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207 Cards in this Set
- Front
- Back
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What is the length of the liver?
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15 cm measured in the midclavicular line
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How much does the liver weigh in an adult?
|
1500 g
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What 3 types of cells make up the liver?
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Biliary epithelial cells
Hepatocytes Kupffer cells (macrophages) |
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What is the name of the area in the posteriorsuperior region of the liver, where it contacts the diaphragm directly and Glisson's capsule is missing?
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Bare area
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What is the name of the fibrous layer of connective tissue covering the liver?
|
Glisson's capsule
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What are the 3 lobes of the liver?
|
Right
Left Caudate |
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What 3 structures separate the right and left lobes of the liver?
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Middle hepatic vein (courses within the MLF)
Main lobar fissure (MLF) / Interlobar fissure Gallbladder (sometimes) (Sanders 4) |
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Where does the MLF course?
|
From the neck of the gallbladder to the porta hepatis
(Sanders 4) |
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Which lobe of the liver is the largest?
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Right
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What separates the anterior and posterior segments of the right lobe of the liver?
|
Right hepatic vein
(Sanders 4) |
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What is the name of an enlarged right lobe of the liver in women that is a common variant?
|
Riedel's lobe
It may extend to the level of the iliac crest |
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The left lobe of the liver has medial and lateral segments. What was the former name of the medial lobe?
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Quadrate lobe
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What 3 structures separate the medial and lateral segments of the left lobe of the liver?
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Ligamentum teres (forms the free border of the falciform ligament) / falciform ligament
Umbilical segment of the left portal vein Left hepatic vein (Middleton 50C-F) (Netter 287) (Sanders 4) |
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The ligamentum teres used to be called something else in the fetus.
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Obliterated umbilical vein
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What did the falciform ligament do in the fetus?
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It runs from the umbilicus to the anterior aspect of the umbilical segment of the left portal vein.
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What is the smallest lobe of the liver?
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Caudate lobe
(Netter 289) |
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Where does the caudate lobe lie?
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Posteriorsuperior surface of the right lobe of the liver
Directly anterior to the IVC Adjacent to the fissure for the ductus venosus (Netter 287) |
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What structure boarders the caudate lobe posteriorly?
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Inferior Vena Cava
(Netter 289) |
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What structure separates the caudate lobe from the lateral segment of the left lobe?
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Fissure for the ligamentum venosum
It travels to the posterior aspect of the umbilical segment of the left portal vein (Netter 287) (Middleton 50B&E) |
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What did the ligamentum venosum do in the fetus?
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Ductus venosus
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What is unique about the caudate lobe's vascular system?
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It has its own perfusion and drainage system
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From what 2 vessels is the blood supply to the liver derived?
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Hepatic artery
Portal vein |
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What 3 structures comprise the portal triad?
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Hepatic artery
Portal vein Common bile duct (Netter 290) |
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What structure surrounds the portal triad, accounting for its echogenicity?
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Glisson's capsule
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From where does the right hepatic artery originate? Does it run anterior or posterior to the portal vein?
|
The common hepatic artery arises from the celiac trunk. After the gastroduodenal artery branches off, it is called the proper hepatic artery. At the porta hepatis, the proper hepatic artery divides into the R and L hepatic arteries.
The hepatic artery runs anterior to the portal vein (Middleton 52) |
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What percentage of oxygenated blood does the hepatic artery supply to the liver?
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20-30%
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What percentage of (partially) oxygenated blood does the portal vein supply to the liver?
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70-80%
Nutrients are also supplied |
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What 4 characteristics distinguish portal veins from hepatic veins?
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Portal veins branch toward the diaphragm
Portal veins have echogenic, well-defined boarders Portal veins run with hepatic arteries and bile ducts Portal veins have hepatopetal flow (normally) They have a different waveform on Doppler |
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Why do portal veins and bile ducts have echogenic borders?
|
Glisson's capsule surrounds them
The fibrous tissue is echogenic Netter 290 |
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What 2 veins join to form the main portal vein?
