DMS 223 Chapter 9: Liver

What's another term for an echinococcal cyst?

Hydatid cysts

What is Segment II and III in the liver?

Left superior and inferior lateral segments

What are some pathologic changes of acute hepatitis?

Liver cell injury, swelling of the hepatocytes, and hepatocyte degeneration, which may lead to cell necrosis

___________ are come and usually ___________. Most patients are __________.

Liver cysts benign asymptomatic

What are some of the characteristics of *cirrhosis*?

May be both chronic and progressive, with liver cell failure and portal hypertension as the end stage

What are Segment IVa and IVb in the liver?

Medial segments of the left lobe

___________ _________ is most commonly the result of chronic alcohol abuse, whereas _______-_________ ___________ is caused by chronic viral hepatitis or other infection

Micronodular cirrhosis Macro-nodular cirrhosis

What are some clinical symptoms of *cirrhosis*?

Nausea Flatulence Anorexia Weight loss Jaundice Dark urine Fatigue Varicosities *Chronic cirrhosis may progress to liver failure and portal hypertension*

What are Segments VII and VIII in the liver?

Cephalad to the transverse plane

________________ usually progresses to cirrhosis and liver failure

Chronic active hepatitis

____________ is a benign, self-limiting process

Chronic persistent hepatitis

What can *hemochromatosis* lead to?

Cirrhosis and portal hypertension

Without complications, ________ from acute hepatitis usually occurs within 4 months.

Clinical recovery

_____________ of hepatitis involving damage to the liver may range from mild disease to massive necrosis and liver failure

Complications

The liver must be assessed for what three things?

Contour Size Homogeneous texture

Liver disease is divided into the following parameters:

Diffuse disease Functional disease Abscess formation Trauma Transplantation Benign Malignant Vascular Problems

____________ _________ easily receive the transfer of flow via the collaterals from the portal veins in a normal liver

Hepatic veins

________ is the general name for inflammatory and infectious disease of the liver

Hepatitis

What are some causes of fatty liver?

Obesity Excessive alcohol intake Poorly controlled hyperlipidemia Diabetes Excess corticosteroids Pregnancy Total parenteral hyperlimentation Severe hepatitis Glycogen storage disease Cystic fibrosis Pharmaceutical

What are the basic instrumentations that should be adjusted in the following parameters?

TGC Overall Gain Transducer frequency and type Depth and focus

In ___________, more extensive changes occur than in chronic persistent hepatitis, with inflammation extending across the limiting plate, spreading out in a perilobular fashion, and causing piecemeal necrosis, which is frequently accompanied by fibrosis

chronic active hepatitis

_____________________ develops when the normal venous channels become obstructed

collateral circulation

In an effort to relieve the pressure, __________________ are formed that connect to the systemic veins

collateral veins

Most common collateral pathways are through the _____________ and _______________.

coronary and esophageal veins

Development of increased pressure in the porta-splenic venous system is the cause of ___________ portal hypertension

extrahepatic

Portal hypertension may develop from ________________.

increased portal flow

Portal hypertension may develop from ____________________________ (cirrhosis).

increased resistance to flow

Much of the liver is beneath the ribs, thus _____ spaces are necessary for liver evaluation

intercostal

Cirrhosis is most common cause of _________ portal hypertension

intrahepatic

What is *pneumocystis carinii*?

is the most common organism causing opportunistic infection in patients with acquired immunodeficiency syndrome

Liver failure is one reason for _________

jaundice

The _______________ consists of normal or slightly atypical hepatocytes and frequently contains areas of bile stasis and focal hemorrhage or necrosis.

liver cell adenoma

__________________ _________________ is a common life-threatening infection in patients with HIV.

pneumocystis pneumonia

With polycystic liver disease, a majority of these patients also have ____________________. *Autosomal dominant*

polycystic renal disease

Hepatocellular disease causes the blood pressure in the hepatic circulation to increase and leads to the development of __________________.

portal hypertension

Measurements are made to the liver by taking a __________ dimension.

superior-inferior

The cyst is seen on ultrasound as a _________, ____________, with _________________. *Increased through transmission*

thin, smooth walled structure, posterior enhancement

What are the sources of pyogenic abscess?

