Peds- Liver Flashcards
When imaging perdiatric liver all adult landmarks must be acquired including?
- PV
- PV bifurcation
- CHA
- CBD
- HV’s
- biliary tract
Liver on U/S?
- homogenous
- more echogenic than kidneys
- doppler to see bile ducts
- functional vs. segmental division
4 benign liver tumors?
- hemangioma
- mesenchymal hamartoma
- adenoma
- focal nodular hyperplasia
3 types of hemangioma?
- infantile
- hemangioendothelioma
- cavernous hemangioma
5 malignant liver tumors?
- hepatoblastoma
- HCC
- fibrolamellar HCC
- mesechymal (embryonal) sarcoma
- metastases
what is hemangioma?
- common or uncommon?
- arise from?
- most common?
- rare
- arise from AV malformations
- most common heptatic mass in neonate
what is the most common hepatic mass in neonate?
hemangioma
what is hemangioendothelioma?
- blood filled spaces with multilayered endothelium
what is cavernous hemangioma?
- single layered endothelium
who does hemangioendothelioma mainly affect? what is it associated with?
- affects infants less than 6 months of age
- associated with skin hemangiomas
clinical presentations of hemangioendothelioma?
- symptomatic
- asymptomatic
symptomatic:
- hepatomegly
- congestice heart failure
- hemoperitoneum from rupture
asymptomatic
- causes may undergo complete involution
Hemangioendothelioma sono features?
- single or mulltiple
- varying echo and size
- contains fine linear foci of calcium
- may have enhancement
- vascular
Cavernous Hemangioma?
- mainly found in?
- age?
- usually found how?
- 3x more likely in girls
- evident by 2 months of age
- usually found incidentlly
Cavernous Hemangioma clinical presentation?
- large hemangiomas may cause:
- hepatomegly (palpable)
- obstructive jaundice
- bowel obstruction (vomiting)
- respriratory insufficiency
cavernous hemangioma treatment?
- varies with size of mass
- usually regresses
- lobectomy or resection if needed
sono features Cavernous Hemangioma?
- well defined
- hyperechoic (multiple interfaces between walls of blood-filled vessels)
- can be hypoechoic (atypical)
- enhancement
- vascular
- may calcify with PAS
what is mesenchymal hamargtoma?
- rare
- congenital
- arises from connective tissue of the portal tracts
Mesenchymal Hamartoma clinical presentation?
- painless abdominal swelling
Mesenchymal Hamartoma sono features?
- resembles hemangioma but avascular
Mesenchymal Hamartoma treatment?
- resection
- excellent prognosis
adenoma is highly associated with?
- glycogen storage disease
adenoma sono apperance?
- hyper or hyopechoic
FNH?
rare in children
FNH sono features?
- isoechoic
- doppler- blood in centre of lesion
what fraction of solid pediatric liver tumors are malignant?
2/3
Most common pediatric liver mass?
heptaoblastoma
Hepatoblastoma is most common in?
boys younger than 5
Hepatoblastoma clinical presentation?
- hepatomegaly
- painless, palpable abdominal mass
Advanced cases:
- fever
- weight loss
- pain
- nausea and vommiting
- jaundice
- anemia
Hepatoblastoma lab values?
- increased AFP
- increased LFT
Hepatoblastoma treatment?
- resection if it occupies one lobe and didn’t invade portal vein
- chemotherapy improved operability
Hepatoblastoma sono features?
- Solitary multinodular mass
- Heterogeneous
- Hyperechoic
- ill-defined borders
- Areas of necrosis and hemorrhage
- Calcifications
HCC (hepatoma) affects? associated with (3)?
- affects children older than 3 years of age
associated with:
- glycogen storage disease
- wilson’s disease
- hepatitis
HCC (Hepatoma) clinical presentation?
- sudden liver failure due to thrombosis of portals or HVs
- hepatomegaly
- pain
- GI bleeding, anemia
- ascites
HCC (hepatoma) lab values?
- increased AFP
- Hypoglycemia
HCC (hepatoma) sono features?
