Flashcards in Liver Abnormalities Deck (201):
_____ of the liver is incompatible with life (not having one).
Often, with agenesis of the RLL, the _____ lobe is also absent.
T or F? With agenesis, compensatory hypertrophy of the remaining lobes normally occurs and the LFTs are normal.
This position abnormality is when the liver is found in the left hypochondrium.
situs inversus totalis
In congenital diaphragmatic hernias or omphalocele, varying amounts of liver may herniate into the _____ or outside the _____ cavity.
If someone has kidney cysts, they probably have _____ cysts too.
T or F? Kidney cysts are more common than liver cysts.
Liver cysts occurrence increases past the age of _____.
Benign hepatic cysts are _____ (echogenicity) with well-demarcated _____ (thickness) walls and posterior acoustic enhancement.
Is active intervention of cysts recommended in patients without symptoms?
Occasionally, the patient may develop pain and fever secondary to cyst hemorrhage or infection. In this case, the cyst may contain internal _____ and _____, a _____ wall, or may appear _____ .
T or F? Cyst ablation with alcohol can be performed using U/S guidance.
Rather than ablation with alcohol, what is another treatment for cysts?
A hemorrhagic liver cyst will appear as a cyst with _____ _____, accompanied by (2)
acute RUQ pain
If you see cysts in the kidneys, always check the _____ for cysts as well.
The adult form of _____ _____ disease is inherited in an autosomal dominant pattern. The frequency with liver cysts in association with this disease is high.
polycystic kidney disease
_____ is a term for liver inflammation due to viruses or toxins.
Hepatitis is _____ when it lasts for less than 6 months.
This kind of hepatitis is more likely to be asymptomatic in younger people. The convalescent stage is 7 to 10 days, with the total illness lasting 2 to 6 weeks.
acute viral hepatitis
If you see a hypoechoic liver parenchyma, hepatomegaly, and hyperechoic PV walls, this is a sign of
This hepatitis shows diffuse swelling of the hepatocytes, proliferation of Kupffer cells, and infiltration of the portal areas by lymphocytes and monocytes.
More specific symptoms of acute hepatitis are (6)
profound loss of appetite
aversion to smoking (in smokers)
yellowing of the eyes
These 2 symptoms of the most common presenting symptoms of acute hepatitis.
What are the 6 kinds of hepatits?
Hepatitis A is also called
Hepatitis A is transferred by what route?
Does Hepatitis A have an acute and chronic stage?
No, just acute
Hepatitis A occurs most frequently in _____ world countries. There is a vaccine that prevents it for up to _____ years. People with Hep A are advised to _____, _____, _____ . Hep A can spread through consumption of raw sea food or contaminated _____ .
Which hepatitis is the least serious?
The combination of these two forms of hepatitis can cause a _____, and even without cirrhosis, leading to a life-threatening form of fulminant hepatitis.
Hep A and Hep C
Does Hep B have both acute and chronic versions?
A vaccine for Hep B exists that prevents infection for how long?
This form of hepatitis can lead to hepatocellular carcinoma.
The methods of transmission for Hep B are
blood and body fluids
Symptoms of this kind of hepatitis occur long after the initial infection, around 4 to 24 weeks and patients may not even experience them. The pain can resemble arthritis, affecting specific joints and accompanied by redness and swelling.
5-10% of people with Hep B eventually develop
Hep B poses a risk for _____ cancer.
Hep C is also called
This is the most common blood-borne infection.
People can get this type of hepatitis from inadequately sterilized medical or dental equipment.
Hep C is spread by contact with
infected human blood
T or F? Hep C can be passed from an infected mother to her baby during birth.
Does breastfeeding increase transmission of Hep C?
Before 1990, Hep C was primarily transmitted by
Most patients with Hep C _____ (do/do not) experience symptoms.
If someone experiences symptoms from Hep C, it is often after _____ months of infection.
Chronic hepatitis C can be present for _____ - _____ years, and _____ or _____ can sometimes develop before patients experience any clear symptom.
Nearly 40% of liver transplant patients are infected with Hep _____.
Is liver transplantation a cure for Hep C?
This kind of hepatitis is only dangerous if you also have Hep B.
Hep D is also called
hepatitis delta virus
T or F? Hep D was discovered as an antigen in Hep B virus by Dr. Mario Rizzetto in 1977.
