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Ultrasound > Requisite (GB and Liver) > Flashcards

Requisite (GB and Liver) Flashcards

1
Q

Please described normal anatomy of GB in

  • Transverse dimension
  • Longitudinal dimension
  • Wall thickness
A

4 cm - Transverse dimension
10 cm - Longitudinal dimension
3 cm - Wall thickness

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2
Q

Gallbladder variation, what is the difference of GB folds and septated GB?

A

Septation of GB
Thin wall separation the GB lumen with a small hole connected between lumen.

Folded GB
Thick separation GB lumen

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3
Q

What are the findings of hepatomegaly in US?

A
  1. Hepatic length in right MCL > 15 cm
    “may varies in other text book”
  2. Hepatic tip is extend over lower pole RK
    “In absence of Riedel’s lobe, normal variation”
  3. Rounding of the right hepatic tip
    “> 75 degree”
  4. Extension of left lobe over the spleen
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4
Q

Between
“ligamentum teres” and “ligamentum venosum”

Which one separate ?

  • caudate lobe / left lobe liver
  • medial and lateral segment of Lt hepatic lobe
A

“ligamentum teres” separate…
medial and lateral segment of Lt hepatic lobe

“ligamentum venosum” separate…
caudate lobe / left lobe liver

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5
Q

What are the land mark anatomy that separate Liver in …
A) Left lateral / Left medial segments
B) Left medial / Right anterior segments
C) Right anterior / Right posterior segments
D) Caudate / Left lobe

A 
A) Left lateral / Left medial segments
   >> Ligamentum teres
   >> Umbilical segment of left portal vein
   >> Left hepatic vein
B) Left medial / Right anterior segments
   >> Interlobar fissure
   >> Gallbladder
   >> Middle hepatic vein
C) Right anterior / Right posterior segments
   >> Right hepatic vein
D) Caudate / Left lobe
   >> Ligamentum venosum
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6
Q

The _________ is the anteromedial extension of the caudate lobe, which may appear separate from the liver and mimic lymphadenopathy.

A

papillary process

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7
Q

What is the most common focal liver lesion?

A

Simple hepatic cyst

เนื่องจากเนื้อ ตับ ปกติมีลักษณะ
homogeneous so easily to detect liver cyst

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8
Q

How much percentage of ADPCD

(autosomal dominant polycystic disease) involved liver?

A

About 40-50%

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9
Q

What is the typical appearance of hepatic hemangioma in US ?

When atypical what it look like and why it look atypical?

Does target appearance occur in hemangioma?

A

Typical appearance of hepatic hemangioma in ultrasonography is…
Round / lobulated Homogeneous hyperechoic lesion with perihpheral vascular flow.
______________________________
For atypical appearance some has been suggested possible mechanism.. Which are..
- In setting of fatty infiltrated hemangioma could appear hypoechoic < compare to liver >
- The large hemangioma likely to have fibrosis, thrombosis and necrosis, so able to give appearance of heterogeneous or hypoechoic.
______________________________
Yes and also able to give reverse target lesion.

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10
Q

Please naming the most common, uncommon and rare causes of cystic liver lesion?

A

Most common
- Liver cyst

Uncommon
- Abscess, hematoma, Cystic metastasis, Biloma and echinococus

Rare
- aneurysm, arterioportal fistula, Portal-hepatic vein fistula, hemorrhagic adenoma, biliary cystadenoma(-carcinoma)

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11
Q

Please ranking the echogenicity between spleen, liver, pancrea and kidneys.

A

According to fat appearance in US give echogenicity to image

  1. Spleen and pancres
  2. Liver
  3. Kidneys
    ______________________
    Spleen and pancreas are the most echo (ขาว)
    โดยอาจจะเท่ากาน มากกว่า น้อยกว่าได้หมด
    แต่ spleen and pancreas จะ > liver and kidney
    Liver > = kidneys
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12
Q

What are the first and second most common benign liver neoplasm?

A

1st Hemangioma

2nd Focal nodular hyperplasia

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13
Q

When follow up liver hemangioma most common are stable but how much are grow larger, regress, and decreased echogenicity?

A

10% decrease liver echo in F/U
5% regress partially or complete
2% grow larger

Σ（ﾟдﾟlll）

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14
Q

What is the incidence of multiple liver hemangioma?

A

10%

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15
Q

Does calcification in hepatic hemangioma is common?

A

Nooo

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16
Q

What is the “rapid change of hemangioma” in US?

A

Rare condition that hemangioma change it sonographic appearance during a course of a examination.

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17
Q

If the lesion that suspected cavernous hemangioma size > 2 cm and not adjacent to heart or major hepatic vasculature, what the other image modality can be use?

A

Tc 99 m RBC

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18
Q

Please give the other DDx of hyperechoic lesion in liver?