- similar to Hepatoblastoma
- solid hyperechoic mass involving the entire liver
- well-defined or ill-defined borders
- anechoic areas within mass from necrosis
- hypo-anechoic halo around mass
What is Fibrolamellar HCC? who does it mainly affect?
- Histologic subtype of HCC
- affects teenagers ad young adults
Fibrolamellar HCC clinical presentation?
- abdominal pain
- mass, fever, weight loss
- diarrhea
- vomiting
Fibrolamellar HCC lab values?
AFP normal or mildly elevated
Fibrolamellar HCC sono features?
- solitary well0 marginated
- variable echogenicity
- focal calcifications
What is Mesenchymal Sarcoma? how does it mainly affect?
- rare
- 5-10 year old
- fast growing tumor
Mesenchymal Sarcoma clinical presentations?
- abdominal pain
- swelling
- palpable mass
- AFP normal
Mesenchymal Sarcoma sono features?
- single
- round, well-defined
- variable echogenicity with anachoic/ cystic spaces creating enhancement
Metastases is usually associated with? (4)
- neuroblastoma
- wilm’s tumor
- leukemia
- lymphoma
most common cause of metastases in children?
neuroblastoma
Metastases non features?
- variable apperance
- multiiple masses
infectious and inflammatory diseased of the liver? (2)
- hepatitis
2. abscess
3 kinds of abcesses?
- amebic abscess
- pyogenic abscess
- fungal abscess
what is hepatitis?
- viral?
- non viral?
- diffuse infaction of the liver
- inflammation and necrosis of hepatic cells
almost all cases are viral:
- A, B, C, D, E, CMV, herpes
non-viral causes:
- toxins
- drugs
hepatitis symptoms?
- hepatomegly with pain
- jaundice
- nausea
- fever
- loss of appetite
chronic hepatitis symptoms?
- cirrhosis
- liver damage
- cancer
hepatitis sono apperance?
- hyper or hypoechoic
- hepatomegly
- prominent portal vein
liver abscess results from?
- neonatal infection from the umbilicus or surgery
- seeded into liver through the portal or umbilical vein
- high mortality rate
liver abscess treatment?
- antibiotic therapy
- drainage
- surgery
who does amebic abscesses affect?
- children in areas where drinking water is contaminated and sanitation is poor
amebic abscess enters body? forms?
- enters the liver from colon through portal system
- forms a cavity in liver and becomes abscess
Amebic Abscess lab values?
- mildly elavated LFT’s
- anemia
- leukocytosis
Amebic Abscess clinical presentation?
- abdo distention
- fever
- RUQ pain
Amebic Abscess cono features?
- hypoechoic spherical lesion
- right lobe
What is Pyogenic Abscess?
- rare
- can be fatal in children
- E.coli / Klebsiella pneumoniae
- Immunocompromised children
Pyogenic Abscess sono features?
- discretely marginated hypoechoic structures with enhancement
- complex hyperechoic with poorly defined walls
- if contains gas – shadowing and reverberation artifacts
- bull’s eye appearance
What is Fungal Abscess?
- immunocompromised children
- cansisa albicans
Fungal Abscess sono features?
- multiple small lesions
- irregular walls
- round and hypoechoic
- target or wheel within a wheel appearance
Diffuse Liver Disease examples (3)?
- fatty liver
- cirrhosis
- hepatic fibrosis
fatty infiltration is caused by?
- chronic hepatic injury and results from an accumilation of abnormal triglycerides and lipids
- can be diffese or focal
fatty infiltration associates with?
- many pathological conditions
- child obesity
- can be reversable
Diffuse Fatty Infiltration sono features?
- mild
- moderate
- severe
- large and echogenic liver with decreased visualization of hepatic veins
Mild - increased echo
Moderate - increased echo, decreased penetration, faint visualization of vasculature
Severe - unable to penetrate liver, no visualization of vasculature
focal fatty infiltration sono features?
- distinct areas of increased echogenicity
- mimics mass without mass effect
- does not change the contour of the liver
What is cirrhosis?
- parenchymal destruction, scarring, fibrosis, and nodular regeneration
cirrhosis is due to?
