URR 20 Flashcards by Billie Harney

The umbilical vein demonstrates ___ flow

hepatofugal

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The umbilical vein is best evaluated in the sagittal plane to the left of midline at the level of the _____

ligamentum teres

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In portal hypertension, hepatic vein flow becomes ____

monophasic

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As portal hypertension progresses and the liver rejects incoming blood flow, resistance to arterial flow ____ and portal venous flow is ____

increased
reversed

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Adjacent vascular changes that should be evaluated with portal hypertension

size of the spleen
collateral formation at the porta hepatis and splenic hilum
umbilical vein recanalization

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Signs of portal hypertension

caput medusa
cavernous transformation
esophageal varices
ascites
hemorrhoids

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In portal hypertension, hepatic arteries become dilated and resistance to flow ____

increases

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Non-tumoral causes of portal vein thrombosis

portal hypertension
inflammatory process
trauma
post-op complications

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Tumoral causes of portal vein thrombosis

extrinsic compression by a mass
metastasis
pancreatic head mass

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Clinical symptoms of portal vein thrombosis

pain
fever
rigid abdomen
nausea
vomiting

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Lab tests associated with portal vein thrombosis

increased LFTs
leukocytosis

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Portal vein thrombosis is a contraindication to:

portal shunt placement

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Portal vein thrombosis shows an increased diameter of the ____ and ___

splenic vein
SMV

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Sonographic appearance of acute portal vein thrombosis

echogenic debris in the PV lumen
>13mm diameter
absence of flow

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Sonographic appearance of chronic portal vein thrombosis

more echogenic debris in the PV lumen
<13 mm diameter
cavernous transformation
numerous collaterals
decreased flow

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Cavernous transformation occurs at the ____

porta hepatis

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malignant thrombosis

tumor invasion of the portal vein

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Tumor invasion of the portal vein is associated with:

hepatocellular cancer

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Tumor formation extends into the portal vein and thrombosis can occur

tumor invasion of the portal vein

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used to alleviate portal hypertension and allow blood flow to bypass liver

portosystemic or portal-caval shunt

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TIPS catheter inserted into the internal jugular vein and advanced into the hepatic vein through the liver and into the portal system

portosystemic or portal-caval shunt

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A shunt is most commonly placed between the portal system, usually ____ and the hepatic vein, usually ____

right portal vein
right hepatic vein

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Shunt that connects hepatic vein to portal vein

Transjugular intrahepatic portosystemic shunt (TIPS)

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Shunt that connects proximal splenic vein connected to renal vein

Proximal splenorenal shunt (Linton shunt)

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Shunt that connects distal splenic vein to the renal vein

distal splenorenal shunt (Warren shunt)

Shunt that connects SMV to the IVC

Mesocaval shunt

Complications of portosystemic or portal-caval shunt

infection abscess shunt stenosis thrombosis

Contraindications to portosystemic or portal-caval shunt

hepatobiliary or pancreatic malignancy portal vein thrombosis polycystic liver disease biliary obstruction/cholangitis

Sonographic evaluation of a fasting patient should include measurement of flow velocity and documentation of flow direction in the:

main portal vein SMV splenic vein at confluence three hepatic veins portal anastamosis mid shunt hepatic anastamosis

Flow should be ____ in the shunt

hepatofugal

Air is retained within the shunt after placement which limits the US evaluation for the first ___ days

3-5

Sonographic appearance of shunt walls

very echogenic with linear echoes

most common cause of shunt stenosis is:

neointimal hyperplasia at the hepatic vein anastamosis

After a shunt, flow is from the ____ to the ____

portal system hepatic system

The main portal vein show demonstrate ____ flow

hepatopetal

Peak flow velocity at any point along the shunt should not be less than ___cm/s or exceed ___ cm/s

50 200

Direct signs of shunt failure

absence of flow in the shunt with occlusion hepatopetal flow in the intrahepatic portal branches hepatofugal flow in the main portal vein change in peak velocity since last exam; decrease >40 cm/s or >60 cm/s increase main portal vein <30 cm/s reversal of flow in the hepatic veins, away from IVC

secondary signs of shunt failure

recanalization of the umbilical vein reaccumulation of ascites reappearance of varice

Portal venous gas is caused by ____ or ____

ulcerative colitis necrotizing enterocolitis

Echogenic bands within the portal vein system

portal venous gas

Bubbles/reflectors mover with the blood, gas causes dirty shadowing and ring down artifact

portal venous gas

Portal venous gas is seen near:

periphery of liver

Doppler evaluation demonstrates _____ transient signals when the air bubbles cross the sample volume when portal venous gas is present

high-intensity

A _____ can be congenital or secondary to portal hypertension

portal vein aneurysm

Most common location for portal vein aneurysm

junction of splenic vein and SMV

Hereditary Hemorrhagic Telangiectasia is also known as:

Osler-Weber-Rendu Disease

Genetic disorder, AV malformations, fibrosis, cirrhosis, recurrent episodes of bleeding

hereditary hemorrhagic telangiectasia

Sonographic appearance of hereditary hemorrhagic telangiectasia

dilated hepatic artery (up to 10mm) multiple dilated tubular structures with color flow demonstrated dilated hepatic veins due to increased inflow from hepatic artery