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The splenic vein (SV) and the superior mesenteric vein (SMV)
(Netter 309) |
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What happens to the portal vein at the porta hepatis?
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It divides into the right and left portal vein
(Netter 290) |
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What branches of the right portal vein supply the right anterior and right posterior lobes of the liver?
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Right portal vein anterior and posterior branches
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Where does the hepatic and portal blood mix?
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Sinusoids
(Netter 290) |
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What is at the center of the sinusoids that drains into the hepatic veins?
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Hepatic venules
(Netter 290) |
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What is located at the periphery of the sinusoid?
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Portal triad (hepatic artery, portal vein, and bile duct)
(Netter 290) |
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How many hepatic veins are there?
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3 - Right, Middle, and Left
|
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What 3 characteristics anatomically define hepatic veins?
|
Increase in diameter as they approach the diaphragm
Branch towards the feet Do not have echogenic walls |
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What are 4 functions of the liver?
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Excretory
Metabolic Storage Synthetic |
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How much bile does the liver secrete daily?
|
1-2 L
|
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The ___ vein runs between the right anterior and posterior segments.
The ___ vein runs between the left medial and lateral segments. The ___ vein runs between the left medial and right anterior segments. |
Right hepatic vein
Left hepatic vein Middle hepatic vein (Middleton 50A) |
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Which 2 hepatic veins usually join just prior to entering the IVC?
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Middle and left hepatic vein
This vein and the right hepatic vein join the IVC at the hepatic confluence (Middleton 50 A) |
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Small hepatic veins from which 2 lobes may join the IVC individually below the level where the 3 hepatic veins join?
|
Caudate lobe
Right posterior lobe (Middleton 51) |
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Hepatic veins (separate/run through) hepatic segments and lobes.
Portal veins (separate/run through) hepatic segments. |
Hepatic veins separate segments/lobes
Portal veins run through segments/lobes |
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Portal veins are named according to the segments of liver that they supply. What is the one exception?
|
Umbilical segment of the left portal vein. It runs between the left medial and left lateral segments.
(Middleton 50B) |
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What is the interlobar fissure?
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A shallow indentation on the posterior aspect of the liver that separates the right and left lobes. It is the same as the MLF, and identifies the gallbladder fossa.
(Middleton 50C) |
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What are diaphragmatic fissures?
|
Triangular, echogenic fissures arising from the diaphragm and extending into the liver. They are common variations caused by hypertrophied diaphragmatic muscle bundles.
Middleton 53 |
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What are some indirect signs of hepatomegaly?
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Extension of the right lobe below the lower pole of the kidney
Rounding of the inferior tip of the liver Extension of the left lobe into the left upper quadrant above the spleen |
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How should the echogenicity of the liver compare to the kidney, spleen, and pancreas?
|
slightly more echogenic than the right kidney
less echogenic than the spleen equal to or less than the pancreas |
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Do cysts in the liver usually cause symptoms or changes in LFTs?
|
No
If PCKD is severe dominant type, it could cause elevation of LFTs. |
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Overall liver echogenicity may be increased/decreased if polycystic liver disease is present.
|
Increased from multiple tiny cycsts that cannot be resolved as cycts and are seen as echos
|
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What are the features of simple cycts
|
smooth walls, anechoic contents, good through transmission, well-defined back wall, posterior enhancement
|
|
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What is the most common focal liver lesion?
|
Simple hepatic cyst
(Middleton 54 Fig 3-5) |
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|
What is peripheral puckering?
|
A partial septation of a cyst commonly seen
(Middleton 54 Fig 3-5C) |
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|
What are the characteristics of complex cysts?
|
internal echoes, thick wall, septations that are numerous or thick, solid elements, calcification
|
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What are some uncommon causes of complex liver cysts?
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hematomas, abscesses, bilomas, echinococcus, cystic metastases, hemorrhagic or necrotic tumors
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How often is the liver involved in autosomal dominant polycystic disease?
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40-50% of the time.
