Pediatric Sonography- Liver

what is the most common hepatic mass in neonates?

hemangioma

what are the 2 types of pediatric hemangiomas?

cavernous hemangioma

hemangioendothelioma

Hemangioendotheliomas are composed of what?

blood filled spaces

multilayered endothelium

cavernous hemangiomas are composed of what?

single layer endothelium

Hemangioendothelioma affects infants under ____ months of age

6

Hemangioendothelioma is associated with what other pathology?

skin hemangioma

what are the clinical presentations of Hemangioendothelioma? (3)

hepatomegaly

congestive heart failure

hemoperitoneum (from rupture)

what is the sonographic appearance of Hemangioendothelioma?

single or multiple

varying echos/sizes

fine, linear foci of calcium

may have enhancement

vascular

cavernous hemangiomas are ___ times more likely in girls

3

cavernous hemangiomas are evident by ____ months of age

2

while normal sized cavernous hemangiomas are asymptomatic, what signs/symptoms can large ones cause?

hepatomegaly

obstructive jaundice

vomiting due to a bowel obstruction

respiratory insufficiency

what treatments can be done for cavernous hemagiomas that are large and threatening to a child's health?

lobectomy or ressection

what is the sonographic appearance of cavernous hemangioma?

well defined

hyperechoic (can be hypo)

enhancement

vascular

may calcify with PAS

Mesenchymal Hamartoma is a rare tumour arising from what?

connective tissue of the portal tracts

what are the signs/symptoms of Mesenchymal Hamartoma?

painless abdominal swelling

what is the sonographic appearance of Mesenchymal Hamartoma?

the same as cavernous hemangioma, expect it's not vascular

what is the treatment for Mesenchymal Hamartoma?

ressection

adenomas are highly associated with what disease?

glycogen storage disease

what is the sonographic appearance of adenomas?

isoechoic

vascularity in the center of the lesion

true or false- 2/3 of solid liver lesions in peds are malignant

true

what is the most common pediatric liver mass?

hepatoblastoma

hepatoblastoma is most common in which age group?

boys under 5

what are the clinical presentations of hepatoblastoma?

hepatomegaly

painless palpable mass

typical malignancy symptoms; fatigue, weight loss, N & V, jaundice, anemia, etc

what lab value will be elevated with a finding of hepatoblastoma?

AFP

what is the treatment for hepatoblastoma?

resection if has not metastisized to PVs

chemo

what is the sonographic appearance of hepatoblastoma?

solitary multinodular mass

heterogenous

hyperechoic

ill-defined borders

areas of necrosis/hemorrhage

calcifications

HCC occurs in children over ___ years old

3

what diseases can be associated with HCC in peds? (3)

glycogen storage disease

wilson's disease

hepatitis

what are the clinical presentations of HCC?

sudden liver failure

hepatomegaly

GI bleeding

anemia

ascites

pain

what lab value will be elevated with HCC?

AFP

what is the sonographic appearance of HCC?

solid

hyperechoic

involves entire liver

necrotic areas (anechoic)

hypo or anechoic halo around mass

what is a histologic subtype of HCC that affects teenagers and young adults?

fibrolamellar HCC

what are the clinical presentations of Fibrolamellar HCC?

abdo pain

mass

fever

weight loss

diarrhea

vomiting

what is the sonographic appearance of Fibrolamellar HCC?

solitary

well defined

variable echogenicity

focal calcifications

Mesenchymal Sarcoma is a fast growing malignancy affecting which age group?

5-10 y/o

what are the clinical presentations of Mesenchymal Sarcoma?

abdominal pain

abdominal swelling

palpable mass

what is the sonographic appearance of Mesenchymal Sarcoma?

single

round & well-defined

variable echogenicity

cystic spaces within creating enhancement

what is the most common cause of liver mets in peds

neuroblastoma

which pathology is described as inflammation of the liver causing necrosis of hepatic cells?

hepatitis

almost all cases of hepatitis in peds are viral. what are some possible non-viral causes of hepatitis?

toxins

drugs

what are the signs/symptoms of hepatitis?

hepatomegaly with pain

jaundice

nausea

fever

loss of appetite

if acute hepatitis becomes chronic, what other pathologies can it cause? (3)

cirrhosis

liver damage

cancer

what is the sonographic sign used to describe hepatitis?

starry sky sign

how do liver abscesses occur?

infection from the umbilicus or surgery

what are the 3 types of liver abscesses?

amebic

pyogenic

fungal

true or false- liver abscesses have a good prognosis

false

what is the treatment for liver abscesses?

antiobiotics

drainage

surgery

which type of liver abscess affects children where drinking water is contaminated?

amebic abscess

amebic abscesses are caused by which microorganism?