A
  • Liver metastasis
  • Hepatocellular carcinoma
  • Focal Fatty infiltration
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19
Q

Does all the case with focal homogeneous hyperechoic hepatic mass need to do more investigation?

If not, what it depend on??

A

Not need to do more Ix.
> Depend on based patient risk of malignancy.
» In the absence of other primary cancer that capable to co’z liver metastasis and chronic liver disease, require no further investigation.
» In presence of of other primary cancer that capable to co’z liver metastasis and chronic liver disease, require to confirm Dx by other image modality.

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20
Q

What are the FNH comprise of cells?

A

Kuffer cells, hepatocyte, and biliary structure.

But lack of normal lobular portal triads and central vein.

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21
Q

What is the typical appearance of FNH?

When apply CDUS to FNH what is the typical appearance?

A

Mostly are isoechoic, ก้อเนื่องจากมานประกอบด้วย เซลล์ตับ

In CT & MR มักเห็น central, stellate scar.
แต่ใน US ธรรมดา มักไม่เห็น ยกเว้นใช้ contrast.

Image appearance อื่นๆ ให้นึกถึง malignant ก่อน
» Target appearance
» Calcification, hemorrhage and necrosis
is very uncommon
_________________________
Spoke-wheel pattern

22
Q

Between men and women, which gender are common to encounter FNH.?

A

Woman about 80-90%

23
Q

What is the malignancy that able to give spoke-wheel appearance on CDUS.？

A

Fibrolamellar hepatocellular carcionoma.

(；´Д`A

24
Q

Does birth control pills contributes to occurence and growth of FNH..?

A

Birth control pills is only relate to growth of FNH

While the hepatic adenoma is increase the incidence with usage of birth control pill.

25
Q

Please desccribed the histology of hepatic adenoma.

A
  1. Few Kupffer cells
  2. No bile ductules

that why it does not uptake Primovist.

「ในขณะที่ FNH แทบจะเหมือน เนื้อ liver เลย」
Kuffer cells, hepatocyte, and biliary structure.
But lack of normal lobular portal triads and central vein.

26
Q

As known that Hepatic adenoma is common in female but in male patient what is the co-exist factor that contribute to developed hepatic adenoma ?

A

Anabolic Steroid usage

27
Q

What are the condition that multiple hepatic adenoma name?

And what is the associated factor in developed this condition?

A

Type I glycogen storage disease.

28
Q

What is the majority of appearance of liver metastasis in US?

A

Target appearance.

Iso- / hyper echo center with hypoecho halo

29
Q

What is the image appearance of hepatic adenoma?

A

For small uncomplicated adenoma
» Homogeneous hypoechoic mass.

For Internal hemorrhage and necrosis
» Give heterogeneous appearance with complex cystic component

Calcification occur about 10%
Intratumoral fat may give hyperechoic appearance.
Free intraperitoneal fluid is seen (rupture)

30
Q

In the target appearance of liver metastasis there is the thin and thick rim appearance… What are they referred to?

A

In thin halo appearance…
» dilated peritumoral sinusoid
or compression of liver parenchyma

In thick halo appearance…
» proliferating tumor

31
Q

What are the DDx of target appearance?

A

Common
- Liver metastasis and HCC

Uncommon
- FNH, lymphoma, Fungal abscess
Small hemangioma, Complex pyogenic liver Abscess, Hepatic adenoma

32
Q

What are the other appearance of liver metastasis rather than target appearance?

A

Hyperechoic metastasis
» GI tract, colon
» Neuroendocrine tumos

Calcified metastasis
» Colon
» Mucinous CA of ovary and stomach

Cystic metastasis, พบไม่บ่อย unusual
» usually thick walls,septation or with obvious solid component. แทบไม่เหมือน simple cyst เลย
» cystic primary tumor (ovary), necrotic tumor from squamous cell CA, Sarcoma or large tumor.

Diffuse heterogeneous
» typical for CA breast (ไม่รุเล่มไหนเพิ่ม CA lung)
» other DDx. Cirrhosis, hepatic lymphoma, fatty infiltration and diffuse HCC

33
Q

Please give the DDx of calcified liver mass..

A

Large, with or without mass
» metastasis, Fibrolamellar HCC,
old Hematoma and old abscess

Small, without mass
» granulomas, pneumocystis,
biliary stones, hepatic artery

34
Q

Please give the DDx of diffuse hepatic inhomogeneity…

A

Common
» Cirrhosis, metastasis, fatty infiltration

Uncommon
» HCC (diffuse), Hepatic fibrosis, lymphoma

อาจารย์จำนงค์เพิ่ม Glycogen storage disease
และ metabolic disease

35
Q

What are the less common risk factor of HCC?

A

Hemochromatosis, Wilson’s disease, type I glycogen storage disease.

The common are …
HBV HCV Alcohol cirrhosis

36
Q

Please described the sequence in developing HCC..?

