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Penninck US > Ch 6 Liver > Flashcards

Ch 6 Liver Flashcards

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1
Q

Name the liver lobes/sublobes/processes

A

left (med, lat), quadrate, right (med, lat), caudate (processes: caudate, papillary)

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2
Q

Which of the 4 lobes is the largest?

A

left - 1/3 to 1/2 of entire liver

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3
Q

which lobes make contact with the gallbladder ?

A

left: left medial
centrally: quadrate
right: right medial

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4
Q

which part of the liver extends the most caudally, and where is it?

A

caudate process (of caudate lobe), on the right side (to the R kidney)

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5
Q

In ________, the liver normally extends to the costal arch. It may also extend beyond that point in ____________.

A
  • small-breed dogs, and cats
  • puppies
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6
Q

normal GB and CBD wall thickness in cats and dogs? (Hittmair et al. 2001)

A

<1mm

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7
Q

CBD normal lumen in cats and dogs?

A

4mm in cats (Léveillé et al. 1996)
3mm in dogs (chapter authors, Hecht amd Penninck)

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8
Q

What percentage of the afferent hepatic vasculature is portal?

A

80% portal
20% hepatic arteries

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9
Q

Portal veins can be differentiated from hepatic veins because of the consistent _________________, regardless of the ultrasound beam orientation.

A

hyperechogenicity of their walls (arrows)

However, the walls of the hepatic veins can also appear hyperechoic when the ultrasonographic beam is directed perpendicularly.

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10
Q

in standard doppler, which should be portal - red or blue?

A

red - towards the periphery/transducer

blue: hep veins (towards the cava)

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11
Q

which vessels can be distinguished on b-mode?
- arteries
- hep veins
- portal veins

A

hep veins
portal veins

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12
Q

When measured at the same depth, the diameters of the PV and HV:

A) Hepatic = Portal
B) Hepatic > Portal
C) Hepatic < Portal

A

A) Hepatic = Portal

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13
Q

When measured at the level of the porta hepatis, the PV luminal diameter varies between ________ mm in normal cats and between ________mm in normal dogs.

A

3.4 and 5.0
3.3 and 10.5

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14
Q

When comparing the maximal luminal diameter of the PV and the aorta, PV/aorta ratios of ___________ are normally expected in dogs/cats (d’Anjou et al. 2004).

A

0.71 – 1.25

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15
Q

Mean flow velocity is calculated by: ______________ ,

A

maximal velocity (e.g. 25 cm/s) multiplied by a factor of 0.57 (= e.g. 14.3)

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16
Q

Portal flow mean velocity can be measured with spectral Doppler, after the use of an insonation angle correction of less than __ degrees.

A

60

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17
Q

Mean velocity can be measured or calculated. For measurement, the sample gate must….

A

fill the entire width of the main PV.

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18
Q

If the sample gate fills about half the PV lumen, the machine will measure _____.

A

max flow velocity - this can then be used to calculate (multiple by 0.57) the mean velocity.

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19
Q

What are the normal mean portal flow velocities and unit, in cats and dogs?

A

dogs: 15 +/- 3 (12-18?), or 18 +/- 8 (10- 26?)

cats : 10-18

centimeters per second (cm/s)

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20
Q

causes of diffuse hypoechoic liver

A

congestion
acute hepatitis
leukemia
histiocytic neoplasia

amyloidosis (also mixed)
lymphoma (can also by hyper or mixed)

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21
Q

causes of a small liver

A

PSS
Microvascular dysplasia/primary PV hyoplasia
cirrhosis
fibrosis
severe hypovolemia

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22
Q

what appearance of the liver might you expect in a dog with lepto?

A

diffuse hypoechogenicity

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23
Q

normal or abnormal?