Blood-filled cavities form in the liver tissue

peliosis hepatis

associated with chronic wasting disorders, renal and liver transplantation, many drugs, HIV

peliosis hepatis

Sonographic appearance of peliosis hepatis

single or multiple masses of heterogeneous echogenicity calcifications

Liver transplants are most commonly performed due to cirrhosis caused by ____ or ____ in adults

hepatitis C alcoholism

Liver transplants are most commonly performed due to ____ in children

biliary atresia

used to determine severity of liver disease and need for transplant

Model for End-Stage Liver Disease

Contraindications for liver transplant

cirrhosis extrahepatic malignancy cholangiocarcinoma advanced cardiopulmonary disease active alcohol or drug abuse

Contraindications for a liver transplant in a patient with hepatocellular carcinoma

tumor >5cm more than three primary tumors metastatic disease

entire liver replaced by allograft from recently deceased patient; most common

Orthotropic Liver transplant

portion of a healthy liver is removed from a living donor and transplanted into the patient

Living Donor Transplant

Sonographic evaluation for rejection of liver transplant

IVC, HV, PV patency Hepatic artery patency biliary tree and anastamosis site

The ____ patency is the most important evaluate with a liver transplant because it is the only way oxygenated blood is supplied to the biliary tree

hepatic artery

Sonographic evaluation after a liver transplant to rule out:

AV fistula pseudoaneurysm biliary stricture biloma hematoma

Liver rejection is treated using:

immunosuppresive therapy

A ____ transducer ___ - ___ MHz used for sonographic evaluation of liver

curvilinear or phased array 2-6.5

Color and PW Doppler for patency post liver transplant

hepatic artery - native vessel, anastamosis, donor artery, right and left hepatic arteries,

When checking for patency of vessels measure ___, ____, and ____

peak velocity resistive index acceleration time

hepatic confluence of transplant liver attached to native IVC

piggyback liver transplant

donor IVC segment replaces a segment of native IVC

interposition liver transplant

Common site for complication in liver transplant

anastamosis sites

The ___ is normally removed from the donor liver prior to the transplant

gallbladder

What is the echotexture in a normal liver transplant?

homogenous or slightly heterogeneous

There can be a small amount of free fluid present for __-__ days post op

7-10

The biliary tree shoudl demonstrate _____ walls after a normal liver transplant

thin, imperceptible

Normal portal vein waveform normal liver transplant

monophasic, continuous hepatopetal flow with slight respiratory phasicity

Normal hepatic vein and IVC waveforms after normal liver transplant

triphasic with respiratory phasicity

The hepatic artery PSV should be <___cm/s with a sharp systolic upstroke with antegrade flow throughout diastole with a normal liver transplant

200

After a normal liver transplant, RI values should be ___-___

0.5 0.8

In the immediate post-op patient there can be ____ hepatic pressure usually secondary to edema

increased

most common arterial complication and most significant complication that leads to loss of allograft

hepatic artery thrombosis

Hepatic artery thrombosis causes ____, ___, and ____

abnormal LFTs biliary leak hepatic necrosis

Hepatic artery stenosis usually affects the _____ and presents >3 months post op

anastamosis

With hepatic artery stenosis the PSV will be >__ cm/s

200

Hepatic artery stenosis demonstrates ____ acceleration time

prolonged

With hepatic artery stenosis, ____ waveforms will be present in the intrahepatic arteries, RI <0.5

tardus parvus

dilated ducts from stricture point into the liver; new onset of jaundice; no sign of stone or mass at pancreas head

biliary stricture or leakage

usually occurs at anastamosis, elevated velocity, monophasic or reversed flow in portal vein

portal vein stenosis

presents as lower extremity edema, ascites, elecated velocity at site of stenosis and monophasic hepatic venous waveform; monophasic or reversed flow

IVC/Hepatic vein stenosis

Increased parenchymal resistance to arterial and portal inflow can indicate:

rejection

High resistance flow in the hepatic artery indicates

elevated distal reistance

Tardus parvus waveform in the right and left hepatic arteries can indicate:

stenosis of common hepatic artery

causes for stenosis at anastamosis site

improper stitching, kinking, and extrinsic compression

Post surgical complications of liver transplant

hepatic artery thrombosis hepatic artery stenosis biliary stricture or leakage PV thrombosis PV stenosis IVC/hepatic vein thrombosis IVC/hepatic vein stenosis ascending cholangitis pseudoaneurysm fluid collections liver transplant rejection

Most patients have pre-existing Ebstein Barr virus which causes:

overproliferation of B lymphocytes

associated with immunosuppressive therapy used to prevent allograft rejection

post-transplant lymphoproliferative disorders

Findings of post-transplant lymphoproliferative disorders

lymphadenopathy new mass formation at liver hilum

Blunt trauma to liver area can lead to ____ and ____

blood vessel damage hematoma formation

between the capsule and liver tissue

subcapsular

outside the liver capsule

extracapsular

within the liver tissue

intraparenchymal

Chronic thrombosis of the hepatic veins results in compensatory enlargement of which liver lobe? a. posterior right b. anterior right c. lateral left d. caudate

All of the following are findings associated with Budd-Chiari syndrome, except: a. bicolored hepatic vein flow b. thick walled hepatic veins c. triphasic hepatic vein waveform d. ascites