Abdm Ultra: 100505: Liver

Front 1

What area of the liver does the midclavicular line intersect?

Back 1

The right lobe - and in particular, the "dome", or rightmost area of the right lobe, which is somewhat dome shaped

Front 2

What is the length of the liver at its greatest extent?

Back 2

About 15 - 17 cm, but this measurement is kind of subjective and not too precise.

Front 3

What outer lining covers most but not all of the liver?

Back 3

The peritoneum

Front 4

What 5 areas of the liver are not covered by the peritoneum?

Back 4

1. At the line of attachment for the falciform ligament
2. The gallbladder fossa
3. The porta hepatis
4. The areas surrounding the IVC
5. The "bare area"

Front 5

What inner lining completely covers the liver?

Back 5

Glisson's Capsule

Front 6

Is Glisson's capsule sonographically visible?

Back 6

Yes, it is highly reflective, and changes with certain diseases. For instance, sonographically visible bumps develop on livers with cirrhosis.

Front 7

What % of the blood coming from the heart flows into the liver?

Back 7

25-30%

Front 8

Are there lymph nodes present in the liver?

Back 8

No

Front 9

What fraction of the body's lymph fluid is produced by the liver?

Back 9

1/3

Front 10

The superior surface of the liver is _(smooth/rough)___ and __(concave/convex)__.

Back 10

smooth
convex

Front 11

The inferior (visceral) surface of the liver is __(concave/convex)___.

Back 11

concave

Front 12

The anterior surface of the liver is __(thin/thick)__ and _(dull/sharp)___.

Back 12

thin
sharp

Front 13

The posterior portion of the liver is _(squared/round)___ and _(narrow/broad)___ on the right, and __(narrow/broad)__ on the left.

Back 13

round
broad
narrow

Front 14

The posterior portion of the liver is in direct contact with the _____, and forms the _____.

Back 14

diaphragm
bare area

Front 15

What two tissues are hyperechoic compared to the liver?

Back 15

1. renal sinus
2. pancreas

Front 16

What 2 tissues, along with the liver, are hypoechoic to the renal sinus and pancreas?

Back 16

1. spleen
2 renal cortex

Front 17

The liver and spleen are _______ to each other, and the renal cortex can be _____ or _____ to the liver and spleen.

Back 17

isoechoic
isoechoic
hypoechoic

Front 18

The falciform ligament:
1) attaches the liver to the ____ and _____;
2) separates _____ and _______ segments of the _____ lobe;
3) is the most _____ ligament
4) contains the ______

Back 18

1) diaphragm and anterior abdominal wall
2) lateral and medial segments of the left lobe
3) "stretchy"
4) ligamentum teres

Front 19

Which ligament attaches the posterior surface of the liver to the diaphragm?

Back 19

coronary ligament

Front 20

Which two ligaments extend from the diaphragm to the liver?

Back 20

The right and left triangular ligaments

Front 21

Which ligament attaches the undersurface of the liver to the lesser curvature of the stomach and the first portion of the duodenum?

Back 21

gastrohepatic ligament

Front 22

Which ligament surrounds the portal triad?

Back 22

hepatoduodenal ligament

Front 23

Which are the 2 ligaments which are most sonographically visible?

Back 23

Ligamentum venosum and ligamentum teres

Front 24

What is another name for the ligamentum teres?

Back 24

The round ligament

Front 25

What ligaments are normally not sonographically visible, but become more apparent if ascites is present?

Back 25

The falciform ligament and the coronary ligament

Front 26

What does the ligamentum teres result from?

Back 26

The obliterated left umbilical vein

Front 27

What is the ligamentum venosum a remnant of?

Back 27

The fetal ductus venosus

Front 28

What does the ligamentum venosum divide?

Back 28

The caudate lobe from the left lobe

Front 29

What is the ligamentum venosum a continuation of?

Back 29

The ligamentum teres

Front 30

What are the commonly accepted ways of dividing the liver, and how many lobes or segments are defined in each?

Back 30

1. "Traditional" or "pure anantomist" - 4 lobes
2. Sonography - 3 lobes
3. Couinaud's - 8 segments

(Note: Debra considers the "segmental" way, in which 4 lobes are defined, to be a subset of the "sonography" way)

Front 31

What does the ligamentum venosum run along?

Back 31

The inferior surface of the liver

Front 32

In the "traditional" or "anatomical" style of liver division, the 4 lobes are the ____, _____, _____, and _____.

