Liver Pathology Flashcards
What are granulomas, what are they caused by and what is their sonographic appearance?
a small collection of macrophages
caused by histoplasmosis or TB
small organized calcifications in the liver/spl
What causes histoplasmosis?
spores (fungus) floating in the air, grows in the bird/bat droppings, commonly found in chicken/pigeon coops, old barns, caves
What is hepatitis?
Liver inflammation resulting from infectious (viral, bacterial, fungal, and parasitic organisms) or noninfectious (medications, toxins, and autoimmune disorders) agents
Labs associated with hepatitis
elevation of ALT, AST, conjugated/unconjugated bilirubin
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?
HAV - fecal/oral
HBV - blood/body fluids
HCV - blood/body/fluids (usually from sharing of drug needles)
What is the most frequent cause/indication for liver transplantation
HCV associated chronic liver disease
Sonographic appearance of acute hepatitis
hypoechoic liver parenchyma
liver enlargement
hyperechoic portal vein walls (“starry night” from periportal cuffing)
-generally prominent vessels from the decrease in parenchyma
Sonographic appearance of chronic hepatitis
hyperechoic liver parenchyma
small liver
decreased echogenicity of portal vein walls
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.
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
T/F - Pyogenic bacterial abscesses more often affect the left lobe of the liver.
False - they affect the right lobe more than left, 2:1
Sonographic appearance of pyogenic abscess
a complex mass in the liver with gas and reverberation artifact
Symptoms of a pyogenic abscess
RUQ pain leukocytosis fever elev LFTs (aspiration is needed to confirm Dx)
3 major forms of liver abscesses
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)
Amebic abscess- symptoms and labs
RUQ pain (hepatomegaly) diarrhea fever leukocytosis elevated LFTs *onset of symptoms usually 8-12 weeks from date of travel
Sonographic features of an amebic liver abscess
round, hypoechoic, complex mass
typically in the RT dome of the liver
contiguous with the capsule
aspiration may be needed to conform Dx
Etiology of an amebic liver abscess
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)
T/F - the appearance of fungal liver abscesses can change over the course of the disease process.
True
sonographic appearance of fungal liver abscesses
“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
_______ abscess is due to a mycotic infection in the blood that results in small liver abscesses.
Fungal abscess (candidiasis)
Humans become infected from either directly handling or from ingesting food contaminated with tapeworm eggs passed from the fecal material of infected carnivores (sheepdog).
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.
Sonographic appearance of Hydatid disease
“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
Lab studies for echinococcal cyst
Casoni skin test
detection of anti-echinococcus antibodies (indirect hemagglutination, enzyme-linked immunosorbent assay)
Rupture of aspiration of echinococcal cyst is associated with _______ shock.
Anaphylactic
treatment is epinephrine by injection
One of the most common parasitic infections in humans.
Schistosomiasis
_______ is the genius of several species of parasitic trematodes.
Schistosomiasis
In addition to HCV, ______ is another major cause of portal HTN worldwide and is endemic to tropical areas.
Schistosomiasis
not common in US but estimated 400,000 infected persons have immigrated
Schistosomiasis eggs reach the liver through the portal vein, inciting a granulomatous reaction resulting in _________ fibrosis.
Periportal fibrosis - intrahepatic vein become occluded resulting in portal HTN
sonographic findings associated with Schistosomiasis
occluded intrahepatic portal veins
thickening of portal vein walls
Secondary signs of portal HTN
splenomegaly
ascites
esophageal variceal bleeding
portosystemic collaterals (aks portal-systemic venous collaterals)
Complications of HIV (9)
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
Accumulation of triglycerides within the hepatocytes is known as?
Fatty infiltration of the liver, steatosis
Fatty liver disease is most commonly associated with _______ syndrome.
Metabolic syndrome (DM II, obesity, hypertriglyceridemia)
In addition to metabolic syndrome, _______ liver disease is associated with drugs, alcohol, metabolic abnormalities, nutritional status, and other health problems.
fatty
incidence of fatty liver disease in approx. 30% in the US
Sonographic appearance of fatty liver steatosis
increased echogenicity and decreased acoustic penetration
increased attenuation makes it difficult to see the posterior liver and diaphragm
What are the two patterns of fatty infiltration?
