Module 4 : Metabolic Disease Flashcards
what is a metabolic disease
- an abnormality that occurs globally and affects severe organs
what is hepatocellular disease and why does it occur
- dysfunction of hepatocytes
- normal liver tissue is replaced with fat or fibrosis
is hepatocellular disease focal or diffuse
- usually diffuse process
what lab tests will be abnormal with hepatocellular disease
- LFTs
what physical aspect of the liver is usually affected by hepatocellular disease
- the liver size
what are two types of hepatocellular disease
- fatty infiltration
- cirrhosis
what is fatty infiltration
focal or diffuse?
- accumulation triglycerides (fat) in hepatocytes
+ precursor to significant chronic disease - not always uniform throughout the liver
diffuse or focal
what is another name for fatty infiltration
- steatosis
what is steatosis
- fat accumulation within hepatocytes
is fatty infiltration developmental or acquired, reversible or permanent?
- aquired
- reversible
+ life style change required
2 most common causes of fatty infiltration
- alcohol abuse
- obesity
what 4 things do we look for when assessing for fatty infiltration
- echogenicity changes
- echo texture changes
- attenuation characteristics
- ability to visualize vessels (paucity)
what 3 machine factors are important to consider when assessing fatty infiltration
- gains
- TGC
- focus
sonographic appearance of mild (grade 1) fatty infiltration
- slight increase in liver echogenicity
- diaphragm and vessels clearly defined
sonographic appearance of moderate (grade 2) fatty infiltration
- increase in liver echogenicity
- vessels and diaphragm not sharply
sonographic appearance of severe(grade 3) fatty infiltration
- liver echogenicity is increased markedly
- extremely difficulty to define diaphragm and vessel walls
what are the two types of focal fatty changes
- focal fatty infiltration
- focal fatty sparring
what is focal fatty infiltration
- focal areas of increased echogenicity
+ fatty deposits - mostly normal liver parenchyma
what is focal fatty sparring
- majority of liver parenchyma has experienced fatty infiltration
- focal hypo echoic areas (normal liver tissue)
what are 4 similarities between fatty sparring and fatty infiltration
- both commonly involve the periportal area of the medial LL (segment 4)
- no mass effect
- rapid change with time
- map like boundaries (LINEAR vs round)
what 3 lab values could be elevated with fatty infiltration
- ALT
- AST
- if related to alcohol abuse then GGT
what is cirrhosis and what does it result in
- a diffuse process that destroys the liver cells
- resulting in fibrosis with nodule changes
what are the underlying causes of cirrhosis
- alcohol abuse
- chronic viral hepatitis
- primary sclerosing cholangitis
what is the most common underlying cause of cirrhosis
- alcohol abuse
what is the progressive change that occurs in liver cells with cirrhosis
- cell death» fibrosis» regeneration
is cirrhosis reversible
- no
what are the two types of nodular change
- micronodular
- macro nodular
what causes micro nodular cirrhotic change
- alcohol consumption
what causes macro nodular cirrhotic change
- chronic viral hepatits
what is the sonographic appearance of acute cirrhosis
- same as severe fatty infiltration
- enlarged liver
- textural changes
what is the sonographic appearance of chronic cirrhosis
- small liver (CL/RL >0.65)
- course echo texture
- nodular surface
- paucity of vessels
what does paucity mean
- poor ability to see vessels
what does chronic cirrhosis eventually lead to
- portal hypertension»_space; end stage liver failure
what associated abnormality is commonly seen with cirrhosis
- ascites quite common
what do the lab value levels for cirrhosis depend on
- stage of disease
which 6 lab values will be increased with cirrhosis
- AST
- ALT
- LDH
- ALP
- bilirubin (conjugated)
- GGT
what lab value will be decreased with cirrhosis
- serum albumin
what other organ is affected by liver cirrhosis and why
- the spleen due to portal hypertension
what are the 3 classic clinical presentation of patients with cirrhosis
- hepatomegaly
- jaundice
- ascites
what are three less common clinical presentations of cirrhosis
- diarrhea
- feeling of fullness
- weight loss
what is glycogen storage disease and what causes it
- autosomal recessive disorder
- excess glycogen deposits in the hepatocytes
what is another name for glycogen storage disease
- GSD
- Von Gierkes disease
what 2 other abnormalities is GSD associated with
- benign adenomas and HCC
does GSD begin in adults ?