Hep D is an uncommon infection in North America, but the people who are primarily infected are
IV drug users
How is Hep D spread?
thought to be similar to Hep B, blood
possibly sexual transmission
Is there any specific treatment for Hep D? But what is a possible alternative-type treatment that has been used in the past with some success? And what is another possible treatment?
High dose of interferon given for over 12 years
orthotopic liver transplant
Persistence of biochemical abnormalities beyond 6 months is
What is the sonographic appearance of chronic hepatitis?
small, shrunken liver
decreased echogenecity of PV walls
(opposite of acute hepatitis)
Abscesses = ? and ?
This is a puss-filled area in the liver.
Pyogenic liver abcess
What are some of the causes of liver abscesses?
-Abdominal infection such as appendicitis, diverticulitis, or a perforated bowel
-Infection in the blood
-Infection of the liver secretion (biliary) tract
-Recent endoscopy of the biliary system
-Trauma that damages the liver
The most common presenting features of pyogenic liver abscess are:
Fever, chills, leukocytosis
Loss of appetite
Pain in right upper abdomen (more common) or throughout the abdomen (less common)
Unintentional weight loss
Yellow skin (jaundice)
Pyogenic liver abscesses most commonly occur in the ______ lobe.
How do pyogenic liver abscesses reach the liver (4)?
Varied appearances of pyogenic liver abscesses are:
***There is “air” within the abscess***
Purulent abscesses appear cystic with the fluid ranging from echofree to highly echogenic
Early suppuration may appear solid with altered echogenicity, usually hypoechoic
The abscess wall can vary from well-defined to irregular and thick
Gas-producing organisms give rise to echogenic foci with a posterior reverberation artifact.
For true diagnosis of pyogenic liver abscesses, what must be done?
aspirate the abscess
Treatment for pyogenic liver abscesses is
draining the abscess
along with this procedure, you will receive long-term antibiotic therapy (usually 4 - 6 weeks).
sometimes antibiotics alone can cure the infection
With pyogenic liver abscesses, what life-threatening condition could develop?
Even with treatment, pyogenic liver abscesses can be life-threatening in _____% to _____% of patients.
10% - 30%
When you hear "air in the abscess", you should automatically think
pyogenic liver abscess
This is a liver infection that occurs when a parasite that came from the intestines reaches the liver, and travels through the portal vein.
This is the most common extraintestinal complication of amoebic dysentery
Transmission of amebic abscess is by the _____-_____ route. The most common bacterial agent related to this is ______.
The most common presenting symptoms of amebic abscess are
right upper quadrant pain
Sonographic signs of amebic abscesses are (7)
Round or oval-shaped lesion
Absence of a prominent abscess wall
Hypoechoic compared to a normal liver
Fine low-level internal echoes
Contiguity with the diaphragm/liver capsule
Typically occurs in the dome of the liver (RLL)
T or F? For amebic abscesses, amebicidal drugs are effective and symptoms improve by 24-48 hours but complete resolution of the abscess varies from 1.5 – 23 months with a median of 7 months.
Possible dangerous risks of amebic abscesses are
may rupture into the abdominal cavity, the lining of the lungs, the lungs, or the sac around the heart
could spread to the brain
This is a mycotic (fungal) infection of the blood that results in small abscesses in the liver. The appearance of these lesions can change over the course of the disease process.
The ultrasonic appearance of Candida infection in the livers of immunosuppressed patients is quite characteristic:
"Wheel Within A Wheel”: a lesion with a peripheral hypoechoic zone, an inner echogenic wheel and a hypoechoic center. This is the earliest manifestation of a fungal infection and the most recognizable.
After some time, later the “wheel within a wheel” turns into a “______” appearance when the hypoechoic center ______.
It will then turn into a(n) uniformly ______ (echogenecity) focus and then a(n) ______ (echogenecity) focus representing scar formation.
What is the most common cause of hydatid disease?
This is a result of a parasite infestation (tapeworm) associated with sheep and cattle raising countries.
Eggs of Echinococcus granulosus are swallowed by the intermediate host (man) and pass into the ______ ______ system where the larva hatch and move into the ______.
portal venous system
The tapeworm of the parasite infestation for an echinococcal cyst is ______-______ mm in length and usually lives in the intestines of the definitive host (dog), excreted in the dog’s feces and swallowed by the intermediate hosts (sheep, cattle, goats or humans).