Back 32

1. left
2. right
3. caudate
4. quadrate

Front 33

In the sonography style of liver division, the lobes are the ____, ____, and ____.

Back 33

1. left
2. right
3. caudate

Front 34

In sonography, what do we consider the quadrate lobe to be?

Back 34

The medial segment of the left lobe

Front 35

What fold of connective tissue divides the liver into true anatomic right and left lobes?

Back 35

The main lobar fissure, which is also referred to in some books as the "transverse fissure"

Front 36

What does the main lobar fissure join?

Back 36

The gallbladder fossa with the portal vein

Front 37

Which vein could we say divides the liver into left and right lobes?

Back 37

The middle hepatic vein, since it runs in the main lobar fissure, which divides the liver into left and right lobes.

Front 38

What runs within the main lobar fissure?

Back 38

The middle hepatic vein

Front 39

What letter can be imagined on the inferior surface of the liver, and what makes it up?

Back 39

Viewing the inferior surface of the liver as it sits in a supine patient (with the right lobe on the viewer's left), one can imagine a capital "H", with:
1. The top left arm made by the gallbladder fossa
2. The bottom left leg made by extending the top left arm to the vena cava
3. The central crossbeam made by the porta hepatis
4. The top right arm made by the ligamentum teres, which lies within the falciform ligament
5. The bottom right leg made by ligamentum venosum

Front 40

About how many times larger is the right lobe than the left?

Back 40

6x

Front 41

What do we mean when we say we are using the liver as an "acoustic window"?

Back 41

We mean that we are directing our sound beam through it, as a fairly homogenous tissue, to see a structure of interest behind it - eg., the gallbladder. Similar to how we use a full urinary bladder.

Front 42

What is an "access window"?

Back 42

A way of scanning an area at an angle to avoid some other structure - e.g., scanning the liver intracostally, or subcostally.

Front 43

What 3 fossae mark the inferior surface of the liver?

Back 43

1. porta hepatis
2. gallbladder
3. IVC

Front 44

What will you see if the gallbladder has been removed?

Back 44

A hyperechoic line in the empty gallbladder fossa.

Front 45

In what region(s) is the right lobe located?

Back 45

The right hypochondriac region

Front 46

In what region(s) is the left lobe located?

Back 46

The left hypochondriac region and the epigastric region

Front 47

What does the ligamentum teres help divide?

Back 47

The medial and lateral segments of the left lobe.

Front 48

The caudate lobe is anterior to ____, posterior to ____, and superior to _____.

Back 48

1. The IVC
2. The ligamentum venosum
3. The main portal vein

Front 49

You may occasionally see a ____ _____ on the ________ aspect of the caudate lobe, but this is a normal variant, not a pathology.

Back 49

rounded projection, also called a "rounded papillary"
anterioinferior

Front 50

Does the caudate lobe play a prominent role in several pathologic conditions?

Back 50

Yes

Front 51

On what surface of the liver does the quadrate lobe lie?

Back 51

Visceral

Front 52

What are the lateral borders of the quadrate lobe?

Back 52

The gallbladder fossa and the ligamentum teres

Front 53

What are the anterior and posterior borders of the quadrate lobe?

Back 53

posterior: porta hepatis
anterior: anterior / inferior surface of the liver

Front 54

In the segmental division scheme, what single anatomical feature most defines the segments?

Back 54

The hepatic veins.

Front 55

Are the portal veins referred to as "intersegmental" or "intrasegmental"?

Back 55

intrasegmental

Front 56

Are the hepatic veins referred to as "intersegmental" or "intrasegmental"?

Back 56

intersegmental

Front 57

Where do all 3 hepatic veins normally drain, and what is a normal variant?

Back 57

They usually drain into the IVC, but a normal variant is for any or all of them to drain directly into the right atrium.

Front 58

Per the "segmental" liver division scheme, how do the hepatic veins divide the liver?

Back 58

1. The middle hepatic vein divides the liver into left and right lobes.
2. The right hepatic vein divides the right lobe into anterior and posterior segments.
3. The left hepatic vein divides the left lobe into medial and lateral segments.

Front 59

What is the reasoning behind the 8 segments defined by Couinaud's divisions?

Back 59

The segments are divided according to blood supply and biliary drainage. Each segment has its own vascular inflow, outflow, and drainage, so it could be surgically removed without affecting another segment.

Front 60

What is a normal variant pertaining specifically to draining of the middle hepatic vein?