*Sources of infection include* - *Cholangitis* - Portal pyemia secondary to appendicitis - Diverticulitis - Colitis - Direct spread from another organ - Trauma with direct contamination - Infarction after embolization or from sickle cell anemia

How does Hepatitis A spread?

*Type A* spread by *fecal contamination, oral anal contact, or contaminated food*

How does Hepatitis B spread?

*Type B* can be contracted from *infected blood, seminal fluid, vaginal secretions, or contaminated drug needles, and mother to newborn* - Greatest risk to health workers

What is ALK POS?

- (alkaline phosphate) is elevated when there is hepatic obstruction or liver disease

What is fatty infiltration?

- *Fatty infiltration* is a benign process that can be reversed with a patients lifestyle chance - Common causes are *alcoholic abuse, diabetes, and obesity* - Disorder of *metabolism*, resulting in an accumulation of triglycerides within the hepatocytes - Fatty infiltration implies *increased lipid accumulation* in the hepatocytes and is the result of major injury to the liver or a systemic disorder leading to impaired or excessive metabolism of fat

What is the mesocaval shunt?

- Attaches the mid-distal superior mesenteric vein to the IVC - May be difficult to image if overlying bowel gas is present

What is the splenorenal shunt?

- Attaches the splenic vein to the left renal vein - Shunt and connecting vessel should be documented with real-time pulsed Doppler and color Doppler to determine flow patterns and patency

*Two patterns* have been found in patients with *fatty infiltration of their liver*:

- Decreased amplitude of phasic oscillations with loss of reversed flow - Flattened waveform

How does Hepatitis spread? And what does it impair?

- Disease may result from a local infection, from an infection elsewhere in the body, or from chemical or drug toxicity - *Mild inflammation impairs hepatocyte function*, whereas more severe inflammation and necrosis may lead to obstruction of blood and bile flow in the liver and *impaired liver cell function*.

What is AST?

- Elevated in liver disease patients - Demonstrates that there is injury or death to liver cells, thus this enzyme is released into the blood stream

What is ALT?

- Evaluates liver function and elevates mildly with acute cirrhosis and pancreatitis - Is highly elevated with hepatocellular disease

What are other characteristics about fatty infiltration?

- Fatty infiltration does *NOT* always effect the entire liver and *focal fatty sparing* will appear as *hypoechoic* areas - *Do not* mistake these areas for *lesions* in the liver - The most *common* areas for FFS is the *gallbladder, caudate lobe, and portal vein areas*

Biliary obstruction proximal to the cystic duct can be caused by:

- Gallstones - Carcinoma of the CBD - Metastatic tumor invasion of the porta hepatis

What are the sonographic findings of Glycogen Storage disease?

- Hepatomegaly - Increased echogenicity - Increased attenuation - Associated with hepatic adenomas and focal nodular hyperplasia

What are the sonographic findings of *hemochromatosis*?

- Hepatomegaly - Cirrhotic changes increased echogenecity may be seen uniformly throughout hepatic parenchyma

What is the overall summary of viral hepatitis?

- In the U.S, approximately *60%* of *acute viral hepatitis* is *type B*, *20%* is *type A*, and *20%* is other types - Patients with *acute* and *chronic hepatitis* may initially have flulike and gastrointestinal symptoms, including a loss of appetite, nausea, vomiting, and fatigue - *Viral hepatitis may be fatal* with secondary acute hepatic necrosis or chronic hepatitis, which may lead to portal hypertension, cirrhosis, and hepatocellular carcinoma

What is glycogen storage disease?

- Inherited - Abnormal storage and accumulation of glycogen in liver - Categorized based on clinical symptoms and enzymatic defects - Type 1 von Gierke's Dz

What is diffuse hepatocellular disease?