- no begins neonatally
how is GSD managed
- controlled and monitored diet
sonographic appearance of GSD
- diffuse fatty infiltration (cannot differentiate between causes)
- adenomas = solid masses with variable echogenicity
what is the only metabolic disease of the peritoneum
- ascites
what is ascites
- accumulation of serous fluid in the peritoneal cavity
what are the two types of fluid in ascites
- transudate
- exudate
what is transudate fluid
- contains little protein or cells
- suggests a non inflammatory response
two non inflammatory responses causing ascites
- cirrhosis
- CHF
sonographic appearance of transudate ascites
- anechoic fluid
what is exudate fluid
- high protein content
- blood, pus, chylous
- suggests an inflammatory or malignant cause
what is chylous
- milky fluid with a high fat content
- usually from lymphatic system
sonographic appearance of exudate ascites
- internal echoes
- echogenic
- locations
characteristics of free fluid in peritoneum
- changes with patient position
- conforms to surrounding organs
characteristics of loculated fluid in peritoneum
- no change with movement
- rounded margins
- mass effect
- walled off
what are the three most dependant spaces in the peritoneal cavity
- Morrisons pouch (rt kidney and liver)
- pouch of Douglas (uterus and rectum)
- parabolic gutters
what is biliary sludge and what is it a precursor to
- a mixture of particulate matter and bile
- precursor to biliary disease
2 other names for biliary sludge
- biliary sand
- microlithiasis
symptoms of biliary sand
- asymptomatic
- biliary colic and infmallation of GB and panc
can biliary sludge resolve on its own
- yes
what is the most likely cause of biliary sand
- bile stasis
what are 4 causes of bile stasis
- prolonged fasting
- rapid weight loss
- TPN (total parenteral nutrition IV food)
- extra hepatic biliary obstruction
what is the sonographic appearance of biliary sand
- no shadowing
- homogeneous low level echoes
- layers in the dependant portion of the gallbladder
+ fluid-fluid levels - moves with change in patient position
what are tumefactive sludge/ sludge balls
- sludge that mimic polypoid tumors
- to differentiate look at vascularity, mobility, and GB wall thickness
what is hepatization
- when sludge has sam echogenicity of liver
- camouflages the GB
what is pseudo sludge
- imaging artifact
- caused by excessive gains, slice thickness or side lobe artifact
- idependent of gravity
what is empyema
- presence of pus in bile
what is hemobilia
- presence of blood in bile
- usually due to liver biopsy and percutaneous biliary procedures
what is milk of calcium / limey bile
- rare
- separate category from biliary sludge
- GB becomes filled with semi solid substance (calcium carbonate)
sonographic appearance of milk of calcium / limey bile
- highly echogenic with posterior shadowing
- changes with patient position
- forms calcium/bile fluid level
what is cholelithiasis / gallstones
- most common disease of the gallbladder
what 3 factors affect gallstone formation
- abnormal bile composition
- stasis of bile
- infection
3 different compositions of stone
- cholesterol (most common)
- bilirubin (pigment stone)
- calcium
what are the 5 F risk factors with gallstone
- female
- forty
- fatty
- fertile
- family history
what is the clinical presentation of gallstones
- asymptomatic
- RUQ pain (after meals) radiates to back
- nausea and vomitting
- belching
sonographic appearance of gallstones
- echogenic focus
- posterior shadowing
- MOBILITY
- may float in the bile
what size should stones being to shadow in GB
- > 5mm
what is the WES sonographic sign
- Wall > Echo > Shadow
- seen when gallbladder is filled with multiple stones or one large stone
what lab values will be altered with GB stones
- AST
- ALT
- ALP
- BILIRUBIN
what 3 things in the gallbladder also cause shadowing
- valves of heister
- fat of portahepatis
- duodenal gas
5 complications of gall stones
- biliary colic (MOST COMMON)
