Liver Pathologies Flashcards
Granuloma
Definition/Description: A collection of immune cells that forms when the body attempts to wall of foreign substances that it is unable to eliminate. They mostly occur in the parenchyma.
Signs and symptoms: usually asymptomatic, even with extensive infiltration. They may cause minor hepatomegaly and little to no jaundice.
Lab Values: ALP elevated. Diagnosis of granulomas is usually based on liver biopsy.
Sonographic findings and their USA: Granulomas of the liver may be multiple and small, in which case the liver may look coarse and hyperechoic. More often they are small, discrete lesions which may be hypo- or isoechoic. They sometimes have a hypoechoic rim like a target, or calcified with distal shadowing.
Hepatitis
Definition/Description: an inflammatory and infectious disease of the liver, of which there are many causes. It can either be acute or chronic.
Characteristics: Mild inflammation impairs hepatocyte function, whereas more severe inflammation and necrosis may lead to obstruction of blood and bile flow in the liver and impaired liver cell function.
Signs and symptoms: may initially present with flu-like and GI symptoms. Specifically with chronic hepatitis, patients may present with anorexia, weight loss, tremors, jaundice, dark urine, fatigue, and varicosities.
Lab Values: For both acute and chronic hepatitis, patients may have elevated AST, ALT, and Bilirubin, as well as leukopenia (decreased WBC’s.)
Sonographic findings and their USA: Acute hepatitis appears as normal to slightly increased echogenicity of the liver parenchyma, increased brightness of portal vein borders, hepatosplenomegaly, and increased GB wall thickness. Chronic hepatitis appears as coarse hepatic parenchyma with increased echogenicity, decreased visualization brightness of portal triad, and any fibrosis may produce soft shadowing.
Pyogenic (bacterial) abscess
Definition/Description: a pus-forming abscess.
Signs and symptoms: Fever, RUQ pain, pleuritis, nausea, vomiting, and diarrhea.
Lab Values: Elevated liver function tests and WBC count; Anemia
Sonographic findings and their USA: Varies- hypoechoic to complex to hyperechoic when fluid level present; round to oval or irregular with sizes that vary from 1-cm to very large; complex; right central lobe most common site.
Amebic abscess
Definition/Description: A collection of pus formed by disintegrated tissue in a cavity.
Characteristics: Usually in liver, but primarily a disease of the colon that spreads to the liver, lungs, and brain.
Causes/Associated with: Caused by protozoan parasite Entamoeba histolytica by ingesting the cysts in contaminated water and food.
Signs and symptoms: May be asymptomatic or may show GI symptoms of abdominal pain, diarrhea, leukocytosis, and low fever.
Lab Values: Elevated WBC’s
Sonographic findings and their USA: Mass is variable; round or oval; lack notable borders; hypoechoic with debris.
Fungal abscess (Candidiasis)
Definition/Description: Infection of the liver caused by a species of Candida, usually in immunosuppressed patients.
Characteristics: Small abscesses randomly spread throughout the organ.
Signs and symptoms: Persistent fever; localized pain.
Lab Values: Elevated WBC
Sonographic findings and their USA: Multiple small hypoechoic masses with echogenic central core; “bullseye” lesions; “wheel-within-wheel” pattern.
Echinococcal cyst (Hydatid disease)
Definition/Description: Infectious cystic disease common in sheep-herding areas of the world.
Characteristics: A tapeworm that infects humans as the intermediate host; The cysts have 2 layers: inner and outer (inflammatory or reaction) layer. Smaller, daughter cysts may develop from the inner layer.
Signs and symptoms: RUQ pain and tenderness, hepatomegaly, jaundice, fever and/or anaphylactic reaction.
Lab Values: Elevated WBC
Sonographic findings and their USA: Varies from simple cyst to complex cysts; acoustic enhancement; oval or spherical; calcifications; honeycomb appearance or “water lily” sign.
Schistosomiasis
Definition/Description: Schistosomiasis is and infection caused by a parasitic worm, Schistosoma, causing periportal fibrosis and liver cirrhosis due to deposition of eggs in the portal venous system.
Signs and symptoms: Abnormal LFT, jaundice, GI symptoms, abdominal pain, weakness, shortness of breath.
Lab Values: May have elevated BUN, creatinine, hyperglobulinemia, and hypoalbuminemia.
Sonographic findings and their USA: Fibroids around portal vein appear as well-defined, solid masses with similar echogenicity to the liver, but sometimes may be hypoechoic; “pipe-stem” fibrosis.
Sonographic findings related to AIDS
Definition/Description: Many of the anti-viral medications used to treat HIV and AIDS can cause hepatotoxicity.
Characteristics: AIDS patients may have the following liver characteristics: hepatomegaly, portal hypertension, periportal fibrosis, fatty fibrotic changes, extrahepatic ducts dilatation.
Signs and symptoms: Jaundice, GI symptoms, symptoms of other liver diseases associated with AIDS.
Lab Values: Depends on cause of liver problems, but will typically show elevated liver enzymes if liver damage is present.
Sonographic findings and their USA: Depends on underlying condition. May have hepatomegaly, dilated portal vein, ascites, fibroids (solid, well-defined masses).
Fatty infiltration
Definition/Description: Acquired, reversible disorder, resulting in an accumulation of triglycerides within hepatocytes.
