Quiz 2 review pt 2 Flashcards
What is the classic clinical presentation of cirrhosis?
hepatomegaly, jaundice, ascites, splenomegaly, varices
How does the liver appear with alcoholic cirrhosis?
Micronodular
How does the liver appear with biliary cirrhosis?
Macronodular
What is Budd-Chiari syndrome caused by?
Thrombosis of the hepatic veins or IVC
If a patient presents with abdominal pain, massive ascites, jaundice, vomiting, diarrhea, and hepatic vein thrombosis what is most likely the diagnosis?
Budd-Chiari syndrome
Budd-Chiari syndrome is classified as?
Primary or secondary
Which type of Budd-Chiari syndrome is caused by congenital obstruction of the HVs or IVC?
Type 1- congenital obstruction
Which type of Budd-Chiari syndrome is a result of thrombosis in the HVs or IVC?
Type 2- thrombosis in HVs or IVC
What are the sonographic findings on Budd-Chiari?
HV thrombus, Ascites, Portal HTN
Which disease is characterized by abnormal storage and accumulation of glycogen in the tissues?
Glycogen storage disease
What is the main key in diagnosing glycogen storage disease?
Hypoglycemia
Which form of glycogen storage disease causes abnormally large amounts of glycogen to be deposited in the liver and kidneys?
Type 1 or Von Gierke disease
What is hemochromatosis? What is Wilson’s disease?
Hemochromatosis- abnormal iron storage; Wilson’s disease- abnormal copper storage
With both hemochromatosis and Wilson’s disease, how does the liver appear on ultrasound?
Increased size and echotexture
What is the shotgun sign in ultrasound?
When intrahepatic ducts are dilated
also called ‘parallel channel’ or ‘too many tubes’
What extrahepatic mass can cause biliary obstruction?
Usually pancreatic head mass
An inherited disease in an autosomal dominant (one parent) pattern that affects 1 in 500 individuals:
Polycystic liver disease
How does polycystic liver disease appear?
Small, cystic, less than 2-3 cm, and multiple throughout hepatic parenchyma
What does pyogenic mean?
Forming pus
pyo: pus ; genic: forming
What is a pyogenic abscess?
Pus forming abscess, bacteria gains access to liver
What labs will be elevated with a pyogenic abscess? What is the most common cause?
Elevated LFTs, WBCs, anemia; most common cause is E. coli
How does pyogenic abscess appear on ultrasound?
Variable, hypoechoic, complex, fluid level
How does bacteria gain access to the liver?
Biliary tree, portal vein, or hepatic artery; direct extension from a contiguous infection; hepatic trauma (rarely)
Which liver disease appears as a bullseye, target, or wheel within a wheel on ultrasound?
Hepatic candidiasis
Hepatic candidiasis is most common in which patients? How does it appear on ultrasound?
Most common with immunocompromised patients (AIDS, chemo); appears as multiple small hypoechoic masses with echogenic central cores (bullseye/target)
What is chronic granulomatous disease?
Susceptible to bacterial and fungal infections (abscess); masses of immune cells that form at sites of infections or inflammation; poorly marginated; irregular mass of calcifications
What is amoebic abscess? Where is it found?
Collection of pus from disintegrating tissue, usually found in RLL
Where do parasites begin and how do they reach the liver? How is amoebic abscess contracted?
Begin in the colon and reach the liver through PV; contracted by ingesting contaminated food or water
Which disease is associated with mosquitos? What would patient presentation be?
Malaria; clinical symptoms of fever and chills
What is the sonographic appearance of malaria?
Hepatomegaly, portal HTN, massive splenomegaly
What is the most widespread infectious disease in the world; also the leading cause of death worldwide?
Malaria
How does malaria affect RBCs?
It causes them to rupture
Echinococcal cyst is also known as?
Hydatid disease
Where are you most likely to contract hydatid disease?
In sheep-herding and cattle areas of the world
What is echinococcas?
A tapeworm that infects humans as the intermediate hosts; the worm resides in the small intestine of dogs
What is the sonographic appearance of hydatid disease/echinococcal cyst?
‘Water-lily sign’
larger cyst (pericyst) contains one or more daughter cysts (endocysts) and internal echoes (hydatid sand)
What is the most common parasitic infection in humans? How does it enter the body?
Schistosomiasis; a parasitic worm enters the bloodstream then GI tract from wading or bathing in contaminated water; also spread by snails; can enter the skin through cuts and nicks
How does schistosomiasis appear sonographically?
Progressive periportal fibrosis due to granulomatous reaction; distended, echogenic, debris-filled intrahepatic portal veins; splenomegaly; ascites; portal HTN
What is the most common opportunistic infection in patients with AIDS?
Pneumocystic carinii
Besides AIDS patients, who else can be affected with pneumocystic carinii?
Patients undergoing bone marrow and organ transplantation or patients receiving chemo
What is the sonographic appearance of pneumocystic carinii?
