🟠Liver 2 Qs

Pyogenic abscess is caused by:

bacterial infection

Most common source of infection associated with pyogenic abscesses is:

e coli

What is amoebic abscess?

a type of liver abscess caused by a parasite (entamoeba histolytica)

Pyogenic, amoebic abscess, hepatic candidiasis, and echinococcal cyst signs and symptoms include:

fever, chills, leukocytes, elevated LFTs, pain

U/S appearance of pyogenic and amoebic abscess is:

Round or ovoid hypoechoic mass with internal echoes, may contain gas (dirty shadowing if it is caused by gas- forming bacteria) or calcification; the walls tend to be irregular

The routs for the pyogenic abscess to get to the liver are:

1) Biliary tree, PVs, HA or lymphatic channels

(2) A direct extension from a contiguous infection (can result from the spread of infection from inflammatory conditions such as appendicitis, diverticulitis, cholecystitis, cholangitis, and endocarditis)

and, rarely (3) hepatic trauma

The common route for the amebic abscess to get to the liver is:

From the colon and invades the liver via the portal vein

Amebiasis is contracted by:

Ingesting the cysts in contaminated water and food

Hepatic candidiasis is caused by:

fungus candida albicans

Hepatic candidiasis is mostly occurring in what patients?

immune compromised patients

U/S appearance of hepatic candidiasis is:

hepatomegaly, Bull's eye or target lesion, halo sign, "Wheel within a wheel", calcification may be seen in later stage

Hydatid disease is also called

echinococcal cyst

The organism that causes hydatid disease is

Parasitic echinococcus granuloses (Tapeworm) associated with sheep and cattle raising countries

In addition to the liver, other organs echinococcal cyst might be present are

kidney, pancreas, lung, bine, brain

Hydatid disease is commonly seen in what regions/continents?

south america, africa, asia

The tapeworm gets to the liver how? What are sign & symptoms of hydatid disease?

From the colon and invades the liver via the portal vein. SS: leukocytosis, fever, chills, elevated LFTs, RUQ pressure, obstructive jaundice, pain, nausea

Ultrasound appearance of hydatid disease is:

Mother/daughter endo cysts, the water lily sign, honey comb cysts (fluid filled w/ septations), the cyst can be anechoic with some debris (the debris is called hydatid sand), simple cyst with or without wall calcification

What other test (in addition to U/S) is used to diagnose hydatid disease?

casoni skin test

_____ is the most common fungus causing opportunistic infection in patients with acquired immunodeficiency syndrome, patients undergoing bone marrow and organ transplantation or patients receiving chemotherapy

pneumocystis carinii

Sonographic findings of pneumocystis carinii are

Pattern ranges from diffuse, tiny, non-shadowing echogenic foci to extensive replacement of the liver parenchyma by various echogenic clumps of calcification (hepatic granulomas)

A primary malignant liver tumor in adults associated with cirrhosis, hepatocarcinogens, and hepatitis B/C; frequently invades portal and hepatic veins is called

hepatocellular carcinoma (HCC)

You are scanning a patient with known liver cirrhosis and notice a focal mass within the posterior right lobe. What laboratory test would be most helpful in determining if this mass is hepatocellular carcinoma?

increased alpha fetoprotein

Hepatocellular Carcinoma (HCC) is also called:

hepatoma

Clinically the patients with hepatoma may present with a:

history of cirrhosis, palpable mass, hepatomegaly, unexplained weight loss

Most common u/s appearance of hepatocellular carcinoma (HCC) is:

most are hypoechoic, halo sign

Hepatocellular carcinoma commonly invades which structures?

venous structures (PV, hep veins, and IVC)

The flow pattern for hepatocellular carcinoma (HCC) is:

Hypervascular, hyperemia (the flow characteristics of malignant masses is increased velocity & low resistance)

The most common primary malignant disease of the liver in children is:

hepatoblastoma

Hepatoblastoma - Most occurrences are prior to what age?

2 years

Hepatoblastoma - What does the patient present with?

abdominal enlargement, hepatomegaly, weight loss, nausea/vomiting

Hepatoblastoma – it’s associated with which genetic condition?

Beckwith Wiedemann syndrome

Hepatoblastoma - What is the sonographic appearance?

predominantly echogenic mass

Hepatoblastoma - There can be increased levels of what lab value?

serum alpha fetoprotein

Hepatoblastoma - Invades what structures?

portal vein invasion and lung metastasis

When do elevated levels of AFP occur?

Hepatocellular carcinoma (hepatoma), hepatoblastoma (childhood), hepatic angiosarcoma, and metastatic liver cancer

What are the most commonly encountered solid masses (malignant) of the liver?

metastatic tumors

Metastatic liver disease is more common than HCC. T/F?

true

The most common source of metastatic involvement is from where?

lung

Sonographic patterns of hyperechoic metastases suggest from where (what’s the primary site)?

gastrointestinal tract, pancreas, kidney

Sonographic patterns of hypoechoic, Bull's eye target or halo sign metastases suggest from where?

lymphoma, lung, breast

Sonographic patterns of calcified metastases suggest from where?

GI

U/s appearance of lymphoma of the liver is:

enlarged liver w/ multiple hypoechoic masses

Patients with hematomas (from liver trauma) have decreased what?

hematocrit

What are the 3 types/locations of trauma to the liver?