- obstruction of cystic duct or CBD
+ leads to GB hydrops - bacterial infection
- cholecystitis
- ascending cholangitis
what 3 questions should an US investigation of biliary obstruction try to answer
- are the bile ducts or GB dilated
- if yes, to what extent
- if no , what is the cause
what are the 3 causes of biliary dilation
- obstruction (MOST COMMON)
+ stone, tumor - loss of duct wall elasticity
- ampulla of vater dysfunction
is biliary dilation intra or extrahepatic
both
2 clinical presentation of biliary obstruction
- painless jaundice
- painful jaundice
what is painless jaundice indicative of
- neoplastic conditions (panc head)
- choledochal cysts
what is painful jaundice idicitve of
- acute obstruction
- infection of biliary tree
4 signs and symptoms of biliary obstruction
- jaundice
- clay coloured stools
- abnormal LFTs
- pain, nausea
what is choledochallithiasis (intra or extra hepatic)
- stones in biliary tree
what is the secondary causes to biliary stones
- stones pass from gallbladder to ducts
+ MOST COMMON
what are the 4 primary causes to biliary stones
- inflammation
- infection
- carolis disease
- prior surgery
what is the most common location for stones in biliary tree
- distal CBD at ampulla of vater
+ difficult to visualize due to bowel gas
+ look for hyperchoic foci with shadowing
+ false positives = air, surgical clips, edge artifact
what lab values will be abnormal with biliary obstruction
- ALP
- AST
- ALT
- bilirubin
what is treatment of biliary obstruction
- ERCP spincterotomy
- ERCP extraction
- stenting
what is ERCP
- endoscopic retrograde cholangiopacreatography
+ put endoscopic through esophagus into duodenum to open up ampulla of vater
definition of urolithiasis
- stones in urinary system
definition of nephrolithiasis
- stones in the renal collection system
defintion of nephrocalcinosis
- calcifications in the renal parenchyma
is nephrolithiasis common or uncommon
- very common
- caucasian males
does it increase or decrease with age
- increase with age
what are 4 underlying risk factors for getting nephrolithiasis
- hereditary
- limited water intake
- high animal protein diet
- urinary stasis
can stones move through the collecting system
- yes
- can lodge in the natural narrowing of the ureter
what are the three natural narrowings of the ureter
- just past UPJ (ureteropelvic junction)
- at the iliac vessels
- at the UVJ (most common) (ureterovesicular junction)
what must the size of stone be in order to be able to pass
< 5mm
clinical presentation of nephrolithiasis
- asymptomatic
- hematuria (microscopic or gross)
- flank pain
what is the sonographic appearance of kidney stones
- echogenic focus
- posterior shadowing
- twinkle artifact
what 5 things should you asses for the rad
- number
- size
- location
- complications
what is stag horn calculi
- calcification filling the collecting system
+ an entire major or minor calyc
what are 5 things that can cause false positives
- intrarenal gas
- renal artery calcification
- calcified sloughed papilla
- calcified tumors
- ureteric jet
what are 3 other imaging modalities that can detect urolithiasis
- x ray
- tomography
- CT
characteristics of stones in ureter
- location creates imaging problems
- stones lode at narrowest point
- look for dilated tubes
- identify echogenic foci with shadowing at distal end
characteristics of bladder calculi
- usually single
- asymptomatic
- may migrate from kidney or be result of urinary stasis (neurogenic bladder or BPH)
- patient may present with hematuria and pain
- check for mobility to dependant portion of bladder
what is hydronephrosis
- dilated renal vessels
- due to obstructive or non obstructive causes
- may lead to renal atrophy
obstructive causes of hydronephrosis
- intrinsic (stone/mass) or extrinsic (mass/aneurysm) obstruction to flow
- can be diagnosed on ultrasound
non obstructive causes of hydronephrosis
- reflux
- infection
- polyuria (to much urine production=diabtetes mellitus)
