Pathology Flashcards
Name 3 liver developmental anomalies…
Agenesis - incompatible with life
Position - situs inversus
Vascular anomalies
Name 4 things about liver parenchyma…
Size
Configuration
Homogeneity
Contour
What are the 3 classifications of liver disease?
Parenchymal disease
Hepatobiliary disorders
Hepatic vascular disorders
Name the 6 diffuse disease…
Fatty infiltration Granulomas Hepatitis Cirrhosis Glycogen storage Hemochromatosis
What does hepatocellular-diffuse diseases do?
Interferes with liver function
Describe fatty infiltration…
Increased lipid and triglycerides
Benign and may be reversible
Asymptomatic
Symptoms - jaundice, nausea, vomiting, pain
Causes of fatty liver…
Obesity, excessive alcohol intake, poorly controlled hyperlipidemia, diabetes, excess corticosteroids, pregnancy, feeding through a tube, severe hepatitis, glycogen storage disease, cystic fibrosis, drug use
Fatty infiltration is a result of what?
Major injury to the liver or a systemic disorder leading to impaired or excessive metabolism of fat
Describe fatty infiltration sonographically…
Increased echogenicity
Hepatomegaly
Posterior liver diaphragm and vessels may be difficult to see due to the attenuation of the sound
What are the types of fatty infiltration?
Grade 1 - slight
Grade 2 - moderate
Grade 3 - marked
What is steatosis?
Cellular pathology of fatty infiltration
What is fatty sparing?
Anterior to GB or PV
Near porta hepatis
Posterior left lobe
What is granulomas?
Small calcifications in liver and spleen
What are granulomas caused by?
Histoplasmosis - breathing in fungus from bat or bird droppings
Tuberculosis - bacteria found in lymph nodes and bloodstream
What do granulomas look like sonographically?
“Pearls” image
What is hepatitis?
Inflammatory and infectious disease
Hep A - from fecal - oral route
Hep B - from needles/blood - body fluid contact
Also there is Hep C, D, E, G, etc
What can hepatitis lead to?
Inflammation can lead to cirrhosis, portal hypertension, and hepatocellular carcinoma
What are 8 symptoms of hepatitis?
Nausea, vomiting, RUQ pain, fatigue, anorexia, fever, headache, jaundice
What is the lab report for hepatitis?
Marked increase in AST
ALT falls rapidly after several days
Bilirubin increases
Describe acute hepatitis…
Mild to necrosis
Hepatocyte injury
Kupffer cell enlarging and regeneration
What does hepatitis look like sonographically?
Non shadowing foci - portal radicals (branches)
Hepatosplenomegaly
GB wall thick
“Starry night” picture
Describe chronic hepatitis…
Fibrosis
May progress to liver failure and cirrhosis
Sonographically - coarse, smaller in size, soft shadow from fibrosis
Describe cirrhosis…
Degenerative disease Necrosis Fibrosis Progress to liver failure and portal hypertension Chronic alcohol abuse
Cirrhosis sequela…
Portal hypertension
Varicosities in the ABD
Portal vein thrombosis
Spenomegaly
Symptoms of cirrhosis…
Fatigue and weakness Abdominal bloating Anorexia Jaundice Later symptoms - GI bleeding, varicose veins on the ABD, red palms, clubbing of nails and fingers
Cirrhosis lab values…
AST, ALT, and bilirubin increased
Cirrhosis sonographically…
Coarse Decreased vascular As cites Hepatosplenomegaly progresses to smaller size Nodularity Dilated portal vein
Describe size of liver depending on stage…
Early stage - liver enlarged
Advanced stage - liver small
** caudate lobe increases in size
Doppler characteristics of cirrhosis…
Waveform is abnormal
Hepatic veins develop luminal narrowing with increased velocities and turbulence of the flow patterns
Doppler gets pointier
Describe glycogen storage disease…
Type 1 - VON GIERKE
genetic disorder of carbohydrate metabolism
Abnormally large amounts of glycogen are deposited in the liver and kidneys
Von Gierke sonographically…
Hepatomegaly
Increased echogenicity
Adenomas
Associated nephromegaly
Describe hemochromatosis…
Rare
Iron metabolism
Sonographically - hepatomegaly, cirrhostic changes
Describe biliary obstruction…
Origin of bile in the liver
Prox biliary tree is within the liver
Distal biliary tree in closest to pancreatic head
Biliary dilatation usually occurs prox to level of obstruction
MOST COMMON obstruction is distal CBD with dilatation CBD, BG, intrahepatic ducts
Described PROXIMAL biliary obstruction…
Gallstones, CA, mets Jaundice pruritus (itchy) Elevated bilirubin and Alk Phos Sonographic - dilated duct, GB normal in size "Railroad sign"
Described DISTAL biliary obstruction…
Stones in CBD Mass Stricture RUQ pain, jaundice, pruritus Increased bilirubin and Alk Phos Sonographic - dilated ducts, GB size may be small, gallstone
Describe extrahepatic mass obstruction…
In porta hepatis
Sonographic - ductal dilation, hydropic GB (distended), lesions may be lymph or pancreatic CA
Describe common duct stricture obstruction…
Jaundice, previous cholecystectomy, increased bilirubin and Alk Phos
Sonographic - dilated ducts
Describe passive hepatic congestion obstruction…
Secondary to CHF
Hepatomegaly
Sonographic - dilation of IVC, SMV, HV, PV, SV
What are the 5 focal diseases?