The patient is usually asymptomatic and LFTs are usually normal unless fibrosis is present (rare) (Middleton 54 Fig 3-7) Mass effect of numerous cysts or cyst hemorrhage may cause symptoms. |
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What does "replaced" mean?
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arising from an anomalous origin (e.g. replaced right hepatic artery arises from the SMA in 20% of pts and from the left gastric artery in 20% or pts)
Middleton 52 Fig 3-3 |
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What does "anomalous" mean?
|
accessory or additional
|
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What causes echinococcal cysts?
|
Tapeworms (Echinococcus granulosus)
Commonly seen in sheep- and cattle-raising areas |
|
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What are common lab values abnormalities in echinococcal disease?
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Elevated alk phos and WBC
|
|
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What are symptoms of echinococcal disease?
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pain, fever, jaundice, anaphylactic shock (if cyst ruptures)
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What is the sonographic appearance of an echinococcal cyst?
|
hydatid cyst in the right lobe
"cyst within a cyst", or daughter cyst, or water lily sign results from the collapse of the germinal layer with a resultant membrane within the cyst may appear like a mass with internal echos or calcify as it ages (Middleton 67 Fig 3-23) |
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What are sonographic findings of a pyogenic abscess?
What is the differential diagnosis? |
Variable
Complex, heterogeneous fluid collection with good through transmission and an irregular, thick wall DDx: hematoma, hemorrhagic cyst, necrotic or hemorrhagic tumor, solid mass (Middleton 65 Fig 3-20) |
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What commonly causes amebic abscesses?
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protozoa Entamoema
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What are the clinical features of an amebic abscess?
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tropical region
poor sanitation diarrhea, abdominal pain elevated LFTs |
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What are the sonographic findings of an amebic abscess?
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round, hypoechoic or hyperechoic mass when compared to the liver
indistinguishable from a pyogenic abscess |
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What are the common bacteria that cause pyogenic abscesses?
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E Coli and S aureaus
Pyogenic abscesses usually develop from intestinal sources (appy or diverticulitis), direct extension from cholecystitis or cholangitis, or from endocarditis |
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What are the lab findings that might accompany a pyogenic abscess?
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elevated alk phos and WBC count
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What type of patients are susceptible to fungal abscesses?
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Immunocompromised
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What pathogen usually causes liver fungal abscesses?
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Candida albicans
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What are the sonographic findings of a fungal abscess?
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multiple tiny target lesions with hypoechoic center if the lesion is in the early stages, echogenic or calcified center if in the healing stages
"wheel within a wheel" appearance (Middleton 66 Fig 3-21) |
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What is the sonographic appearance of Pneumocystis carinii?
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multiple, small, diffuse, nonshadowing, hyperechoic granulomas
shotgun (Middleton 66 Fig 3-22) |
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In what region of the world is schistosomiasis prevalent?
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Middle East
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What causes schistosomiasis?
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parasite
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Where does schistosomiasis affect the liver the most?
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porta hepatis
it causes a granulomatous periportal fibrosis and increased echogenicity |
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What is a complication of schistosomiasis?
|
portal vein thrombosis
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What are clinical scenarios when one might evaluate for a hematoma?
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trauma
postop hematocrit drop |
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What is the sonographic appearance of an intrahepatic hematoma?
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hyperechoic or hypoechoic, depending on the time since injury
irregular may be difficult to distinguish from liver tissue |
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What is the sonographic appearance of a subcapsular hematoma?
|
curvilinear shape
displace the liver centrally or inferiorly hypoechoic or echogenic, depending on age |
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Where is aspartate aminotransferase (AST) found?
