Textbook of Diagnostic Sonography - Chapter 9 Liver - Pathology of the Liver Including Diffuse Diseases (Fatty Infiltration, Acute & Chronic Hepatitis, Cirrhosis, Glycogen Storage Disease, & Hemochromatosis)

Essential feature of cirrhosis

simultaneous parenchymal necrosis, regeneration, nad diffuse fibrosis resulting in disorganization of lobular architecture

fatty infiltration acute and chronic hepatitis early alcoholic liver disease acute and chronic cirrhosis

sub categories of diffuse parenchymal disease

sonographic comparison of the liver parenchyma to these organs are useful in determining if fatty infiltration is present

the kidney the pancreas - its parenchyma is more echogenic than the liver

on sonography, fatty infiltration most commonly appears in a diffuse distribution and results in

uniform increased echogenicity of the liver

With fatty infiltration of the liver,, the patient is

usually asymptomatic some patients may present with jaundice, nausea, vomiting, and abdominal tenderness or pain

Causes of chronic hepatits

viral metabolic autoimmune drug induced

Acute Hepatitis

without complications, clinical recovery usually occurs within 4 months *complications may include liver cell injury, swelling of the hepatocytes, and hepatocyte degeneration, which may lead to cell necrosis. *retinculoendothelial and lymphocytic response with Kupffer cells enlarging *regeneration

name a diffuse hepatocellular disease that is a benign process that may be reversible with correction of the process.

fatty infiltration

If the liver appears more hyperechoic than the pancreas,

fatty infiltration should be considered

chronic illness can cause

fatty liver

cystic fibrosis can cause

fatty liver

excess corticosteroids can cause

fatty liver

glycogen storage disease can cause

fatty liver

poorly controlled hyperlipidemia causes

fatty liver

pregnancy can cause

fatty liver

severe hepatitis can cause

fatty liver

Patients with hepatitis may initially present with

flulike and gastrointestinal symptoms including loss of appetite, nausea, vomiting, and fatigue

hepatitis

general name for inflammatory and infectious disease of the liver, of which there are many causes May result from local infection (viral hep.), from infection elsewhere in the body (mono or amebiasis), or from chemical or drug toxicity

What disorders may lead to cirrhosis and portal hypertension

hemochromatosis chronic hepatitis is one... add the others here late

Patients with cirrhosis have an increased risk of what kind of tumors?

hepatoma

classic clinical presentation of patient with cirrhosis

hepatomegaly, jaundice, and ascites

Sonographic Findings with Acute Hepatis

*Texture may be normal or portal vein borders may be more echogenic than usual (Starry Sky sign). *Parenchyma slightly more echogenic. *Attenuation may be present. *Hepatosplenomegaly *Gallbladder wall markedly thickened w/contraction of lumen

Sonographic findings of cirrhosis

*hepatomegaly - first finding (early) *shrunken r. lobe w/enlarged caudate and l. lobe (severe) May find: -Increased echogenicity & attenuation -Coarse parenchyma echotexture -fibrosis and nodular surface irregularity -decreased vascular markings (chronic) -hepatosplenomegaly w/ascites surrounding liver ascites -portal hypertension & regeneration of nodules

Sonographic findings of glycogen storage disease

-Hepatomegaly -Increased echogenicity -Slightly increased attenuation (similar to diffuse fatty infiltration) -adenomas (round, homogeneous (when small), echogenic)

Fatty infiltration implies

increased lipid accumulation in the hepatocytes

Regenerating nodules of cirrhosis are _____ to the liver parenchyma and thus may be indistinguishable from normal liver texute

isoechoic

chronic cirrhosis may progress to

liver failure and portal hypertension

fatty infiltration results from

major injury to the liver or a systemic disorder leading to impaired or excessive metabolism of fat

Characteristics of fatty infiltration

-not always uniform -does not displace normal vascular architecture -margins may appear nodular, round, or interdigitated with normal ttissue -has ability to resolve rapidly **focal sparing** suspected in patients with masslike hypoechoic areas in a liver that is otherwise increased in echogenicity.

How many categories of glycogen storage disease? How are they divided?

6. Divided on basis of clinical symptoms and specific enzymatic defects

3 grades of liver texture defined in sonography for classification of fatty infiltration

mild moderate severe

Von Gierke disease (type I)

Abnormally large amounts of glycogen are deposited in the liver and kidneys

Hepatitis B

B= blood and body fluids (hep c is the same) Virus exists in the bloodstream. Spread by transfusions or contaminated needles. Also found in body fluids such as saliva and semen and can be spread by sexual contact

Sonographic Findings of Chronic Hepatitis

Course parenchyma No change in liver size Increased echogenicity Decreased brightness of portal triad Fibrosis may produce soft shadowing posteriorly

Hepatitis C (HCV)

Diagnosed by presence in blood of antibody to HCV (anti-HCV). No vaccine available.

Why can viral hepatitis be fatal?

Due to secondary acute hepatic necrosis or Chronic hepatitis, which may lead to portal hypertension, cirrhosis, and hepatocellular carcinoma

What form of hepatitis is the greatest risk to health care workers?

