liver pathology Flashcards
what is the etiology of a focal lesion of the liver (cystic)?
how can you tell if its a true cyst?
Congenital (True): usually are a result of a defect during development of the bile ducts.
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secondary reasons for cyst development: Traumatic
Parasitic:, Inflammatory
A true cyst will have an epithelial lining; epithelium is one of the primary tissues. This tissue type is found in coverings and linings. Skin-coverings Cyst-linings It is the epithelia lining which makes the fluid, there for if aspirated they will re-occur. Abscesses, parasitic, and post traumatic are not true cysts because they lack the epithelial lining.
what are the clinical signs of a focal lesion (simple hepatic cyst).
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Asymptomatic, unless very large
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Normal LFT’s, unless causing bili. obstruction (but normally doesn’t happen)
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Usually incidental finding
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More common in females than males
what is the us appearance of a simple hepatic cyst (focal lesion)
what can you adjust to get the best picture.
Smooth, thin walled
Anechoic
Posterior enhancement; through transmission
These are items that you as a sonographer need to make sure demonstrate in the image. Use the gain, TGC, depth, and transducer angles to make sure a cyst looks like a cyst.
what do you see? how can you tell?
Smooth walls Anechoic/mostly anechoic; fluid filled Through transmission
what is the etiology of polycystic liver dx?
autosomal dominant
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60% of patients with polycystic liver dz will have associated polycystic renal dz
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50-70% of patients with polycystic renal dz will have 1 or multiple liver cysts
what clinical signs are associated w/ ploycystic liver dx?
give some examples
Asymptomatic, unless large
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Normal LFT’s, unless biliary obstruction, jaundice
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Or complication of Polycystic dz, like infection, hemorrhage. an be kidney or liver
e.
e.g. decrease in hemoglobin or hematocrit means she is bleeding or hemorrhaging. for infection - could be running a fever, increased wbc, chills…
what is this? how can you tell?
what would you check after finding this?
Sonographic appearance
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Smooth walled- most a thin walled, but this can be hard to tell when cysts are of all sizes
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Anechoic
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Posterior enhancement
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Additional steps
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Check kidney’s, pancreas, spleen for cysts. multi-organ ands opposed to simple cysts which are generally just one organ
ddx for polycystic liver dx
Necrotic metastasis - cancer. h/o 70 lb weight loss etc
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Echinococcal (e-kin-no-coccal) cyst - tapeworms. (hang out w/ some sheep, went to a different country) may be assymptomatic.
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Hepatoma
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Abscess - increased wbc
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Liver cystadenoma
what etiolgies are there associated w/ a hematoma?
what would the labs show a decrease in….?
what do you need ot be aware about for the sonographic appearance?
H/O Trauma
Bleeding disorder
The epithelial lining of the cyst bleeds
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Lab
May have a decrease in hemaglobin
May have a decrease in hematocrit
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Sonographic appearance
Differs with age of hematoma
what do you see here?
what is the sonographic difference? what is the difference b/t resolving and chronic
after a few days pass it starts to organize and begins to harden
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Acute: anechoic or swirling debris seen. Anaechoic before coagulation starts to take place, swirling if large amount of blood is within hematoma, or clotting is just beginning.
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Subacute: complex clot, anechoic with clot and/or dependent layering. Organization of clot has occurred, may see dependent debris layering within the hematoma.
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Resolving: partially anechoic with enhancement
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Chronic: anechoic with calcifications, or solid gelatinous stuff
what do you see?
hematoma
_____ are one-celled organisms visible only with a microscope. They’re so small that if you lined up a thousand of them end to end, they could fit across the end of a pencil eraser. They’re shaped like short rods, spheres or spirals.
____ are much smaller than cells. In fact, viruses are basically just capsules that contain genetic material. They may be shaped like rods, spheres or tiny tadpoles. To reproduce, viruses invade cells in your body, hijacking the machinery that makes cells work. Host cells are eventually destroyed during this process.
There are many different varieties of ____, and we eat quite a few of them. Mushrooms are fungi, as is the mold that forms the blue or green veins in some types of cheese. And yeast, another type of fungi, is a necessary ingredient to make most types of bread.
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_____are single-celled organisms that behave like tiny animals —hunting and gathering other microbes for food. Many protozoa call your intestinal tract home and are harmless. Others cause disease, such as:
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____ are among the larger parasites. The word comes from the Greek for “worm.” If this parasite — or its eggs —enters your body, it takes up residence in your intestinal tract, lungs, liver, skin or brain, where it lives off the nutrients in your body. The most common form are tapeworms and roundworms.
Bacteria
Viruses
fungi
Protozoa
Helminths
what does this etiology describe?
Liver parenchyma is disintegrated by a parasite, usually a protozoan. Liver tissue disintegrates and pus is formed in the cavity. The organism is called (Entamoeba histolytica)
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Common world wide, reaches the liver via the portal vein. Takes a long time to heal. With as many foreign people that are in this country, city going to school it isn’t too unusual to find this type of abscess. There are no U/S specific findings. It will look like any other abscess. It will be the pt.s history that will help in the diagnosis, and the lesion may need to be aspirated to find the specific pathogen. That way the correct course of antibiotics can be used.
amebic abscess - get in thru portal system (which comes from intestine)
what are some clinical signs of an amebic abscess?