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liver, muscles, tissues with high metabolic rates
increases do not necessarily mean liver disease |
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Match these:
AST ALT SGOT SGPT |
AST = SGOT
ALT = SGPT |
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Name some liver abnormalities that cause an increase in AST
|
hepatitis
cirrhosis hepatic necrosis liver injury metastasis to the liver fatty liver changes |
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Name some things that elevate AST that are not associated with the liver
|
mononucleosis
myocardial infraction |
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Where is alanine aminotransferase (ALT) formed?
|
Hepatocytes
ALT is more specific to the liver than AST. L is for "liver" |
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What causes an elevation in ALT
|
all forms of hepatitis
obstructive jaundice hepatocellular disease shock and drug toxicity that cause hepatocyte death |
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Where is alkaline phosphatase formed? (5)
|
liver
kidneys bones intestines placenta |
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Name 3 diseases of the bile duct that can cause elevation of alk phos, AST, and ALT
|
bile duct obstruction
primary biliary cirrhosis sclerosing cholangitis |
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Name 3 causes of nonbiliary increased alk phos
|
abscesses
liver carcinoma cirrhosis |
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Is LDH specific to the liver?
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No. It is formed all over the body, and primarily used for the detection of pulmonary and myocardial infarction.
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Name 4 hepatic causes of elevated LDH
|
hepatitis
cirrhosis hepatic congestion obstructive jaundice |
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Name 1 non-hepatic cause of elevated LDH
|
mononucleosis
and many others |
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What organ synthesizes albumin, which maintains osmotic pressure in the blood?
|
liver
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What can cause decreased albumin levels? (3)
|
liver dysfunction
malnutrition renal disease |
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Name a Vit K dependent clotting factor produced in the liver
|
prothrombin
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What is a way to equalize PT measurements from one lab to another
|
International Normalized Ratio (INR)
|
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What can shorten prothrombin time (PT)?
|
extrahepatic duct obstruction
gallbladder carcinoma cholecystitis |
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What INR cut-off is usually used for a large-bore biopsy? A skinny-needle biopsy?
|
1.5
2.0 |
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Gamma-globulins are extremely sensitive indicators of liver dysfunction, but elevations can also be seen in normal patients
T/F |
True
|
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The breakdown of this substance by Kuppfer cells results in bilirubin formation
|
RBCs
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What causes an elevation in unconjugated (indirect) bilirubin?
|
isolated acute hepatocellular disease
hemolysis |
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What causes an elevation of conjugated (direct) bilirubin?
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biliary duct obstruction
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How can you distinguish a vascular lesion from a cyst in the liver?
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Doppler
(Middleton 54 Fig 3-6) |
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Fatty infiltration is a benign, reversible disorder in which triglycerides are deposited in hepatocytes, predominantly within the ___ lobe of the liver.
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right
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What are the causes of fatty liver?
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ETOH
obesity pregnancy severe hepatitis starvation glycogen storage disease corticosteroid therapy DM massive tetracycline therapy cholesterol-lowering drugs toxins (carbon tetrachloride) total parentaeral nutrition (TPN) chemotherapy |
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What are the clinical features of fatty liver
|
hepatomegaly
RUQ discomfort patient may be asymptomatic |
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What are common lab abnormalities seen in fatty liver disease?
|
normal labs
or increased AST, ALT, and conjugated bilirubin |
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What are the sonographic findings of fatty liver
|
enlarged liver
more echogenic (markedly more echogenic than the kidneys and more echogenic than the pancreas/spleen) vessel boarders cannot be seen due to increased beam attenuation increased attenuation may prevent visualization of the diaphragm or kidneys finer echotexture (Middleton 69) |
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Fatty liver can be focal or diffuse, and the appearance can change over time
T/F |
True
|
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What is a common area spared by fatty infiltration?
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Near the portal bifurcation or gallbladder
When spared, it appears more hypoechoic than the rest of the liver (Middleton 69 E/F) |
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Spared, hypoechoic areas of fatty infiltration can be mistaken for hypoechoic lesions. What can distinguish them?
|
Focal sparing is not usually spherical
It is located anterior to the portal vein, portal bifurcation, or near the gallbladder |
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Cirrhosis is reversible/irreversible
|
Irreversible
|
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What are the long-term complications of replacing hepatocytes with fibrosis, as seen in cirrhosis? (2)
|
liver failure
portal hypertension |
|
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What are the causes of cirrhosis?
|
ETOH
hepatitis B & C poor nutrition biliary obstruction drugs idiopathic |
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What are the clinical features of cirrhosis?
