CH 9 The Liver Pathology I
The following are sonographic findings associated with _______: Hepatomegaly, fatty infiltration with increased echogenicity and attenuation, hepatic adenomas, nephromegaly.
von Gierke's Glycogen Storage Disease
Sonographically, cirrhosis presents like _______ in the early stages.
fatty infiltration
The classical clinical presentation of a patient with cirrhosis is: _______ _______ and ________
hepatomegaly, jaundice, ascites
The most common cause of cirrhosis in the United States is: A. Alcoholism B. Cholangitis C. Hepatitis D. Portal hypertension
A. Alcoholism
Clinical findings of fatty infiltration of the liver include: A. Elevated LFTs B. Fatigue C. Fever D. Weight loss
A. Elevated LFTs
What are the symptoms of hepatitis?
Abnormal LFTs Elevation of ALT, AST, conjugated and unconjugated bilirubin Dark Urine Fatigue Flu-like (fever and chills) GI distress Hepatosplenomegaly Jaundice Loss of Appetite Nausea/Vomiting
What causes the "starry sky" appearance?
Acute Hepatitis . Decreased echogenicity of the liver parenchyma results in the PV walls being brighter than usual.
What are liver enlargement, hepatosplenomegaly and a thickened GB wall indicative of?
Acute hepatitis
Which hepatitis can be described as having mild destruction to massive liver failure?
Acute hepatitis
What are the causes of hepatomegaly?
Amyloidosis Biliary obstruction Congestive heart failure Cystic (polycystic, congenital hepatic fibrosis) Fatty infiltration Gaucher's Disease Glycogen storage disease Hemochromatosis Inflammatory (hepatitis, cirrhosis) Leukemia Lymphoma Neoplasm Vascular (Budd-Chiari)
Fatty Infiltration is usually symptomatic or asymptomatic?
Asymptomatic
Acute hepatitis ..... A. can lead to cirrhosis and liver failure B. decrease in liver echogenicity C. increase in liver echogenicity D. no increase in liver size E. all of the above
B. decrease in liver echogenicity Chronic active hepatitis usually progresses to cirrhosis and liver failure
Hepatitis B..... A. due to fecal contamination B. due to blood transfusions or sexual contact C. half of cases develop into chronic hepatitis D. lasts <6 weeks
B. due to blood transfusion or sexual contact (Blood or body fluids)
What are causes of cirrhosis?
Biliary cirrhosis Chronic alcohol abuse - most common micronodular cirrhosis and most common cause of cirrhosis overall Chronic viral hepatitis - most common macronodular cirrhosis Hemochromatosis Primary sclerosing cholangitis Wilson's disease
How is Hepatitis Type C spread?
Blood or body fluids
Hepatiits B (60% acute USA) is spread through what ways?
Blood, saliva, and sexual contact ( greatest risk to health care workers)
Which hepatitis can progress to cirrhosis and liver failure?
Chronic active hepatitis
What are the possible sequelae of hepatitis?
Chronic hepatitis Fatal due to acute necrosis Cirrhosis Portal hypertension Hepatocellular carcinoma (HCC)
Macronodular cirrhosis is caused by what?
Chronic viral hepatitis or other infection
Chronic degenerative disease of the liver is called _____.
Cirrhosis
The following are other possible sonographic findings related to ____________: Dilated PV, hepatofugal flow or thrombosis in PV Portsystemic varices Increased hepatic arterial flow (compensate for decreased portal flow) Splenomegaly (Blood flow backs up from PH) Recanalization of the umbilical vein Ascites (albumin, oncotic pressure)
Cirrhosis
The following are the sonographic findings of _______: Coarse liver parenchyma with nodularity, increased echogenicity, increased attenuation, decreased vascular markings with acute, hepatosplenomegaly with ascites, decrease in size with chronic, regeneration of hepatic nodules, portal hypertension
Cirrhosis
What disease is chronic and progressive with simultaneous parenchymal necrosis, regeneration, and diffuse fibrosis resulting in disorganization of lobular architecture?
Cirrhosis
What are the sonographic features of chronic hepatitis?
Coarse liver parenchyma Increased echogenicity Decreased visualization of portal vein walls Fibrosis may produce soft shadowing
What are the sonographic features of cirrhosis?
Coarse liver parenchyma with nodularity Increased echogenicity Increased attenuation Decrease vascular markings with acute cirrhosis Hepatosplenomegaly with ascites Shrunken liver with chronic cirrhosis (increased nodularity) Regeneration of hepatic nodules Portal hypertension
What are the sonographic features common to focal fatty sparing and focal fatty infiltration?