- It is diagnosis by abnormal LFT's due to cell necrosis - ALK Phos and Bilirubin increase - This disease process includes the entire liver and may or may not include sonographic findings - It affects the *hepatocytes*, which control all the function of the liver - *chronic hepatitis* and *fatty liver* fall under this category

How does *fatty infiltration* occur? And what does it look like on ultrasound?

- It occurs from *fat accumulation* in the *hepatocytes* which causes damage to these cells - On ultrasound, the liver looks *hyperechoic* and can even be enlarged - The vascular structures may be difficult to visualize because of the increased attenuation

What does chronic hepatitis look like on ultrasound?

- Liver parenchyma is coarse with decreased brightness of the portal triads - Degree of attenuation is not as great as is seen in fatty infiltration - Liver does not increase in size with chronic hepatitis - Fibrosis may be evident which may produce "soft shadowing" posteriorly

What is the summary of possible ultrasound appearances in *cirrhosis*?

- May appear *normal* in the early stages - May begin to have a *coarse texture* accompanied by *fatty change* and *hepatomegaly* - Late stages - *small liver* with *nodular* surface

What are the sonographic findings of acute hepatitis?

- May appear normal - Portal vein borders are more prominent than usual - Liver parenchyma is slightly more echogenic - Gallbladder wall might be thickened - Attenuation may be present - Hepatosplenomegaly is present - Starry night effect

What are the sonographic findings of *cavernous hemangioma*?

- Sonographically the mass is seen as *hyperechoic* with *acoustic enhancement* - The older larger hemangiomas have mixed texture patterns because of *necrosis*

Biliary obstruction distal to the cystic duct may be caused by:

- Stones in the CBD - Extrahepatic mass in the porta hepatis - Stricture of the common duct

What is Hep C and how does it spread?

- The infection is often *asymptomatic*, but once established, chronic infection can progress to scarring of the liver - Advanced scarring (*cirrhosis*) could continue into liver cancer - Spread by blood-to-blood contact - Sexual activity and needle use are very common routes of transmission

What are the sonographic findings of *pyogenic abscesses*?

- The mass is a varying size and *hypoechoic* in echo texture - You may see floating debris with *acoustic enhancement* - If the abscess contains gas it is *hyperechoic* with some *posterior shadowing* - The margins are typically *irregular*

What is *cirrhosis*?

- This is a disease process in which the liver parenchyma degenerates and the lobes are infiltrated with fat - The most common cause of cirrhosis is *alcohol abuse*

What is *Budd-Chiari Syndrome*?

- Thrombosis of the hepatic veins or IVC - Characterized by abdominal pain, massive ascites, and hepatomegaly - Poor prognosis - Presentation may be acute or a chronic illness lasting from a few weeks to several years - *Extensive* hepatic vein occlusion is usually fatal within weeks or months of the onset of symptoms

What are the sonographic findings of *cirrhosis*?

- When the *cirrhosis* is not very advanced the liver may appear hyperechoic and coarse - When the disease progresses a nodular contour is evident - Early stages of *cirrhosis* shows hepatomegaly, ascites, and decreased vasculature - End stage of *cirrhosis* the liver becomes small and nodular that is generally surrounded by ascites - The Doppler flow may also be disrupted

What are the symptoms of Budd Chiari?

-Ascites -Abdominal pain -Hepatosplenomegaly -Jaundice -Vomiting and diarrhea -Underlying disease (renal cell carcinoma, primary cancer of the liver, thrombophlebitis migrains, and polycythemia) - When thrombus is found in the IVC, edema of the legs is gross and venous distention develops over the abdomen, flanks, and back - Albuminuria may be found

A normal PV should not exceed _______ in AP diameter

16mm

What is pyogenic abscess?

A *pyogenic abscess* is one that "pus" - The usually arise because of trauma, surgery, biliary disease, penetrating wound patient presents with fever, *increased WBCs*, and RUQ pain

_______ may have mild to massive necrosis and possibly liver failure

Acute hepatitis

What does *amebiasis* affect?

Affects the colon and cecum. - Organism remains within the GI tract

What are the developmental anomalies of the liver?

