Metabolic Diseases Flashcards
What is hepatocellular disease?
A diffuse dysfunction of the hepatocytes where normal liver tissue is replaced with fat or fibrosis and the liver size is often affected.
What lab values would you expect to affected by hepatocellular disease?
LFT’s
What is another name for fatty infiltration?
Steatosis
What is fatty infiltration?
Accumulation of triglycerides (fat) within hepatocytes
What are the 2 most common causes of fatty infiltration?
Alcohol abuse and obesity
What is fatty infiltration a precursor to?
Significant chronic disease (Cirrhosis)
What four things should be looked for when evaluating the liver for fatty infiltration?
- Echogenicity changes
- Echotexture changes
- Attenuation characteristics
- Ability to visualize vessels
What is the sonographic appearance of fatty infiltration?(3)
- Difficult penetration
- Paucity of vessels
- Echogenicity change
What is the prognosis of fatty infiltration and the prognosis of focal fatty changes?
Infiltration - Can be reversed by fixing lifestyle habits
Fatty changes - Can resolve rapidly (as fast as 6 days)
Describe the sonographic characteristics of MILD fatty infiltration: (2)
- Slight increase in liver echogenicity
- Diaphragm and vessels clearly defined
Describe the sonographic characteristics of MODERATE fatty infiltration: (2)
- Increase in liver echogenicity
- Vessels and diaphragm not sharply defined
Describe the sonographic characteristics of SEVERE fatty infiltration: (2)
- Liver echogenicity increased markedly
- Extremely difficult to define diaphragm and vessel walls
What are two types of focal fatty change?
Infiltration and sparing
Describe the sonographic characteristics of focal fatty infiltration:
Focal areas of increased echogenicity and mostly normal liver parnechyma
Describe the sonographic characteristics of focal fatty sparing:
Majority of liver parenchyma has fatty infiltration, focal hypoechoic areas (normal liver tissue)
What lab values could potentially be elevated with fatty infiltration?
ALT, AST, possibly GGT
What is cirrhosis?
A diffuse process that destroys the liver cells and results in fibrosis of liver parenchyma with nodular changes
What is the most common cause of cirrhosis and what are the other underlying?
Most common = Alcohol abuse
Other:
- Chronic viral hepatitis
- Primary sclerosing cholangitits
What are the three stages of progressive change in cirrhosis?
Cell death, fibrosis, and regeneration (of fibrotic tissue)
Is cirrhosis reversible?
No, it’s irreversible
What are the two types of nodular change with cirrhosis?
Micro nodular and macro nodular
What would micro nodular cirrhosis likely be due to?
Alcohol consumption
What would macro nodular cirrhosis likely be due to?
Chronic viral hepatitis
How does acute cirrhosis appear?
Same as severe fatty infiltration
How does chronic cirrhosis appear? (4)
- Small liver (CL/RL >.65)
- Coarse echotexture
- Nodular surface
- Paucity of vessels
Why does cirrhosis have the potential to progress to end stage liver failure?
Blockage of vessels within the liver leads to portal hypertension
What do lab values depend on when assessing cirrhosis?
The stage of the disease
What lab values would you see increased in a patient with cirrhosis?
AST, ALT, LDH, ALK PHOS, conjugated bilirubin, GGT
What lab values would you see decreased in a patient with cirrhosis?
Serum albumin
Which other organ can be affected by liver cirrhosis?
Spleen
What is the classical presentation of cirrhosis?
Hepatomegaly, jaundice, and ascites
What is glycogen storage disease also known as?
GSD and Von Gierke’s disease
What kind of disorder is glycogen storage disease?
Autosomal recessive
What is glycogen storage disease?
Enzyme deficiency causing excess glycogen deposits in hepatocytes
What is GSD associated with?
Benign adenomas and HCC
Is ascites a metabolic condition?
No, but occurs along with most of them
What is ascites?
Accumulation of free serous fluid in the peritoneal cavity
What are the two kinds of ascites?
Transudate and exudate
What is transudate ascites?
Contains little protein or cells and suggests a non-inflammatory process
In what two situations would you see transudate ascites?
Cirrhosis and CHF
What is exudate ascites?
High protein content of blood, pus, and chylous, and suggests an inflammatory or malignant cause
What would be the sonographic difference between transudate and exudate ascites?
Exudate ascites will have internal echoes and loculations
Free fluid in the peritoneal cavity may be what two things?
Free or loculated
What is the sonographic confirmation of free fluid?
Changes with patient position and conforms to surrounding organs
What is the sonographic confirmation of loculated fluid?
No change with patient movement and rounded margins
What are the three most dependent spaces in the peritoneal cavity?
Morrison’s pouch, posterior cul-de-sac, and pericolic gutters
What is biliary sludge also known as?