A

abnormal - increased prominence of the vasculture, this liver is diffusely hypoechoic

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24
Q

Name a parasite that causes multifocal granulomatous cholangitis in dogs

A

Heterobilharzia americana

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25
Which type of neoplasia is most likely to cause diffuse hepatic involvement?
Round cell; lymphoma most likely, as histiocytic neoplasms are more commonly associated with hypoechoic nodules, but diffuse hypoechogenicity is reported. other round cell: MCT
26
cirrhosis, lobes are small and hyperechoic, with hypoechoic nodules deforming the contours. note peritoneal effusion.
27
Amyloidosis has which breed predisposition in dogs and cats?
dogs - shar-pei cats - abyssinian and siamese
28
in amyloidosis, the liver is a) the same size b) smaller c) larger
c) larger (usually)
29
which syndrome can give this honeycomb appearance?
hepatocutaneous syndrome
30
Which is more sensitive for detecting a thrombus and why - power or color doppler?
Power Doppler is more sensitive and not direction-dependent, helping to better assess the presence of flow around or within the thrombus, particularly when the vessel is aligned perpendicularly to the probe or if the flow is significantly reduced.
31
Hepatic venous congestion is commonly caused by _______________, such as _________________.
right-sided heart insufficiency, cardiac tamponade
32
What are some US liver changes suggestive of hepatic congestion?
The CVC and hepatic veins appear dilated, and the liver is typically enlarged and diffusely hypoechoic. Also gallbladder wall edema.
33
Which of these can be usually diagnosed by cytology? - vacuolar hepatopathy (lipidosis, HHAC) - lymphoma - hepatitis
all of them
34
Why/via which route, is the liver a common metastatic target?
mainly through the portal system, which drains most abdom- inal structures
35
It has been reported that the finding of at least one target lesion in the liver or spleen had a positive predictive value of ____ for malignancy in small animals (Cuccovillo and Lamb 2002). Other features supportive of malignancy include lesion size (____) and presence of _____________(Guillot et al. 2009; Murakami et al. 2012).
74% >3cm peritoneal effusion
36
Hepatic metastases
37
cats
Biliary cystadenomas and cystadenocarcinomas in cats.
38
cystic or cavitary tumors are more common in cats/dogs.
cats
39
Benign cysts with cellular debris or haemorrhage can mimic abscesses - what is one thing that could help differentiate the two?
The rim - in cysts, the rim is thinner and more well-defined. Abscesses are poorly marginated
40
What kind of cyst may immitate an abscess, with the addition of mineralisation?
Parasitic - liver fluke/trematode, tapeworm/hydatid/echinococcus
41
What are causes of pyogranulomatous liver disease?
fungal cats: FIP, eosinophilic sclerosing fibroplasia (although liver is not a classic location of changes - see https://onlinelibrary.wiley.com/doi/10.1111/jvim.16992)
42
Granulomas tend to be - hyperechoic/hypoechoic - heterogenous / homogenous
Granulomatous lesions tend to be hyperechoic and inhomogeneous, as is the case in humans (Mills et al. 1990).
43
How should a hematoma behave over time (compared to a neoplasia)?
With time, hematomas tend to develop a cystic component following clot lysis. This feature, as well as the progressive reduction in size on follow-up exams, should help in differentiating spontaneous hematomas from neoplastic processes.
44
Mineralisation (besides cholelithiasis) occurs only in malignant processes - t or f?
false, it can also occur in hematomas or granulomas.
45
hepatic abscess b) poorly marginated and con- tains several reverberating, hyperechoic foci consistent with gas d) complex mass (arrowheads). Intraparenchymal reverberating hyperechoic foci consistent with gas are noted dorsally (arrow)
46
abscess, granuloma, cyst or neoplasia - best guess?
granulomas a - incidental b - FIP c - eosinophilic sclerosing fibroplasia
47
14y Shih Tzu