Agenesis Anomalies of position Accessory fissures Vascular anomalies

______________ is contracted by ingesting the cysts in contaminated water and food.

Amebiasis

What are some liver function tests?

Aspartate aminotransferase AST (SGOT) Alanine aminotransferase ALT (SGPT) Lactic acid dehydrogenase (LDH) Bilirubin Prothrombin time Albumin and globulins Alk pos

What is the portacaval shunt?

Attaches the main portal vein at the superior mesenteric vein-splenic vein confluence to the anterior aspect of the IVC

Acute onset of hepatic vein occlusion (__________________), constructive pericarditis, or congestive heart failure with tricuspid regurgitation

Budd-Chiari syndrome

What are Segments V and VI in the liver?

Caudal to the transverse plane

What is Segment I in the liver?

Caudate lobe

What causes *hepatic candidiasis*? Where does it occur? Where does it invade? What is its sonographic findings?

Caused by a *fungus* (Candida) - Occurs in persons that are *immunocompromised* (HIV, Chemo pts, or organ transplant pts) - Invades the *bloodstream and any organ* - On ultrasound, the liver presents with small *hypoechoic* masses with a *echogenic center* referred as a *target lesion* "very characteristic"

What is *chronic granulomatous*?

Genetic disease process that renders that patients ability to ward off types of bactertia - Occurs more frequently in children and *boys* due to *recessive* trait - Poorly marginated, *hypoechoic* mass is seen with *posterior enhancement* - Calcification may be present with *posterior shadowing* - *Aspiration* is necessary to classify the mass specifically as granulomatous disease

Organ size will vary with what 4 things?

Height, weight, age, and body surface

__________ waveform also shows altered flow dynamics in cirrhosis and chronic liver disease

Hepatic artery

The ______ _______ velocity waveform reflects the hemodynamics of the right atrium

Hepatic vein

What are the different types of portacaval shunts?

Portacaval Mesocaval Splenorenal

What are the signs of portal hypertension when talking about *cirrhosis*?

Possible thrombosis, varices, and collaterals Some other signs could be ascites, splenomegaly, and lymphadenopathy

_________ type is caused by _________ obstruction of the hepatic veins or inferior vena cava by membranous webs across the upper vena cava at or just above the entrance of the left and middle hepatic veins

Primary congenital

__________ is an enzyme in the blood that allows the blood to clot

Prothrombin

_____________ type results from __________ in the hepatic veins or IVC

Secondary thrombosis

What is the assessment criteria for the liver?

Size of the liver in the longitudinal plane Attenuation of the liver parenchyma Liver texture Presence of hepatic vascular structures, ligaments, and fissures

What is a *echinococcal cyst*?

This infectious disease is found in sheep herding areas of the world - It is cause by a tapeworm that resides in dogs and eggs are deposited in the feces

What is *cavernous hemangioma*?

This is a very common tumor that is *benign* - It is a tumor that contains *blood filled spaces* - Patients are typically *asymptomatic*, but pain can arise of these tumors begin to bleed

You must have a sufficient amount of _________ in your body for ________ to take place

Vitamin K Prothrombin

An _______ is a tumor of the *glandular epithelium* in which the cells of the tumor are arranged in a recognizable *glandular structure*.

adenoma

A _________ _________ can lead to a more serious condition such as _____________, ___________, and __________.

hepatic cyst infection abscess necrosis

Diverted blood flow causes embryologic channels to reopen; blood flows ________________ (away from the liver) and is diverted into collateral vessels.

hepatofugally

If the liver length is greater than 15cm (17cm) ________ may be suspected

hepatomegaly

Portal hypertension may develop when ____________________ (toward the liver) is __________ by thrombus or tumor invasion.

hepatopetal flow impede

Intrahepatic shunt is a _________________.

transjugular intrahepatic portasystemic shunt (TIPS)

This _________ pattern has two large antegrade diastolic and systolic waves and a small retrograde wave that corresponds to the atrial kick (from the heart)

triphasic

These are known as ____________ and occur most frequently in the area of the esophagus, stomach, stomach, and rectum.

varicose veins