three classifications of hydronephrosis
- grade 1 = mild
- grade 2 = moderate
- grade 3 = severe
grade 1 / mild hydro
- slight separation of renal collecting system
+ 2mm seperation
grade 2 / moderate hydro
- anechoic separation of entire central renal sinus
- pelvis and calyces are dilated
- clubbed calyces
grade 3 / severe hydro
- thinning renal cortex
- extensive enlargement of renal sinus and calyces
- loss of individual calyx definition
what should we do when we see hydronephrosis
- look for cause of hydro
what 4 things could cause false positives for hydro
- over distended bladder
- extra renal pelvis
- multiple paraplevic cysts
- AV malformation
what assessment should you always do when you see hydro
- POST VOID
what is another name for renal parenchymal calcium deposits
- nephrocalcinosis
can renal parenchymal calcium deposits be bilateral or unilateral, cortical or medullary
- yes they can be both
what are 3 things renal parenchymal calcium deposits caused by
- ischemia
- necrosis
- hypercalcemic states
what other disease is hard to differentiate between renal parenchymal calcium deposits
- medullary sponge kidneys
sonographic appearance of renal parenchymal calcium deposits
- increased cortical echogenicity
- echogenic pyramids or wall of pyramids
- possible shadowing
characteristics of Anderson-Carr kidney
- theory of stone progression
- high concentration of calcium in fluid (early development of stone)
- results in deposits of calcium in margins of the medulla
sonographic appearance of Anderson-Carr kidney
- non shadowing echogenic rims of renal pyramids
what is medical renal disease
- disease affecting renal parenchyma diffusely and bilaterally (always both)
+ cortex
+ medulla - broad term used to describe renal disorders
- describes poorly functioning but unobstructed kidneys
- can lead to renal failure
what is needed to identify cause of medical renal disease
- renal biopsy
what is the treatment of medical renal disease
- initially treatable by medication rather than surgery
5 areas to evaluate sonographically with medical renal disease
- renal size and contour
- cortical echogenicity
- CM junction distinction
- renal pyramids
- renal sinus
what lab value will be increased with medical renal disease and why
- creatinine
- sent for US as initial screening
- purpose of US is to check for a mechanical obstruction.. if there is no obstruction this indicates a renal parenchymal abnormality
sonographic appearance of medical renal disease
- depending on underlying cause
- acute and chronic
acute medical renal disease sonographic appearance
- diffuse increase in cortical echogenicity
- prominent CM junction
+ exception = if the pyramids are affected then CM junction will not be defined - enlarged kidneys
- KIDNEYS MAY APPEAR NORMAL
chronic stage medical renal disease sonographic appearance
- small
- echogenic
5 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
what is acute tubular necrosis
- deposits of debris in the renal collecting tubules
- can have hematuria
- can be result of toxic or ischemic insults
+ chemotherapy, antibiotics, antifreeze
ultrasound appearance of acute tubular necrosis
- kidneys most often appear normal but may be bilaterally enlarged
- echogenic pyramids
- RI > 0.75 (abnormal resistance to flow)
what is acute cortical necrosis
- rare cause of acute renal failure
- ischemic encores of the cortex with sparing of the pyramids
- due to sepsis, burns, severe dehydration PIH (pregnancy induced hypertension)
ultrasound appearance of acute cortical necrosis
- initially normal size, hypo echoic cortex and loss of CM junction
- over time kidneys atrophy and cortex calcifies
what is acute glomerulnephritis
- autoimmune reaction
- patient presentation
+ hematuria, hypertension, azotemia
ultrasound appearance of acute glomerulonephritis in early stage
- may be normal or enlarged
- cortex may be normal , echogenic, or hypo echoic
- EXTREMELY VARIABLE
ultrasound appearance of acute glomerulonephritis in lateraled stage
