kristi flashcards

Name three lobes of the liver

Right, left, caudate

Name segments of the liver

Caudate

Left lateral superior

Left lateral inferior

Left medial superior

Left medial inferior

Right anterior superior

Right anterior inferior

Right posterior superior

Right posterior inferior

What is couinaud’s anatomy?

Universal segmentation of the liver used for hepatic lesion localization. It’s based on the functional distribution of the portal veins. Each segment has its own bile duct, hepatic artery, and portal vein

Which portion of the liver receives both rt and lt portal branches

Caudate lobe; drains directly into the inferior vena cava via the emissary veins

What’s another name for glisson’s capsule

Visceral peritoneum; covers the abdominal organs

Name the lining of the abdominal cavity

Parietal peritoneum

Explain how glisson’s capsule, visceral peritoneum, is created

The liver, like the spleen, invaginates into the peritoneum, which covers the surface of the liver

What is the sequence of echogenicity in normal abdominal structures hyper to hypo?

Renal sinus, pancreas, liver/spleen, renal cortex

Which vessels are considered to be INTERsegmental within the liver?

The thin walled hepatic veins course between the segments of the liver, and are intersegmental

Which vessels are considered to be INTRASEGMETAL within the liver

The portal vein, hepatic artery, and bile duct (triad). Surrounded by fibrofatty tissue which causes their walls to be echogenic

Describe the location of the main lobar fissure

The MLF is an incomplete sonographic boundary which can be located by an imaginary line from the gb fossa to the ivc. This boundary separates the rt and lt lobes of the liver. The mid hepatic vein is a landmark of this fissure

Which two segments of the liver does the mlf separate

rt and lt, also the rt anterior segment of the rt lobe from the Lt medial segment of the Lt lobe

Describe the location of the rt intersegmental fissure

The rt intersegmental fissure is a coronal division of the rt lobe of the liver. It divides the rt lobe into anterior and posterior sections. The rt hepatic vein is a landmark of the rt intersegmental fissure

Describe the location of the Lt intersegmental fissure

The Lt intersegmental fissure is a sagittal division of the Lt lobe of the liver. It divides the Lt lobe into medial and lateral sections. The Lt hepatic vein, Lig T, falciform ligament, and the ascending segment of the Lt portal vein are landmarks of the intersegmental fissure

What is the ligamentum venosum?

A remnant of the ductus venosus, which prenatally conducts blood from the Lt portal vein to the ivc. The ligamentum venosum and the prox portion Of the Lt portal vein separate the medial segment of the Lt lobe of the liver from the caudate lobe

what are the boundaries of the caudate lobe

Posteriorly by the ivc

Anterioinferiorly by the prox Lt portal vein

Anterolaterally by the ligamentum venosum

Inferiorly by the main portal vein

what is the bare area?

the posterior, crescent shaped portion of the liver that is not covered by peritoneum

what is the coronary ligament?

The coronary ligament is the reflection of the parietal peritoneum onto the liver surface, becoming the visceral peritoneum

what are the rt and lt triangular ligaments?

they are coronary ligaments, “reflections” at each corner of the bare area

what is reidel’s lobe

a tongue like projection of the rt lobe which extends beyond lower pole of kidney

reidels lobe is more common in

women

what is the measurement for hepatomegaly measured at mid clavicular

approx 15.5cm

how to pyogenic abscesses (bacterial) form in the liver

bacteria reaches the liver via the bile ducts, portal vein, hepatic arteries, and lymphatic channels.

they are solitary and rt lobe occurring

sono app of pyogenic abscess

hypoechoic, round, fluid filled with varying levels of debris, echogenic foci / artifact due to gas producing organisms

sono app of acute hepatitis & sign

“starry night sky”

echogenic pv and hypoechoic liver echotexture thats enlarged

sono app chronic hepatitis

small, hyperechoic liver tissue, with decreased echogenicity of pv walls

sono app of fungal abscess & 2 signs

“wheel within wheel”

