ARDMS Abdomen Review (Based off Susanna Ovel 2nd Edition)

Functions of the liver (6)

1. break down RBC, producing bile pigments

2. secretes bile into duodenum through bile ducts

3. converts amnio acids into urea and glucose

4. stores glucose as glycogen

5. releases glucose

6. produces heparin

The left lobe of the liver is divided into medial and lateral segments by the

left hepatic vein

ligamentum teres

The left lobe of the liver is separated from the caudate lobe by the

ligamentum venosum

The left lobe of the liver is separated from the right lobe superiorly by the _____ and inferiorly by the _____

middle hepatic vein

main lobar fissure

The right lobe of the liver is divided into anterior and posterior segments by the

right hepatic vein

The falciform ligament attaches the liver to the

anterior abdominal wall

The gastrohepatic ligament connects the liver to the

lesser curvature of the stomach

The hepatoduodenal ligament connects the liver to the

proximal duodenum

The ligamentum teres lies within what structure, and what was it previously

falciform ligament

fetal umbilical vein

The triangular ligament is the most lateral portion of what ligament, and what does it connect the liver to

coronary ligament

body wall

What is the ligamentum venosum

obliterated ductus venosum

Where does the hepatic artery enter the liver, how much of the liver's blood supply is through the hepatic artery, it lies _____ to the common hepatic duct and _____ to the main portal vein, what is normal diameter

porta hepatis

30%

medial

anterior

2-4mm

The left portal vein divides into:

The right portal vein divides into:

How much of the liver's blood supply is through the portal veins, what kind of blood does it transport to the liver, what should diameter never exceed

left medial and lateral portal veins

right anterior and posterior veins

70%

nutrient rich (oxygen poor) blood from GI tract

13mm

Is the liver intraperitoneal or extraperitoneal

intraperitoneal

Causes of hepatomegaly (7)

1. congestive heart failure

2. inflammatory processes

3. polycystic disease

4. fatty infiltration

5. biliary obstruction

6. neoplasm

7. budd-chiari syndrome

Symptoms of hepatomegaly (3)

asymptomatic

RUQ pain

RUQ mass

Portal vein sonographically

hyper echoic walls

hepatopedal flow

Indications for examination of liver (7)

1. abnormal liver function tests

2. hepatocellular disease

3. biliary disease

4. abdominal pain

5. postprandial pain

6. palpable liver or spleen

7. pancreatitis

Symptoms of hepatic cyst (2)

asymptomatic

dull RUQ pain

Hepatic cyst sonographically (5)

anechoic

round or oval shape

well-defined

posterior acoustic enhancement

may contain septations or low-level internal echoes

What is a cystedenoma, what age group and gender is it more common in

rare, benign neoplasm containing cystic structures within the lesion

middle-aged women

Symptoms of Cystadenoma (2)

hepatomegaly

palpable RUQ mass

Cystadenoma Sonographically (4)

multiloculated cystic mass

well-defined margins

thin septations

thick septations/mural nodules suspicious for malignancy

What is Polycystic disease of the liver, what age group and gender is it more common in

inherited cystic disorder

middle aged females

Polycystic disease of the liver symptoms (4)

asymptomatic

hepatomegaly

palpable RUQ mass

RUQ pain

Polycystic disease of the liver sonographically (3)

multiple cystic structures

posterior acoustic enhancement

multiple cysts may also be found in kidneys, pancreas, spleen

Causes of hepatic abscess (5)

ascending cholangitis

recent travel abroad

biliary infection

appendicitis

diverticulitis

Hepatic abscess symptoms (7)

abdominal pain

fever

chills

leukocytosis

elevated alkaline phosphatase

jaundice

hepatomegaly

Hepatic abscess sonographically (5)

complex mass

oval/round shape

irregular wall margins

usually solitary

posterior acoustic enhancement

Hepatic candidiasis cause

fungal infection

Hepatic candidiasis symptoms (5)

immune-suppressed patient

abdominal pain

fever

chills

palpable liver

Hepatic candidiasis sonographically (5)

hypoechoic

thick wall

hepatomegaly

target or "wheel within a wheel"

hyper echoic lesions with posterior acoustic shadowing

Echinococcal cyst cause

parasite (echinococcus granulosum)

recent travel to underdeveloped countries

Echinococcal cyst symptoms (5)

