The Liver

Reidel’s lobe

• tongue like extension of inferior tip of right lobe which may extend to iliac crest

• more common in thin women

caudate lobe

• smallest lobe of the liver

• bordered posteriorly by the IVC and anteriorly by the ligamentum venosum

ligamentum teres

the _____________ may recanalize and form collateral pathway leading to anterior abdominal wall in patients with portal hypertension

ligamentum venosum

separates the left lobe from the caudate lobe

ligamentum venosum

remnant of the fetal ductus venosus

gallbladder fossa

• located at the main lobar fissure

• separates the right and left lobes

portal triad

the _____________ is made up of a branch of the portal vein, the hepatic artery, and bile duct

middle hepatic vein

drains the caudate lobe

bile

the liver secretes ____________, which is important for the digestion of fats

glucose

the liver absorbs dietary sugars from blood and converts them to ______________

lipoprotein complexes

hepatocytes make ___________________ which attach to fats so they can be transported in blood plasma to adipose tissue for storage

AST, ALT, ALP, LAD, and GGT

hepatic enzymes include:

prothrombin

protein produced by the liver that helps blood to clot

indirect bilirubin (unconjugated)

• mild elevation: hepatitis

• mild to severe elevation: hemolytic anemia, other hemorrhage causing excessive lysis of RBCs

direct bilirubin (conjugated)

• mild elevation: hepatitis, biliary obstruction

• may be elevated with liver cancer

left lateral decubitus (LLD)

if lots of bowel gas present, roll patient into _____________ position

true accessory fissures

• very rare

• caused by peritoneum folding in on itself within the liver

diaphragmatic slips

• folds of dome of diaphragm that protrude into liver

• seen as very echogenic linear structures extending into liver from diaphragmatic surface

• may mimic hepatic mass

grade I/mild fatty liver infiltration

• slight increase in echogenicity of liver

• diaphragm and hepatic vessels look normal

grade II/moderate fatty liver infiltration

• liver more echogenic

• diaphragm & intrahepatic vessels slightly difficult to see

• right posterior lobe a little hard to penetrate; must increase far gain

grade III/severe fatty liver infiltration

• liver very echogenic

• diaphragm & intrahepatic vessels very difficult to see or non-visible

• very difficult to penetrate posterior right lobe

hepatitis A

• spread via fecal contamination & poor handwashing

• strictly an acute infection—patient either makes a full recovery or dies of acute hepatic failure

hepatitis B

• spread via blood/body fluids

• can become chronic hepatitis

hepatitis C

• spread via blood/body fluids

• 85% of patients with this will develop chronic hepatitis

hepatitis D

• mainly seen in IV drug users

• must co-exist with hepatitis B (chronic)

hepatitis E

• typically transmitted via water or food that is contaminated with fecal matter or by eating raw shellfish

• cause of most water-contamination epidemics in India

hepatitis G

• transmitted via blood/body fluids

• appears to have protective effect in HIV patients by interfering with replication of HIV virus

acute hepatitis

with _______________, the rim of the portal triad may look more prominent and the GB wall may be thickened

chronic hepatitis

clinical or biochemical signs of hepatitis for more than 6 months

alcohol abuse

the most common cause of cirrhosis is _____________

choliangiocarcinoma

adenocarcinoma of intrahepatic or extrahepatic bile ducts

porta hepatis

cholangiocarcinoma can invade ________________

• stones in CBD (choledocholithiasis)

• stricture of CBD

• extrinsic compression of CBD by extrahepatic mass

the causes of biliary obstruction distal to the cystic duct include:

• cholangiocarcinoma of CBD

• metastatic tumor invasion

the causes of biliary obstruction proximal to the cystic duct include:

cysts

fluid-filled space with an epithelial lining

• fever

• malaise/no energy

• RUQ pain

• anorexia/loss of appetite

the main symptoms of a pyogenic abscess are:

pyogenic abscess

may be complex, have septations, or have echogenic foci with comet tail artifact—gas produced by the bacteria

central right lobe

a pyogenic abscess is usually located in the _____________

hepatic candidiasis

• abscess caused by fungal infection—yeast

• patients usually have weakened immune system—Aids, CA, etc.

hepatic candidiasis

the wheel within a wheel lesion and bull’s eye lesion are common sonographic appearances of:

chronic granulomatous disease

• one of the inflammatory hepatic diseases

• results from WBC defect

echinococcus

cyst within a cyst sonographic appearance is associated with _____________

schistosomiasis

• parasitic disease

• organisms ova get into liver via the portal vein and cause a granulomatous reaction

schistosomiasis

clay-pipe stem fibrosis is associated with _____________

cavernous hemangioma

• most common benign tumor

• made up of multiple tiny vascular channels separated and supported by fibrous septae

• generally asymptomatic, incidental finding

• almost always echogenic

hepatocellular adenoma

• benign tumor more common in women

• associated with oral contraceptives and Von Gierke Disease

focal nodular hyperplasia (FNH)

• 2nd most common benign liver tumor

• occurs mostly in women under 40

• associated with oral contraceptive use

hepatocellular carcinoma (HCC)

• most common primary liver cancer

• more common in males, high mortality rate

• alcohol cirrhosis

• chronic hepatitis B or C

• hepatotoxins

causes of hepatocellular carcinoma (HCC) include:

• weight loss

• RUQ pain

• abdominal swelling, hepatomegaly

• unexplained fever

• 70% patients have elevated AFP

symptoms of hepatocellular carcinoma include:

hepatocellular carcinoma (HCC)

______________ often invades/causes thrombus in HVV, PV, IVC

hepatocellular carcinoma (HCC)

with ______________, diffuse infiltration may appear as inhomogeneous texture throughout liver without discrete mass

fibrolamellar carcinoma

______________ is a subtype of hepatocellular carcinoma (HCC)

hemangiosarcoma

• extremely rare

• associated with thorotrast, arsenic, and polyvinyl chloride exposure

hepatoblastoma

• rare malignant tumor

• most common liver mass in infants

• colon (GI)

• lung

• breast

the most likely cancers to metastasize to the liver are:

rejection, infection, and neoplasia

the most common complications of liver transplantation are:

rejection

the single most common cause of hepatic problems after liver transplant

hepatic artery, portal vein, and hepatic vein

after liver transplant, vascular thrombosis may occur in the:

cirrhosis

the most common cause of intrahepatic portal hypertension is _______________

biphasic

as the portal hypertension becomes more severe, the flow becomes ___________ or back and forth and then eventually becomes hepatofugal

transjugular intrahepatic portosystemic shunt (TIPS)

metallic stents are placed that connect the portal vein to the hepatic veins

Budd-Chiari syndrome

with ______________, sonographically:

• ascites is always present

• enlarged caudate lobe & hepatic veins

• atrophy of right lobe

• hypoechoic liver (in acute phase) or echogenic liver (in chronic phase)

hepatic veno-occlusive disease

progressive occlusion of the hepatic venuoles

ligamentum teres

remnant of the fetal paraumbilical vein