Hepatits B

HCC

Hepatocellular carcinoma

classification of cirrhosis as micronodular

nodules 0.1 -1 cm in diameter

classification of cirrhosis as macronodular

nodules up to 5 cm in diameter

common causes of fatty liver include

obesity alcohol abuse cholesterol-lowering medications diabetes certain chemotherapy agents total parenteral hyperalimentation (nutrition) poorly controlled hyperlipidemia pregnancy severe hepatitis glycogen storage disease cystic fibrosis chronic illness excess corticosteroids

Difference between chronic active hepatitis and chronic persistent hepatits

In the active form, inflammation extends across the limiting plate, spreading out in a perilobular fashion, causing piecemeal necrosis, and fibrosis. Patients may present w/nausea, anorexia, weight loss, tremors, jaundice, dark urine, fatigue, and varicosities

Moderate Fatty Infiltration

Increased echogenicity with slightly impaired visualization of the diaphragm and intrahepatic vascular borders

Glycogen Storage Disease

Inherited disease; characterized by abnormal storage and accumulation of glycogen in the tissues, especially the liver and kidneys.

Mild Fatty Infiltration

Minimal diffuse increase in hepatic echogenicity with normal visualization of the diaphragm and intrahepatic vascular borders

Mild inflammation from hepatitis impairs hepatocyte function, whereas more severe inflammation and necrosis may lead to

obstruction of blood and bile flow int he liver and impaired liver cell function

Severe Fatty Infiltration

Significant increase in echogenicity of the liver parenchyma, decreased penetration of the posterior segment of the right lobe of the liver, and decreased to poor visualization of the diaphragm and hepatic vessels

When portal vein borders are more echogenic than usual - what is that called? What condition is this associated with?

Starry Sky Sign Associated with Acute Hepatitis

fatty livers are sonodense - resulting in

portal vein structures difficult to visualize because of increased attenuation typical gain settings do not allow penetration to posterior border, so it is more difficult to see the outline of the portal vein and hepatic vein borders the increase in echo texture may result from increased collagen content of the liver or increase in lipid accumulation

Dysplastic nodules or adenomatous hyyperplastic nodules are larger than regenerating nodules and are considered ______. They contain well-differdentiated hepatocytes, portal venous blood supply, and atypical cells.

premalignant

chronic active hepatitis

progressive liver destruction with cirrhosis, chronic liver failure and death

viral hepatitis

results from infection by a group of viruses that specifically target the hepatocytes (local infection)

Fatty infiltration is not always uniform. It is not uncommon to see patchy distribution of hypoechoic masses (fat) within a dense, fatty infiltrated liver, especially in the ___ lobe.

right

fatty infiltration of the liver is the precursor for

significant chronic disease in some patients

Most common type of glycogen storage disease

Type 1, Von Gierke's disease.

How do you know when hepatitis is chronic?

When there is clinical or biochemical evidence of hepatic inflammation that extends beyond 6 months.

Chronic persistent hepatitis

a benign, self-limiting process.

hepatocyte

a parenchymal liver cell that performs all functions ascribed to the liver

Hemochromatosis

a rare inherited disease of iron metabolism characterized by excess iron deposits in the body; a bronze color of the skin may be noticed

diffuse hepatocellular disease measured through

a series of liver function tests

asymptomatic or may have nausea, flatulence, ascites, light-colored stool, weakness, abdominal pain, varicosities, and spider angiomas

acute cirrhosis presentation

Hepatitis A

acute infection that leads to either complete recovery or death from acute liver failure. -usually transmitted orally through fecal contamination of food or water Ends in a vowel, comes from the bowel Endemic in developing countries - occurs very early in life

diffuse hepatocellular disease

affects hepatocytes and interferes with liver function

interruption in the flow of bile through any part of the biliary system, from the liver to duodenum (cholestasis) causes

alkaline phosphatase and direct bilirubin levels to increase

Fatty Infiltration of the Liver

an acquired, reversible disorder of metabolism, resulting in intracellular accumulation of triglycerides within hepatocytes

Most common areas for focal sparing

anterior to the gallbladder or the portal vein and the periportal region of the medial segment of the left lobe of the liver.

Other causes of cirrhosis besides alcohol abuse, chronic viral hepatitis, or other infection

biliary cirrhosis Wilson's disease premary sclerosing cholangitis hemochromatosis

hepatic enzyme levels are elevated with

cell necrosis

Micronodular cirrhosis is most commonly the result of

chronic alcohol abuse

Cirrhosis

chronic and progressive degenerative disease of the liver in which hepatic lobes are covered with fibrous tissue, parenchyma degenerates, and lobules are infiltrated with fat liver cell failure and portal hypertension as the end stage

What disease process shows surface nodularity of the liver edge, especially if ascites is present?

chronic cirrhosis

neausea, anorexia, weight loss, jaundice, dark urine, fatigue, or varicosities

chronic cirrhosis presentation

Macronodular cirrhosis is caused by

chronic viral hepatitis or other infection

The evaluation of the ratio of the caudate lobe width to the right lobe width (C/RL) has been used as an indicator of what? A C/RL value of 0.65 is considered indicate of this disease.

cirrhosis

Sonographic findings of hemochromatosis

cirrhotic changes hepatomegaly some increased echogenicity seen uniformly throughout parenchyma

focal subcapsular fat may be found in these patients

diabetics receiving insulin in peritoneal dialysate

Glycogen storage disease is associated with

diffuse fatty infiltration, hepatic adenomas, focal nodular hyperplasia

when there are defects in protein synthesis, there may be

elevated serum bilirubin levels and decreased serum albumin and clotting factor levels