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ABD > Liver Pathology > Flashcards

Liver Pathology Flashcards

1
Q

What are granulomas, what are they caused by and what is their sonographic appearance?

A

a small collection of macrophages
caused by histoplasmosis or TB
small organized calcifications in the liver/spl

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2
Q

What causes histoplasmosis?

A

spores (fungus) floating in the air, grows in the bird/bat droppings, commonly found in chicken/pigeon coops, old barns, caves

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3
Q

What is hepatitis?

A

Liver inflammation resulting from infectious (viral, bacterial, fungal, and parasitic organisms) or noninfectious (medications, toxins, and autoimmune disorders) agents

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4
Q

Labs associated with hepatitis

A

elevation of ALT, AST, conjugated/unconjugated bilirubin

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5
Q

Viral infections account for most cases of hepatitis. May occur through blood transfusions and transplants. What are the general routes of transmission for HAV, HBV, HCV?

A

HAV - fecal/oral
HBV - blood/body fluids
HCV - blood/body/fluids (usually from sharing of drug needles)

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6
Q

What is the most frequent cause/indication for liver transplantation

A

HCV associated chronic liver disease

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7
Q

Sonographic appearance of acute hepatitis

A

hypoechoic liver parenchyma
liver enlargement
hyperechoic portal vein walls (“starry night” from periportal cuffing)
-generally prominent vessels from the decrease in parenchyma

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8
Q

Sonographic appearance of chronic hepatitis

A

hyperechoic liver parenchyma
small liver
decreased echogenicity of portal vein walls

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9
Q

Bacteria can reach the liver via bile ducts, portal veins, hepatic arteries, or lymphatic channels but ______ ______ disease is the most common source of pyogenic (bacterial) liver abscesses.

A

Biliary tract disease because obstruction of bile flow allows bacterial proliferation. Common inciting conditions include: biliary stone disease, obstructive malignancy affecting biliary tree, strictures, congenital diseases

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10
Q

T/F - Pyogenic bacterial abscesses more often affect the left lobe of the liver.

A

False - they affect the right lobe more than left, 2:1

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11
Q

Sonographic appearance of pyogenic abscess

A

a complex mass in the liver with gas and reverberation artifact

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12
Q

Symptoms of a pyogenic abscess

A 
RUQ pain
leukocytosis
fever
elev LFTs 
(aspiration is needed to confirm Dx)
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13
Q

3 major forms of liver abscesses

A

Pyogenic (polymicrobial), 80% of cases in US
Amebic (Entamoeba histolytica), 10%
Fungal (Candida), 10%
*Hint - differentiation of pyogenic from amebic is difficult, take note if the patient has traveled outside of the US)

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14
Q

Amebic abscess- symptoms and labs

A 
RUQ pain (hepatomegaly)
diarrhea
fever
leukocytosis
elevated LFTs
*onset of symptoms usually 8-12 weeks from date of travel
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15
Q

Sonographic features of an amebic liver abscess

A

round, hypoechoic, complex mass
typically in the RT dome of the liver
contiguous with the capsule
aspiration may be needed to conform Dx

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16
Q

Etiology of an amebic liver abscess

A

parasite (amoeba) from the intestines, reaches the liver via the MPV
*occurs almost exclusively in immigrants and travelers
(most common extraintestinal complication of amoebic dysentery)

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17
Q

T/F - the appearance of fungal liver abscesses can change over the course of the disease process.

A

True

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18
Q

sonographic appearance of fungal liver abscesses

A

“Wheel within a wheel” - lesion with peripheral hypoechoic zone, inner echogenic wheel and hypoechoic center; earliest manifestation of infection and most recognizable
“Bull’s eye” - when the hypoechoic center calcifies
Uniformly hypoechoic focus - most common presentation
Echogenic focus - calcifications representing scar formation seen late in the disease process

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19
Q

_______ abscess is due to a mycotic infection in the blood that results in small liver abscesses.

A

Fungal abscess (candidiasis)

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20
Q

Humans become infected from either directly handling or from ingesting food contaminated with tapeworm eggs passed from the fecal material of infected carnivores (sheepdog).