RUQ pain

leukocytosis

fever

hepatomegaly

elevated alkaline phosphatase

Echinococcal cyst sonographically (6)

septated cystic mass (honeycomb)

mobile internal echoes (snowflakes)

cyst containing smaller daughter cysts

collapsed cyst within a cyst (water lily sign)

round/oval shape

smooth wall margins

Hepatitis A cause

viral infection

Hepatitis B cause

viral infection transmitted by infected blood/body fluids

Hepatitis C cause

dirty needle from blood transfusion

Hepatitis Symptoms (6)

fatigue

loss of appetite

fever

chills

nausea

non obstructive jaundice

Hepatitis sonographically (5)

normal to hypoechoic liver parenchyma

prominent portal veins (starry night)

hepatomegaly

splenomegaly

increased parenchymal echogenicity (chronic cases)

What is peliosis hepatitis

rare disorder in chronically ill patients

Peliosis hepatitis symptoms

hepatomegaly

Peliosis hepatitis sonographically

focal or diffuse cystic liver masses

necrotic, blood-filled liver spaces communicating with hepatic veins

Schistosomiasis cause

parasite entering skin

Schistosomiasis symptoms

rash

fever

diarrhea

lymphadenopathy

RUQ pain

Schistosomiasis sonographically

increased echogenicity of portal walls

thick portal walls

atrophied right lobe

hypertrophied left lobe

thickened gallbladder wall

portosystemic collaterals

Cause of hepatic adenoma

long history of use of oral contraceptives

Hepatic adenoma symptoms

asymptomatic

normal labs

RUQ pain

Hepatic adenoma sonographically

solid, slightly hypoechoic mass

hypoechoic halo

complex mass with hemorrhage and necrosis

What is the most common benign liver mass

cavernous hemangioma

What is a cavernous hemangioma, what gender is it more common in

benign congenital neoplasm consisting of large blood-filled cystic spaces

females

Cavernous hemangioma symptoms

asymptomatic

RUQ pain

Cavernous hemangioma sonographically

homogenous

hyper echoic mass

well-defined

round

may increased in size

Cirrhosis causes (7)

1. alcoholism

2. chronic hepatitis C

(two most common cause in US)

3. biliary obstruction

4. viral hepatitis

5. budd-chiari syndrome

6. nutritional deficiencies

7. cardiac disease

Cirrhosis symptoms (8)

1. weakness

2. fatigue

3. abdominal pain

4. ascites

5. skin changes

6. hair loss

7. nonobstructive jaundice

8. elevated aspartate amniotransferase, alanine amniotransferase, and bilirubin

Cirrhosis sonographically (7)

1. increased parenchymal echogenicity

2. irregular nodular contour

3. inability to distinguish portal vein wall margins

4. sound attenuation

5. enlarged caudate lobe

6. splenomegaly

7. ascites

Fatty infiltration causes (8)

1. obesity

2. diabetes

3. cirrhosis

4. hepatitis

5. alcohol abuse

6. hyperlipidemia

7. metabolic disorder

8. ulcerative colitis

Fatty infiltration symptoms

asymptomatic

elevated liver function tests

hepatomegaly

Fatty infiltration sonographically

increased parenchymal echogenicity

normal vessel wall margins

normal liver parenchyma appears as hypoechoic mass adjacent to IVC or anterior to portages hepatis

What is the second most common benign liver mass

focal nodular hyperplasia

Focal nodular hyperplasia cause, typical symptom

hormone influence, congenital vascular malformation

asymptomatic

Focal nodular hyperplasia sonographically

hyperechoc or isoechoic liver mass

well-defined

sub capsular location

hypoechoic central stellate scar

peripheral/central blood flow

What is glycogen storage disease, what is the most common type

autosomal recessive disorder of excessive deposition of glycogen in liver, kidneys, and GI tract

type I-Von Gierke disease

Glycogen storage disease symptoms

hepatomegaly

stunted growth

kidney failure

hypoglycemia

bruising

osteoporosis

Glycogen storage disease sonographically

diffuse increase in liver echogenicity

increased attenuation

hepatomegaly

solid liver masses

What is the most common symptomatic vascular tumor in infancy, what is its usual symptom