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malaise
weight loss abdominal pain with distension skin changes jaundice portal hypertension splenomegaly hypoalbuminemia edema ascites |
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What are the sonographic findings of cirrhosis?
|
early - hepatomegaly, initial redistribution of liver volume to caudate and left lateral lobe
later - fatty infiltration with increased attenuation final - increased inhomogenious echogenicity from fibrotic tissue and hypoechoic regeneration islands; lobulated contour of liver and vein lumens; poor visualization of vessels end stage - portal hypertension (Middleton 70) |
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How can you distinguish ETOH from viral hepatitis-induced cirrhosis?
|
ETOH = micronodular (<1cm)
Hep B&C = macronodular (1-5cm) |
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What is hepatopetal flow?
|
Normal portal vein flow toward the liver.
|
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What is hepatofugal flow
|
Reversed flow through the portal vein
|
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What are causes of portal hypertension?
|
cirrhosis
portal vein thrombosis hepatocellular disease Budd-Chiari syndrome metastases trauma (rare) |
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Give an example of a collateral forming in the paraumbilical veins
|
The umbilical vein in the ligamentum teres may reopen
|
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Describe cavernous transformation of the porta hepatis
|
Collateral veins form near the porta hepatis if the portal vein is thrombosed
|
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Describe the physics behind portal hypertension
|
Scarring in the sinusoids causes increased resistance to portal venous flow. It is initially overcome by increased portal venous pressure. As resistence increases, hepatic artery flow increases. Eventually, the liver resistance is overwhelming, and flow diverts to collaterals and reverses through the portal vein (hepatofugal flow)
|
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Where does hepatofugal flow occur naturally?
|
hepatic veins
Middleton 71 Fig 3-29 |
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What are the B-mode sonographic findings of portal hypertension?
|
Enlarged portal vein (nonspecific, but >13mm commonly used)
Enlarged hepatic arteries Portosystemic collaterals (umbilical vein and coronary vein) Splenomegaly Ascites Portal vein thrombosis is a common complication |
|
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Where can collaterals be found in the setting of portal hypertension?
|
around the gastroesophageal junction (fundus of the stomach)
bed of the pancreas porta hepatis area hilum of the spleen recanalized ligamentum teres (paraumbilical vein) coronary vein |
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What are the sonographic findings of a recanalized ligamentum teres (paraumbilical vein)
|
Transverse - echogenic ligamentum teres with hypoechoic, round vein opened in the middle. Doppler shows hepatofugal flow.
Longitudinal view - Flow from the umbilical segment of the left portal vein to the umbilical vein collateral down the middle of the ligamentum teres Middleton (72) |
|
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What does the normal portal vein waveform look like?
|
Minimal pulsatility from the cardiac cycle
20-30cm/sec Hepatopetal flow (Middleton 71 Fig 3-28) |
|
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What does the normal hepatic vein waveform look like?
|
Triphasic, with 2 antegrade and 1 retrugrade pulse.
A = atrial contraction and flow away from the heart S = ventricular systole, rapid atrial filling D = ventricular diastole, tricuspid valve opens and atrial filling continues Obtained during END EXPIRATION, as deep inspiration can cause blunting of hepatic vein pulsatility. HEPATOFUGAL (away from the liver) flow (Middleton 71 Fig 3-29) |
|
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What does normal hepatic artery flow usually look like?
|
Low-resistance flow (monophasic) with well-maintained flow throughout diastole.
(Penny 111 Fig 4-18C) |
|
|
What are the 3 categories of portal hypertension?
|
Intrahepatic
Extrahepatic Hyperdynamic |
|
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Describe the location of the coronary vein, a collateral arising from the splenic vein
|
Typically seen over the celiac bifurcation. Abnormal flow would be directed away from the splenic vein.
