liver pathology : diffuse abnormalities Flashcards
____ is due to congestive heart failure. Due to cardiac
insufficiency, blood backs up into liver. This could
be due to Rt. heart failure or Lt. heart failure.
clinical signs are : Hepatomegaly, there may be ascites
Passive Congestion
describe passive congestion sonographically?
what about the labs?
Acutely the liver is usually large and hypoechoic due to the increase in blood volume within the organ. The liver is congested with a fluid, blood, making it enlarges and more hypoechoic in appearance.
• Dilated IVC, HV’s, PV, Mesenteric and Splenic vein. Loss of diameter changes in these venous systems.
• Prominent walls of the PV will give a “Starry Sky” appearance. In chronic passive congestion the liver will become more fibrotic and the echogenicity
will increase. AJR:178, Jan. ‘02
Labs • Could be normal to slightly elevated
describe passive congestion doppler waveform
which is normal, which is passive congestion?
– Doppler will show less triphasic HV flow & a loss of phasicity. • Note the this type of waveform is not “Pathognomonic” for passive hepatic congestion.
•
“Pathognomonic” = Characteristic or symptomatic of a particular disease or condition. • Other diffuse liver conditions can cause a waveform like this
___ is viral. Other: Alcohol, medicines, chemicals, genetic problems, metabolic disorders, immune related injuries. Obesity can be a cause of liver damage which can lead to inflammation. These are non-infectious causes.
hepatitis
what is described?
viral hepatitis
____ is caused by blood exposure, Blood exposure, transfusions before screening, tattoos, piercing, multiple sex partners, needle sticks injuries. No cure, TX
only option. > 20% of cases the mode of transmission is not identified.
• Asymptomatic or flu like illness lasting a few days, without jaundice.
how long can it go undetected?
is it contagious?
what does it progress into?
hepatitis c
It goes undetected for years. 50-60% of patients develop chronic Hep. C disease, most of these remain contagious for life. Many pt. who have chronic Hep. C disease develop aggressive hepatitis with gradual progression to cirrhosis (permanent scarring) and liver failure.
___ is – Asymptomatic in some individuals.
– Jaundice, loss of appetite, N/V, fatigue, Hepatomegaly and tender, pruritus “PROO-RITIS” (severe itching) caused from too much biliary salts within the subcutaneous tissues.
Hepatitis
what labs are associated w/ hepatitis
– Markedly elevated AST, ALT
– Serum Bili minimally elevated
– Serum Albumin, PT usually are normal particularly in HAV/HBV.
– Late in HCV when cirrhosis has occurred, i.e. liver functions are diminished.
– Albumin will be decreased, (hypoalbuminemia).
– Clotting factors diminish, clotting times will be elevated.
describe how hepatitis is going to look acutely or chronically.
In the acute phase you
may or may not find these appearances.
what do you see?
acute vs chronic
___ is – A chronic disease of the liver characterized by the replacement of normal tissue with fibrous tissue and the loss of functional liver cells. It is a progressive DZ with Liver failure and Portal HTN coming at the end stage.
• Etiologies – Multiple causes; Alcohol abuse, Biliary (primary and secondary), Post necrosis (post hepatitis), metabolic (glycogen storage Dz.), and Unknown.
Cirrhosis
describe the 4 types of cirrhosis
• Alcohol (ETOH)
– Chronic ETOH, common abbreviation on req.’s, intake in toxic to hepatocytes. Fat accumulation and inflammation, damage the architecture of
the hepatocyte by necrosis and fibrosis.
• Biliary
– Primary, Lobular ducts become inflamed and scarred. Very small, very proximal ducts are affected.
– Secondary, bile ducts become inflamed and scarred proximal to an obstruction
• Post necrosis
– Necrotic tissue is replaced with fibrous, nodular scar tissue.
• Metabolic
– Morphologic (deals with the form and structure, NOT function) changes occur, such as inflammation and scarring related to the cause. EXAMPLE;
glycogen storage disease (large amounts of glycogen are deposited into the hepatocytes, thus causing damage to the liver which can result in cirrhosis.
Hemochromatosis: Large amounts of Iron accumulate in the liver and/or other organs.
what clinical signs are associated w/ cirrhosis
– Jaundice
– Ascites
– GI bleeding – Secondary to PV HTN
– Decreased alertness
– Spider angiomas of the face
– Palmer Erythema – Redding of the palms
– Light colored stools
– Nausea
– Anorexia - Loss of appetite
– Abd. pain
which labs are abnormal if a pt has cirrhosis?
– Abnormal LFT’s
– Abnormal albumin
– Abnormal coagulation
describe what cirrhosis looks like on us?
what is volume redistribution?
course echotexture?
nodular surface?
Nodules regenerative and dysplastic:?
Early stages – Liver generally enlarges, Late or advanced stages – Liver generally is small, with relative enlargement of the Lt. and caudate lobe, in comparison with the Rt.
This is a subjective finding and can be made worse with an inappropriate gain or TGC settings.
Irregularity of the liver surface, this correlates to regenerating nodules and fibrosis. Is easier to see when ascites is present.
Regenerating nodules represent regenerating hepatocytes surrounded by a fibrotic septa. There appearance is similar to the architecture of the normal liver. US and CT have a limited ability in there detection. MRI is more sensitive then both US and CT at detecting RN. DYPLASTIC nodules are considered pre malignant. There are hyperplastic nodules and are lager then RN.