“bulls eye”

hypoechoic or echogenic

sono app amoebic abscess

round or oval hypoechoic mass with indistinct borders, debris, enhancement, and is continuous with disphragm

sono app echinococcal cyst aka

hydatid cyst

large cyst with daughter cyst, debris, if old then collapsed and calcified

what is amoebic abscess caused by? how is it diagnosed

protozoan parasites, diagnosed by indirect hemagglutination

where are echinococcal cysts contracted

sheep and cattle raising countries/areas when eggs are ingested

what is the most common parasitic infection world wide ( africa/ south america)

schistosomiasis

what is the most common vascular event associated with schistosomiasis

intrahepatic portal vein occlusion by larvae which leads to portal vein hypertension, splenomegaly, ascites, varices

sono app of schistosomiasis

distended, echogenic and debris filled portal veins

what is the most common organism that causes infection in immunocompromised patients ex aids

pneumocystis carinii

sono app of pneumocystis carinii

liver involvement; non shadowing echogenic foci

focal fatty infiltration sono app

regions of increased echogenicity within the liver

variable extent, but most commonly at the porta hepatis

focal fatty sparing sono app

islands of normal liver tissue within a fatty liver appearing as “masses”

most commonly seen adjacent to gb

glycogen storage disease

large quantities of glycogen being stored within hepatocytes of the liver and convoluted tubules of the kidney

what liver mass is associated with glycogen storage disease?

hepatic adenoma

associated with oral contraceptives

nonspecific sono app that is difficult to distinguish from FNH

what are the 3 major pathologic mechanisms of cirrhosis?

hepatocellular death, fibrosis, and regeneration

what is the classic clinical presentation of a cirrhosis pt?

jaundice, ascites, hepatomegaly

clinical signs of portal hypertension

ascites, splenomegaly, and varices

portal vein thrombosis is associated with

HCC, metastatic liver disease, pancreatic carcinoma, pancreatitis, etc…

portal vein thrombosis sono app

intraluminal thrombus

increased vein diameter (13mm>)

cavernous transformations

define budd chiari syndrome

occlusion / obstruction of the hepatic veins

budd chiari syndrome sono app

hepatic vein thrombosis

ascites

hepatomegaly (acute)

enlarged caudate (chronic)

portal hypertension (not flowing out so more pressure here)

most common benign tumor of the liver

cavernous hemangiomas

cavernous hemangioma sono app

small, asymptomatic

hormone sensitive

well defined and hyperechoic with maybe enhancement

sono app of FNH

solitary, less than 5cm, with a central scar

“stealth lesion” isoechoic

name 4 well defined hyperechoic liver masses

hemangioma

hepatic lipomas

echogenic metastasis

focal fatty infiltration

what is the most common primary malignant tumor of the liver

HCC - hepatocellular carcinoma

hypoechoic mass

comes from alcoholic cirrhosis, chronic hep B & C, portal vein invasion

how is the functionality of TIPS assessed

demonstrate flow within the shunt and presence of hepatofugal flow in rt and lt portal veins

with a properly functioning TIPS, what should the flow direction be for the rt and lt portal veins (no recanalized umbilical vein)

hepatofugal

what are two types of gb folding

phrygian cap and junctional fold

what are the two terms used to describe a gb that is stone filled and contracted

WES (wall echo shadow) and double arch shadow sign

what is the purpose of administering a fatty meal to a pt

assessing biliary obstruction;

obstructed bile duct will increase in size after this meal. non obstructed bile duct would decrease in size

what does a significant increase in conjugated (direct) bilirubin levels indicate? (3 things)

obstructive jaundice (hepatitis), intrahepatic cholestasis, or biliary tree obstruction

gb wall limit measurement

.3mm

what are some gb wall thickening causes?

cholecystitis, ascites, hypoalbuminemia, hepatitis, CHF, renal disease, AIDS, sepsis

sono app of gallstones

mobile, echogenic structures within the gb with posterior shadowing

what are gallstones made of?

cholesterol, calcium bilirubinate, and calcium carbonate

describe acute cholecystitis

typically caused by a stone lodged in the cystic duct (mirizzis?) which leads to lack of venous drainage and an inflamed gb wall with varying degrees of necrosis/infection

clinical findings of acute cholecystitis

ruq tenderness, fever, guarding, chills, and leukocytosis (infection!)

