liver pathology pp Flashcards
what 3 functions does the liver do?
metabolic
excretory
defense
The utilization of several tests, known as
_____________________________, improve
the detection and the severity of the
hepatic disease.
liver function tests, (or LFTs)
- Some of the most useful hepatic laboratory tests are
– serum bilirubin
– alkaline phosphatase
– transaminase.
_______________ predicts the severity of
hepatocellular disease. Need this prior
to any biopsy!!!
Prothrombin time
Urine _________ is normally absent except
in the presence of hepatobiliary disease.
bilirubin
Increased Alkaline phosphatase levels can be
expected with:
A. Biliary obstruction
B. Children
C. Hepatocellular disease
D. Pregnancy
E. Drug overdose
F. Liver transplant rejection
_____________ and ___________________
are sensitive indicators of liver injury.
Aspartate transaminase(AST)
alanine aminotransferase (ALT)
AST aspartate transaminase is also present in the which organs.
heart, skeletal muscle, brain, and kidney
_________________ is found primarily in liver cells
is reliable for routine screening for liver
disease (hepatitis).
alanine aminotransferase (ALT)
when would Lactic dehydrogenase (LHD) be high?
with liver tumors
Which lab is
decreased in chronic liver disease
(cirrhosis and ascites) because of the
increased volume of distribution.
Serum albumin
Where is Alphafetoprotein (AFP) synthesized?
fetal liver (and is
normally elevated in the mother and
newborn)
When is High elevations of alphafetoprotein (AFP) primary seen?
in hepatocellular carcinoma.
- Diffuse Diseases
- Cystic Lesions
- Inflammatory Lesions
- Hematoma
- Benign neoplasms
- Malignant Neoplasms
what are 3 diffuse diseases of the liver
- Fatty infiltration (Steatosis)
- Hepatitis
- Cirrhosis
CT terminology for a fatty liver/ fatty infiltration
Hepatic steatosis
- This is a diffuse hepatocellular disease
that interferes with normal liver function - Caused by the abnormal accumulation of
lipids, particularly triglycerides within
hepatocytes - is common, affecting ~25% of the population.
- can lead to fibrosis and
cirrhosis.
fatty infiltration (steatosis)
__________________________ is the most frequent cause
of abnormal liver tests in both
adults and children
NAFLD Nonalcoholic fatty liver disease
- sonographic appearance:
– obscure portal vein walls because the
brightness of the liver becomes equal to
the brightness of the portal vein walls
(isoechoic)
– Severity?
– Diffuse, brightly reflective pattern,
granular texture
– hepatomegaly
– poor penetration
– usually diffuse, may be focal
FATTY INFILTRATION
Loss of the bright
walls that portal
vessels typically have due to fatty liver
diffusely fatty liver
that demonstrates
the inability to
clearly visualize the
diaphragm (arrows)
what is this
focal fatty infiltration (steatosis)
what is this
focal fatty infiltration (steatosis)
Focal fatty infiltration with areas of sparing
Focal fatty infiltration with areas of sparing
inflammatory disease usually caused by
hepatitis virus A, Hepatitis virus B, or
other non-A, non-B viruses
VIRAL HEPATITIS
This virus is found primarily in
feces and causes a transient viremia (virus found in
the blood).
The method of transmission is usually via
fecal or oral pathway and in common in children and
young adults in areas of poor sanitation or water
contamination.
A short incubation occurs prior to the
acute onset of symptoms leading to a complete
recovery or death from acute liver failure (mortality
under 1%)
Hepatitis A - (HAV)
This virus is found in greatest
concentration in liver and less in blood.
Transmission occurs through blood, blood products, or other body fluids. HBV has a carrier state with the highest carrier rates in Southeast Asia, China, Africa and Greenland.
Symptoms follow a long incubation period (2-12
weeks) and present with insidious onset, with 10% of
the cases continuing onto a chronic state. HBV has a
strong epidemiological association with hepatocellular
carcinoma.