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
________ _______ ______ 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.
Glycogen Storage Disease
A person with GSD has an absence or deficiency of one of the enzymes responsible for making or breaking down glycogen
There are 11 types of GSDs, Type 1a, caused by a defect in enzyme glucose -6-phosphatase, was originally known as _____ ________ ________.
von Gierke’s Disease
Diffuse process of fibrosis and distortion of normal liver parenchyma
Cirhosis
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
Cirrhosis
Causes of cirrhosis (6)
HCV alcoholic liver disease Non-alcoholic fatty liver disease (NAFLD) non-alcoholic steatohepatitis (NASH) HBV Misc
Miscellaneous causes of cirrhosis (8)
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
Cirrhosis is associated with which abnormally increased liver functions (5)?
AST/SGOT ALT/SGPT GGT LDH (lactate dehydrogenase) Conjugated bilirubin
Sonographic findings of acute cirrhosis
hepatomegaly
Possible sonographic findings of chronic cirrhosis
liver atrophy caudate lobe enlargement surface nodularity fatty infiltration, increased echogenicity of parenchyma changes related to portal HTN increased incidence of HCC
Alcoholism used to be the major cause of cirrhosis in the US, now ____ is the leading cause of both chronic hepatitis and cirrhosis.
Hepatitis C
What is normal portal pressure?
5-10 mmHg, which is slightly higher than the normal IVC pressure
Major cause of portal HTN?
cirrhosis
T/F - Portal HTN is symptomatic.
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.
Four types of portal HTN
Extrahepatic presinusoidal (ex: PVT) Intrahepatic presinusoidal (ex: schistosomiasis) Intrahpatic (ex: cirrhosis, most common) Intrahepatic postsinusoidal (ex: hepatic vein thrombosis)
surgical techniques to lower portal pressure (4)
portacaval shunt
splenorenal shunt (Linton shunt)
Distal splenorenal shunt (Warren shunt)
TIPS
________ _______ _______ connect the portal system to the IVC, bypassing the liver.
portal systemic collaterals
5 types of portal systemic collaterals
gastroesophageal varices (most deadly) recan umbilical vein splenorenal varices intestinal varices rectal varices
The left gastric vein is also known as the ______ vein.
coronary vein
Physical signs of collaterals (4)
dilated veins on anterior abd wall
caput medusa - tortuous collaterals around umbilicus
hemmorrhoids
ascites - fluid wave
What does TIPS stand for
Transjugular Intrahepatic Portal-Systemic Shunt
TIPS are placed to …… (3)
lower portal pressure/portal HTN
avoid the development or rupture of gastroesophageal varices
reduce the accumulation of ascites
Typical TIPS placement?
Between the RHV and RPV
Routine Doppler evaluation of TIPS is performed at 6 month intervals and should demonstrate ________ flow in the RPV and LPV.
hepatofugal
Criteria for TIPS malfunction (5)
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
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.
3-5 days
Indication for liver transplant in children
Biliary atresia
MELD score
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
Postoperative evaluation of an OLT should look closely at the ______ for thrombosis or stenosis.
Hepatic artery
provides the only blood supply to the biliary tree
Chronic portal vein thrombosis can lead to extensive collaterals at the liver hilum referred to as _________ __________ of the portal vein.
cavernous transformation
Sonographic findings of PVT
Hypoechoic thrombus within portal vein
increased PV caliber
cavernous transformation (chronic obstruction)
portal systemic collaterals
Non-tumoral causes of PVT
pancreatitis cirrhosis/hepatitis (most common) inflammatory bowel disease trauma splenectomy hypercoagulation portal lymphadenopathy
Sonographic appearance of cavernous transformation
numerous worm-like peripheral collaterals that parallel the chronically thrombosed PV
typically seen with benign causes of PVT
Tumoral causes of PVT
HCC
Metastatic liver disease
Pancreatic carcinoma - compresses PV leading to stagnation of blood, thrombus
A number of medical conditions may lead to portal vein thrombosis, particularly causing _______, and less commonly hypercoagulability.