Asymptomatic
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Symptoms can include fulminating dysentery, bloody diarrhea, weight loss, fatigue, abdominal pain, and amoeboma. The amoeba can actually ‘bore’ into the intestinal wall, causing lesions and intestinal symptoms, and it may reach the blood stream. From there, it can reach different vital organs of the human body, usually the liver, but sometimes the lungs, brain, spleen, etc. A common outcome of this invasion of tissues is a liver abscess, which can be fatal if untreated. Ingested red blood cells are sometimes seen in the amoeba cell cytoplasm.
what is this?
amebic abscess. an anaerobic partisitic protozoan
what focal lesion…
Routes of entry bili tree, pv, ha, direct extension from a contiguous infection and trauma.
Sources of infection include cholangitis, diverticulitis, colitis, and direct spread from an adjacent organ, infarction after embolization and in a trauma with direct contamination.
Most common organism to cause this is Escherichia coli and other anaerobic bacteria.
Clinical signs »Fever, pain, N/V, diarrhea
Pyogenic Abscess : “pus forming”
what is this? describe it sonographically.
hint: – Lab: Increased LFT’s, Leukocytosis Increased WBC, anemia
pyogenic abscess
Multiple abscess formation in 50-67% of pts. Size is variable from 1cm to very large.
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Hypoechoic, acoustic enhancement, shaggy walls, dependent debris, may have a fluid - fluid level. Gas may be present in which case the would be a strong echo with dirty shadowing.
what will • US alone will not differentiate these two types of abscess. A sample will need to be aspirated and sent to the microbiology lab where they will cultivate the sample. Once they have a large enough sample they will identify it and use different antibiotics on it to see which is most efficacious.
pyogenic and amebic abscess
what is a Echinococcal cyst ? what is is aka
Hydatid cyst
The worm has a life cycle that requires definitive hosts and intermediate hosts. Definitive hosts are normally carnivores such as dogs, while intermediate hosts are usually herbivores such as sheep and cattle. Humans function as accidental hosts, because they are usually a ‘dead end’ for the parasitic infection cycle. *
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The disease cycle begins with an adult tapeworm infecting the intestinal tract of the definitive host. The definitive host is usually a carnivore. The adult tapeworm then produces eggs which are expelled in the host’s feces. Intermediate hosts, usually herbivores, become infected by ingesting the eggs of the parasite. Ingestion of eggs can occur by consumption of fecal contaminated food. Inside the intermediate host, the eggs hatch and release tiny hooked embryos (called protoscoleces) which travel in the bloodstream, eventually lodging in an organ such as the liver, lungs and/or kidneys. There, they develop into hydatid cysts. Inside these cysts grow thousands of tapeworm larvae, the next stage in the life cycle of the parasite. When the intermediate host is predated or scavenged by the definitive host, the larvae are eaten and develop into adult tapeworms, and the infection cycle restarts.
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The resultant cyst has two layers, small daughter cysts may develop from the inner layer. The cysts can grow quite large and rupture. The cyst can also impinge on blood vessels, leading to infarction or thrombosis.
_____ can be Asymptomatic…
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Dull pain, shock if large cyst ruptures. Complications of rupture, infection, bleeding.
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These can spread to the brain and other organ within the body if left untreated.
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Mortality rate in some parts of the world are 50-60% and go up to 100% if left untreated.
Echinococcal cyst aka Hydatid cyst
a _______ may have an increase in labs alkaline phosphatase. »
Simple looking cyst to complex with enhancement. Oval, round, walls may be fairly smooth or irregular.
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Can have calcifications.
echinicoccal cyst
note; If a cyst within a cyst is seen, small daughter cysts, echinococcal disease should be suspected R/O
what is this?
Echinococcal cyst
what focal lesion is
Asymptomatic unless large, can cause pain, ache
Can hemorrhage into the lesion causing pain.
Can increase in size with pregnancy
Cavernous Hemangioma aka Hemangioma
identify these.
A. Classic appearance
B. Single large hemagioma
C. Slightly echogenic, central area of hypoechogenicity, maybe due to necrosis Atypical
E. Classical and Atypical
F. Atypical
G. Exophytic
H. Hypoechoic with through transmission
I. 2 hyperechoic, one with calcification
what might this be…
34yo male with RUQ pain
Atypical hemangioma
what is the Most common benign vascular liver tumor in the first 6 months of life. define it.
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Clinical Presentations
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CHF 2o Arteriovenous shunting, Hepatomegaly, rarely associated with cutaneous hemangiomas.
Liver Masses
Infantile Hemangioendothelioma
Benign vascular liver tumor composed of anastomosing vascular channels lined by plump endothelial cells
what lesion has – Variable echogenicity, Hepatomegaly, Large solitary lesions are often associated with central hemorrhage or necrosis. in 2D
Doppler – Increased flow within lesion
Infantile Hemangioendothelioma
*large HV’s, all this blood is flowing into the Rt. heart
what is the 2nd most commong tumor of the liveR?
secondary to what?
describe it.