hemangioendothelioma

abdominal mass

Hemangioendothelioma sonographically

multiple hypoechoic lesions

multiple peripheral vessels

large draining veins with dilated proximal abdominal aorta with AV shunting

What is hemochromatosis

rare disease with excess iron deposits throughout body

Hemochromatosis symptoms

fatigue

SOB

heart palpitations

chronic abdominal pain

Hemochromatosis sonographically

hepatomegaly

increased echogenicity

What is a mesenchymal hamartoma

rare lesion occurring in children less than 2 years of age

Mesenchymal hamartoma symptoms

abdominal distension

palpable abdominal mass

Mesenchymal hamartoma sonogaphically

well-defined

large

complex

anechoic

lace like configuration

Hemangiosarcoma causes

exposure to:

arsenic

polyvinyl

thorotrast

Hemangiosarcoma symptoms

abdominal pain

loss of appetite

lethargy

Hemangiosarcoma sonographically

heterogeneous

hyper echoic mass

cystic mass with septations

internal blood flow

What is the most common malignant tumor in children 3 years old or less

hepatoblastoma

Hepatoblastoma symptoms

abdominal distension

nausea

vomiting

weight loss

precocious puberty

elevated AFP

Hepatoblastoma sonographically

heterogeneous

hyper echoic mass

cystic mass with internal septations

low resistance internal arterial flow

Hepatocellular carcinoma causes

cirrhosis

chronic hepatitis B

exposure to carcinogens

Hepatocellular carcinoma symptoms

palpable mass

abdominal pain

weight loss

fever

jaundice

elevated alanine amniotransferase, aspartate amniotransferase, alkaline phosphatase, and alpha-fetoprotein

Hepatocellular carcinoma sonographically

solid mass

variable echogenicity

possibly hypoechoic halo

hepatomegaly

ascites

multiple nodules or diffuse infiltrative masses

Where does the metastases to the liver usually come from

colon

pancreas

breast

lung

Metastases to the liver symptoms

hepatomegaly

RUQ pain

weight loss

loss of appetite

jaundice

increased in AST, ALT, bilirubin, and alkaline phosphatase

Metastases to the liver sonographically

bull's eye/target lesion

hyper echoic masses

cystic masses

complex masses

diffuse pattern

Budd-Chiari syndrome causes (4)

1. hepatocellular carcinoma

2. tumor extension

3. hematologic disorder

4. congenital webbing of IVC or right atrium

Budd-Chiari syndrome symptoms

abdominal pain

hepatomegaly

lower-extremity edema

increased alkaline phosphatase

Budd-Chiari syndrome sonographically (8)

1. thrombus in hepatic and portal veins

2. dilated hepatic veins

3. vein wall thickening

4. absence/altered hepatic venous flow

5. hepatomegaly

6. enlarged caudate lobe

7. ascites

8. hyper echoic liver

Portal hypertension causes (5)

1. cirrhosis

2. hepatitis

3. fatty infiltration

4. portal vein obstruction

5. Budd-Chiari syndrome

Portal hypertension symptoms

splenomegaly

hepatomegaly

elevated LFTs

hematemesis

jaundice

abdominal distension

Portal hypertension sonographically (7)

1. MPV>13mm

2. splenomegaly

3. ascites

4. splenic and SMV>10mm

5. hepatofugal, pulsatile, decreased velocity in portal vein

6. collaterals

7. RI >0.8 in hepatic artery

Portal vein thrombosis causes (6)

1. hepatocellular carcinoma

2. liver metastasis

3. sepsis

4. blood coagulation disorders

5. cirrhosis

6. idiopathic

What is trans jugular intrahepatic portosystemic shunt (TIPS)

shunt placed between a portal and hepatic vein

Normal Gray Scale findings of TIPS

echogenic, non shadowing, tubular structure

connects portal vein to right hepatic vein

8-12mm diameter

Normal Doppler findings of TIPS

MPV: hepatopedal flow

20-60cm/s

R/LPV: hepatofugal flow

peak flow velocity in stent 65-225cm/s

Portal hypertension collaterals

coronary vein

gastroesophageal

mesoenterocaval

paraumbilical vein

splenorenal

Portal hypertension portal caval shunts

mesocaval

portacaval

splenorenal