Hepatitis B - (HBV).
has now become the most common cause
of cirrhosis and liver cancer in the United States and
is the leading indication for liver transplantation.
hepatitis C
an ongoing infection of HBV is necessary before
the_____________ replicates.
Delta agent
Hepatitis D
demonstrates the clinical
characteristics of hepatitis A infection and is
transmitted via the fecal-oral route. It is
found more frequently in water-borne
epidemics in India.
hepatitis E
sonographic appearance of acute hepatitis
normal to hypoechoic;
diffuse enlargement,
increased brightness of portal radicles (“stary night”)
sonographic appearance of chronic hepatitis
hyperechoic due to fibrosis,
can decrease in size;
coarse echo-pattern
a diffuse process characterized by fibrosis
and conversion of normal liver
architecture into structurally abnormal
nodules
CIRRHOSIS
- CLINICAL SYMPTOMS:
– jaundice
– fatigue
– weight loss
– diarrhea
– possibly abdominal pain
– portal hypertension
– compromised liver function
cirrhosis
four forms of cirrhosis
1) alcoholic- toxic effects of chronic, excessive alcohol intake
2) biliary- cause unknown
3) post-necrotic- viral hepatitis, toxins
4) metabolic- metabolic defects & storage disease
The accumulation of fluid in the
peritoneal cavity, which is the space
between the visceral peritoneum and the
parietal peritoneum
ASCITES
caused in part by increased pressure in
the mesenteric tributaries of the portal
vein. This hydrostatic pressure forces
water out of these vessels and into the
abdominal cavity
ASCITES
what is portal hypertension
- Increased pressure in the portal-
splenic venous system
is portal hypertension common with cirrhosis?
yes
- Hepatofugal blood flow in portal
vein - Portal vein enlarged (>1.6 cm)
- Identification of recanalized
umbilical vein
portal hypertension
what is Caput Medusae Sign?
dilated
veins seen on the abdomen of a
patient with cirrhosis of the liver.
The closest way that the portal vein
can connect with vena cava drainage
is at:
1) esophagus
2) rectum
3) umbilicus
4) bowel that is in retroperitoneal
space
Hence, Varices in these areas are common.
Esophageal varices are life-threatening
- Used in treatment of portal
hypertension - Shunt placed from portal vein
directly to hepatic vein to bypass
liver tissue - Ultrasound used to check patency of
shunt
- Transjugular Intrahepatic
Portosystemic Shunts T.I.P.S
- Thrombosis of the hepatic veins or
IVC - Characterized by abdominal pain,
massive ascites, and hepatomegaly - Sonographically identified when
caudate lobe is enlarged, with
atrophy of right lobe and enlarged
hepatic veins - This WILL be on your boards!!
BUDD-CHIARI SYNDROME
2 CYSTIC LESIONS
- Hepatic cysts
- Polycystic Liver Disease
is hepatic cyst congenital or acquired or both
both but most are congenital
what causes hepatic cysts
may be multiple and may be caused
by trauma, parasites, or
inflammatory reaction
which pathology
– developmental defects of bile
ducts
– asymptomatic
– incidental finding
– solitary
– more often affects the right
lobe
– vary in size from mm to 20 cm
HEPATIC CYSTS-Congenital
which pathology
– categorized as traumatic (hematoma,
parasitic (echinococcal), or
inflammatory (abscess)
– usually symptomatic
– simple cyst to complex mass
HEPATIC CYSTS-Acquired
is POLYCYSTIC LIVER DISEASE autosomal dominant or autosomal recessive
autosomal dominant
which pathology
- Autozomal dominant
- Affects 25-50% of patients with
polycystic kidney disease - Multiple small cysts (2-3 cm)
- Check for cysts in kidneys!