Back 60

Usually it drains directly into the IVC, but a normal variant is for it to drain into the left hepatic vein.

Front 61

Where are Couinaud's 8 segments defined to be?

Back 61

There are 4 in the right lobe, 3 in the left lobe, plus the caudate lobe.

Front 62

How do we go from the 4 segments defined by the hepatic veins to Couinaud's 8 segments?

Back 62

In Couinaud, 4 additional segments are defined, as follows:
1. The 2 right segments are each divided into superior and inferior portions (creating 2 additional segments)
2. The left lateral segment is divided into superior and inferior portions (creating 1 additional segment)
3. The caudate lobe is counted as its own segment (creating 1 additional segment)
4. The left medial segment (aka the quadrate lobe) is left alone (creating 0 additional segments)

Front 63

What is Reidel's lobe?

Back 63

The most common of the normal variants, in which the right lobe has a small, tongue-like projection, extending inferiorly to the iliac crest

Front 64

Is Reidel's lobe more common in males or females? By what ratio?

Back 64

Females, 4:1

Front 65

What might Reidel's lobe be misdiagnosed as?

Back 65

Hepatomegaly

Front 66

Reidel's lobe provides an acoustic window which enables an enhanced sonographic view of the ___ ____.

Back 66

right kidney

Front 67

Does the hepatic artery or the portal vein supply most of the oxygenated blood to the liver?

Back 67

The portal vein does. Even though the portal vein's blood is less oxygen-rich than the hepatic artery, because it supplies a greater volume (70-80%) of blood, it turns out that most of the liver's oxygenated blood is supplied by the portal vein.

Front 68

From what does the middle hepatic artery arise?

Back 68

The left hepatic artery

Front 69

What is the term which means "flow away from the liver"?

Back 69

Hepatofugal

Front 70

What is the term which means "flow towards the liver"?

Back 70

Hepatopetal

Front 71

How is the hepatic artery positioned with respect to the hepatic portal vein?

Back 71

Anterior and medial

Front 72

What type of wave form is present in the hepatic artery?

Back 72

A low-resistant wave form

Front 73

What does a low-resistant wave form look like on a screen?

Back 73

A series of medium-high peaks, which gradually taper down

Front 74

What does a low-resistant wave form signify?

Back 74

That blood is supplied at a relatively constant rate

Front 75

A low-resistant wave form is typically associated with what types of vessels?

Back 75

Arteries which supply organs which perform critical body functions, such as the brain or liver, or a non-critical function at a "busy" time, such as the SMA supplying blood to stomach during digestion

Front 76

What are the 5 main vital organs?

Back 76

1. Heart
2. Brain
3. Liver
4. Kidneys
5. Lungs

Front 77

What are a couple of examples of vessels which exhibit low-resistant wave forms?

Back 77

1. The hepatic artery
2. The internal carotid artery

Front 78

What does a high-resistant wave form look like on a screen?

Back 78

A series of steep, high peaks, which rapidly drop

Front 79

What does a high-resistant wave form signify?

Back 79

The blood is supplied intermittently, rather than at a steady rate

Front 80

What is an example of a vessel which exhibits high-resistant wave forms?

Back 80

The external carotid artery

Front 81

A high-resistant wave form is typically associated with what types of vessels?

Back 81

Arteries which supply structures not associated with critical body functions, such as blood flow to the face, or the SMA supplying blood to the stomach when digestion is not occurring

Front 82

Where does the left gastric artery go?

Back 82

To the lesser curvature of the stomach

Front 83

How does the main portal vein course toward the porta hepatis?

Back 83

Cephalad and to the right

Front 84

What 2 minor veins are also part of the portal system?

Back 84

1. Left gastric vein
2. Left gastroepiploic vein

(Be able to recognize and label these on a diagram in a matching-type question. See slide #69 of liver slideset)

Front 85

What aspect of the IVC does the right hepatic vein normally enter?

Back 85

The right lateral aspect

Front 86

What aspect of the IVC does the middle hepatic vein normally enter?

Back 86

The anterior surface

Front 87

What aspect of the IVC does the left hepatic vein normally enter?

Back 87

The left anterior surface

Front 88

What are the largest and smallest hepatic veins?

Back 88

Largest: right
Smallest: left

Front 89

Hepatic and portal blood mix in ______.

Back 89

Sinusoids

Front 90

Where does the caudate lobe drain?