Cysts Abscess Hematoma Tumors Metastases
Characteristics of a simple cyst..
Well defined Anechoic Enhancement Thin smooth walls Round or oval
Describe a cyst…
Congenital
Developmental defects in bile duct formation
Cystic masses that result from trauma are not true cysts
Sonographic - solitary, varied in size
Describe polycystic disorder…
Autosomal dominant
Associated with polycystic kidneys
Sonographic - cyst criteria
Small, less than 2-3 cm, & multiple throughout the hepatic parenchyma
Describe pyogenic abscess…
Bacterial - ecoli and anaerobes
Multiple infection symptoms
Sonographic - various appearances, usually solitary, debris, complex, micro air bubbles or pus cause shadowing
Describe candidiasis abscess…
Fungal
Immunocompromised hosts such as cancer patients and organ transplant patients
Sonographic - multiple hypoechoic masses, target or bulls eye lesions
“Wheel within a wheel” sign - early
Describe chronic granulomatous abscess…
Congenital defect in the leukocytes
Pediatric
Sonographic - hypoechoic mass, calcification with shadowing
Describe amebic abscess…
Parasitic - entamoeba histolytica Contaminated water and food Enters liver through portal vein RUQ pain and fever, traveling outside the us Sonographic - variable appearance
Describe echninoccal abscess…
Parasitic
Hydatid cysts - sheep and cattle herding, parasite causing hydatid disease, tapeworm lives in feces, food contaminated
Clinically - fever, RUQ tenderness
Sonographic - honeycomb, cyst within a cyst, daughter cyst, “water lily” sign
Describe schistosomiasis abscess…
Parasitic - contaminated water
Sonographic - thickened portal walls and dilation (portal hypertension), splenomegaly, collaterals
Name the 4 benign and 2 malignant tumors…
Benign - cavernous hemangioma, adenoma, cystadenoma, focal nodular hyperplasia
Malignant - carcinoma, metastatic
Describe cavernous hemangiomas tumors…
MOST COMMON benign tumor of the liver Large network of vascular endothelium Females Sonographic - hyperechoic CT and MRI helpful; biopsy may be indicated
Describe adenoma tumors…
Glandular
Female - oral contraceptive
May be malignant
Sonographic - hyperechoic with central hypoechoic
Describe focal nodular hyperplasia tumors…
SECOND MOST COMMON benign liver mass
Women under 40
Sonographic - well defined, multiple nodules, STEALTH LESION
Describe hemangioendothelioma tumors…
Infantile Benign overgrowth Females Presents with ABD mass Sonographic - multiple lesions with hyperechoic margins
Describe hamartoma tumors…
Rare Benign Children under 2 Palpable ABD mass Sonographic - well defined large complex mass
Describe hepatocellular carcinoma - HEPATOMA…
MOST COMMON primary malignant neoplasm Related to cirrhosis Male Unexplained mild fever Invasive Destroy vessels Sonographic - halo lesions, hepatomegaly
Symptoms of HCC - hepatoma…
Elevated alpha fetoprotein Abnormal liver function tests Unexplained weight loss Palpable mass Ascites
HCC presents in one of what three patterns…
Solitary massive tumor
Multiple nodules throughout the liver
Diffuse infiltrative masses in the liver
HCC pathologically presents how…
Focal lesion
Invasive lesion with necrosis and hemorrhage
Poorly defined lesion
What has HCC been known to do…
Invade the be
ASIC veins to produce Budd-Chiari syndrome
Describe angiosarcoma tumors…
Malignant from the blood vessels
Rare
60-80 year olds
Sonographic - solid mass
Describe metastatic disease tumors…
MOST COMMON form of neoplastic involvement of the liver
Primary: breast, colon, lung
Abnormal LFT
Sonographic - multiple nodes, bulls eye lesions, calcifications
Metastatic disease patients with SHORT SURVIVAL RATE…