The sonographic signs for an echinococcal cyst are (5)
Cysts with detached endocysts secondary to rupture (a cyst within a cyst)
Cyst with multiple daughter cysts
Cyst with detached membrane (water lily sign)
An old test used to diagnose hydatid disease was called the ______. It was usually about ______% sensitive.
Casoni skin test
For treatment of an echinococcal cyst, _____ is the conventional treatment, but success has been obtained with _____ as well.
The fluid within the echinococcal cyst is very toxic, so if a cyst ruptures _____ can occur.
This is one of the most common parasitic worm infections in humans, affecting 200 million people worldwide found in parts of the world where the water is contaminated.
It is a major cause of portal HTN worldwide.
Explain how schistosomiasis occurs
Freshwater becomes contaminated by Schistosoma eggs when infected people urinate or defecate in the water. The eggs hatch, and if certain types of snails are present in the water, the parasites grow and develop inside the snails. The parasite leaves the snail and enters the water where it can survive for about 48 hours.
Adult worms are about 10 mm long.
Parasites reach maturity in 6 to 8 weeks, at which time they begin to produce eggs.
Up to half the eggs released by the worm pairs become trapped in the mesenteric veins, or will be washed back into the liver, where they will become lodged. Worm pairs can live in the body for an average of four and a half years, but may persist up to 20 years.
Eggs travel to the liver or pass into the intestine or bladder, causing inflammation or scarring.
Eggs from schistosomiasis reach the liver through the _____ inciting a _____ reaction resulting in _____ .
The peri-portal fibrosis caused by schistosomiasis causes _____ which will lead to _____.
What is seen sonographically with schistosomiasis? (5)
intrahepatic PVs occlude
This is the most common fungal organism causing opportunistic infection in patients with AIDS.
It is the most common cause of life-threatening infection in patients with HIV.
This condition also affects patients undergoing bone marrow and organ transplants, as well as those receiving corticosteroids or chemotherapy.
The sonographic appearance and medical results of pneumocystis are (10)
Fatty liver infiltration
May involve the liver with diffuse, nonshadowing hyperechoic foci.
May cause the bile ducts and GB wall to be thickened.
This infection and this malignancy can signal the final stages of HIV/AIDS.
Another word for pneumocystis carini is
2 other AIDS related findings are
cholangitis (thickend bile ducts)
Kaposi's sarcoma (intrahepatic mass)
A fatty liver is an acquired, reversible disorder of metabolism, resulting in an accumulation of _____ within the hepatocytes.
The most common causes of a fatty liver are ______ and ______.
The 2 patterns of a fatty liver are
focal fatty infiltration (diffuse)
focal fatty sparing (focal)
The echogenicity of the liver compared to the kidney is more ______ than the kidney.
A potential problem in the presence of diffuse fatty infiltration is
misdiagnosis of a hypoechoic solid lesion as a simple cyst
How does the misdiagnosis of a hypoechoic solid lesion as a simple cyst occur?
Since the overall gain is turned down to compensate for a bright liver, low level echoes within a solid lesion may be missed. With the TGC turned up to compensate for reduced through transmission, the hypoechoic solid lesion may have posterior enhancement.
What visual finding can help distinguish between a solid lesion and simple cyst?
The solid lesion will lack the specular reflection seen in the posterior wall of a cyst, as it does not have a fluid tissue interface.
Fine-needle aspiration may be necessary if the ultrasound findings are equivocal.
Focal regions of increased echogenicity within normal liver parenchyma is
focal fatty infiltration
Focal regions of normal liver parenchyma within a fatty infiltrated liver.
focal fatty sparing
Sparing commonly occurs adjacent to the ______, in the porta hepatis, the ______, and at the liver margins.
A genetically acquired disorder that results in the excess deposit of glycogen in the liver and tubules of the kidney.
glycogen storage disease
This is associated with diffuse fatty infiltration and hepatic adenomas (well-demarcated, solid masses of variable echogenicity).
glycogen storage disease
______ is a diffuse process of fibrosis and distortion of normal liver architecture.
Patients with cirrhosis are at an increased risk for ______.
With cirrhosis, initially there is ______ enlargement, but continued insult results in ______. Parenchymal changes compress the biliary and ______ channels resulting in ______ and ______.