Common locations for either Periportal region Gallbladder fossa Liver margin Left medial segment Lack of mass effect* Geometric margins*
What are the sonographic features of hepatomegaly?
Compare liver to right kidney Extension of liver lobe beyond lower pole of right kidney in absence of Reidel's lobe Length > 15 cm at mid-clavicular line Rounding of inferior tip Compression of right kidney
Clinical or lab findings for Glycogen Storage Disease are...
Disturbance of acid-base balance
The most common cause of fatty liver in the United States is ____________________.
ETOH abuse
What is the most common cause of cirrhosis?
ETOH abuse
What are the abnormal lab values associated with fatty infiltration?
Elevated AST and ALT Elevated ALP and Direct bilirubin
What are the abnormal lab values associated with cirrhosis?
Elevated AST and ALT Elevated ALP and direct bilirubin Leukopenia (decreased WBC)
Increased lipid accumulation in the hepatocytes is a result of _____.
Fatty Infiltation
The following are the sonographic findings of ________: Increased echogenicity, increased attenuation, impaired visualization of borders of portal/hepatic structures, hepatomegaly, patchy/inhomogenous, focal sparing
Fatty infiltration
Which liver pathology is the most common cause of abnormal LFT's?
Fatty infiltration
What are types of diffuse liver disease?
Fatty infiltration, cirrhosis, hepatitis (acute and chronic), glycogen storage disease, and hemochromatosis.
A rare disease of iron metabolism, characterized by excess iron deposits throughout the body. There are no specific sonographic signs related to this disease.
Hemochromatosis
What is a rare disease of excessive iron deposits throughout the body?
Hemochromatosis
An inflammatory and infectious disease of the liver is called ____.
Hepatitis
The general name for inflammatory and infectious disease of the liver that causes flulike and gastrointestinal symptoms is known as what?
Hepatitis
What are differential considerations for fatty infiltration?
Hepatitis Cirrhosis Metastases
What is the most common type of hepatitis?
Hepatitis B
What type of hepatitis is the most common requiring liver transplantation?
Hepatitis C
What are the sonographic features of Glycogen Storage Disease?
Hepatomegaly Increased attenuation Increased echogenicity von Gierke's adenoma
There are three grades of liver texture that have been defined in sonography for classification of fatty infiltration: _____- minimal diffuse increase in hepatic echogenecity with normal visualization of the diaphragm and intrahepatic vasculature ______- increased echogenecity with slightly impaired visualization of the diaphragm and intrahepatic vasculature borders ________- marked increase in echogenecity of liver parenchyma, decreased penetration of posterior segment of right lobe, and decreased to poor visualization of the diaphragm and hepatic vessels
mild, moderate, severe
What are the sonographic features of fatty infiltration?
Increased echogenicity Increased attenuation Decreased visualization of hepatic vasculature Hepatomegaly Heterogenous liver echo texture Focal sparing or focal infiltation
Define hepatitis.
Inflammation of the liver
How does hemochromatosis appear sonographically?
It is sonographically indistinguishable from fatty infiltration. Hepatomegaly, cirrhotic changes and increased echogenicity.
Define focal fatty sparing.
Liver is diffusely fatty infiltrated except for areas that are spared or normal.
Define focal fatty infiltration.
Liver is normal with focal areas of increase fatty infiltration.
Fatty infiltration results from: ____ and _____.
Major injury to liver Systemic disorder causing excessive metabolism of fat
What are the causes of fatty infiltation?
Obesity ETOH abuse Hyperlipidemia Diabetes mellitus Steroids Pregnancy Total parenteral hyperalimentation (nutrition) Severe hepatitis Glycogen storage disease Hemochromatosis Cystic fibrosis Drugs Chronic illness
Hemochromatosis
Rare, hereditary disorder causing excessive accumulation of iron within the liver. It is seen more frequently in men by 7:1 and increases the risk for HCC by 200x
What are the two anomalies associated with abnormal liver positions?
Situs Inversus Congenital diaphragmatic hernia
What are the three conditions in which the liver will be found in other locations?