A 
Echinococcal Cyst (Hydatid disease) 
The eggs hatch into embryos in the intestines, penetrate the lining and are carried by blood to major filtering organs, and then develop into cysts.
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21
Q

Sonographic appearance of Hydatid disease

A

“Cyst within a cyst”
“Water-lily sign” - detachment of the endocyst membrane, resulting in floating membranes within the pericyst
Classically described on plain x-ray when the collapsed membranes are calcified

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22
Q

Lab studies for echinococcal cyst

A

Casoni skin test

detection of anti-echinococcus antibodies (indirect hemagglutination, enzyme-linked immunosorbent assay)

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23
Q

Rupture of aspiration of echinococcal cyst is associated with _______ shock.

A

Anaphylactic

treatment is epinephrine by injection

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24
Q

One of the most common parasitic infections in humans.

A

Schistosomiasis

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25
Q

_______ is the genius of several species of parasitic trematodes.

A

Schistosomiasis

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26
Q

In addition to HCV, ______ is another major cause of portal HTN worldwide and is endemic to tropical areas.

A

Schistosomiasis

not common in US but estimated 400,000 infected persons have immigrated

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27
Q

Schistosomiasis eggs reach the liver through the portal vein, inciting a granulomatous reaction resulting in _________ fibrosis.

A

Periportal fibrosis - intrahepatic vein become occluded resulting in portal HTN

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28
Q

sonographic findings associated with Schistosomiasis

A

occluded intrahepatic portal veins

thickening of portal vein walls

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29
Q

Secondary signs of portal HTN

A

splenomegaly
ascites
esophageal variceal bleeding
portosystemic collaterals (aks portal-systemic venous collaterals)

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30
Q

Complications of HIV (9)

A

TB
Cytomegalovirus
Candidiasis
Cryptococcal meningitis
Toxoplasmosis
Kaposi’s sarcoma - tumor of blood vessel wall
Lymphomas - swelling of LN in neck, armpit, groin
Kidney disease/nephropathy - inflammation of the glomerulus, presents as larger than normal kidneys on ultrasound

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31
Q

Accumulation of triglycerides within the hepatocytes is known as?

A

Fatty infiltration of the liver, steatosis

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32
Q

Fatty liver disease is most commonly associated with _______ syndrome.

A

Metabolic syndrome (DM II, obesity, hypertriglyceridemia)

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33
Q

In addition to metabolic syndrome, _______ liver disease is associated with drugs, alcohol, metabolic abnormalities, nutritional status, and other health problems.

A

fatty

incidence of fatty liver disease in approx. 30% in the US

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34
Q

Sonographic appearance of fatty liver steatosis

A

increased echogenicity and decreased acoustic penetration

increased attenuation makes it difficult to see the posterior liver and diaphragm

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35
Q

What are the two patterns of fatty infiltration?

A

Focal fatty infiltration - focal regions of inc. echogenicity within normal liver parenchyma, commonly occurs around the porta hepatis

Focal fatty sparing - focal regions of normal liver prarenchyma within a fatty liver, sparing commonly occurs near the GB, porta hepatis, caudate lobe, and liver margins

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36
Q

________ _______ ______ is a genetically acquired disorder that results in the excess deposition of glycogen in the liver and is associated with fatty infiltration and hepatic adenomas.

A

Glycogen Storage Disease

A person with GSD has an absence or deficiency of one of the enzymes responsible for making or breaking down glycogen

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37
Q

There are 11 types of GSDs, Type 1a, caused by a defect in enzyme glucose -6-phosphatase, was originally known as _____ ________ ________.