Entamoeba histolytica

how does Entamoeba histolytica get to the liver to form an abscess?

through the colon and up the portal vein

what will the lab values be with an amebic abscess?

high LFTs

leukocytosis

anemia

what are the signs/symptoms of amebic abscess?

abdo distention

fever

RUQ pain

what is the sonographic appearance of an amebic abscess?

hypoechoic

spherical lesion

in right lobe

which type of liver abscess occurs mainly in immunocomprimised children and is caused by E.coli or Klebsiella pneumoniae?

pyogenic abscess

a pyogenic abscess is caused by which microorganism?

E.coli or Klebsiella pneumoniae

what is the sonographic appearance of pyogenic abscess?

discretely marginated hypoechoic structures with enhancement

can also be complex hyperechoic with poorly defined walls

if contains gas - shadowing and reverberation artifacts

bull's eye appearance

a fungal abscess is caused by what microorganism?

Candida albicans

what is the sonographic appearance of a fungal abscess?

multiple small lesions

irregular walls

round

hypoechoic

target sign or wheel within wheel sign

which pathology presents as a large and echogenic liver with decreased visualization of the hepatic veins?

fatty infiltration

what are the 3 stages of fatty infiltration?

mild, moderate, severe

does fatty infiltration affect the contour of the liver?

no

which pathology appears as a parenchymal destruction, scarring, fibrosis and nodular regeneration in the liver?

cirrhosis

what are the signs/symptoms of cirrhosis?

hepatomegaly

jaundice

ascites

what will lab values be with cirrhosis?

high AST, ALT and LDH

high direct and indirect bilirubin

what is the sonographic appearance of cirrhosis?

shrunken liver

surface nodularity

coarse/heterogeneous texture

increased echogenicity

which pathology is caused by excessive connective tissue build up due to chronic injury?

hepatic fibrosis

what are the clinical presentations of hepatic fibrosis?

hepatomegaly

portal hypertension

what is the sonographic appearance of hepatic fibrosis?

increased echogenicity

biliary dilitation

which pathology is described as increased resistance to normal portal flow?

portal hypertension

what are the signs/symptoms of portal hypertension?

splenomegaly

ascites

caput medusa

what is the sonographic appearance of portal hypertension?

hepatofugal portal flow

varices

splenomegaly

ascites

cirrhosis

what are the causes of portal vein thrombosis?

dehydration

catheterization

shock

portal hypertension

tumour invasion from HCC/hepatoblastoma

what are the signs/symptoms of portal vein thrombosis?

acute abdominal pain

splenomegaly

what is the sonographic appearance of portal vein thrombosis?

enlarged & echogenic PVs

absent doppler signal

visible tumour invasion

cavernous transformation (chronic only)

collaterals (chronic)

what pathology is described as thrombosis of the hepatic veins?

budd-chiari syndrome

what are some causes of budd-chiari?

idiopathic occlusion

neoplasm invasion

thrombosis

what is the sonographic appearance of budd-chiari?

hepatomegaly

echogenic clot in PVs

absent flow in PVs

secondary: pleural effusion, ascites, GB wall edema

why is hepatic infarction uncommon?

because the liver has dual blood supply

what is the sonographic appearance of hepatic infarction?

wedge shaped hypoechoic area

well marginated

changes from hypo to hyper to calcified

true or false- liver is the most commonly injured abdominal organ in blunt abdominal trauma in children

true

what is the echogenicity of fluid in hemoperitoneum?

hyperechoic

hepatic cysts are associated with what 2 genetic disorders?

MCDK

von hippel lindau syndrome

what are the clinical presentations of hepatic cysts?

palpable if large, otherwise asymptomatic

what is the sonographic appearance of hepatic cysts?

smooth walled

anechoic

enhancement

which type of liver cysts are caused by a parasitic tapeworm?

Hydatid echinococcal cysts

what are the causes of Hydatid echinococcal cysts?

exposure to livestock/dogs/farming

a parasitic tapeworm reaches the liver to form a cyst via which structure?

portal vein

what is the sonographic appearance of Hydatid echinococcal cysts?

daughter cysts

septated

debris

floating membranes

what are the clinical signs of hydatid echinococcal cysts?

urticaria

RUQ pain

hepatomegaly

what happens if a hydatid echinococcal cyst ruptures?

anaphylactic shock