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