A

von Gierke’s Disease

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38
Q

Diffuse process of fibrosis and distortion of normal liver parenchyma

A

Cirhosis

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39
Q

Condition in which there may be initial liver enlargement, but continued insult results in hepatic atrophy resulting in blood coagulopathy, hepatic encephalopathy, and portal HTN

A

Cirrhosis

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40
Q

Causes of cirrhosis (6)

A 
HCV
alcoholic liver disease
Non-alcoholic fatty liver disease (NAFLD)
non-alcoholic steatohepatitis (NASH)
HBV
Misc
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41
Q

Miscellaneous causes of cirrhosis (8)

A 
autoimmune hepatitis
primary biliary cirrhosis
primary sclerosing cholangitis
hemochromatosis (iron deposition)
Wilson diseases (copper deposition)
Drug-induced liver disease
venous outflow liver disease (Budd-Chiari)
Right-sided heart failure/Tricuspid regurg
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42
Q

Cirrhosis is associated with which abnormally increased liver functions (5)?

A 
AST/SGOT
ALT/SGPT
GGT
LDH (lactate dehydrogenase)
Conjugated bilirubin
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43
Q

Sonographic findings of acute cirrhosis

A

hepatomegaly

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44
Q

Possible sonographic findings of chronic cirrhosis

A 
liver atrophy
caudate lobe enlargement
surface nodularity
fatty infiltration, increased echogenicity of parenchyma
changes related to portal HTN
increased incidence of HCC
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45
Q

Alcoholism used to be the major cause of cirrhosis in the US, now ____ is the leading cause of both chronic hepatitis and cirrhosis.

A

Hepatitis C

46
Q

What is normal portal pressure?

A

5-10 mmHg, which is slightly higher than the normal IVC pressure

47
Q

Major cause of portal HTN?

A

cirrhosis

48
Q

T/F - Portal HTN is symptomatic.

A

F - asymptomatic, patients usually present with upper GI hemorrhage due to rupture of esophageal varices that extend from the RT and LT gastric veins that branch from the portal vein.

49
Q

Four types of portal HTN

A 
Extrahepatic presinusoidal (ex: PVT)
Intrahepatic presinusoidal (ex: schistosomiasis)
Intrahpatic (ex: cirrhosis, most common)
Intrahepatic postsinusoidal (ex: hepatic vein thrombosis)
50
Q

surgical techniques to lower portal pressure (4)

A

portacaval shunt
splenorenal shunt (Linton shunt)
Distal splenorenal shunt (Warren shunt)
TIPS

51
Q

________ _______ _______ connect the portal system to the IVC, bypassing the liver.

A

portal systemic collaterals

52
Q

5 types of portal systemic collaterals

A 
gastroesophageal varices (most deadly)
recan umbilical vein
splenorenal varices
intestinal varices
rectal varices
53
Q

The left gastric vein is also known as the ______ vein.

A

coronary vein

54
Q

Physical signs of collaterals (4)

A

dilated veins on anterior abd wall
caput medusa - tortuous collaterals around umbilicus
hemmorrhoids
ascites - fluid wave

55
Q

What does TIPS stand for

A

Transjugular Intrahepatic Portal-Systemic Shunt

56
Q

TIPS are placed to …… (3)

A

lower portal pressure/portal HTN
avoid the development or rupture of gastroesophageal varices
reduce the accumulation of ascites

57
Q

Typical TIPS placement?

A

Between the RHV and RPV

58
Q

Routine Doppler evaluation of TIPS is performed at 6 month intervals and should demonstrate ________ flow in the RPV and LPV.

A

hepatofugal

59
Q

Criteria for TIPS malfunction (5)

A 
low shunt velocity (<50cm/sec)
high focal shunt velocity (>190cm/sec)
hepatopedal LPV or RPV
hepatofugal MPV
absent shunt flow
*exception - if recan umbilical vein, LPV may be in either direction
60
Q

Most commonly used TIPS material is CORE Viatorr endoprosthesis, a porous material that retains air after placement, for this reason, sonographic evaluation should not be performed in the first ___ to ____ days after placement.

