Liver 2.0

Sonographic appearance of the liver

homogeneous echotexture, smooth contour. Slightly more echogenic or isoechoic to the right kidney cortex

Hepatomegally

Enlargement of the liver over 15cm

Riedel lober

downward projection of the anterior edge of right liver lobe. Common in women. May reach as far as iliac crest

The gastrointestinal tract supplies nutrients to what blood system?

Portal venous blood

Portal Venous flow

monophasic, little pulsatility and normal flow velocity 15-18 cm/second. increase in velocity after eating

Right Hepatic vein

Largest and coursing between anterior an posterior segments, divides right lop into AP segments

Left hepatic vein

Smallest hepatic vein, locating in cephalic portion of left intersegmental fissure diving left lobe into lateral and medial segments

Hepatic vein flow

hepatofugal toward IVC, pulsatile relative to right atrial filling, constraction and relaxation

Porta Hepatis (hepatoduodenal ligament)

Bile duct ventral (anterior) and lateral, hepatic artery ventral and medial, PV dorsal (posterior)

Functions of the liver

factory for chemical compounds. warehouse for short and long term storage, power plant for producing heat, waste disposal for excreting waste, regenerate mildly damaged tissue

Hepatocyte in parenchyma

Most abundant cell, carries out most metabolic functions

Biliary epithealia cells

line biliary system, bile ducts, canaliculi, gallbladder

Kupffer Cells

Phagocytic, belong to the reticuloendothelial system

Reasons for hepatomegaly

masses, cysts, hepatitis, polycystic, liver, nonalcoholic fatty liver, riedel lobe

Fatty infiltration

accumulation pf fatty triglycerides within liver cells. Alcohol abuse and obesity are leading causes. Other factors include chemo, cystic fibrosis, pregnancy, GI disorders, glycogen storage disease (Von Geirke)

Diffuse Fatty infiltration

Diffuse increased echogenicity of liver parenchyma, decreased acoustic penetration due to increased attenuation of sound beam. possible hepatomegaly

Focal Fatty Infiltration

local increased echogenicity area, could be confused with liver mass (vessels not displaced)

Focal Fatty Sparing

area of liver parenchymal tissue is spared, appears as hypoechoic area surrounded by echogenic liver. Common in medial segment of left liver lobe near porta hepatis

Glycogen Storage Disease (von Geirke)

autosomal recessive disorder, Excessive deposits of glycogen in the liver, intestinal tract and kidneys. May cause hypoglycemia, abdominal distension, fatigue and irritability

Sonographic feature of Type 1 (von geirke)

marked diffuse increase in parenchymal echogenicity and decreased penetration indicating a fatty liver, hepatomegaly, possible solid liver masses (adenoma)

Glycogen storage disease Type 3 and 4

associated with cirrhosis and potentially with HCC

Hepatitis

Inflammation of the liver, causes by reactions to viruses and toxins, A,B,C,D,E 95% of acute hepatitis

Hepatitis A

highly contagious infection caused by hep A virus. Fecal-or@l eating infected food or water, especially shellfish

Hep B

serious liver infection cause by hep b virus. Sexual contact, mother to infant, contaminated needles, blood, body fluids, tattoo tools

Hep C

infection caused by virus that attacks liver and leads to inflammation, can lead to primary liver cancer if untreated. sexual contact, exposure to contaminated needles, body fluids, tattoo tools

Hep D

Cause by hep D virus. contact with infected needles with Hep B already

Hep E

Passed through contaminated water

Sonographic appearance of Acute Hepatitis

Possibly normal. Liver enlarged, hypoechoic. Portal vein walls appear hyperechoic (starry sky), periportal cuff, most common cause of non tender thickened gallbladder wall

Chronic persistent hepatitis

Fibrosis with secondary fatty change producing coarser and more hyperechoic texture, portal vein walls are less discrete compared to reflective parenchyma. Milder often benign

Chronic Active Hepatitis

Progression to liver failure or cirrhosis, aggressive

Cirrhosis

diffuse process that destroys normal liver lobule architecture, dense fibrous tissue septa replace normal liver tissue followed by formation of regenerative nodules. Initially, macronodular, becomes micronodular (atrophy)

Clinical findings of cirrhosis

fatigue, weight loss, diarrhea hepatomegaly, jaundice, ascites, portal hypertension. Elevated AST, ALT, LDH 4/5, serum and urine conjugated bilirubin elevated, Serum albumin decreased, albumin- globulin proteins increased.