Situs inversus, congenital diaphragmatic hernia, or omphalocele
Chronic _______ hepatitis usually progresses to cirrhosis and liver failure.
active
The following are sonographic findings in ______ hepatitis: May have normal appearance, overall decreased echogenicity, possible hepatomegaly, increased echogenicity of portal vein wall, thickened gallbladder wall.
acute
The following are sonographic findings in _______ hepatitis: Hyperechoic, secondary to fatty change and fibrosis, texture may be course, small liver, decreased echogenicity of PV walls (comparative), "soft shadowing" posteriorly (caused by fibrosis).
chronic
Hemochromatosis leads to __ and ___
cirrhosis and portal hypertension
Clinical or lab findings for Hemochromatosis are...
elevated levels of iron in the blood
What are the common areas in the liver affected by focal fatty sparing or focal fatty infiltation?
Anterior to GB Anterior to PV Periportal region of left medial segment
What is diffuse hepatocelluar disease?
Affects the hepatocytes and interferes with liver function AST, ALT are elevated ALP and direct bilirubin elevated with cholestasis Bilirubin increase, albumin and clotting factors (increases PT, PTT, and INR values) decrease with defects in protein synthesis
What parts of the liver are least affected with cirrhosis?
Caudate lobe
Define liver agenesis
Congenital absence of liver Parital or complete Complete incompatiable with life
Clinical findings of hepatitis include all of the following except: A. Chills B. Fever C. Jaundice D. Pericholecystic fluid
D. Pericholecystic fluid This is seen with acute cholecystitis. With hepatitis, thickening of GB wall may be demonstrated.
Chronic hepatitis ..... A. coarse hepatic texture B. fatty changes and fibrosis C. gallbladder wall thickening D. hepatomegaly E. a and b F. all of the above
E. a and b; coarse hepatic texture, fatty changes, and fibrosis
Micronodular cirrhosis is most commonly caused by what?
ETOH abuse
Hepatitis A (20% acute USA) is an acute infection primary spread by what?
Fecal contamination
How is Hepatitis Type A spread?
Fecal-oral route
What are the effects of fatty infiltration?
Generally no harmful effects; some LFTs may become elevated if fatty infiltration is extensive enough to affect liver function.
Abnormal amounts of glycogen deposited in the liver and body tissues describes _____.
Glycogen Storage Disease
The following are the sonographic findings of ________: hepatomegaly, increased echogenicity, increased attenuation, von Gierke's adenoma (round, homogeneous).
Glycogen Storage Disease
What does glycogen storage disease affect?
Glycogen metabolism. Large quantities of glycogen are stored in hepatocytes and the convoluted tubes of the kidneys.
What are the grades of fatty infiltation?
Grades I, II, and III Mild, moderate, and severe Sonographic features worsen with severity
The following is the sonographic finding of __________: Increased echogenicity throughout liver (with increased iron levels in blood)
Hemochromatosis
Define hepatomegaly
Liver enlargement
What is the most common vascular variant in the upper abdomen?
Replaced right hepatic artery Right hepatic artery arises directly from SMA Travels inbetween portal vein and IVC
What is situs inversus?
Reversal of organs (liver on left; spleen on right) Complete or partial
What is the most common type of glycogen storage disease?
Type I; von Gierke's
What are accessory fissures or pseudofissures?
Uncommon Caused by infolding of peritoneum AKA cough fissures
Chronic, degenerative, diffuse disease process characterized by fibrosis and conversion of normal liver architecture into structurally abnormal nodules.
cirrhosis
Fatty Liver- sonographic appearance Although the process is diffuse, fatty infiltration may also be focal resembling a _______________ mass.
hyperechoic
Focal fatty infiltration will appear _____ sonographically.
hyperechoic
Focal fatty sparing will appear _____ sonographically.
hypoechoic
The following are sonographic findings of _____ stage cirrhosis: small, heterogenous, course liver texture, relative caudate lobe enlargement, surface nodularity (irregular).
late or end stage
Chronic _______ hepatitis is a benign, self-limiting process.
persistent
Fatty Liver- sonographic appearance There will also be decreased visualization of the intrahepatic _____ _____ as the surrounding liver tissue becomes more echogenic.
vessel walls
Define fatty infiltration.
Acquired, reversible, benign disorder of metabolims Increased accumulation of fat (triglycerides) within hepatocytes
How is Hepatitis Type B spread?
Blood or body fluids
What are the sonographic features of acute hepatitis?
Normal Hepatomegaly Decreased echogenicity Accentuated brightness of portal vein walls (starry night) Secondary GB wall thickening
Fatty Liver- sonographic appearance To distinguish between tumors and fatty changes, focal fatty infiltration and sparing will NOT cause a mass effect on hepatic vessels whereas tumors ________________ surrounding vessels.
displace or distort