A

3-5 days

61
Q

Indication for liver transplant in children

A

Biliary atresia

62
Q

MELD score

A

Model for End-Stage Liver Disease
scoring to prioritizing receipt of liver transplant
dervied from a formula that uses the patient’s values for Bilirubin, creatinine, PT-INR

63
Q

Postoperative evaluation of an OLT should look closely at the ______ for thrombosis or stenosis.

A

Hepatic artery

provides the only blood supply to the biliary tree

64
Q

Chronic portal vein thrombosis can lead to extensive collaterals at the liver hilum referred to as _________ __________ of the portal vein.

A

cavernous transformation

65
Q

Sonographic findings of PVT

A

Hypoechoic thrombus within portal vein
increased PV caliber
cavernous transformation (chronic obstruction)
portal systemic collaterals

66
Q

Non-tumoral causes of PVT

A 
pancreatitis
cirrhosis/hepatitis (most common)
inflammatory bowel disease
trauma
splenectomy
hypercoagulation
portal lymphadenopathy
67
Q

Sonographic appearance of cavernous transformation

A

numerous worm-like peripheral collaterals that parallel the chronically thrombosed PV
typically seen with benign causes of PVT

68
Q

Tumoral causes of PVT

A

HCC
Metastatic liver disease
Pancreatic carcinoma - compresses PV leading to stagnation of blood, thrombus

69
Q

A number of medical conditions may lead to portal vein thrombosis, particularly causing _______, and less commonly hypercoagulability.

A

Stasis, most commonly results from portal HTN

70
Q

Budd-Chiari syndrome

A

a disorder characterized by hepatic vein obstruction

71
Q

Patients with Budd-Chiari present with signs associated with portal HTN including: ______, ________, _______.

A

ascites, hepatomegaly, splenomeagly

72
Q

Why is the caudate lobe often spared with Budd-Chiari and portal HTN, while the RT and LT lobes atrophy?

A

Because the emissary veins drain the caudate lobe directly into the IVC

73
Q

Causes of Budd-Chiari syndrome

A 
Frequently idiopathic (50%)
Hepatic vein stenosis or hypoplasia
Hypercoagulable states (many conditions including sickle cell and OCPs)
Infections
Pregnancy/Postpartum - walk!
Tumors (HCC, RCC, Adrenal Carcinoma)
74
Q

In infants, intrahepatic portal vein gas is due to __________ ___________

A

Necrotizing entercolitis

75
Q

Air in the intrahepatic portal veins is usually from the ____ _____. It is associated with ischemic and non-ischemic conditions.

A

Biliary tract

76
Q

Sonographic appearance of liver cysts.

A

anechoic, thin-walled, acoustic enhancement

77
Q

Liver cysts typically later in the 5th decade, if they occur at an earlier age, they are associated with what kidney disease?

A

autosomal dominant polycystic kidney disease

78
Q

Patient presents with acute RUQ pain and decreasing hematocrit. What is the possible diagnosis?

A

Hemorrhagic cyst - appears as a cyst with internal echoes

79
Q

What is the most common benign liver tumor?

A

Cavernous hemangioma

80
Q

Sonographic appearance of hemangiomas

A

hyperechoic, posterior enhancement - only one that does this

Hemangiomas consist of multiple vascular channels that create multiple sonographic interfaces which give this mass the characteristic hyperechoic appearance.

81
Q

Sonographic appearance of hemangiomas

A

hyperechoic, posterior enhancement (slice-thickness artifact) - only one that does this

  • if fatty infiltrated liver, may appear hypoechoic
  • typically no flow, contrast enhanced demonstrates centripetal flow
  • Hemangiomas consist of multiple vascular channels that create multiple sonographic interfaces which give this mass the characteristic hyperechoic appearance0.
82
Q

Focal nodular hyperplasia

A

benign solid liver mass

  • believed to be a developmental hyperplastic lesion, rather than a true neoplasm
  • overgrowth of hepatocytes
83
Q

Sonographic appearance of focal nodular hyperplasia

A

solid mass with varying echogenicity
solitary lesion (80-95%)
central fibrous scar *
-most lesions are well-circumscribed, unencapsulated, and nodular with a central fibrous zone and light tan parenchyma
-stealth lesion, FNH that has echogencity equal to surrounding liv parenchyma
-FNH produces a mass effect, displacing intrahepatic blood vessels

84
Q

FNH is more common in _________

A

females

-linked to oral contraceptives

85
Q

Is there a risk of malignant transformation with FNH?