Characteristics: Increased lipid accumulation in the hepatocytes- benign process.
Signs and symptoms: Asymptomatic; Possible jaundice, nausea and vomiting, and abdominal tenderness/pain.
Lab Values: Normal to elevated liver enzymes; Elev. alk phos. and direct bilirubin.
Sonographic findings and their USA: Increased echogenicity and attenuation of liver parenchyma; Impaired visualization of borders of portal/hepatic structures; Hepatomegaly; May be patchy/inhomogeneous; Focal sparing.
Cirrhosis
Definition/Description: Chronic, degenerative disease of liver in which lobes are covered with fibrous tissue, the parenchyma degenerates, and the lobules are infiltrated with fat. Results in lobular architecture. Micronodular (0.1-1.0 cm nodules) or macronodular (nodules up to 5 cm.)
Signs and symptoms: May be asymptomatic; Nausea, flatulence, ascites, light-colored stools, weakness, abdominal pain, varicosities, and spider angiomas. **Classic presentation- hepatomegaly, jaundice, and ascites.
Lab Values: Elevated Alk phos, Direct bilirubin, AST, ALT and leukopenia (decreased WBCs)
Sonographic findings and their USA: Coarse liver parenchyma with nodularity; Increased echogenicity and attenuation; Decreased vascular markings with acute cirrhosis; Hepatosplenomegaly with ascites; Shrunken liver with chronic cirrhosis (also inc. nodularity); Regeneration of hepatic nodules; Portal hypertension.
Portal systemic collaterals
Definition/Description: When normal venous channels become obstructed and diverted blood causes embryologic channels to reopen.
Characteristics: Blood flows hepatofugally (away from liver) and into collateral vessels (gastric veins, esophageal veins, recanalized umbilical vein, splenorenal, gastrorenal, retroperitoneal, hemorrhoidal, or intestinal veins). **In 80-90% of patients, collateral flow is through coronary (gastric) and esophageal veins.
Signs and symptoms: Symptoms of PV hypertension- jaundice, GI bleeding.
Lab Values: Decreased WBC and platelets; Increased liver enzymes
Sonographic findings and their USA: Dilated venous structures near the SMV-splenic vein confluence, the MPV, and the gastric vein. Recanalized umbilical vein looks like bullseye in trans. Use Doppler to assess flow characteristics within PV system.
Surgically created portosystemic shunts
Definition/Description: An artificial channel within the liver that establishes communication between the inflow portal
vein and the outflow hepatic vein.
Characteristics:TIPS or TIPSS
Sonographic findings and their USA: Ultrasound is used to evaluate for patency of the shunt. Stenosis may occur at the hepatic vein level or within the shunt. The shunt itself appears hyperechoic as it is composed of metal. The shunt makes the vessel walls appear hyperechoic.
Liver transplantation
Definition/Description: Hepatectomy and replacement with a cadaveric allograft, revascularization of a new liver.
Performed in patients with end-stage liver disease to eliminate irreversible disease.
Sonographic findings and their USA: Vascular structures of liver should be assessed for size and patency in the preoperative evaluation along with a liver parenchyma and biliary system evaluation. Normal liver transplant should have homogeneous or slightly heterogeneous echotexture. Vascular patency of the transplant is assessed and biliary tree should appear normal. Small amount of free intraperitoneal fluid or small periphepatic seroma/ hematoma may be present right after surgery but should resolve within a week.
Portal vein thrombosis
Definition/Description: Clotting or obstruction of blood flow along the portal vein and into the liver.
Signs and symptoms: May cause portal vein hypertension. Ascites is a primary complaint, causing abdominal pain. Other symptoms may include nausea, vomiting, and diarrhea.
Lab Values: D-dimer levels in the blood may be elevated
Sonographic findings and their USA: Absence of portal flow with an echogenic thrombus within the lumen of the portal vein, the development of portal vein collaterals, expansion of the caliber of the vein, and cavernous transformation of the vessels. Ascites is usually visualized on the ultrasound. Splenomegaly and bleeding varices may also be present.
Budd-Chiari syndrome
Definition/Description: An uncommon, often dramatic illness caused by thrombosis of the hepatic veins or IVC.
Characteristics: Budd-Chiari syndrome is best treated by liver transplantation in patients with end-stage liver disease.
Signs and symptoms: Abdominal pain, massive ascites, and hepatomegaly. Ascites is the most characteristic clinical
feature of the disease. Other symptoms include jaundice, vomiting, and diarrhea. Edema of the legs may be present if the thrombus is in the IVC.
Lab Values: Albuminuria may be present. Aminotransferases and alkaline phosphatase indicate mild or moderate impairment of hepatic function, depending on the stage of the disease.
Sonographic findings and their USA: The caudate lobe is enlarged, usually with atrophy of the right lobe of the liver. The liver appears hypoechoic in the early stages of acute thrombosis and appears hyperechoic and inhomogeneous with fibrosis in the later stages. The hepatic veins are enlarged with thrombosis, but in chronic cases of Budd-Chiari syndrome they are not usually visualized. At least one vein may show abnormalities such as stenosis, dilation, thick wall echoes, abnormal course, extrahepatic anastomoses, and thrombosis. Doppler may show altered blood-flow patterns in the hepatic veins and IVC. Flow may change from phasic to absent, reversed, turbulent, or continuous.