POLYCYSTIC LIVER DISEASE
which pathology
- Hemorrhage
- Tender, can cause weakness or
shock if significant - Appearance depends on age
HEMATOMA
which pathology
- Parasitic tapeworm
- Fecal/oral route
- Larvae ingested by humans hatch in
intestine and migrate to the right
hepatic lobe - Clinical symptoms range from a
slight elevation of alkaline
phosphatase and jaundice to
anaphylactic shock
ECHINOCOCCAL CYSTS
- If larvae develop, produce
generations of “daughter cysts” - Unilocular-looking cyst, develops
into a structure made up of
hundreds of cysts of varying sizes - “cyst within cyst”
– solitary cyst with or without
calcifications
– multiple cysts with dense
daughter cells
– fluid collections with septa
presenting a honeycomb
appearance
– solid looking cysts with or
without calcification
more on echinococcal cysts
2 INFLAMMATORY LESIONS
- Pyogenic abscess
- Amebic abscess
which pathology
- Usually caused by bacterial
infection - Can be intrahepatic, subhepatic, or
subphrenic in location - Caused by infection
- Appears as single or multiple
- Appearance varies from anechoic
to complex
PYOGENIC ABSCESS
which pathology
* Formed by disintegrated tissue in a
cavity caused by a parasite
* Usually begins in colon with spread
to liver, lungs, and brain
* Contracted by ingesting
contaminated water or food
AMEBIC ABSCESS
what ages are benign and malignant liver neoplasms most common
benign- Neonates and infants
malignant- Older children and adults
types of benign live neoplasms
- Cavernous Hemangioma
- Adenoma
- Focal Nodular Hyperplasia
most common benign liver neoplasm
cavernous hemangioma
which pathology
- most common
- arteriovenous malformation
- most common in women
- increased frequency with age
- asymptomatic
- incidental finding
- usually homogeneous,
hyperechoic mass, sharp well
defined margins, may have
posterior enhancement
cavernous hemangioma
which pathology
- rare, benign tumor
- contains normal cellular elements of liver
tissue, lacks normal hepatic architecture
and functions poorly - most common in women <40 yrs
- ASSOCIATED WITH BIRTH CONTROL PILL USAGE
- appears as a well-circumscribed,
hypoechoic or hyperechoic mass - can also appear isoechoic with normal
tissue
FOCAL NODULAR HYPERPLASIA
Which pathology
- an encapsulated neoplasm
consisting of normal to slightly
atypical hepatocytes often
with areas of bile stasis, focal
hemorrhage and necrosis - usually solitary with
identifiable margins - rare - most common in women
of childbearing age; frequency
increases with use of oral
contraceptives
HEPATIC ADENOMA
types of malignant neoplasms
- primary hepatic tumors
- metastases
- hepatomas (hepatocellular
carcinoma) - hepatoblastoma (children)
which pathology
- highly malignant
- focal or multiple nodules,
- can be diffuse
- pt usually presents with RUQ pain,
sudden deterioration of hepatic
function, a palpable mass, rapid liver
enlargement, and fever of unknown
origin - usually advanced by discovery
- 5 year survival rate is 1%
HEPATOMA
- metastatic lesion arising from
other areas of the body - usually GI, breast, or lungs
- frequently asymptomatic until
larger - clinical course relates to growth
- multiple nodules can suggest
“seeding” - poor prognosis due to poor
response of treatment - 5 year survival rate less than 5%
METASTASIS
There are
three morphologic patterns of Hepatic Cellular Cancer HCC:
– a solitary tumor
– multiple nodules throughout the liver
– and diffuse infiltration.
* Each of these patterns may cause
hepatomegaly.
which pathology
Most common liver mass in
children younger than 5 yrs old
Usually occurs in first 3 years
of life
More common in boys
Usually located in the right
lobe of the liver, but can affect
both lobes
consists chiefly of embryonic
hepatic tissue
HEPATOBLASTOMA
also
known as hilar Cholangiocarcinoma is a
cancer of the biliary tree occurring at the
confluence of the right and left hepatic bile
ducts.
