic of large HCC:

This is seen as an early or prolonged enhancement of the portal vein or as as wedge-shaped area of parenchymal enhancement adjacent to the tumor

A

Arterioportal shunting

75
Q

Imaging characteristic of large HCC:

Finding that causes the tumor to appear hyperdense on CT and T1 on MR

A

Excessive copper accumulation

*Creator’s notes: Bleed/ hemorrhage could also be the same

76
Q

This refers to a benign solid mass consisting of abnormally arranged hepatocytes, bile ducts and Kupffer cells.

It is the second most common benign liver tumor

Solitary, less than 5 cm, hypervascular with central fibrous scar containing thick-walled vessels

A

Focal nodular hyperplasia

77
Q

US finding of focal nodular hyperplasia

A

Very subtle mass, blending with surrounding parenchyma because the lesion consists of the same elements

A slight bulge in the liver contour or subtle alteration of parenchymal echogenicity may be the only clues

Color Doppler may shows central vascularity

78
Q

CT scan finding of FNH

A

Unenhanced images: Slightly hypoattenuating lesions

Postcontrast - Intense homogeneous enhancement in arterial phase sometimes with visualization of large feeding vessels

Contrast washed early on portal venous phase

Lesion is isointense and commonly near-invisible on delayed-phase images

79
Q

Key finding of FNH on MR

A

A key to diagnosis is to recognize that the lesion is near isointense to liver parenchyma on all precontrast MR sequences

The central scar, if present, is hypointense on T1 and hyperintense on T2

80
Q

Hepatocyte-specific MR contrast agents show uptake within FNH appearing iso to hyperintense to parenchyma

Images are obtained how many hours after contrast administration?

A

1 to 3 hours

81
Q

Benign tumor that carry a risk of life-threatening hemorrhage and potential for malignant degeneration

Found most commonly in women on long-term oral contraceptives

Additional risk factors: androgenic steroid intake and glycogen storage disease

A

Hepatic adenomas

82
Q

US finding of hepatic adenoma

A

Well-circumscribed tumor that is usually heterogeneous depending on presence of fat, necrosis, hemorrhage, or rarely calcification

High fat content or acute intratumoral hemorrhage makes the lesion appear hyperechoic

Contrast -enhanced US shows prominent arterial phase enhancement

83
Q

This disease is characterized by the presence of multple adenomas (>10) in an other wise normal liver in patients

Usually young women without risk factors for hepatic adenomas

A

Liver adenomatosis

Considered as a sperate clinical entity

84
Q

A hepatocellular malignancy that typically present as large liver mass in an adolescent or young adult (ave age 23)

No risk factors for HCC

No AFP elevation

No cirrhosis or chronic liver disease

Surrounding liver is normal

A

Fibrolamellar carcinoma

85
Q

Characteristic appearance of fibrolamellar carcinoma

A

Large, lobulated hepatic mass with central scar and calcifications

Creator’s notes: Similar to FNH

86
Q

Finding of hepatic lymphoma

A

Diffusely infiltrative and undetectable by imaging methods
Poorly defined hypodense mass
Hypodense T1, variabal intensity T2
Lesion enhances poorly or not at all

87
Q

MR finding of hepatic hematomas

A

Subacute - bright on T1WI (effect of methemoglobin)
Chronic hematomas - dark on T2WI (effect of hemosiderin)
Rim enhancement

88
Q

Also known as Osler-Weber-Rendu syndrome

Autosomal dominant disorder of fibrovascular dysplasia resulting in multiple telangiectasias and arteriovenous malformations

A

Hereditary hemorrhagic telangiectasia

89
Q

Clinical findings of hereditary hemorrhagic telangiectasia

A

Epistaxis
Intestinal bleeding

If AV fistulas in the liver: Pain, jaundice, portal hypertension, and high-output cardiac failure

90
Q

In hereditary hemorrhagic telangiectasis

Term used for nodular transformation of the liver parenchyma without fibrosis

A

Pseudocirrhosis

91
Q

In hereditary hemorrhagic telangiectasia:

What is the appearance of a telangiectasia

A

Hypervascular rounded masses resembling an asterisk

Usually a few millimeters in size

They may become confluent to form large vascular masses

92
Q

This is a rare disorder associated with chronic wasting from cancer or tuberculosis, or associated with use of oral contraceptives or anabolic steroids

A

Peliosis hepatis

93
Q

Imaging finding of peliosis hepatis

A

Cystic dilatation of the hepatic sinusoids and multiple small (1 to 3 mm) blood-filled spaces characterize the lesions

MR shows variable signal due to hemorrhage on T1
Hyperintense on T2

94
Q

Imaging findings of benign hepatic cyst

A

US - anechoic with thin walls and may have fine thin septa
Posterior acoustic enhancement confirms their fluid nature
Internal debris - if they have internal hemorrhage or previous infection

CT - low internal attenuation near water, thin walls, and thin septa w/o enhancing solid components

MR - homogeneous low signal on T1W and homogeneous low signal on T2W

Cyst do not enhance

*Creator’s notes:
AS ALL CYST SHOULD BE

95
Q

It is in the spectrum of autosomal dominant polycystic disease and occasionally occurs in the absence of polycystic kidneys

A

Polycystic liver disease

Number and size of cysts increase over time and may eventually result in massive hepatomegaly and affect hepatic function

Cysts are prone to hemorrhage and infection

96
Q

Also known as von Meyenburg complexes

These are small benign neoplasms consisting of dilated cystic branching bile ducts embedded within fibrous tissue

A

Bile duct hamartomas

97
Q

Bile duct hamartomas are best recognized on what modality?

A

MR

They appear as multiple tiny (<1 cm) cystic lesions throughout the liver

They are low signal on T1WI, high signal on T2WI, and show peripheral enhancement postcontrast

CT shows widespread tiny cystic lesions
The cysts are usually too small to be seen with US

98
Q

Rare cystic neoplasm of the biliary epithelium

Tumors typically contain mucin and appear as large (up to 35 cm) multiloculated cystic mass

A

Biliary cystadenoma/ cystadenocarcinoma

99
Q

Findings seen on biliary cystadenoma/ cystadenocarcinomas

A

Cyst adenomas - fine septations

Cystadenocarcinomas - may have mural nodules and papillary projections

100
Q

Presence of thick, coarse calcifications favors:

a. Biliary cystadenoma
b. Biliary cystadenocarcinoma

A

b. Biliary cystadenocarcinoma

101
Q

Usual pathogens that cause pyogenic abscess

A

E. coli
S. aureus
Streptococcus
Anaerobic bacteria

102
Q

Imaging finding of pyogenic abscess

A

Echongenic/ appear solid on US
Peripheral rim enhances with contrast
Gas is present within the lesion

103
Q

Amebic abscess is usually caused by what pathogen?

A

Entamoeba histolytica

Patient often resides or has travelled to endemic areas (India, Africa, the Far East, Central and South America)

104
Q

“anchovy paste” material is seen on:

a. Pyogenic abscess
b. Amebic abscess
c. Hydatid cyst

A

b. Amebic abscess

105
Q

Pathogen of hydatid cyst

A

Echinococcus granulosis or E. multilocularis tapeworn

106
Q

Finding of hydatid cyst

A

Single or multiple cystic masses usually have well-defined walls that commonly calcify (50%)

The cyst wall and septations usually enhance

Daughter cysts may be visualized within the parent cyst

Gastrointestinal Imaging (Beri) (26 decks)

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