- small
- echogenic kidneys
what is amyloidosis
- systemic metabolic disorder resulting in amyloid (protein) deposits in the kidney
- patient presents with proteinuria
ultrasound appearance of amyloidosis
- variable appearance
+ large, normal, or small kidney size = hypo or hyper
diabetes mellitus
- MOST COMMON CAUSE OF CHRONIC RENAL FAILURE
- initially kidneys will be enlarged
- end stage = small echogenic, loss of CMJ
what is renal failure
- inability of kidneys to remove metabolites from blood
what does renal failure result
- azotemia (uremia)
what is azotemia
- overload of urea and nitrogenous wastes in the blood
three different causes of renal failure
- pre renal
- renal
- post renal
pre renal causes of renal failure
- sepsis
- renal artery stenosis
renal cause of renal failure
- parenchymal disease
post renal cause of renal failure
- obstruction of collecting system
+ complete obstruction = irreversible damage in 3 weeks
+ incomplete obstruction = irreversible damage in 3 months
acute stage of renal failure
- reversible
- medical renal disease (renal parenchymal disease)
sonographic appearance of acute stage renal failure
- most often normal
- may be enlarged or hypo echoic
- check for hydronephrosis, obstruction
- check echogenicity of parenchyma (usually increased)
chronic stage of renal failure
- irreversible
- most common cause is diabetes mellitus
sonographic appearance of renal failure
- small kidney
- echoegenic cortex
what lab values increased
- serum creatinine (most common and most important)
- BUN
- Uric acid
- RBC/WBC in urine
- protein uria
treatment for renal failure
- dialysis or renal transplant
what is dialysis
- removes waste from blood
- “artificial kidney”
what is a renal transplant
- usually on R sides of pelvis and document nature kidney too
3 causes of hyperadrenalism
- cushings syndrome
- conns disease
- MEN (multiple endocrine neoplasia)
what is cuchsings syndrome a result of
- excess secretion of cortisol
what are 4 causes of bushings syndrome
- adrenal hyperplasia
- adrenal adenoma
- adrenal carcinoma
- exogenous corticosteroid administration
clinical presentation - of cushings syndrome
- moon face
- buffalo hump (upper neck/lower back)
- truncal obesity (eggs on legs)
- hirsutism
- amenorrhea
- hypertension
what is the different between cushings syndrome and cuttings disease
- syndrome = due to adrenal abnormality
- disease = due to pituitary adenoma producing too much cortisol
what causes conns disease
- excess aldosterone secretion
what 3 things causes an excess of aldosterone
- ADENOMA (aldosteronoma)
- hyperplasia
- carcinoma (uncommon)
clinical presentation of Conns disease
- hypernatremia = increased sodium in blood
- hypokalemia = decreased potassium
- hypertension
- muscle cramps
- altered renal function
sonographic appearance of Conns disease
- small
- solid
- round mass
- hypo echoic
MEN (multiple endocrine neoplasia)
- 3 types
- tumors develop in several endocrine glands
+ adrenal
+ panc
+ pituitary
+ parathyroid gland - excessive hormones produced
- benign or malignant
MEN type 2
- autosomal dominant
- pheochromocytomas in adrenal (usally benign but with MEN its malignant)
- typically bilateral
- malignant
what is hypoadrenalism
- due to primary disorders of the adrenal cortex or disorders of the hypothalamus or pituitary
- may cause adrenal atrophy
two types of hypoadrenalism
- Addisons disease
- Waterhouse-friderichsen syndrome
2 types of Addisons disease
- autoimmune (80%)
- TB (20%)
what is Addisons disease
- chronic
- primary hypoadrenalism
autoimmune Addisons disease
- females
- not typically identified on ultrasound
TB Addisons disease
- males
- enlarged, firm, nodular adrenals
- hyperpigmentation
- low blood pressure, muscle weakness, fatigue
- 90% of gland is nonfunctioning
what is Waterhouse-friderichsen syndrome
- acute hypoadrenalism
- secondary to hemorrhage, infection
- massive destruction of adrenals
- glucocorticoid therapy necessary