HCC and carcinoma of the pancreas, stomach, and esophagus
Metastatic disease patients with LONGER SURVIVAL RATE…
Head and neck carcinoma and carcinoma of the colon
Describe lymphoma tumors…
Hodgin’s and non-Hodgin’s
Hepatomegaly
Sonographic - bull’s eye, multiple
Name the 3 PEDIATRIC malignant tumors…
Hepatoblastoma - liver
Neuroblastoma - adrenal gland
Wilm’s - kidney
Leukemia
Describe hepatoblastoma tumors…
Associated with beckwith-wiedemann Genetic growth disorder - defect in chromosome 11 Before age 5 Elevation in alpha fetoprotein Palpable mass Weight loss
Describe TORCH…
Infections - neonate - hepatomegaly
Baby contracts TORCH in the uterus
Toxoplasmosis, other infections, rubella, cytomegalovirus, herpes
Describe trauma…
Sonographic but CT more specific
Free fluid
Hematoma
Decrease in hematocrit and hemorrhage
Name 2 hyperechoic surgical structures seen in the liver…
Post operative air
Surgical clips
Indications, complications, and sonographic appearance of liver transplants…
Indications - cirrhosis, hepatitis, cholangitis, hepatoma, Budd-Chiari
Complications - rejection, thrombosis, infection, neoplasia, biliary stricture
Sonographic - evaluate the portal system and hepatic artery, ascites may be present
What is done before a liver transplant…
Vascular structures are assessed for size and patency
Liver parenchyma should be examined to rule out the presence of hepatic architecture disruption
What is portal venous hypertension…
Cirrhosis causes the blood pressure in the hepatic circulation to increase and leads to the development of portal hypertension
Describe portal venous hypertension…
Increase in portal venous pressure or hepatic venous gradient present
Cirrhosis (most common), thrombus, tumor
Collateral damage - coronary and esophageal vein - varices tortuous dilations
Abnormalities of portal venous hypertension…
In an effort to relieve pressure, collateral veins are formed that connect to the varicose veins
Varicose veins occur most frequently in the area of the esophagus, stomach, rectum
Rupture of these veins can cause massive bleeding that may result in death
Clinically seen in portal venous hypertension…
Portal vein greater than 1.3 cm
Splenic vein greater than 1.0 cm
No change in respiration
Recanalization of the umbilical vein (ligamentum teres) - medusa’s head
Color Doppler - flow should be hepatopetal - towards
Indications for portal venous hypertension…
Suspected secondary to liver disease
Portal vein compression or thrombosis
Acute onset of hepatic vein occlusion (Budd-Chiari), constrictive pericarditis, or congestive heart failure with tricuspid regurgitation
Congenital, traumatic, or neoplastic arterioportal fistula
Describe portal vein thrombosis…
Collaterals develop - wormlike at the porta hepatis
Describe portal venous hypertension shunts…
Portacaval - PV confluence - IVC - wall stent
Mesocaval - SMV - IVC
Splenorenal - SV - LRV
TIPS - transjugular intrahepatic portosystemic shunt
Describe TIPS…
Placement of a stent between the portal and hepatic veins to shunt blood and reduce the pressure
Temporary treatment
Portal hypertension sonographic findings…
Initially hepatomegaly Shrunken right lobe Enlarged caudate and left lobe Nodular surface Coarse texture Splenomegaly Ascites Mono phasic flow in hepatics Hepatofugal flow in portals Enlarged PV, SMV Reversed flow in splenic vein
Describe Budd-Chiari Syndrome…
Thrombosis of hepatic vein or IVC
Ascites, jaundice, ABD pain, hepatomegaly, edema of legs, vomiting, diarrhea
Poor prognosis - 2 types: primary (congenital) and secondary (thrombosis)
Sonographic - caudate lobe enlarged, atrophy of rt hepatic lobe thrombosis vein enlarges, splenomegaly
