pathology Flashcards
Diffuse disease
affects hepatocytes and interferes with liver function
the hepatocytes is a parenchymal liver cell that
Performs all the functions ascribed to the liver
how is diffuse disease measured?
through a series of liver function tests
diffuse diease what are hepatic enzyme level elevated with?
with cell necrosis
increased in LFT’s
fatty liver
is an aquired, reversible disorder of metabolism resulting in an accumulation of triglycerides within the hepatocytes
true or false
fatty liver is reversible
true
what does fatty infiltration imply?
implies increased lipid accumlation in the hepatocytes and is the result of major injury to the liver or systemic disorder leading to impaired or excessive metabolism of fat
what is attenuation?
is the reduction in power and intesity of sound waves as they travel through tissue
Mild Fatty Infiltration
Minimal diffuse increase in hepatic echogenicity with normal visualization of the diaphragm and intrahepatic vascular borders
Moderate Fatty Infiltration
Increased echogenicity with slightly impaired visualization of the diaphragm and intrahepatic vascular borders
Severe Fatty Infiltration
Significant increase in echogenicity of the liver parenchyma, decreased penetration of the posterior segment of the right lobe of the liver, and decreased to poor visualization of the diaphragm and hepatic vessels
what are the causes of fatty liver?
obesity
excessive alcohol intake
poorly controlled hyperlipidemia
diabetes
excess corticosteriods
pregnancy
total parenteral hyperlimentation
severe hepatitis
glycogen storage disease
cystic fibrosis
pharmaceutical
focal fatty sparing is most commonly seen
adjacent to the gallbladder and right portal vein
What can focal fatty sparing mimic?
a mass/tumor
what doppler do you use on focal fatty sparing?
color doppler
Focal fatty sparing scan
area of hypoechogencity
focal fatty sparing
manifestation of fatty liver disease in which an area of the liver is spared from fatty infiltration
viral hepatitis
inflammation of the liver caused by a virus
hepatitis is the general name for
inflammatory and infectious disease of the liver
Where does viral hepatitis disease result from?
From a local infection (viral hepatitis) from an infection elsewhere in the body (infectious mononucleosis, amebiasis) or from chemical or drug toxicity
What does the mild inflammation impair
Impairs hepatocyte function
What does the severe inflammation and necrosis may lead to and impairs
may lead to obstruction of blood and bile flow in the liver
impairs liver cell function
What are the common hepatitis?
Hepatitis A Virus (HAV)
Hepatitis B Virus (HBV)
Hepatitis C Virus (HCV)
What is hepatitis considered to result from?
an infection by a group of viruses that specifically target the hepatocytes
Where is Hepatitis A Virus (HAV) found?
Is found worldwide
How is Hepatitis A Virus (HAV) spread?
Primarily by fecal contamination because the virus lives in the alimentary tract
Hepatitis A Virus (HAV)
Is an acute infection that leads to either complete recovery or death from acute liver failure
how is hepatitis b virus caused?
By the type B virus, which exists in the bloodstream
How is hepatitis b spread?
Can be spread by transfusions of infected blood or plasma or using contaminated needles
Which virus is the greatest risk to health care workers?
Hepatitis B
Where else can the hepatitis b virus be found?
In body fluids, such as saliva and semen and may be spread by sexual contact
How is Hepatitis C Virus (HCV) diagnosed?
Is diagnosed by the presence in blood of the antibody to HCV (anti-HCV)
Acute hepatitis ultrasound
Liver texture may appear normal, or portal vein borders may be more prominent than usual. -STARRY SKY
Liver parenchyma is slightly more echogenic than normal.
Attenuation may be present.
Hepatosplenomegaly is present.
Gallbladder wall is thickened.
Chronic hepatitis
exists when clinical or biochemical evidence of hepatic inflammation extends beyond 6 months
What are the causes of chronic hepatitis?
Viral, metabolic, autoimmune, or drug-induced
What are patients symptoms of chronic hepatitis?
Nausea, anorexia, weight loss, tremors, jaundice, dark urine, fatigue, and varicosities
Chronic persistent hepatitis is a
Benign, self limiting process
Chronic hepatitis ultrasound
-Liver parenchyma is coarse with decreased brightness of the portal triads
-Degree of attenuation is not as great as is seen in fatty infiltration
-Liver does not increase in size with chronic hepatitis
-Fibrosis may be evident, which may produce soft shadowing posteriorly
Cirrhosis
chronic degenerative disease of the liver
What happens to the liver with cirrhosis?