Biliary sand and microlithiasis
What is biliary sludge?
Mixture of particulate matter and bile
Biliary sludge is a potential precursor to what?
Gallbladder disease
What are four causes of bile stasis?
Prolonged fasting, rapid weight loss, TPN, and extrahepatic biliary obstruction
What are tumefactive sludge balls?
Sludge that mimics polypoid tumors
How can you differentiate between tumefactive sludge balls and polypoid tumors?
Assess vascularity, mobility, and GB wall thickness
What is hepatization in terms of biliary sludge?
When sludge has the same echogenicity as the liver
What is empyema?
Presence of pus in bile
What is hemobilia?
Presence of blood in bile
How does Milk of Calcium appear in the gallbladder?
Highly echogenic with posterior shadowing, mobile, fluid-fluid level, stretches like fluid unlike a stone
What is the most common disease of the gallbladder?
Cholelithiasis
What are three factors that affect gallstone formation?
Abnormal bile composition, stasis of bile, and infection
What is the most common composition of gallbladder stones?
Cholesterol
What are the risk factors of cholelithiasis?
Female, fat, fertile, forty, family history
What can false shadowing in the gallbladder be caused by?
Valves of Heister, fat of porta hepatis, duodenal gas
How can you differentiate between between false shadowing and true shadowing?
Whether its dirty or not
Gallbladder stones less than what measurment will not shadow?
<5mm
What is the WES sign?
Wall, echo, shadow
What lab values would you expect to see altered with cholelithiasis?
AST, ALT, ALP, and bilirubin
Whats the most common complication of gallstones?
Biliary colic
What causes ducts to dilate?
Obstruction, loss of duct wall elasticity, amupullary dysfunction
Which is more serious, painless or painful jaundice?
Painless
What does painless jaundice suggest?
Neoplastic conditions, choledochal cysts
What is choledocholiathiasis?
Stones in the biliary tree
What is the most common cause of choledocholiathiasis?
Stones pass from gallbaldder to ducts (secondary)
What are primary causes of choledocholiathiasis?
Inflammation, infection, Caroli’s disease, prior surgery
Where is the most common location for stones in the biliary tree?
Distal CBD
What lab values would you expect to see increased with choledocholiathiasis?
ALP, AST, ALT, bilirubin
What is urolithisasis?
Stones in the urinary system
What is nephrolithiasis?
Stones in the renal collecting system
What is nephrocalcinosis?
Calcifications in the renal parenchyma
What are the underlying risk factors of nephrolithiasis?
Hereditary, limited water intake, high animal protein diet, urinary stasis
What are the three natural narrowings of the ureter?
UPJ, iliacs, and UVJ
80% of stones get lodged where?
UVJ
Stones of what measurement can be passed?
<5mm
Hematuria can be what two things?
Microscopic or gross (Frank)
What is a possible sign and symptom of kidney stones?
Nausea and vomiting
What are complications of nephrolithiasis?
Hydronephrosis, absent jets
Tiny stones can be difficult to identify, what can you look for?
Twinkling artifact
What is staghorn calculi?
Calcifications filling the collecting systemq
What are false positives of nephrolithiasis?
Intrarenal gas, renal artery calcifications, calcified sloughed papilla, calcified tumors, ureteric stent
What are 3 other imaging modalities that can detect urolithiasis?
X-ray, tomography, CT
Bladder calculi are usually what?
Single
What should you check for with bladder calculi?
Mobility
Hydronephrosis can be due to what two causes?
Obstructive or non-obstructive
What is obstructed flow broken down into?
Intrinsic and extrinsic
What are examples of non-obstructive hydronephrosis?
Reflux, infection, polyuria
What could hydronephrosis lead to?
Renal atrophy
What is Grade 1 Mild hydro?
Slight separation of renal collecting system
What is Grade 2 Moderate hydro?
Separation of entire central renal sinus including dilated pelvis and calyces
What is Grade 3 Severe hydro?
Thin renal cortex, extensive enlargement of renal sinus and calyces, loss of calyx definition
What are false positives of hydro?
Over distended bladder, extra-renal pelvis, multiple parapelvic cysts, AV malformation
What are renal parenchymal calcium deposits referred to as?
Nephrocalcinosis
Renal parenchymal calcium deposits are bilateral and what?
Diffuse
What can renal parenchymal calcium deposits be caused by?
Ischemia, necrosis, or hypercalcemic states
What is a DDx of renal parenchymal calcium deposits?
Medullary sponge kidney
What is the sonographic appearance of renal parenchymal calcium deposits?
Increased cortical echogenicity with echogenic pyramids or wall of pyramids
What is thought to be a possible precursor to development of renal stones?