Focal nodular hyperplasia (FNH) is the second most common tumor of the liver, surpassed in prevalence only by hepatic hemangioma. FNH is believed to occur as a result of a localized hepatocyte response to an underlying congenital arteriovenous malformation. FNH is a hyperplastic process in which all the normal constituents of the liver are present but in an abnormally organized pattern. Results of liver function tests in these patients usually are within the reference range. Hormonal influences may be a factor because FNH is more common in females than males, particularly in childbearing years. Like hemangiomas FNH is invariably an incidental finding.
what clinical signs are associated w/ focal nodular hyperplasia.
what labs?
Asymptomatic, typically female with h/o BCP (birth control pills) use, under 40 y.o.
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Also found in pt. post anti-neoplastic therapy for tumors elsewhere in the body.
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Labs –None
what liver dx is Generally; subtle mass, variable echo appearance, can be difficult to differentiate from surrounding liver parenchyma.
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US contrast is useful to make the diagnosis.
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Correlative imaging: Nuc. Med will be normal
Focal Nodular Hyperplasia
what is • Less common than FNH. Has been a dynamic rise, that has been clearly linked to BCP usage. Again, mostly found in females typically as an incidental finding.
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The hepatocytes contain fat and glycogen and can produce bile; however, no bile ducts are present. A characteristic lack of portal vein tracts and terminal hepatic veins is noted. Approximately 80% of adenomas are solitary, and 20% are multiple. Most hepatic adenomas do not contain Kupffer cells.
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Histologically, sheets of well-differentiated hepatocytes characterize hepatic adenomas.
hepatic adenoma
what is Usually solitary, well encapsulated tumor 8-15cm in size. Pathologically normal or slightly atypical hepatocytes.
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Clinical Signs
Asymptomatic, usually female (BCP usage), these benign tumors can bleed into themselves and cause pain.
hepatic adenoma
looks like everything else but less common than fnh
what liver tumor has
Associated findings:
Beckwith-Wiedemann Syndrome
Hemihypertrophy
Precocious puberty
what type of tumor is it?
Hepatoblastoma
Germ Cell Tumor
Infantile form of hepatocellular carcinoma
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what is the Most common primary malignant liver tumor in kids under 5
hepatoblastoma
what has
Clinical presentation:
Increased Alpha-fetoprotein (AFP - tumor marking protein created by CNS), Increased girth, Hepatomegaly, Wt. loss, N/V, Precocious puberty
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Sonographic findings
Heterogeneous or Complex
Poorly marginated
Calcification may be seen
May have areas of necrosis
Hepatoblastoma
what is Related to Hepatitis B and C 80% of these tumors occur in cirrhotic livers.
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More common in men then women and more common in blacks then whites.
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Disease is silent and usually is in an advanced stage by the time it is diagnosed. Pt has only 3-4 months to live.
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Hepatocellular Carcinoma
Primary liver cancers are relatively rare.
This is why we screen some many pt. for HCC.
what has the following sonographic appearance?
Varies
Usually more or less echogenic then liver. So they can be hyper or hypo echoic.
Ill defined borders
Solitary or multiple lesion. It can be also be diffusely spread through the liver.
Hepatocellular carcinoma
what are teh most common liver malignancies?
where is the etiology
metatastic liver dx
primary sites: colon, breast, lung
Clinical signs
Same as hepatoma
Asymptomatic
RUQ pain, palpable mass, hepatomegaly, jaundice if bili obstr., liver failure, weight loss, ascites, fever
If mass is impinging on PV, pt can have Portal HTN and splenomegaly.
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Labs
Same as hepatoma, with the exception of the Alpha feto protein.
Abnormal LFT’s
Increased bili’s if obstruction occurs.
Sonographic appearance
Varied
Well-defined hypoechoic mass, lymphoma
Well-defined hyperechoic mass, colon CA
Mixed echos
Bull’s eye or target pattern: Hypoechoic peripheral zone
metastatic dx
identify the following
A. Multiple tiny hyperechoic metastases from choriocarcinoma
B. Adenocarcinoma; metastatic dz from colon CA
C. Large, echogenic poorly differentiated adenocarcinoma (we do not know where it came from)
D. Panc
E. Lung
F. Unknown
G. Cystic metastastes; liposarcoma
H. Cystic metastastes; sarcoma (connective tissues) from small bowel
I. Cystic metastastes; neuroendocrine tumor (Neuroendocrine tumor refers to the type of cell that a tumor grows from rather than where that tumor is located. Neuroendocrine cells produce hormones or regulatory proteins, and so tumors of these cells usually have symptoms that are related to the specific hormones that they produce)
what do you see?
metastatic dx
The following image shows an incidental finding in a 28 yo women, being scanned to R/O gallstones. Of the following choices which does this most likely represent?
a) hepatic cystadenoma
b) cavernous hemangioma
c) solitary hepatocellular carinoma
d) hemorrhagic cyst
b