Lobes are covered with fibrous tissue
parenchyma degenerates
lobules are infiltrated with fat
What is an essential feature with cirrhosis?
parenchymal necrosis, regeneration, and diffuse fibrosis, resulting in a disorganization of lobular architecture
What is the process of cirrhosis of the liver?
is a diffuse process of fibrosis and distortion of normal liver architecture.
initially there is liver enlargement but continued insult results in hepatic atrophy
what are the causes of cirrhosis?
hepatitis c and b
alcoholic liver disease
nonalcoholic fatty liver disease
what is the most common cause of cirrhosis?
hepatitis c
what may chronic cirrhosis progress to?
to liver failure and portal hypertension
Sonographic findings of cirrhosis
hepatomegaly (acute)
liver atrophy (chronic)
ascites may be present
surface nodularity
fatty infiltration increased echogenicity
changes related to portal vein
increased incidence of hepatocellular carcinoma
portal venous hypertension
increase in portal venous pressure or hepatic venous gradient present
When does portal venous hypertension exist?
when the portal venous pressure is above 10 mmHg or the hepatic venous gradient more than 5 mmHg
what diameter of the portal vein suggests portal hypertension?
greater than 13 mm
True or False
portal hypertension is asymptomatic
true
what is a major cause of portal hypertension?
cirrhosis
what do patients usually present with?
with upper GI hemorrhage to rupture of the esophageal varices
what can acute or chronic hepatocellular disease block?
can block the flow of blood throughout the liver, causing it to back up into the hepatic portal circulation
what does hepatocellular disease cause?
caused the blood pressure in the hepatic circulation to increase and leads to the development of portal hypertension
what happens to relieve the pressure?
collateral veins are formed that connect to the systemic veins
where does varicose veins most occur?
most frequently in the area of the esophagus, stomach and rectum
What is the most common cause of intrahepatic portal hypertension?
cirrhosis
when may portal hypertesion develop?
when hepatopedal flow (toward the liver) is impeded by thrombosis or tumor invasion
what is used to confirm diagnosis of portal hypertension?
color doppler
what indicates portal hypertension?
reversal of flow (hepatofugal)
portal hypertension=
hepatofugal flow in the main portal vein
to blood becomes obstructed as it pass through the liver to the hepatic veins
and is diverted to collateral pathways in the upper abdomen
what happens when the blood vessels decrease in diameter?
the pressure increases
collateral veins
tiny capillary size veins
varices or varicose veins
enlarged, tortuous and dilated veins
when do collateral veins exist?
when the functional veins can’t do their job properly
Intrahepatic portal hypertension
cirrhosis
schistosomiasis
hepatitis
veno-occlusive disease
sclerosing cholangitis
primary biliary cirrhosis
wilson’s disease
hemochromatosis
alpha-1 antitrypsin
granulomatous disease
congential fibrosis
Recanalized umbilical vein
Re-opening of the umbilical vein (ligamentum teres) to act as a collateral
how can recanalized umbilical vein occur?
in patients with long-standing portal hypertension to provide a collateral venous channel
what is the most common treatment for portal hypertension?
a transjugular intrahepatic portosystemic shunt or TIPS
what does the treatment TIPS do?
helps reduce the pressure that is being caused by the portal hypertension and in turn is causing the recanalized umbilical vein
what can portal vein thrombosis lead into?
portal hypertension
A recanalized umbilical vein is a sonographic finding that is most common in patiets with?
cirrhosis and portal hypertension
What are the characteristics features that are seen using doppler when recanalized umbilical vein is present?
hepatofugal flow and lack of phasicity
what is the most common complication of portal venous hypertension?
ascites
What is ascites?
accumulation of fluid in the peritoneal cavity
What are the symptoms of ascities?
early feeling of fullness
increase in size of abdomen
feeling out of breathe
What is paracentesis?
removal of fluid from the abdominal cavity
what are the three types of shunts?
portacaval, mesocaval, splenorenal
portacaval shunt
Attaches the main portal vein at the superior mesenteric vein-splenic vein confluence to the anterior aspect of the inferior vena cava.
mesocaval shunt
Attaches the mid-distal superior mesenteric vein to the inferior vena cava
May be difficult to image if overlying bowel gas is present
splenorenal shunt
Attaches the splenic vein to the left renal vein
what should shunt and connecting vessels be documented with?
real-time pulsed Doppler and color Doppler to determine flow patterns and patency
What is a shunt?
redirect blood flow in cases of long standing portal hypertension
in cases there are no good hepatic vein what shunt is used
splenorenal
what is the number one complication for TIPS procedure?
stenosis
How is portal vein thrombosis defined?