Anderson-Carr Kidney
What is Anderson-Carr kidney?
High concentration of calcium in fluid around tubules
High concentration of calcium in the fluid around the tubules of Anderson-Carr kidney results in what?
Deposits of calcium in the margins of the medulla
What is the sonographic appearance of Anderson-Carr kidney?
Non-shadowing echogenic rims of renal pyramids
What is medical renal disease?
Disease affecting renal parenchyma diffusively and bilaterally
What does medical renal disease describe?
Poorly functioning but unobstructed kidneys
What is the sonographic appearance of acute medical renal disease?
Increase in cortex echogenicity, prominent CM junction, enlarged kidneys
When would the CM junction not be defined with acute medical renal disease?
If the pyramids are affected
What is the sonographic appearance of chronic medical renal disease?
Small, echogenic kidneys
What are the causes of medical renal disease?
Acute tubular necrosis, acute cortical necrosis, acute glomerulonephritis, amyloidosis, diabetes mellitus
What is the most common cause of acute reversible renal failure?
Acute tubular necrosis
Acute tubular necrosis can be the result of what?
Toxic or ischemic insults
What is the sonographic appearance of acute tubular necrosis?
Bilaterally enlarged with echogenic pyramids and an RI >0.75
What is a considered to be a rare cause of medical renal failure?
Acute cortical necrosis
What is acute cortical necrosis?
Ischemic necrosis of the cortex with sparing of the pyramids
How would acute cortical necrosis appear on ultrasound?
Initially normal, more hypoechoic cortex with loss of CM junction. Kidneys become atrophied over time and cortex calcifies
What is an an autoimmune reaction that causes medical renal disease?
Acute glomerulonephritis
What are the three patient presentations of someone with acute glomerulonephritis?
Hematuria, hypertension, azotemia
Describe the sonographic appearance of acute glomerulonephritis
Early stages are variable. Later stages show small, echogenic kidneys
What is amyloidosis?
Systemic metabolic disorder resulting in amyloid deposits in the kidneys
How does amyloidosis occur sonographically?
Variable (large, normal, small, hypo or hyper)
What is the most common cause of chronic renal failure?
Diabetes mellitus
Explain the sonographic appearance of diabetes mellitus:
Enlarged kidneys initially, end stage shows small, echogenic kidneys with loss of CMJ
What is renal failure?
Inability of kidneys to remove metabolites from blood?
What does renal failure result in?
Azotemia
What is azotemia?
Overload of urea and nitrogenous wastes in the blood
What 3 things does renal failure cause?
Pre-renal, renal, and post-renal
What is pre-renal failure?
Sepsis, renal artery stenosis
What is renal failure characterized by?
Parenchyma disease
What is post-renal failure?
Obstruction of collecting system
The obstruction of the collecting system in post-renal failure is further categorized into what?
Complete and incomplete obstruction/
What is complete obstruction in post-renal failure?
Irreversible damage in 3 weeks
What is incomplete obstruction in post-renal failure?
Irreversible damage in 3 months
Which stage of renal failure is reversible? Irreversible?
Acute stage is reversible, chronic stage is irreversable
What is the sonographic appearance of acute renal failure?
Possibly enlarged, hypoechoic kidneys
What is the sonographic appearance of chronic renal failure?
Small kidneys with an echogenic cortex
What is the most common cause of chronic renal failure?
Diabetes mellitus
What lab value is most commonly increased with renal failure?
Serum creatinine
What are examples of hyperadrenalism?
Cushing’s syndrome, Conn’s disease, and MEN
What is Cushing’s syndrome?
Result of excess secretion of cortisol
What is the clinical presentation of someone with Cushing’s syndrome?
Moon face, buffalo hump, truncal obesity, hirsutism, amenorrhea, and hypertension
What is the difference between Cushing’s syndrome and Cushing’s disease?
The disease is due to a pituitary adenoma
What is Conn’s disease?
Excess aldosterone secretion
What is the most common cause of Conn’s disease?
An aldosteronoma
What is the clinical presentation of someone with Conn’s disease?
Hypernatremia, hypokalemia, hypertension, muscle cramps, and altered renal function
What is MEN?
Where tumors develop in several endocrine glands
Which type of MEN is malignant?
Type 2
What is hypoadrenalism due to?
Primary disorders of the adrenal cortex or disorders of the hypothalamus or pituitary
What are examples of hypoadrenalism?
Addison’s disease and Waterhouse-Friderichsen
What are the two different causes of Addison’s disease? Which is more common?
Autoimmune and tuberculosis. Autoimmune at 80%
Waterhouse-Frederichsen syndrome is an example of what kind of hypoadrenalism?
Acute
What does Waterhouse-Frederichsen syndrome result in?
Massive destruction of adrenals