The 2 most common causes of cirrhosis are
ETOH abuse (alcohol abuse)
ETOH was once the main cause of cirrhosis in the U.S. ______ has emerged as the leading cause now
The 3 major pathologic mechanisms which create cirrhosis are
Tissue Regeneration (bad kind)
Cirrhosis is classified as ______ (nodules 0.1 – 1 cm in diameter) or ______ (nodules up to 5 cm in diameter).
______ is the MOST COMMON cause of micronodular cirrhosis.
______ is the MOST FREQUENT cause of macronodular cirrhosis.
chronic viral hepatitis
Clinical presentations of cirrhosis are (3)
This condition can cause you to be "crazy" because the liver cannot get rid of the toxins and ammonia, which causes encephalopathy.
Cirrhosis - match the volume distribution with the type:
Small liver, large Caudate lobe
Acute - Hepatomegaly
Chronic - Small liver, large Caudate lobe
The 3 sonographic patterns for cirrhosis are:
1) volume redistribution
2) coarse echotexture
3) nodular surface
The nodularity with cirrhosis corresponds to the presence of regenerating ______ and ______.
Late stages of cirrhosis characteristics are (2)
This is defined as increased pressure in the portal venous system.
Normal portal pressure is ______-______ mm Hg which is slightly ______ than the normal IVC pressure.
5 - 10 mm Hg
Normal portal vein diameter is < ______ mm
______ flow in the MPV is a sign of portal HTN.
What are the 2 major causes of portal HTN?
Portal HTN is asymptomatic. Patients typically present with sudden painless upper GI ______ due to rupture of esophageal ______.
What are the 4 types of portal HTN?
A. Extrahepatic pre-sinusoidal = portal vein thrombosis
B. Intrahepatic pre-sinusoidal = schistosomiasis
C. Intrahepatic = cirrhosis (most common) accounting for 90% of the cases in the West
D. Intrahepatic post-sinusoidal = hepatic vein thrombosis
What is the most common type of portal HTN?
What are the secondary signs of portal HTN? (3)
splenomegaly ( >13 cm)
portosystemic venous collaterals
What are 5 major sites of portosystemic venous collaterals?
1) Gastroesophageal junction
2) Paraumbilical vein
3) Splenorenal and gastrorenal
Gastroesophageal junction: between the coronary and ______and the ______ .
short gastric veins
Paraumbilical vein: runs in the ______ ligament and connects the LPV to the ______ near the umbilicus, recanalizing the ______.
Splenorenal and gastrorenal: tortuous veins may be seen in the region of the ______ and ______.
left renal hilum
Intestinal: regions in which the gastrointestinal tract becomes ______, so that the veins of the ascending and descending ______, ______, ______, and ______ may anastomose with the renal, phrenic and ______ veins.
Hemorrhoidal: ______ region where the superior rectal veins anastomose with the ______ and ______ rectal veins.
These are created to decompress the portal system to avoid the development or rupture of gastroesophageal varices with portal HTN.
The 3 types of traditional portosystemic shunts are
What does TIPS stand for?
A TIPS shunt is placed between a ______ and a ______. Usually the ______ (right/left).
______ ______ ______ is utilized to detect early shunt compromise for prompt shunt revision, usually every 3-6 months.
routine doppler evaluation
What are the 4 criteria for TIPS malfunction?
1. Shunt velocity < 50 cm/sec
2. Focal velocity increase (usually at the hepatic end)
3. Hepatopedal flow in the LPV or RPV
4. Hepatofugal flow in the MPV
Hepatopedal flow in the LPV or RPV is a sign of what (involving shunts)?
Hepatofugal flow in the MPV is a sign of what (involving shunts)?
Echogenic thrombus within the lumen of the portal vein
The 6 causes of PV thrombosis are
Metastatic Liver Disease
Hypercoagulation (women on birth control pills)
With traditional shunts for lowering portal pressure, the mesocaval shunt connects the ______ and the ______.
With traditional shunts for lowering portal pressure, the splenorenal (Warren) shunt connects the ______ and the ______.
With traditional shunts for lowering portal pressure, the portacaval shunt connects the ______ and the ______.
Wormlike vessels at the porta hepatis, which represent periportal collateral circulation, occurring in longstanding PV thrombosis, requiring up to 12 months to occur.
Cancer = ______ (increased/decreased) risk of blood clots.
A relatively rare disorder characterized by occlusion of the hepatic veins with or without occlusion of the IVC by either thrombus or tumor. Typically seen in young adult women taking birth control pills.