parencymal mineralisation
48
What is a differential for the hypoechoic lobe (adjacent lobe L is normal)?
torsion
49
this is an example of a hepatic....
infarction! Within the liver is an irregular hypoechoic region (arrows) with peripheral vascular signal. Ultrasound-guided biopsy revealed infarction of uncertain origin.
50
Choledochal cyst
51
The concurrent presence of multiple cysts in the _________ assists in the diagnosis of congenital cystic changes of the biliary tree.
kidneys
52
In which order (of biliary anatomy) does dilation occur folllowing complete extrahepatic biliary obstruction? i.e. gall bladder before
After complete obstruction of the CBD, retrograde dilatation is expected that initially affects the CBD and GB, followed by the extra- and intrahepatic ducts (Nyland and Gillett 1982).
53
A CBD more than ______ mm wide is usually predictive of obstruction in cats (Léveillé et al. 1996; Gaillot et al. 2007). This is probably also true in dogs, although it has not been described. Within _____ days, irregular and tortuous anechoic tubes with hyperechoic walls can be found in the liver, following the more linear PVs and unassociated with color flow, indicating dilated hepatic ducts. This sign, also referred to as the “__________” sign, is usually indicative of complete obstruction.
4 – 5 (mm) 5 – 7 (days) too many tubes (sign)
54
What are some reasons why the gallbladder wouldn't distend with EHBO?
- gallbladder contraction - inflammation / fibrosis of the gallbladder (limits its ability to distend) - the hepatic parenchyma has reduced compliance
55
In Gaillot et al. 2007, gallbladder dilatation was in fact seen in less than ___% of cats with extrahepatic biliary obstruction. In this same study, choleliths and plugs were found to be responsible for the obstruction in _____ out of 30 cats.
50 (thus, CBD dilation (>4mm) is a more reliable indicator of EHBO than GB distension in cats) 7
56
EHBO in dogs particularly, is caused by:
1. pancreatitis (which causes edema, inflammation, fibrosis of the duodenal wall and major papilla or CBD). 2. chronic duodenitis or cholecystitis can also cause the above changes 3. biliary tract inflammation can cause amorphous plugs and cholelithiasis (although this can be secondary to above inflammatory processes). 4. neoplasia (usually carcinoma)
57
With hypoplasia / atresia of the CBD, the remaining bile ducts will be A) narrower than normal B) the same as normal C) wider than normal
C) wider than normal
58
The acoustic enhancement (*) is a distinctive feature of ____________.
EHBO.
59
Causes of GB wall edema
portal hypertension hypoalbuminemia R-CHF biliary obstruction inflammation anaphylaxis (because of the high concentration of mast cells)
60
match the Dg (some are not pathognomonic, this is just for fun): - chronic cholecystitis - biliary carcinoma - cholelith - pancreatitis
A - cholelith B - carcinoma C - cholecystitis / cholangiohepatitis (suppurative) D - pancreatitis / cholangitis (fibrous stenosis)
61
The CBD returns to normal after EHBO causes are alleviated - T or F?
In chronic cases, the CBD may remain dilated.
62
63
Which is more mature - stellate or kiwi-pattern gallbladder mucocoele?
Kiwi
64
GBM rupture - hyperechoic fat suggestive of perforation (confirmed at surgery)
65
Choleliths can form secondary to an obstruction - true or false?
True Subsequent intrahepatic or extrahepatic biliary obstruction can be observed, although choleliths may also form because of an obstruction (Mayhew et al. 2002).
66
Signalment for IHPSS
large-breed dogs
67
categories of IHPSS
left-divisional central-divisional right-divisional
68
What is the most common form of IHPSS?
Left-divisional
69
What are left-divisional IHPSS caused by?
patent ductus venosus
70
Where is a left-divisional IHPSS found?
Within the left liver, it originates from the intrahepatic PV, goes into the left liver (left hepatic vein, which drains into CVC). The right is the same, but into the R hepatic vein in the R liver.
71
What kind of shunt is this?
central divisional IHPSS
72
73
74
75