Diffuse, tiny, non-shadowing echogenic foci with various echogenic clumps of calcification replacing liver parenchyma
What sign is associated with pneumocystic carinii?
‘Starry sky’ sign due to microabscesses
What is the most common benign tumor of the liver?
Cavernous hemangioma
Where is cavernous hemangioma most commonly found?
73% in RLL
Which liver disease is associated with glycogen storage disease and has a nonspecific variable appearance?
Liver cell adenoma
What is the 2nd most common benign liver mass?
Focal nodular hyperplasia
Which liver mass affects women less than 40 and is non-encapsulated?
Focal nodular hyperplasia
What is the size of focal nodular hyperplasia?
Usually < 5 cm
What is the primary malignancy of the liver? (both names)
HCC (hepatoma)
What is the most common liver cancer?
Metastatic disease (mets)
What is the most common complication of a liver transplant?
Rejection
What are 5 hyperechoic well-defined liver masses?
- Hemangioma 2. Focal nodular hyperplasia 3. Focal fatty infiltration 4. Echogenic metastatic lesions 5. Lipoma
HCC occurs more frequently in men or women?
Men
Presentation of HCC is in one of three patterns which are?
Solitary massive tumor, multiple nodules throughout liver, diffuse infiltrative masses in the liver
What does CEUS stand for?
Contrast-enhanced ultrasound
Patients with short survival rate after initial detection of mets are those with?
HCC, and carcinoma of the pancreas, stomach & esophagus
Patients with a longer survival rate are those with carcinoma of?
Head and neck carcinoma and carcinoma of the colon
How does mets spread to the liver?
Tumor erodes the wall and travels through the lymphatic system or through the bloodstream to the PV or hepatic artery of the liver
A malignant neoplasm of lymph nodes is called?
Lymphoma
Liver mets in children is most common from?
Neuroblastoma, Wilms tumor, leukemia
What does FAST stand for?
Focused Assessment with Sonography in Trauma
What is the most common indication for liver transplant?
Hep C
After liver transplant, what is ultrasound used for?
Evaluate vasculature in transplant
What is a sonographic finding post-op that can indicate possible liver rejection?
A high resistance waveform on the HA
What is the most common cause of intrahepatic portal hypertension?
Cirrhosis
Dilated portal vein is greater than 13 mm, this is an indication for what?
Portal venous hypertension
What are some sonographic findings for portal hypertension?
Hepatofugal flow, enlarged hepatic artery, ascites, recanalized umbilical vein, splenomegaly
What is caput medusa a sign of? (palm tree sign)
Portal hypertension causing dilated, distended/engorged veins around umbilicus
Causes of portal HTN
Prehepatic: portal vein thrombosis; Intrahepatic: cirrhosis, schistosomiasis; Posthepatic: Budd-chiarii syndrome, CHF
What are 3 types of shunts used to decompress portal HTN? Which is most common?
Portacaval (most common), mesocaval (attaches mid-distal SMV to IVC), splenorenal (attaches SV to LRV)
What does TIPS stand for?
Transjugular intrahepatic portosystemic shunt
What kind of direction of blood flow is expected with TIPS shunt?
Flow in the LPV/RPV will be hepatofugal
What does a TIPS shunt do?
It connects the PV to one of the HVs or IVC. The shunt allows the blood flow normally through the liver to the hepatic vein/IVC
What is the normal measurement for CBD with and without GB?
With GB: no more than 6mm; cholecystectomy: up to 10mm
What is the normal measurement for CHD?
4mm
What is a Rokinansky-Aschoff sinus?
Small outpouchings, pockets, diverticula in wall of GB
association with adenomyomatosis
The GB receives blood from?
Cystic artery
Normal measurement for GB wall?
Less than 3 mm
Which labs are associated with biliary disease?
Bilirubin and Alk phos
Which lab is associated with jaundice?
Bilirubin
Eating a fatty meal will make the GB do what? What triggers this?
Contracts to release bile; CCK
Clinical symptoms of GB and biliary system pathology:
RUQ pain to back, N&V, positive Murphy sign, jaundice, fever & chills, midepigastric pain, chest pain, right shoulder pain
Low-level echoes in dependent portion of GB is called:
Sludge
Most common cause of biliary stasis:
Prolonged fasting
What is tumefactive sludge?
Combination of thick and thin sludge
What is the term for inflammation of the GB? What is the most common cause?
Cholecystitis; most common cause: a stone impacted in the cystic duct
What is patient presentation/sonographic findings for cholecystitis?
Dilated GB, thickened GB wall, positive Murphy sign, pericholecystic fluid collection, increased color doppler
What is the medical term for stones? How do they appear on ultrasound?