___ is Fibrosis with in the hepatocytes is affecting the flow of blood through the liver. The flow of blood slows to < 16 cm/s2. The volume of blood will remain the same. There is still the same amount of blood going to the liver. The pressure within the PV and tributaries increases as a result of the liver not allowing blood to flow freely through it. The pressure causes the diameters of the PV and
tributaries to enlarge. > 13mm in diameter is abnormal in UIHC Radiology. The spleen will enlarge, WHY?, and Ascites will develop.
Portal Hypertension:
this Sonographic Appearance describes ______:
– Depends on Acute or Chronic
– Hepatomegaly or small atrophic liver
– Increased attenuation
– Nodularity seen, particularly on the surface; nodules are easier seen when ascites is present
– Possible ascites
– Decreased visualization of vascularity
– Generally more echogenic than kidney
cirrhosis
what does the gross appearance of cirrhosis look like?
Many regenerative nodules
____ is An accumulation of lipids in the hepatocytes. (AKA steatosis) Due to injury which affects the function of the liver or systemic diseases like DM, ETOH, obesity, malnourishment, steroids. it is acquired and reversible.
- Why Obesity?
- WHY Malnourishment? .
- A Fatty liver
- Steroids
Fatty infiltration - Steatosis
- Why Obesity? because excess glycogen is being stored in liver.
- WHY Malnourishment? Liver is storing much fat to prevent starvation.
• A Fatty liver is a non specific sign. It can be the result of several problems.
• Steroids – Not necessarily abuse like weightlifters, but also pt. with CF, and other conditions where
steroids are used.
• It is acquired and it is reversible.
what are these • Clinical Signs associated with?
– Asymptomatic
– Depends on Etiology
– Hepatomegaly- maybe
– Pain – maybe
labs are variable » Depends of severity
» LFT’s can increase
Fatty infiltration
what types of diffuse fatty inflitration of the liver are there?
what about focal?
Mild: minimal diffuse increase in echogenicity; normal
visualization of the diaphragm and intrahepatic blood vessels
» Moderated: moderate increase in echogenicity, slightly impaired visualization diaphragm and intrahepatic blood vessels
» Severe: Marked increase in liver echogenicity, poor penetration of the posterior segment of the rt. liver lobe and poor or nonvisualization of hepatic vessels and diaphragm
Focal: Fatty deposits typically in the periportal area of the medial segment of the Lt. lobe. The will be no mass effect, even though it will look like a mass there will no mass effect. Blood vessels will not be pushed aside.
can you tell which of these fatty infiltration livers are mild and moderate?
a, b, c are mild d is moderate
the below is severe
Focal fatty infiltration and focal fatty sparring OFTEN mimic _______.
Focal Fatty infiltration are areas of increased echogenicity
Notice there is no mass effect to surrounding tissue
neoplasms
what is this?
focal fatty sparring
what’s happening here?
Same pt. from prior slide. 4 ½ yrs. later
fatty sparring resolution
what 3 types of etiology for protal hypertension?
Prehepatic
» PV Thrombosis, Splenic V thrombosis, Cavernous transformation…
– Intrahepatic
» Presinusoidal: chronic HBV, chronic HCV,
hemochromatosis, polycystic liver dz….
» Hepatic: acute viral, acute etoh, acute fatty liver of
pregnancy…
» Postsinusoidal: Venous-occlusive dz. central veins
are scarred…
– Extrahepatic
» Budd-Chiari, heart diseases, valve diseases…
what collaterals are there w/ portal hypertension?
what is happneing w/ the portal hypertensive patient?
Cavernous transformation
– Cavernous transformation of the portal vein is defined as
the formation of venous channels within or around a
previously thrombosed portal vein.
what labs are associated w/ portal hypertension?
PV diameter?
flow?
any other us findings?
– None specific to PV. HTN.
– Cirrhosis labs
– Large PV diameter, >13mm
– Slow flow < 16cm/s2
– Patent Umbilical Vein
– Patent Coronary or Lt. gastric vein
– Flow direction reversals and discrepancies.
– Splenomegaly
– Splenic Varices
– Periportal Varices
– Prominent HA flow – To make up for the lack of PV flow
– Hepatopedal vs. Hepatofugal: Toward the liver and Away from the
liver
what could be happening here. portal hypertension
–
Reverse flow in the lt. gastric vein (coronary v.)
Flow should be from the lt. gastric vein into the MPV. Color Doppler shows the reversal.
what could be happening here? portal hypertension
Reversal of flow in the Splenic V
what is this?
portal hypertension
what is this? how can you tell?
portal hypertension
what do these illustrate?
portacaval shunt, splenorenal shunt; treatment for PHN
how does TIPS work? what is it for?
Transjugular Intrahepatic Portosystemic Shunt
____ is the Occlusion of the hepatic veins with or without occlusion of the IVC. Characterized by massive ascites hepatomegaly and abdominal pain. Relatively rare. Poor prognosis
its etiology is –
Idiopathic, Hypercoagulable states, Chronic Leukemia, trauma, tumor extension from HCC or Renal Cell, Pregnancy, congenital abnormalities such as obstructing membranes within the IVC.
•
Budd-Chiari syndrome
what clinical signs are associated with •
Budd-Chiari syndrome
labs?
ddx?
•
Sudden onset of ascites, RUQ pain.
–
The classic patient in North America is a young female was is taking BCP who presents with acute onset of ascites, RUQ pain, hepatomegaly.
•
Labs
Non specific
variable
–
DX (differential diagnosis)
Portal HTN
what does this look like?
Portal Venous Air
•
PV air is typically disbursed more peripherally in the liver. Air within the biliary tree is typically located more centrally within the liver.
what is this?
portal venous air