76
Congenital EHPSS is suspected if the main PV is __________________. A PV:aorta of ________ predicts the presence of an EHPSS. A ratio of ________ excludes an EHPSS.
smaller than its tributaries less than/= 0.65 more than/= 0.80
77
Where are the PV and aorta measured for the PV:aorta?
PV: just before entering the liver Aorta: cranial abdomen
78
Besides an EHPSS, what else could cause a low PV:aorta?
Primary PV hypoplasia PPVH aka idiopathic non-cirrhotic portal hypertension > leading to multiple acquired PSS
79
A PV:aorta of >= 0.80 excludes EHPSS and is found in normal animals. It however does not exclude:
* IHPSS (left/central/right divisional) * Portal hypertension, caused by chronic liver disease * microvascular dysplasia
80
When observed together, which 3 secondary findings are highly predictive of PSS in dogs?
Microhepatica Renomegaly Urolithiasis
81
What's wrong with this image?
The PV is dilated and contains hepatofugal / reversed / red flow. There is an arterioportal fistula.
82
What's wrong with this image (arrow)?
The blood is flowing caudally in this splenic vein. The vein connected to the R renal vein, acquired splenorenal anastomosis, in a dog with PPVH.
83
Causes of portal hypertension
1. Chronic / cirrhotic liver disease 2. Diffuse hepatic neoplasia 3. Congenital PV hypoplasia (PPVH) 4. Portal thrombosis 5. Arterioportal fistula 6. Extraluminal mass compression on PV
84
Secondary signs of Portal hypertension
Ascites Edema (GB, pancreas)
85
Portal hypertension is suspected when portal flow is ______________.
Reduced (mean <10cm/s) or reversed (hepatofugal)
86
Hepatofugal flow is normal for the portal system. T or F?
False, hepatopetal (towards the liver). Hepatofugal portal flow indicates portal hypertension.
87
Sustained PH leads to opening of pre-existing collaterals. In the dog, a common one is the ____________.
splenorenal anastomosis splenic vein blood flows caudally to the R renal
88
Splenorenal shunts are most commonly observed in: A) Older male cats B) Older female cats C) Younger male cats D) Younger female cats
B) Older female cats
89
Splenorenal shunts are often associated with which condition in cats? A) Hepatopathy B) Nephropathy C) Cardiomyopathy D) Diabetes mellitus
A) Hepatopathy
90
What is a characteristic feature of arterioportal fistulas? A) Decreased portal vein pressure B) Rapidly progressive portal hypertension C) Atrophic intrahepatic portal branches D) Normal blood flow in the portal vein
B) Rapidly progressive portal hypertension
91
What is a specific sign/area of an acquired portosystemic shunt (PSS) in cats?
Visualization of a vein connecting to the left renal vein or CVC near the left renal vein
92
Arterioportal fistulas involve abnormal connections between the portal veins and which arteries? A) Mesenteric arteries B) Renal arteries C) Hepatic arteries D) Splenic arteries
C) Hepatic arteries Intrahepatic portal branches typically become dilated and tortuous in the affected lobe, which can be more difficult to identify.
93
Arterioportal fistulas most commonly affect which part of the liver's vascular system? A) Hepatic veins and central veins B) Hepatic arteries and intrahepatic portal branches C) Portal veins and systemic collateral veins D) Hepatic sinusoids and bile ducts
B) Hepatic arteries and intrahepatic portal branches Intrahepatic portal branches typically become dilated and tortuous in the affected lobe, which can be more difficult to identify.
94
How does the portal vein size differ between primary portal vein hypoplasia and arterioportal fistula? A) Primary portal vein hypoplasia has a normal-sized PV, while arterioportal fistula involves an enlarged PV. B) Primary portal vein hypoplasia has a small PV, while arterioportal fistula has a normal-to-large PV. C) Both conditions result in a small PV. D) Both conditions result in a normal-sized PV.
B) Primary portal vein hypoplasia has a small PV, while arterioportal fistula has a normal-to-large PV.

Penninck US (12 decks)

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