A

Regenerating nodule →
Adenomatous hyperplasia →
Atypical Adenomatous hyperplasia →
HCC

37
Q 
What is the most common echogenicity of HCC?
A. Isoecho
B. Hypoecho
C. Hyperecho
D. None of the above
A

D. HCC can have variably echogenicity.

38
Q

What is the variant of the HCC?

And comparison with HCC, which one is better prognosis?

A

Fibrolamellar HCC has better prognosis.

39
Q

Which age group does fibrolamellar HCC is common, and does it occur in cirrhotic liver?

Fibrolamellar HCC..
is usually solitary and has Ca++?

A

Fibrolamellar HCC

  • occur in Young age group.
  • without pre-exist liver disease.
  • Usually solitary with Calcification,
40
Q

About Hepatic lymphoma…

  • Hodgkin lymphoma
  • Typical homogeneous hyperechoic
  • Can have target appearance

Does following statement are true?

A

Hepatic lymphoma is of NHL variety.

Typically appearance are..
» Target or homogeneous hypoecho

41
Q

In the absence of liver lesion, if we found vascular flow in thrombus in portal veins. Diagnosis of HCC could be make?

A

Yes, CDUS provide the reliable sign of HCC with tumor thrombus.

42
Q

Please described three alternating pattern of HCC…

A

Solitary, Diffuse infiltrating or Multifocal

43
Q

Does HCC is high propensity in the vascular invasion?

And if yes what is more common between portal vein and hepatic vein?

A

Yes
____________________________
Portal v. (30-60%) common > Hepatic v. (15%)

44
Q

Please described the typical appearance of pyogenic liver abscess..?

Please give the DDx the pyogenic liver abscess??

A 
Complex fluid collection with mixed echogenicity.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
The DDx are ....
1. Hematoma
2. Hemorrhagic Cyst
3. Necrotic or hemorrhagic tumour

“Carol DDx เพิ่ม”
Echinococcal / Amebic abscess

45
Q

“wheel with in a wheel” appearance is the image finding of what disease?

What is it appearance ?
A) Hypoecho-Hyperecho-Hypoecho
B) Hyperecho-Hypoecho-Hyperecho
C) None of Above

A

“wheel with in a wheel”appearance is the image findings of early stage of candida liver abscess.

> > from the centrally containing the necrotic or fungal elements

> > Ans is A… ดำ-ขาว-ดำ

46
Q

Please described the image appearance after the early stage (“wheel with in a wheel”) of candida abscess..

A
  1. Early stage (“wheel with in a wheel”)
    &raquo_space; Black-White-Black
  2. After the early stage…(after Rx)
    the central most hypoecho –> hyperecho,
    (become target or Bull’s eye appearance)
    &raquo_space; Central white - periphery black
  3. Progressive fibrosis
    &raquo_space; Uniform hypoecho
  4. Scar formation..
    &raquo_space; Variable Ca++.
    _____________________
    Other form is microabscess.
47
Q

What organism can cause granulomatous lesion in liver ?

And does granulomatous lesion may or may not has calcification?

What is it appearance in US?

A
  • Pneumocytic carinii
  • Mycobacterium Avium Complex
  • Cytomegalovirus (CMV) infection
    _____________________
    Yessss..
    _____________________
    Multiple non-diffuse small echogenic with no posterior acoustic shadow.
48
Q
  1. For echinococcal infection which species is responsible for this infection?
  2. What is the mode of transmission?
    (ถามเล่นๆ)
  3. Which organs are also affected by the infection?
A
  1. Echinococcus granulosus
  2. By ingested egg-infested vegetable.
  3. Liver is the most common, other included
    Lung, Spleen, Bone, Kidney, CNS
49
Q

Please described the appearance of

“Echinococcal cyst”…

A

> > Simple cyst containing multiple daughter cysts.
Cyst with detached floating endocyst membrane.
Cyst with internal debris
Cyst with peripheral or internal Ca++

50
Q

About Hepatitis does it common to developed increased echogenic of portal triad “Starry sky appearance”?

If not what is the most common appearance?

What are the other findings of hepatitis?

A

No, only some cases
Most case are normal findings.
———————————–
Thickening GB wall and contracted GB and periportal lymphadenopathy.

51
Q

Please described ..
» Focal fat sparing location in liver.
» Focal fat infiltration location in liver.

A

> > Focal fat sparing location in liver.

  • In front of right portal vein / Portal bifurcation
  • Around GB
>> Focal fat infiltration location in liver.
- Anterior segment of Lt lobe 
  (medial segment of left lobe)
- Adjacent falciform ligament
- Anterior to portal vein bifurcation
52
Q

Please described sonographic sign of portal hypertension?

A
  • Ascites
  • Splenomegaly
  • Portal vein enlargement
  • Portosystemic collateral
  • Enlarged hepatic arteries
  • Hepatofugal (reversed) portal flow

Ultrasound (2 decks)

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