A Klatskin tumor
an
idiopathic inflammatory condition of the
biliary tree, has been associated with the
development of cholangiocarcinoma in up
to 40% of patients
Primary sclerosing cholangitis
a long-term, progressive disease of the liver and
gallbladder characterized by inflammation
and scarring of the bile ducts
Primary sclerosing cholangitisis
Eventually, this can lead to cirrhosis of the
liver and liver failure.
Up to _____________ of the liver can
be safely removed and the existing
liver liver (if normal) can
regenerate itself to its preoperative
size in 6-8 weeks.
three-fourths
- A diseased liver is replaced
– with a segment of the liver from a healthy
human donor
– From a cadaver – A liver transplant from a
deceased donor (cadaver) needs to occur
within 12 to 24 hours after the liver is
removed from the donor for the organ to
remain viable. - Prior to the surgery, a baseline study is
performed to evaluate the liver
parenchyma to identify the presence of
hepatic lesions, determine the patency
and size of the portal vein, hepatic
veins, and IVC, and assess the biliary
system for dilatation.
about liver transplant
In the post-operative period from liver transplant, ____________ is the most serious complication
in the weeks following the surgery.
thrombosis of the
hepatic artery
- Hepatoma may be singular, multiple or diffuse,
usually malignant. Term usually used for 3 or less
lesions in clinical practice. - HCC is a malignant tumor(s) of the liver that
develop in the setting of chronic liver disease (hep
B or C) and/or cirrhosis. HCC is a more specific
term (used with hepatoma, usually multiple or
diffuse) when those other conditions are present.
– However: with no liver pathology or processes
known; multiple, diffuse lesions will be
regarded as mets in clinical practice.
high Alkaline phosphatase mean
increases in liver disease
high amonia mean
increases in liver disease
increases in Diabetes Mellitus
high Bile and Bilirubin mean
increase during obstruction of the bile ducts
high Glucose mean
increases in liver disease
increases in Diabetes Mellitus
low Hematocrit mean
decreases in cirrhosis of liver
low Hemoglobin mean
decreases in cirrhosis of liver
high Iron mean
increases in liver disease
high Lactic dehydrogenase
(LDH) mean
increases in liver disease
high Lipids-total
Cholesterol- total
HDL
LDL
Triglycerides
Phospholipids
Fatty acids mean
increase cholesterol in chronic hepatitis
low Lipids-total
Cholesterol- total
HDL
LDL
Triglycerides
Phospholipids
Fatty acids mean
decrease cholesterol in acute hepatitis
high Platelet count mean
increase in cirrhosis of liver
high Transaminase mean
increase in liver disease
high urea mean
increase in some liver diseases
low urea mean
decrease during obstruction of bile ducts
Impaired drainage of the
__________ vein into the portal vein can result in varices
within the gallbladder wall.
cystic
In a normal state, the portal venous system is a
low-pressure system with a normal pressure of __________ to
______________ mm Hg
5 to 10 mm HG
Prominent pulsatility of the portal
vein is abnormal/normal and may be indicative of right heart failure, tricuspid regurgitation, hepatic vein/portal vein fistula, or portal hypertension
abnormal
A lack of pulsatility or continuous waveform
in the hepatic vein may indicate ___________ or ___________
compression or
stenosis
The main complication of portal hypertension is gastrointestinal bleeding from ruptured esophageal and gastric
varices.
Enlargement of the portal vein greater than _________ mm is indica-
tive of portal hypertension with a high degree of
specificity (100%) but low sensitivity (45%-50%)
13mm
The _________ or __________ is the most common
portosystemic shunt, occurring in 80% to 90% of
patients
left gastric or coronary vein
The coronary vein is enlarged when its
diameter exceeds ___________
6 mm
Cavernous transformation is readily recognized with
color Doppler as multiple, tortuous, tiny vessels at the
porta hepatis with an absence of a normal portal vein
(Fig. 13). Flow is hepatopetal and primarily venous.
T.I.P.S procedure connects what to what
the right portal vein is shunted to
either the right or middle hepatic vein