Sonographic findings of cirrhosis

Early features, hepatomegaly and textual indicative of diffuse hepatocellular disease.

Late features, liver atrophy in right lobe, caudate lobe hypertrophy, surface nodularity, internal textual changes fine-coarse, hypo-hyperechoic, loss of delineation of intrahepatic vasculature, possible findings related to portal hypertension

Congenital Cysts

True hepatic cyst, simple, or related to hereditary disorder such as polycystic liver disease, affects right lobe more

Acquire Cystic lesions

results from trauma, parasites, or inflammatory reactions. commonly cause by taenia echinococcus or echinococcus granulosus. Can infect organs, lungs, kidney and brain

Sonographic Appearance of Acquired cysts

Originally unilocular eventually filling by cysts of varying size. (Daughter Cyst). Depends of course of larval maturation. 1) solitary cyst with possible mural or shell-like calcification. 2) mother cysts containing internal, peripherally place daughter cysts. 3)fluid collections with septa - honeycomb. 4) Solid looking cysts, with or without calcification

Schistosomiasis

Common parasitic infection in Africa, Asia, Indonesia, China, Japan, south America, and Mediterranean. contaminated water with immature worms penetrate skin and travel lymphatics and bloodstream to mesenteric veins. Eggs travel to intestine and urinary bladder or migrate up portal vein to liver. Ova penetrate portal venous walls and lodge in surrounding liver tissue

Clinical findings of schistosomiasis

Portal hypertension, splenomegaly, gastroesophageal varices, hematemesis, and ascites. possible development of cirrhosis or portal hypertension

Sonographic findings of schistosomiasis

irregular hepatic surface, hyperechoic thickened walls of portal venules giving clay pipe stem pattern or periportal fibrosis. Splenomegaly with portal vein and splenic vein dilatation with maintain continuous hepatopetal flow with normal velocity until portal hypertension

Hepatic Abscessess

Usually due to bacterial or parasitic (amebiasis) infection. Pain, fever and elevated white blood cells (leukocytosis)

Pyogenic Abscess

most often polymicrobial and accounts for almost 80% of all hepatic abscesses. Escherichia coli, commonly referred to as E coli and Klebsiella pneumonia being two most frequently isolated pathogens. biliary tract, appendicitis and ruptured appendix is common cause

Sonographic findings of pyogenic abscess

single or multiple masses variable in shape, usually in right lobe. Internal echoes due to pus, acoustic enhancement due to fluid content, peripheral hypervascularity

Amebic Abscess

Causes by a parasite (entamoeba histolytica) from contaminated food/water. history of GI tract infection. Blood carries parasite via portal.

Clinical findings of amebic abscess

RUQ pain, reactive hepatomegaly, diarrhea, fever, chills, jaundice, and black tarry stool. moderate leukocytosis, mild anemia, and elevated LFTS. Common in travel outside of US

HIV/AIDS

Pneumocystis jiroveci (formerly Pneumocystis carinii) is the most common opportunistic infection in HIV-infected persons. Eventually pneumocystis pneumonia develops. canS spread outside lungs to liver, spleen, pancreas, lymph nodes, thyroid, ect

Sonographic appearance of HIV/AIDS

hyperechoic tiny foci that do not shadow

Fungal infection

Hepatic Candidiasis, liver complication in HIV or other immunocompromised patients. Spread of candida albicans fungus is bloodstream. Display wheel within a wheel imaging pattern

Hematoma

Can form from trauma, secondary to intervental procedures