The main cause of Budd-Chiari syndrome is
With Budd-Chiari syndrome, the ______ lobe is often spared. And why?
because of emissary veins drain directly into the IVC at a lower level than the main HVs
These are sonographic signs of ______:
Ascites is an invariable observation.
Liver is typically large and bulbous acutely. Hemorrhagic infarction may produce significant altered regional echogenicity.
Membranous webs may be identified as echogenic or focal obliterations of the lumen.
______ liver transplantation is performed to eliminate irreversible disease.
The main indication for liver transplants in adults is
Cirrhosis due to Hep C
The main indication for liver transplants in children is
Before orthotopic liver transplant surgery is done, these details should be checked sonographically (4)
Liver size and extent of pathology
PV, HA, IVC patency/size
Presence of venous collaterals
Presence of complicating factors( like AAA or extrahepatic malignancies)
A postoperative U/S for orthotopic liver transplant should include (5)
Biliary tree (CBD)
HA, PV, HV patency***
Perihepatic fluid collections
Unfortunately, in about _____ (fraction) of all patients with chronic hepatitis, the disease recurs after transplantation.
Most common benign tumor of the liver is
The majority of hemangiomas are asymptomatic and discovered incidentally, usually in the _____ lobe of the liver.
Is it possible to see the flow in the tiny vessels that make up hemangiomas on U/S?
May appear hypoechoic within the background of a fatty infiltrated liver
Color or duplex Doppler does not routinely demonstrate flow
These are sonographic signs of what?
This liver mass may enlarge with pregnancy or administration of estrogens.
This is a benign solid liver mass that is believed to be related to an area of congenital vascular malformation. It is typically an incidentally detected liver mass in an asymptomatic patient.
focal nodular hyperplasia
Focal nodular hyperplasia is a mass more common in ______ (men/women).
Well defined solid mass
Central fibrous scar (liver mass with an echogenic line through it)
It is often difficult to differentiate in echogenicity from the adjacent liver parenchyma
These are sonographic signs of what?
focal nodular hyperplasia
This is a solid liver mass associated with the use of oral contraceptive agents.
Patient may present with pain due to tumor hemorrhage. Associated with glycogen storage disease.
These are signs of what liver mass?
Surgical resection is recommended for hepatic adenomas due to the risk of
Sonographic signs of hepatic adenoma are (3)
Cystic component with hemorrhage
Hepatic Adenoma is often difficult to distinguish from ______ on an U/S.
focal nodular hyperplasia
Extremely rare fatty tumors in the liver are
Tuberous sclerosis, a congenital familial disease, is associated with ______ and ______.
Propagation speed artifact
These are sonographic signs of
This may be seen as a broken diaphragm posterior to the fatty mass on an U/S (and diaphragms don’t break).
The MOST COMMON PRIMARY malignancy of the liver is
Another term for hepatocellular carcinoma is
Alcoholic cirrhosis and Hep B and C
Commonly invades PVs, HVs, and IVC
Variable sonographic appearance
Serum alpha-fetoprotein level will be increased
These are signs of what?
hepatoma (hepatocellular carcinoma)
One of the biggest signs of ______ is the increase of serum alpha-fetoprotein levels.
hepatocellular carcinoma (hepatoma)
______ are the most commonly encountered solid masses in the liver.
The most common source of metastatic involvement is from ______, ______, or ______ cancer.
Hyperechoic mets come from
the gastrointestinal tract
Hypoechoic mets come from
Bulls eye or target mets come from
Calcified mets come from
Cystic mets come from
Metastatic tumors can also present as mass of ______ echogenicity.
The most common malignant liver tumor in early childhood is
Hepatoblastoma is the 3rd most common intra-abdominal childhood malignancy after ______ neuroblastoma and ______ tumor.
With hepatoblastoma, most occurrences are prior to ______ years of age. Patients present with an enlarging ______ ______ ______ (10-12 cm). Non-specific sonographic appearance.
asymptomatic abdominal mass
What is the earliest manifestation of a fungal infection (and most easily seen) in the liver?
Wheel within a wheel
Since they are difficult to tell apart, how can you possibly distinguish between a pyogenic abscess and an amebic abscess?
If the patient has traveled outside the US it might be amebic abscess
Central fibrous scar =
Focal nodular hyperplasia