1. capsular

2. subcapsular

3. intraparenchymal

What is performed to eliminate/treat irreversible liver disease?

liver transplantation

Most common indication for transplantation in adults is:

hepatitis c

What is one of the main indications for liver transplantation in children?

biliary atresia

Liver Transplantation - What are included in the sonographic evaluation?

patency of biliary tree, hepatic artery, IVC, AO, portal vein; presence of venous collaterals; postoperative fluid collections (hematoma, biloma)

Liver Transplantation - Postoperatively, what provides the only blood supply to the biliary tree?

hepatic artery

In the postoperative period, _____ is the most serious complication of liver transplantation.

hepatic artery thrombosis

Post-operative fluid collection includes:

biloma (leaked bile), ascites, hematomas, abscess

Fluid accumulation can be identified where:

1. Ascites -Morrison’s Pouch - space between liver & R kidney –

2. Ascites between L & R sub diaphragmatic space

3. Pleural effusion

What is portal hypertension?

Increased pressure in the portal venous system

What are the portal vein, SMV and SV diameters that suggest portal hypertension?

>13 mm for PV & >10mm for SMV & SV

What is the major cause of portal hypertension?

cirrhosis

What are the signs & symptoms of portal hypertension?

Ascites, splenomegaly &varices (patients can present with sudden, painless, upper GI hemorrhage due to rupture of esophageal varices)

What are the sonographic findings, including secondary signs, of portal hypertension?

Splenomegaly, ascites, portal systemic venous collaterals, hepatofugal or portafugal flow, recanalized umbilical vein (patent lig. teres), hepatosplenomegaly (initial)

What are Portosystemic collaterals?

Venous collaterals are created, connecting the portal system to the IVC, bypassing the liver.

What is recanalized umbilical vein?

Re-opening of the umbilical vein (ligamentum teres) to act as collateral from the left portal vein to the IVC

Why is portosystemic shunt created?

To lower portal pressure (portal hypertension)

What does portosystemic shunt avoid?

The development or rupture of varices

What does portosystemic shunt reduce?

The accumulation of ascites

What does TIPS stand for?

Transjugular Intrahepatic Portal-Systemic Shunt

TIPS - Where is the shunt introduced into the patient?

A jugular access

Where is the shunt usually placed? what are the two ends connected?

Between a hepatic vein and a portal vein (Typically the RHV and RPV)

TIPS - What is used to detect early shunt compromise for prompt shunt revision?

Routine Doppler evaluation

With a widely patent TIPS, the RPV and LPV should demonstrate what kind of flow?

hepatofugal

With a recanalized umbilical vein, the flow direction of the left portal vein can be what?

hepatopedal

The velocity range for normal/patent TIPS is:

50-270 cm/sec

What are the 5 criteria for TIPS malfunction?

1. Sunt velocity of < 50 cm/s, v

2. Velocity changes compared to baseline (>+ 50 cm/s),

3. Focal velocity increase,

4. Left and right portal vein hepatopedal flow

5. MPV hepatofugal flow

Budd-Chiari syndrome is a disorder characterized by what?

hepatic vein obstruction

Budd-Chiari syndrome - What do patients present with?

Abdominal pain, massive ascites, and hepatomegaly (abdominal girth), eventually encephalopathy

Primary Budd-Chiari syndrome is caused by:

Congenital obstruction of the hepatic veins or inferior vena cava by membranous webs across the upper vena cava at or just above the entrance of the left and middle hepatic veins

Secondary Budd-Chiari syndrome is caused by:

Thrombosis in the hepatic veins or inferior vena cava

Budd-Chiari syndrome - What are some of the tumors that cause it?

Hepatocellular carcinoma, renal cell carcinoma, adrenal carcinoma

U/s appearance of Budd-Chiari syndrome is:

Acute stage, the liver appears hypoechoic (and enlarged), thrombosis in the HVs /IVC, Tumor in the HVs /IVC;

Chronic stages the liver appears hyperechoic & inhomogeneous, no flow or decrease flow

Budd-Chiari syndrome - Which lobe is usually spared?

caudate lobe

The caudate lobe is usually spared because which veins drain directly into the IVC?

emissary veins

Budd-Chiari syndrome - What happens to the caudate lobe, right, and left lobes (in chronic stage)?

caudate lobe enlarges. right and left lobes atrophy

Schistosomiasis is one of the most common parasitic infections in humans. T/F?

true

. The unique life cycle of schistosomiasis limits endemic areas to where (regions/countries of the world)?

Is found mainly in developing countries in Africa, Asia, South America, the Middle East, and the Caribbean

Schistosomiasis - Eggs reach the liver through the _____.

portal vein

What happens to the portal veins in schistosomiasis?

Causes the intrahepatic portal veins to occlude, resulting in portal hypertension, splenomegaly, varices, and ascites. Thickening and increasing echogenicity of the portal vein walls. Recanalization of paraumbilical veins in the falciform ligament can be identified by ultrasound, collateral circulation, and liver fibrosis (cirrhosis)

What are some secondary signs to portal hypertension?

Splenomegaly, ascites, variceal bleeding, portosystemic collaterals.

Signs and symptoms of schistosomiasis are:

Fever, chills, cough, and muscle aches, abdominal pain, blood in the stools, skin rash

What is portal vein gas?

Air is noted within the intrahepatic portal veins

Portal vein gas could be caused:

Procedure, infection (In infants, is commonly due to necrotizing enterocolitis) or trauma

What pathologies will have elevated/abnormal LFTs?

• pyogenic abscess

• ameobic hepatic abscess

• echinococcal cyst (also known as hydatid disease)

• metastasis

• portal vein thrombosis

What pathologies will have increased WBC (leukocytosis)?

• pyogenic abscess

• ameobic hepatic abscess

• echinococcal cyst