Cholelithiasis; echogenic, posterior shadowing, possible mobility
Conjugated bilirubin (direct) if elevated can indicate:
Obstructive jaundice (hepatitis), intrahepatic cholestasis, biliary tree obstruction
Unconjugated bilirubin (indirect) if elevated can indicate:
Hepatocellular disease, hemolytic anemia
3 causes of jaundice
- Hepatocellular disease 2. Elevated bilirubin 3. Biliary obstruction
An obstructed duct vs non obstructed duct after eating a fatty meal:
Obstructed duct: should increase in size; non-obstructed duct: should decrease in size
What are the 5 F’s associated with GB disease?
Fat, Female, Forty, Fertile, Fair
What does WES mean?
Wall-echo shadow: When the GB is completely packed with stones, the sonographer will only be able to image the anterior wall of GB because of the shadowing from the stones will obscure the posterior border
What is the echogenic layering debris located dependently in the GB?
Biliary sludge
What does acalculous cholecystitis mean?
Inflammation of the GB not related to stones
What are the two most common causes of biliary obstruction?
Mirizzi’s syndrome, Courvoisier’s GB
What is a strawberry GB? What artifact? Polyp should be no bigger than what size?
Cholesterolosis; these polyps are usually found in the middle third of the GB and are <10mm in diameter; comet-tail artifact
Which cholecystitis complication is associated with diabetes and has a high mortality rate? What is the sign associated with this?
Emphysematous cholecystitis; champagne sign (due to gas bubbles)
Which acute cholecystitis may lead to GB perforation and has an increased mortality rate?
Gangrenous cholecystitis
What is the sonographic appearance of gangrenous cholecystitis?
GB wall may be thickened; ulcerations and perforations may be present; gallstones; medium to coarse echogenic densities filling the GB lumen
What are hydrops? What is hydrops associated with?
Enlarged/distended GB, non-inflamed GB due to total obstruction of cystic duct
What are the 5 reasons of hydrops?
Prolonged fasting, GB hydrops due to CD obstruction, choledocholithiasis, Courvoisier GB (panc cancer), diabetes
Hepatocellular disease attacks what cells of the liver?
hepatocytes
What percentage of the liver is made up of hepatocytes?
60%
What percentage of the liver is made up of Kuppfer cells?
30-35%
Will the liver function normally with hepatocellular disease?
No, the disease attacks hepatocytes and it interferes with liver function.
What causes hepatic enzyme levels to be elevated?
cell necrosis
What is the main diffuse disease of the liver?
fatty infiltration
What does accumulation of triglycerides within the hepatocytes result in?
fatty liver
What is another name for fatty infiltration?
steatosis
Is fatty liver reversible?
yes, through diet/exercise and/or medication
What are some causes of fatty liver?
- obesity
- alcohol
- diabetes
- pregnancy
- severe hepatitis
- cystic fibrosis
- pharmaceutical
- glycogen storage disease
- total parental hyperalimentation
- excess corticosteroids
- poorly controlled hyperlipidemia
What are some ultrasound findings of fatty liver disease?
- increased echogenicity
- increased attenuation
- enlargement
- loss of vascularity
- focal sparing: anterior to GB/PV
- increased size > 17 cm RLL
What does focal sparing look like?
islands of normal liver in fatty liver, appears hypoechoic, commonly adjacent to GB
How does focal fatty infiltration appear on ultrasound?
regions of increased echogenicity within liver, common at porta hepatis
What is the general name for inflammatory and infectious disease of the liver?
hepatitis
What is the most common hepatitis in the US?
Hep C
What is the most common hepatitis worldwide?
Hep B
What are initial symptoms patients have with acute and chronic hepatitis?
- flulike
- gastrointestinal symptoms
Without complications, clinical recovery from acute hepatitis usually occurs within?
4 months
What is the ultrasound appearance of acute hepatitis?
- liver texture may appear normal
- portal vein borders may be more prominent than usual (“starry night/sky sign”)
- liver parenchyma slightly less echogenic
- hepatosplenomegaly is present
- GB wall thickened
Chronic hepatitis exists when evidence of hepatic inflammation extends beyond how many months?
6 months
What is the difference between chronic persistent hepatitis and chronic active hepatitis?
- chronic persistence is a benign, self-limiting process (stops at a certain point)
- chronic active is more extensive, usually progresses to cirrhosis and liver failure
What is the ultrasound appearance of chronic hepatitis?
- liver parenchyma is coarsed (somewhat heterogeneous)
- decreased brightness of portal triad
- liver size decreases
- fibrosis may be evident
- hyperechoic
- thickened GB wall
- splenomegaly
- liver becomes nodular
Micronodular cirrhosis is most commonly the result of?
chronic alcohol abuse
Macro-modular cirrhosis is caused by?
Chronic viral hepatitis or other infection
What is the end stage for cirrhosis in the liver?
Liver cell failure and portal hypertension
Cirrhosis is a precursor to?
Hepatocellular carcinoma
What is the ultrasound appearance of cirrhosis?
Small, nodular borders, increased attenuation