As occlusion of the portal vein
cavernous transformation of the portal vein
Numerous wormlike venous collaterals that oarallel the chronically thrombosed PV.
cavernous transformation is typically seen
with bengin causes of PV thrombosis.
what are the causes of portal vein thrombosis?
hepatocelluar carcinoma
metastatic liver diease
pancreatic carcinoma
cirrhosis
Budd-Chiari syndrome
thrombosis of hepatic veins
how is budd-chiari syndrome characterized?
by hepatic vein obstruction
patients with budd-chiari syndrome presents signs associated with?
portal vein: ascites, hepatomegaly, splenomegaly
patients with budd-chiari syndrome shows
enlarged liver, dilated IVC with thrombus
what are symptoms of budd-chiari syndrome?
ascites
hepatomegaly
abdominal pain
hepatosplenomegaly
jaundice
vomiting and diarrhea
liver cysts
fluid filled spaced lined by biliary epithelium
sonographic criteria for liver cyst
anechoic
thin walled
acoustic enhancement
liver cysts can be
simple or complex
how will a complex hemorrhagic cyst appear?
as assist with internal echoes accompanied by retrograde in pain and a decrease in hemocrit (the ratio of the volume of red blood cells to the total volume of blood)
Polycystic liver disease
inherited in an autosomal dominant pattern that affects 1 in 500 individuals.
atleast ____ of patients with polycystic renal disease have one to several hepatic cysts
50% to 74% of patients with polycystic liver disease,60% have associated polycystic renal parenchyma
what is the size of polycystic liver diease?
small, less then 2 or 3 cm and multiple throughout the hepatic parenchyma
polycystic liver diease may
enlarge and cause biliary obstruction in the porta hepatis
what is the most common benign tumor of the liver?
Hemangioma
hemangimos consists of
multiple cascular chanels that create multiple vascular channels that create multiple sonographic interfaces which give this mass
Hemangioma characteristics
hyperechoic apperance
sonographic findings of hemangioma
hyperechoic
posterior enhancement
can be single or multiple
hemangioma may
enlarge with pregnancy administration of estrogen
hemangioma may appear
hypoechoic within the background of fatty infiltrated liver
what does not typically demonstrate flow within the hemangioma?
color Doppler
Benign hepatic tumors- canvernous hemangiomas are found
in the subcapsular hepatic parenchyma or in posterior right lobe more than the left of the lobe
benign hepatic tumors
enlarges slowly and undergoes degeneration, fibrosis, and califaction
Focal nodular hyperplasia
A benign solid liver mass that is believed to be a developmental hyperplastic lesion rather than a true neoplasm
Focal nodular hyperplasia is found
in women under the age of 40
true or false
focal nodular hyperplasia patients are asymtomatic
true
sonographic findings of focal nodular hyperplasia
Solid mass with varying echogenicity
Central fibrous scar
Stellate vascularity
what is focal nodular hyperplasia mass thought to arise?
from developmental hyperplastic lesions related to an area of congential vascular formation
lesions of focal nodular hyperplasia occur
more in the right lobe of the liver
what is the second most common benign liver mass?
hepatic adenoma
Hepatic adenoma
a benign solid hepatic mass
what is hepatic adenoma associated with?
the use of contraceptive agents
sonographic finding of hepatic adeoma
solid hepatic mass
nonspecific echogenicity
may have tumor hemorrhage
may have vascularity
what is recommended for hepatic adeoma?
surgical resection is recommended due to the risk of malignant transformation
Common duct stricture
Clinically, the patient is jaundiced and has had a previous cholecystectomy. Laboratory values show an increase in the direct bilirubin and alkaline phosphatase levels.
Hepatic Lipoma
extremely rare fatty tumor
Sonographic findings hepatic lipoma
hyperechoic mass
what is used to comfirm hepatic lipoma?
ct scan can be useful in confirming the fatty tumors
Hepatocellular carcinoma
liver cancer
what is the most common primary maglignancy of the liver?
hepatocellular carcinoma
Hepatocellular carcinoma occurs
10-25% of patients with cirrhosis
most frequent in men
extrahepatic mass
An extrahepatic mass in the area of the porta hepatis causes the same clinical signs as seen in biliary obstruction
Clinical Presentation of hepatocellular carcinoma
a previous history of cirrhosis or hepatitis B and C, a palpable mass, hepatomegaly, appetite disorder, and fever
Diffuse Abnormalities of the Liver Parenchyma
- Extrahepatic mass
- Common duct stricture
- Passive hepatic congestion
hepatoceullar carcinoma has been known to
invade the hepatic veins to produce Budd-Chiari syndrome
Hepatocellular carcinoma commonly invades
venous structures (portal vein, hepatic veins, IVC)
sonographic findings of hepatocellular carcinoma
multiple hypoechoic solid mass
variable in apperance
Biliary Obstruction: Distal clincal findings
Common duct stones cause RUQ pain, jaundice, pruritus.