the 5 sono criteria of acute cholecystitis

gallstones, + murphys, diffuse wall thickening, gb distention, and sludge

define emphysematous cholecystitis

infection associated with gas producing bacteria within the gb wall (more susceptible to diabetics)

sono app emphysematous cholecystitis

gas shadowing from wall of gb (comet tail artifact)

describe gb hydrops

a stone lodges itself in the cystic duct causing a distended, non-inflamed gb. bile is reabsorbed and the gb is filled with a clear, mucinous secretion from the mucosa

clinical findings of gb hydrops

asymptomatic, may have a palpable ruq mass

sono app gb hydrops

distended, non tender gb, with obstructing stone in cystic duct

what are rokitansky-ascholff sinuses? RAS

diverticula in the wall of the gb

what pathology is associated with RAS

adenomyomatosis;

slude/stones accumulated within these sinuses and look like wall thickening. echogenic foci within gb wall with reverb artifact (fan shadowing)

sono app for gb carcinoma

intraluminal mass within gb, mass filled gb, and/or asymmetric wall thickening

3 findings that should be investigated to confirm gb carcinoma

liver mets, lymphadenopathy, bile duct dilation

two most common causes of biliary tract obstruction

gallstones, pancreatic carcinoma

what lab values are likely to be elevated due to biliary tract obstruction

alkaline phosphatase, conjugated (direct) bilirubin, and gamma glutyml transpeptidase

two signs that indicate intrahepatic bile duct dilation

shotgun sign / parallel channel sign = dilated cbd and portal vein

what is mirizzi’s syndrome?

extrahepatic bile duct obstruction due to a lodged stone in the cystic duct. the stone compresses the common hepatic duct.

sono app of mirizzi’s syndrome

intrahepatic bile duct dilation, normal cbd, large stone in cystic duct

name three extrahepatic biliary ducts

common hepatic duct, cystic duct, cbd

what pathology causes intrahepatic biliary dilation without extrahepatic biliary dilation

klatskin tumor (type of cholangiocarcinoma), found at the hepatic hilum at the junction of the rt and lt hepatic ducts

what is pneumobilia

air in the biliary tree

sono app of pneumobilia

variable length of echogenic foci in the biliary tree with reverb

commonly seen in the hilum of the liver, as this is the direction of bile flow

what happens to cause pneumobilia?

most commonly seen after an endoscopic retrograde cholangiopancreatogram ERCP

also be due to : surgically created biliary enteric anastomosis, incompetence of sphincter of oddi, wall erosion by gallstone or ulcer in the cbd

sono app of choledochal cyst

cyst like structures in the ruq being the cbd and gb

dilated intrahepatic biliary tree

sono app of caroli’s disease

saccular, communicating intrahepatic bile duct dilation

caroli’s is associated with

infantile polycystic kidney disease

congenital hepatic fibrosis

choledochal cysts

what is a courvoisier gb

enlarged, noninflamed gb associated with extrinsic obstruction (like pancreatic carcinoma) of the cbd

sono app of milk of calcium bile

milk of calcium bile appears as fluid-fluid level with posterior shadowing

bile duct carcinoma (cholangiocarcinoma) is uncommon. what predisposing conditions are associated with this?

ulcerative colitis, sclerosing cholangitis, caroli’s disease, choledochal cyst, and parasitic infection

what is the name of the cholangiocarcinoma found at the hepatic hilum

commonly, cholangiocarcinoma is found in the chd and cbd.

a klatskin tumor is a type of this cancer found at the liver hilum. causes intrahepatic dilation without extrahepatic dilation

the head of the pancreas is ______ to the ivc

anterior

the head of the pancreas is ______ to the second portion of the duodenum

medial

the cbd is ________ to the head of the pancreas

posterolateral

the gda is _____ to the head of the pancreas

anteriolateral

the sma and vein are ____ to the neck of the pancreas

posterior

the uncinate process is _____ to the sma and vein

posterior

the aorta is _____ to the body of the pancreas

posterior

the celiac axis arises from the aorta ______ to the pancreas

superior

the gda and cbd run ______ to the first portion of the duodenum

posterior