A

No and very low risk of complications such as hemoperitoneum.
-Many cases are left alone if they can be confidently diagnosed with imaging studies

86
Q

Patients with hepatic adenomas may present with _____ due to ______ ________.

A

Pain, tumor hemorrhage

87
Q

Hepatic adenomas, aka hepatocellular adenomas, are associated with _______ _________ ________

A

glycogen storage disease

88
Q

_______ _______ occur mostly in women of childbearing age and are strongly associated with use of OCPs and otehr estrogen.

A

Hepatic adenomas

89
Q

Are hepatic adenomas at risk for malignant transformation?

A

Yes, surgical resection is recommended

90
Q

DDx that correlate with liver cysts

A 
simple cyst
polycystic liver disease
hydatid cyst
cystic tumors
abscess
91
Q

________ _______ are extremely rare fatty liver tumors.

A

hepatic lipomas

92
Q

sonographic appearance of hepatic lipomas

A

hyperechoic mass with propagation speed artifact (decreased speed of sound in fat results in prolonged sound return time thus, objects posterior to the mass are placed farther away from the transducer such as a broken diaphragm)
CT scan can confirm the fatty nature

93
Q

________ ________, a congenital familial disease, is associated with hepatic lipomas and angiomyolipomas

A

tuberous sclerosis

94
Q

hyperechoic hepatic masses (4)

A

hepatic lipoma
hemangioma*
echogenic metastasis
focal fatty infiltration

95
Q

HCC occurs in ______ of patients with cirrhosis in the US.

A

10-25%

96
Q

Common complication of HCC

A

Invasion of the venous structures (portal veins, hepatic veins, IVC)

97
Q

Lab values associated with HCC

A

alpha fetoprotein
AST/SGOT
ALT/SGPT

98
Q

MOst common primary malignancy of the liver

A

hepatocellular carcinoma, aka hepatoma

99
Q

Sonographic appearance of HCC

A

variable
most are hypoechoic
may present as a single mass or as diffuse growth

100
Q

Number one cause of cancer deaths

A

lung

101
Q

__________ __________ is easily established in the liver due to its dual bood supply and factors that promote cell growth.

A

metastaic disease

-the fenestrations in the sinusoidal endothelium allow malignant cells to be trapped in the space of Disse

102
Q

Sonographic patterns of liver METS

A 
non-sepcific
most are multiple
hyperechoic (GI)
Hypoechoic (Lymphoma)
Bull's eye (lung)
Calcified (colon)
Cystic (leiomyosarcoma)
103
Q

METS to the liver most likely come from

A 
GI tract
Lymphoma
Lung
Mucinous adenocarcinoma of the colon
Leiomyosarcoma
104
Q

Growing liver METS cmpress adjacent liver parenchyma, causing ______ and forming a connective tissue rim. Large ones outgrow their blood supply, causing ______ and ______ at the center of the lesion.

A

atrophy, hypoxia, necrosis

105
Q

Genetic conditions associated with hepatoblastomas

A

Beckwith-Wiedemann syndrome

Familial adenomatous polyposis

106
Q

Lab value associated with hepatoblastomas

A

increased Alpha fetoprotein

107
Q

________ is an uncommon malignant liver neoplasm in infants and children, most occurrences are prior to 2 years of age

A

Hepatoblastoma

108
Q

Hepatoblastomas present as an enlarging asymptomatic mass, measuring _____cm at diagnosis

A

10-12cm

109
Q

sonographic appearance of hepatoblastoma

A

nonspecific

associated with lung mets and portal vein invasion

110
Q

Elastography assessment of liver inflammation and fibrosis is scored using the _______ system.

A

METAVIR

ABD (20 decks)

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