Biliary atresia Cystic fibrosis Chronic hepatitis Metabolic dx Budd-Chiari syndrome Medications
cirrhosis clinical presentation?
- hepatomegaly (early stages)
- jaundice
- ascites
cirrhosis lab tests?
mildly increased:
- AST
- ALT
- LDH
- direct and indirect bilirubin
Cirrhosis u/s features?
Small liver (late stage) Surface nodularity Coarse/heterogenous echo Increased echo Signs of ascites, splenomegaly, portal hypertension
Hepatic fibrosis?
- rare
- associated with ARPKD
- excessive connective tissue build-up due to chronic injury
Hepatic Fibrosis clinical presentations?
- hepatomegaly
- portal hypertension
Hepatic Fibrosis sono features?
- increased echogenicity of liver
- biliary dilatation
Hepatic Vascular Disorders (4)?
Portal Hypertension
Portal Vein Thrombosis
Budd-Chiari*
Hepatic Infarction
Portal Hypertention?
- increased resistance to normal portal flow
Portal Hypertention clinical presentation?
- splenomegly
- ascites
- caput medusa
severe cases:
- hematemesis
- hepatic encephalopathy
Portal Hypertension types of obstruction?
- prehepatic
- PV or SV thrombosis
- intrahepatic (cirrhosis)
- posthepatic (heart conditions)
Portal Hypertension sono features?
- Hepatofugal portal flow
- Varices
- Splenomegaly
- Ascities
- Cirrhosis
Portal Vein Thrombosis caused by?
- thrombosis due to dehydration, catheterization, shock, portal hypertension
OR
- tumor invasion from HCC or hepatoblastoma
Portal Vein Thrombosis clinical presentation?
- acute abdo. pain
- splenomegaly
Portal Vein Thrombosis sono features?
- Enlarged, echogenic portal veins
- Absent doppler
- Visualization of tumor invasion
- Cavernous transformation (in chronic PVT)
- Acute PVT can mimic normal portal vein on grey scale
- Collaterals
What is Budd-Chiari syndrome?
Clinical features of hepatic venous outflow obstruction
Budd-Chiari syndrome causes? (3)
- idiopathic occlusion
- neoplastic invasion
- thrombosis
Budd-Chiari syndrome sono?
- primary findings?
- secondary findings?
Primary findings:
- Hepatomegaly
- Echogenic clot in HVs
- Absence of flow in HVs
Secondary findings:
- Ascites
- Pleural effusion
- GB wall edema
Hepatic Infarction?
Rare due to liver’s dual blood supply
Can occur with hepatic artery occlusion
Hepatic Infarction sono?
- Wedge-shaped, round or oval area of decreased echogenicity
- Good margins
- Changes from hypo to hyper to calcification over time
Hepatic Trauma?
- Liver is the most commonly injured abdominal organ in blunt abdominal trauma in children
- Hemoperitoneum
- Hematomas in liver change with time and vary in echogenicity
- Anechoic to complex with possible calcifications
4 types of hepatic trauma?
- subcapsular
- parenchymal
- lacerations
- fractures
Hepatic Cysts?
- Congenital cysts are rare
- Associated with multicystic kidney disease and Von Hippel Lindau disease
- Can be acquired via trauma
Hepatic Cysts clinical presentations?
- asymptomatic
- unless cyst is large- than palpable
Hepatic Cysts sono?
- smooth-walled
- anechoic
- enhancement
- attaches by stalk
Hydatid echinococcal cysts?
Parasitic (tapeworm)
Echinococcus
Hydatid echinococcal cysts causes?
- Exposure to livestock, farming, dogs
- Parasite reaches liver from intestines through PV
Hydatid echinococcal cysts sono?
- Simple cyst
- Complex cyst (daughter cysts, septa, debris, floating membranes)
Hydatid echinococcal cysts Clinical signs?
- Urticaria
- RUQ pain
- Hepatomegaly
- Lungs, brain, kidneys can be affected
- Rupture of cyst to peritoneum – anaphylactic shock