Abnormal = Away (Middleton 73 Fig 3-31, 3-32) |
|
|
What Doppler findings are present with portal hypertension?
|
Normally, the HA and PV flow in the same direction.
With PV flow reversal, the artery and vein will flow in opposite directions. The artery into the liver and the portal vein away from the liver. (Middleton 74 Fig 3-33) |
|
|
Describe what a portal vein thrombosis looks like
|
a clot in the portal vein
(Middleton 75 Fig 3-35) |
|
|
Name some causes of intrahepatic portal hypertension
|
cirrhosis
veno-oclussive disease (clot, mass, external compression) schistosomiasis lymphoma sarcoidosis |
|
|
Name some causes of extrahepatic portal hypertension
|
pre-hepatic:
portal vein thrombosis portal vein compression post-hepatic: hepatic vein compression/thrombosis IVC obstruction/thrombosis constrictive pericarditis |
|
|
Name some causes of hyperdynamic arterioportal fistula
|
post-traumatic
biopsy congenital atherosclerotic tumor |
|
|
What are the sonographic findings of hepatitis?
|
Findings, usually not present, are subtle if present at all, and usually only seen with acute hepatitis.
Decrease in liver echogenicity causes an apparent increase in portal triad echogenicity "starry night" Thickening of the GB wall or GB contraction Hepatosplenomegaly (Middleton 68 Fig 3-25) |
|
|
What is Budd-Chiari syndrome
|
Hepatic vein thrombosis with or without IVC involvement leads to liver failure
|
|
|
What are causes of Budd-Chiari syndrome?
|
polycythemia rubra vera
chronic leukemia paroxysmal nocturnal hemoglobinuria trauma pregnancy congenital membranes OCP use |
|
|
What are the clinical features of Budd-Chiari syndrome?
|
ascites is always present
HSM RUQ pain |
|
|
What are the sonograpic findings of Budd-Chiari
|
HSM
ascites B-mode shows apparent absence of veins, thrombus in the vein, intrahepatic collaterals, and variable vein size Doppler shows flow reversal, loss of normal pulsatility, or lack of flow in a hepatic vein sparing of the caudate lobe 2/2 independent blood supply (it may become enlarged from collaterals forming) enlarged caudate lobe (if it takes over the function of the non-functioning liver areas) infarcted liver areas that become fibrotic and echogenic (rare) (Middleton 79) |
|
|
Name 3 common benign liver masses
|
Hemangioma
Adenoma Focal nodular hyperplasia |
|
|
What is the most common benign liver tumor?
|
Cavernous hemangioma
|
|
|
Which sex gets cavernous hemangiomas more commonly?
|
Women
|
|
|
In what lobe of the liver are carvernous hemangiomas most commonly found?
|
Right lobe
|
|
|
What causes the hyperechoic appearance of cavernous hemangiomas?
|
The numerous interfaces of the vessel walls
(Middleton 55) |
|
|
What will Doppler show if placed over a cavernous hemangioma?
|
Increased flow around the periphery, but not within the hemangioma
(Middleton 55 Fig 3-8H) |
|
|
In what sex are liver adenomas more common?
|
Women
|
|
|
Why are adenomas often surgically removed?
|
They have a propensity to bleed
Although rare, they can progress to hepatocellular carcinoma |
|
|
To what drug are adenomas linked?
|
OCPs
men taking anabolic steroids |
|
|
Although adenomas are usually asymptomatic, what can cause them to be painful?
|
If they bleed or rupture
|
|
|
What is the sonographic appearance of a liver adenoma?
|
Variable.
Hypoechoic or heterogenious. It is difficult to distinguish from other liver lesions (Middleton 59 Fig 3-12) |
|
|
Is focal nodular hyperplasia common or rare?
|
Rare, and more common in women
|
|
|
What are the sonographic findings of focal nodular hyperplasia?
|
well defined boarder
central scar "spoke wheel" arterial flow (Middleton 58) |
|
|
Name 3 common malignancies found in the liver
|
Hepatocellular carcinoma
Hepatoblastoma Metastases |
|
|
In what sex is hepatocellular carcinoma more common?