Stasis, most commonly results from portal HTN
Budd-Chiari syndrome
a disorder characterized by hepatic vein obstruction
Patients with Budd-Chiari present with signs associated with portal HTN including: ______, ________, _______.
ascites, hepatomegaly, splenomeagly
Why is the caudate lobe often spared with Budd-Chiari and portal HTN, while the RT and LT lobes atrophy?
Because the emissary veins drain the caudate lobe directly into the IVC
Causes of Budd-Chiari syndrome
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)
In infants, intrahepatic portal vein gas is due to __________ ___________
Necrotizing entercolitis
Air in the intrahepatic portal veins is usually from the ____ _____. It is associated with ischemic and non-ischemic conditions.
Biliary tract
Sonographic appearance of liver cysts.
anechoic, thin-walled, acoustic enhancement
Liver cysts typically later in the 5th decade, if they occur at an earlier age, they are associated with what kidney disease?
autosomal dominant polycystic kidney disease
Patient presents with acute RUQ pain and decreasing hematocrit. What is the possible diagnosis?
Hemorrhagic cyst - appears as a cyst with internal echoes
What is the most common benign liver tumor?
Cavernous hemangioma
Sonographic appearance of hemangiomas
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.
Sonographic appearance of hemangiomas
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.
Focal nodular hyperplasia
benign solid liver mass
- believed to be a developmental hyperplastic lesion, rather than a true neoplasm
- overgrowth of hepatocytes
Sonographic appearance of focal nodular hyperplasia
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
FNH is more common in _________
females
-linked to oral contraceptives
Is there a risk of malignant transformation with FNH?
No and very low risk of complications such as hemoperitoneum.
-Many cases are left alone if they can be confidently diagnosed with imaging studies
Patients with hepatic adenomas may present with _____ due to ______ ________.
Pain, tumor hemorrhage
Hepatic adenomas, aka hepatocellular adenomas, are associated with _______ _________ ________
glycogen storage disease
_______ _______ occur mostly in women of childbearing age and are strongly associated with use of OCPs and otehr estrogen.
Hepatic adenomas
Are hepatic adenomas at risk for malignant transformation?
Yes, surgical resection is recommended
DDx that correlate with liver cysts
simple cyst polycystic liver disease hydatid cyst cystic tumors abscess
________ _______ are extremely rare fatty liver tumors.
hepatic lipomas
sonographic appearance of hepatic lipomas
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
________ ________, a congenital familial disease, is associated with hepatic lipomas and angiomyolipomas
tuberous sclerosis
hyperechoic hepatic masses (4)
hepatic lipoma
hemangioma*
echogenic metastasis
focal fatty infiltration
HCC occurs in ______ of patients with cirrhosis in the US.
10-25%
Common complication of HCC
Invasion of the venous structures (portal veins, hepatic veins, IVC)
Lab values associated with HCC
alpha fetoprotein
AST/SGOT
ALT/SGPT
MOst common primary malignancy of the liver
hepatocellular carcinoma, aka hepatoma
Sonographic appearance of HCC
variable
most are hypoechoic
may present as a single mass or as diffuse growth
Number one cause of cancer deaths
lung
__________ __________ is easily established in the liver due to its dual bood supply and factors that promote cell growth.
metastaic disease
-the fenestrations in the sinusoidal endothelium allow malignant cells to be trapped in the space of Disse
Sonographic patterns of liver METS
non-sepcific most are multiple hyperechoic (GI) Hypoechoic (Lymphoma) Bull's eye (lung) Calcified (colon) Cystic (leiomyosarcoma)
METS to the liver most likely come from
GI tract Lymphoma Lung Mucinous adenocarcinoma of the colon Leiomyosarcoma
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.
atrophy, hypoxia, necrosis
Genetic conditions associated with hepatoblastomas
Beckwith-Wiedemann syndrome
Familial adenomatous polyposis
Lab value associated with hepatoblastomas
increased Alpha fetoprotein
________ is an uncommon malignant liver neoplasm in infants and children, most occurrences are prior to 2 years of age
Hepatoblastoma
Hepatoblastomas present as an enlarging asymptomatic mass, measuring _____cm at diagnosis
10-12cm
sonographic appearance of hepatoblastoma
nonspecific
associated with lung mets and portal vein invasion
Elastography assessment of liver inflammation and fibrosis is scored using the _______ system.
METAVIR