Back 90

Directly into the IVC

Front 91

Hepatic vein flow is ______ due to proximity to the heart.

Back 91

pulsatile

Front 92

The liver has over ____ different metabolic functions.

Back 92

500

Front 93

What are the 8 major functions of the liver?

Back 93

1. Carbohydrate metabolism
2. Protein metabolism
3. Fat metabolism
4. Detoxification, especially of ammonia
5. Filtration of bacteria
6. Digestion (through bile formation and secretion)
7. Storage of vitamins and minerals
8. Heat production

Front 94

What are 4 ways of distinguishing hepatic from portal veins?

Back 94

1. Hepatic veins are largest near the IVC, while portal veins are largest near the porta hepatis.
2. Branches of hepatic veins point to the diaphragm, while branches of portal veins point to the porta hepatis.
3. Hepatic veins exhibit a multiphasic Doppler signal, while portal veins exhibit a continuous Doppler signal.
4. The walls of the hepatic veins are less echogenic than the walls of the portal veins.

Front 95

What are the 3 main cell types in the liver parenchyma?

Back 95

1. hepatocytes
2. biliary epithelial cells
3. kupffer cells

Front 96

What is the function of the hepatocytes?

Back 96

They're responsible for metabolic functions

Front 97

What is the function of the biliary epithelial cells?

Back 97

They line the biliary system

Front 98

What is the function of the kupffer cells?

Back 98

They're phagocytes, and are part of the reticuloendothelial system

Front 99

What kind of flow exists in the portal veins?

Back 99

Continuous, but non-pulsatile flow (as opposed to the continuous, pulsatile flow in the hepatic veins, due to their proximity to the heart)

Front 100

Which hepatic artery supplies the caudate lobe?

Back 100

Middle hepatic

Front 101

How much does an average liver weigh?

Back 101

1200 - 1600 grams (3 lbs)

Front 102

Do veins exhibit high- or low- resistant flow?

Back 102

Neither - veins don't have "resistance' - instead they have continuous flow, phasic flow (affected by respiration), or pulsatile flow (affected by heart beating)

Front 103

What type of vessel view should always be used to take a Doppler sample?

Back 103

A longitudinal (lengthened out) view of the vessel

Front 104

____ is an enzyme found in tissues with high metabolic activity (e.g., heart, liver, skeletal muscle, kidney, brain, pancreas), and which is released into blood with cell death or injury.

Back 104

Aspartate Aminotransferase (AST)

Front 105

What is the old name for AST?

Back 105

SGOT

Front 106

____ is an enzyme with with high concentrations in the liver, and lower concentrations in the heart, muscle, and kidney, and which specifically indicates liver cell damage?

Back 106

Alanine Aminotransferase (ALT)

Front 107

What is the old name for ALT?

Back 107

SGPT

Front 108

_____ is an enzyme found throughout the body, which increases with cellular injury or death, but which in non-specific, and usually is used with myocardial infarction or pulmonary infarction?

Back 108

Lactic Acid Dehydrogenase (LDH)

Front 109

___ is an enzyme originating in the bone, liver, or placenta, which is a tumor or space-occupying lesion marker for liver disease, and which rises with biliary obstruction.

Back 109

Alkaline Phosphatase (ALP)

Front 110

_____ results from the breakdown of hemoglobin in the RBCs, is removed in the liver and excreted in the bile, gives bile its greenish-yellowish color, and increases with increased destruction of RBCs, or failure to excrete the normal amounts produced.

Back 110

Bilirubin

Front 111

What is a visible symptom of biliary obstruction?

Back 111

Jaundice

Front 112

What types of bilirubin increases do we measure?

Back 112

1. Indirect (unconjugated)
2. Direct (conjugated)
3. Total (sum of indirect and direct)

Front 113

_____ is a test for the presence of a protein produced by the liver which influences clotting time, and is dependent upon adequate intake of Vitamin K?

Back 113

Prothrombin time

Front 114

____ is a protein synthesized by the liver, which is responsible for maintaining normal distribution of water, and which decreases with hepatocellular damage.

Back 114

Albumin

Front 115

____ is a glycoprotein formed in the yolk sac and fetal liver, normally present after birth only in trace amounts, and which, if present in non-pregnant adults, is a strong marker for hepatocellular carcinoma.

Back 115

Alpha-Fetoprotein (AFP)

Front 116

What is situs inversus?

Back 116

When your liver's on the left side, and your spleen is on the right side