Hemangioma? FNH? Adenoma? |
Men
Women Women Women |
|
|
In what countries is hepatocellular carcinoma (hepatoma) more common?
|
Far east, Greece, Africa 2/2 chronic Hepatitis B and aflatoxin fungus
|
|
|
In the US, what are the 2 most common causes of cirrhosis?
|
ETOH (#1)
hepatitis |
|
|
What are the sonographic findings of hepatocellular carcinoma?
|
solitary or multiple nodules or diffuse infiltration
target lesion with rapidly proliferating hypoechoic halo (Middleton 59 Fig 3-13) |
|
|
What is the most common liver mass in infants?
|
Hepatoblastoma
|
|
|
What blood test will indicate hepatoblastoma in a child?
|
Increased alpha-fetoprotein
|
|
|
What is the sonographic appearance of a hepatoblastoma (a fetal abnormality)?
|
Solitary, highly vascular mass
Possible calcifications |
|
|
The liver is the most common site for metastastasis in the body with over 50% of people dying of cancer having liver mets at autopsy.
What are common primary sites for liver mets? (4) |
Lung
Breast Pancreas GI tract |
|
|
What are the sonographic findings of liver metastasis?
|
Target lesion
Huge range of appearances (Middleton 59-64) |
|
|
Do hemangiomas bleed very often?
|
No
|
|
|
Typical appearance of a hemangioma?
|
<3cm
sharp, smooth margins round or slightly lobulated maybe reverse target appearance with hyperechoic periphery and hypoechoic center little internal flow on Doppler Middleton 55 |
|
|
If you put Doppler on a hemangioma, what will you see?
|
nothing. although a vascular lesion, the blood flow is usually to slow to be detected
|
|
|
T/F
Hemangiomas are usually stable over time, but are the only liver lesion that can change rapidly (30sec) |
true
Middleton 56 Fig 3-10 |
|
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What historical facts would make you likely to w/u a hyperechoic mass in the liver with MRI, CT, or RBC tagged scintigraphy?
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hx of liver disease or malignancy
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If noninvasive tests (MRI, CT, RBC scan) do not establish the diagnosis of hemangioma, can you do a biopsy?
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Yes. Do a core biopsy. Risk of bleeding is low.
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If you put doppler on a suspected hemangioma and it lights up, what is the DDx?
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neoplasm
vascular lesion Hemangiomas do NOT usually light up on Doppler |
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What is the composition of FNH?
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Kupffer cells, hepatocytes, and biliary structures
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Is the central stellate scar of FNH easily seen on US?
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No it is better seen on CT or MRI. However, the spoke-wheel vascular pattern is well displayed with Doppler US.
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If you want to further evaluate a suspected FNH lesion, what test would you order?
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hepatic scintigraphy
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Is FNH related to OCP use?
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No. It may promote a lesion's growth, but the indicence is not higher with OCP's.
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What is the sonographic appearance of FNH?
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isoechoic to liver parenchyma
central, stellate scar (not usually seen with US) spoke-wheel pattern of vascularity Middleton 58 |
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Fibrolamellar cancer most closely simulates FNH. What would make you w/u this lesion further?
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LAD, metastasis, lesional calcification or necrosis
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What are the top 2 causes of target lesions in the liver?
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#1 = metastasis
#2 = hepatocellular cancer Middleton 59 Fig 3-13 |
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What are less common causes of target lesions in the liver?
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lymphoma
FNH fungal microabscess adenoma |
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What are 3 common and 3 uncommon causes of diffuse hepatic inhomogeneity?
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3 common
cirrhosis, metastasis, fatty infiltration 3 uncommon hepatocellular cancer, hepatic fibrosis, lymphoma |
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What is the most common primary malignancy of the liver?
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hepatocellular carcinoma (HCC) aka hepatoma
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What is the progression from cirrhosis to HCC?