Elevated bilirubin and alk phos.
Dilated intrahepatic ducts, usually a small gallbladder, gallstones often present.
Biliary Obstruction: Distal
Caused by stones in the common duct, an extrahepatic mass in the porta hepatis, or stricture of the common duct.
biliary obstruction: proximal clinically the pateint may be
Clinically, the patient may be jaundiced and have pruritus (itching).
with hepatocellular carcinoma increase in lab values
Alpha feta protein, AST and ALT
metastatic liver cancer
is cancer that started in the liver and spread (or metastasized) to other areas of the body
Liver metastases
are cancers that have spread (or metastasized) to the liver from a tumor that started in another par of the body
most live metastes are
multiple
Liver metastasis found most commonly in
i
the colon or rectum
in general, the imagining apperances of liver metastes are
nonspecific and a liver biospy speciments are required for histological diagnosis
metastatic spread to the liver occurs
as the tumor erodes the wall and travels through the lymphatic system or through bloodstream to the portal vein or hepatic artery to the liver
biliary obstruction: proximal liver function tests
Liver function tests show an elevation in the direct bilirubin and alkaline phosphatase levels.
inflammatory disease of the liver
-Hepatic abscesses occur most often as complications of biliary tract disease, surgery, or trauma.
the following 3 basic types of abscess formation occur in the liver:
intrahepatic, subhepatic, and subphrenical (under the diaphragm; upper part of the liver
clinically patients with inflammatory diease have
fever, elevated white cell count, RUQ pain
on sonographic examination of hepatic abscesses
the sonographer searches for solitary or multiple lesions in the liver, abnormal fluid collections in morison’s pouch, sub diaphragmatic or subphrenic space
pyogenic abscess
pus forming abscess
many routes for bacteria to gain access to the liver
the biliary tree, portal vein, or hepatic artery a direct extension from a contiguous infection and rarely
heaptic trauma
sources of the infection include
cholangitis; portal pyemia secondary to appendicitis, diverticulitis, inflammatory disease or colitis
direct spread from the another organ
trauma with direct contamination
infarction after embolization or from sickle cell anemia
Hepatic candidiasis is caused by:
a species of Candida
hepatic candidiasis occurs
in immunocomprised hosts, such as patients undergoing chemotherapy, organ transplant, recipients or individuals with human immunodeficiency infection (HIV)
hepatic candidiasis
a hepatic mass that results from the spread of fungus in the blood to the liver
the candidal fungus invades
the bloodstream and may affect any organ, with kidney, brain, and heart affected the most
Amebic abscess is caused bya parasite called
Entamoeba histolytica
How is Entamoeba histolytica transmitted?
contaminated food and water
what are the main characterized symptoms of amebic abscess?
diarrhea and abdominal pain
what is the treatment of amebic abscess?
includes anti-parasitic via the portal vein
how do parasities reach the liver parenchyma?
via the portal vein
patients with amebic abscess may
be asymptomatic or may show gastrointestinal symptoms of abdominal pain, diarrhea, leukocytosis, and low fever
Hepatic echinococcosis
an infectious cystic disease common in sheep-herding areas of the world
the echinococcosis is
a tapeworm that infects humans as the intermediate host
Pneumocystic pneumonia
is a common life-threatening infection in patients with HIV
invasion of the porta hepatic
Pneumocystic carinii is the most common organism causing
opportunistic infection in patients with acquired immunodificiency syndrome
pneumocystis carinii affects
patients undergoing bone marrow and organ transplantation or a patient receiving chemotherapy
sonographic findings of pneumocystis cariniipattern
ranges, tiny, non-shadowing echogenic foci to extensive replacement of the liver parenchyma by various echogenic clumps of calcifications
biliary obstruction
blockage of bile ducts
biliary obstruction sonographically
extrahepatic mass
biliary obstruction: proximal
Biliary obstruction proximal to the cystic duct can be caused by:
Gallstones
Carcinoma of the common bile duct
Metastatic tumor