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regenerative nodule > adenomatous hyperplasia > atypical adenomatous hyperplasia > HCC
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T/F HCC has a strong tendency to invade the hepatic vasculature?
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True, especially portal vein
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T/F
US is used to screen Asian and sub-Saharan Africa for HCC. The incidence is high there due to high incidence of aflatoxin ingestion and hepatitis. |
True
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T/F
In America, ETOH cirrhosis is the most important predisposing condition for HCC. |
True
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Fibrolamellar HCC is an unusual variant of HCC that occurs in younger patients without coexistent liver disease and has a much better prognosis than HCC. What lesion has a similar sonographic appearance?
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FNH
Middleton 64 Fig 3-18 |
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What is the typical appearance of hepatic lymphoma?
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target lesions or hypoechoic lesions
Middleton 64 Fig 3-19 |
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What is the DDx of a liver abscess?
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hematoma, hemorrhagic cyst, necrotic or hemorrhagic tumor
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What are 2 common parasitic infections of the liver?
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schistosomiasis and echinococcus
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What is the sonographic appearance of a hepatic laceration?
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initially poorly demarcated decreased echogenicity, more hyperechoic when clot forms, and finally may become hypoechoic (liquefactive changes)
Middleton 67 Fig 3-24 |
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What is the upper limit of normal for portal vein diameter?
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13mm AP
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What are the sonographic findings of portal hypertension?
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enlargement of the portal vein >13mm
splenomegaly ascites portosystemic collaterals enlarged hepatic arteries hepatofugal flow Middleton 74 Fig 3-33 |
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upper limit of normal for the umbilical vein?
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3mm
Middleton 72 Fig 3-30 |
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upper limit of normal for coronary vein?
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6mm
Middleton 73 Fig 3-31/32 |
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Thrombus in the portal vein appears ___
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hyperechoic, isoechoic, hypoechoic, and rarely anechoic
Use Doppler! Middleton 75 Fig 3-35 |
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If you suspect portal vein thrombosis, and no thrombus is seen on gray scale, and Doppler does not detect flow...what should you do?
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Have the patient increase portal vein flow by eating a meal. It will convert slow undetectable flow to faster flow that is detectable
Middleton 75 Fig 3-36 |
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What are some false-negative exams for Doppler portal vein thrombosis? (2)
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confusing a periportal collateral with the portal vein
blooming artifact can obscure a flow differential Middleton 75-76 Fig 3-37/38 |
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Are liver infarcts common in the setting of total portal vein thrombosis?
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No, because the hepatic artery can still supply blood
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If you see blood flow in a portal vein thrombus, what should you suspect?
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invasion by HCC
Middleton 77 Fig 3-40 |
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What is the sonographic appearance of cavernous transformation of the porta hepatis?
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multiple cystic and tortuous tubular-appearing structures without a portal vein
Middleton 78 Fig 3-41 |
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What is passive hepatic congestion?
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heart failure that causes hepatomegaly, enlarged hepatic veins, enlarged IVC, and increased pulsatility of the portal vein
Middleton 80 Fig 3-44 |
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What are the 2 most common complications from liver transplant that US can be used to evaluate?
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biliary obstruction and bile leaks
vascular thrombosis and stenosis Middleton 81 Fig 3-45 |
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What vessels are involved in a TIPS (portosystemic shunt)?
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PV or SMV to IVC
SV to left RV |
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What does TIPS stand for?
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transjugular intrahepatic portosystemic shunt
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What is considered to be normal flow rate through a TIPS shunt?
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90-190 cm/sec
Middleton 81 Fig 3-46 |
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What are the sonographic signs of TIPS failure?
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thrombosis or luminal narrowing in the stent
flow in the portal veins away from the stent instead of into the stent elevated velocities across the stent (color aliasing) low portal vein velocity a temporal increase or decrease in max and min stent velocities on serial exams reversal of flow in the draining hepatic vein Middleton 82/3 Fig 3-47/48/49 |
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What is a common area more affected by fatty infiltration?
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adjacent to the ligamentum teres or portal bifurcation
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