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Flashcards in liver pathology power point Deck (51):
1

Diffuse Liver Disease

affects the hepatocytes and interferes with liver function

2

Diffuse Liver Diseases


—Fatty Liver Disease
—Hepatitis
—Cirrhosis
—Portal Hypertension
—Portal vein thrombosis
—Budd-Chiari Syndrome
 

3

Fatty Infiltrate


—An acquired and reversible disease
—Benign
—Increased lipid accumulation in the hepatocytes leading to impaired or excessive metabolism of fat
 

4

Clinical findings of Fatty Liver Disease


—Asymptomatic
—Alcohol abuse
—Chemotherapy
—Diabetes mellitus
—Elevated liver function test
—Obesity
—Pregnancy 
 

5

Sonograhic findings of Fatty Liver Disease


—Diffusely echogenic liver
—Liver may appear patchy, inhomogenous due to focal sparing
—Liver is enlarged(hepatomegaly)
—Increased attenuation of the sound beam
—Walls of the hepatic vasculature and diaphragm will not be easily imaged(secondary to increased attenuation)
—Compare the echogenicity of the right kidney to the liver.
 

6

Locations for Focal Fatty Sparing


—Adjacent to the gallbladder
—Near the porta hepatis
—Entire medial segment of the left lobe
—Can appear much like pericholecystic fluid when seen adjacent to the gallbladder
 

7

Hepatitis


—Broadly defined as inflammation of the liver
—Contracted through contact with fecal matter,contaminated food, body fluids, and blood.
—Acute and Chronic
—Results from infection by a group of viruses that specifically target the hepatocytes
 

8

Hepatitis types


—Hep A(HAV) 
—Hep B(HBV) 
—Hep C(HCV) 

Hep D (HDV) 

Hep E (HEV) 

Hep (HGV)

9


—Hep A(HAV) 


 viral, spread primarily by feces since the virus lives in the alimentary tract.  Found worldwide, accounts for 20% of cases. Acute
—

10



—Hep B(HBV) 


— viral, spread by transfusions of infected blood or plasma or through contaminated needles. Can also be transmitted from body fluids.  Greatest risk for Health Care workers, accounts for 60% of cases
—
 

11


—Hep C(HCV)
 


 viral, diagnosed by the presence in blood of the antibody to HCV. Seen mostly in Italy and other Mediterranean countries
 

12


—Hep D (HDV) 


viral, entirely dependent on HBV for its infectivity, rare in North America, seen primarily in IV drug users Must have HBV to aquire
 

13


—Hep E (HEV)


 viral, caused by fecally infected waters May be seen in liver transplantation
 

14


—Hep (HGV) 
 


 viral, newly discovered, first described in 1996, caused by blood transfusion
 

15

Clinical findings of Hepatitis


—Chills
—Dark urine
—Elevated liver function tests
—Fatigue
—Fever
—Hepatosplenomegaly
—Jaundice
—Nausea
—Vomiting 
 

16

Sonographic findings of hepatitis


—Normal liver
—Enlarged, hypoechoic liver
—Periportal cuffing with “starry sky”
—Gallbladder wall thickening
 

17

Cirrhosis


—Diffuse process characterized by fibrosis and conversion of normal liver parenchyma into structurally abnormal nodules
—Generalized involvement of the liver by parenchymal necrosis, regeneration, and diffuse fibrosis
—Scarring is progressive and irreversible leading to liver cell failure and portal hypertension
 

18

Cirrhosis-Continued


—A leading cause of death in the US
—Most common causeof micronodular cirrhosis is Alcohol Abuse. (.1-1.0 cm)
—Most common cause of macronodular (1.0-5.0 cm) cirrhosis is Viral Hepatitis.
—Other causes of cirrhosis include drug abuse,obesity,chronic bile retention, cardiac insuffiency,and some medications
 

19

Clinical findings of cirrhosis


—Ascites
—Diarrhea
—Elevated liver function tests
—Fatigue
—Hepatomegaly(initial)
—Jaundice
—Splenomegaly
—Weight loss
 

20

Sonographic findings of Cirrhosis


—Hepatomegaly( initially)
—Shrunken right lobe of the liver
—Enlarged caudate and left lobe
—Nodular surface irregularity
—Coarse echotexture
—Splenomegaly
—Ascites
—Monophasic flow within the hepatic veins
—Hepatofugal flow within the portal veins
 

21

Portal Hypertension


—> 90% due to cirrhosis
—Can also be due to obstruction of the portal,hepatic veins, and/or IVC, or longstanding CHF
—Contributes to the formation of ascites,splenomegaly and GI bleeding
—Varices and collateral venous channels
—Caput medusal sign- collateral vessels on the abdominal wall
 

22

Portal Hypertension-Continued


—Portal vein may enlarge (>13mm)
—Flow becomes less phasic and reverses (hepatofugal) as disease progresses
—If red is the top color on the color scale, this means blood flow is toward the probe, toward the liver.  The normal color than for the PV is red. So look for the color bar on the image.
 

23

Sonographic findings of Portal Vein Thrombosis


—Echogenic thrombus within the portal vein
—Cavernous transformation of the portal veins will appear as wormlike or serpiginous vessels within the region of the portal vein
 

24

Budd-Chiari Syndrome


—Obstruction of the hepatic venous outflow
—Etiologies include hypercoaguable states,oral contraceptives,collagen vascular diseases,hepatic tumors
—Portal vein thrombosis has been reported in approx 20% 
 

25

Clinical findings of Budd-Chiari Syndrome


—Ascites
—Elevated liver function test
—Hepatomegaly
—Splenomegaly
—Upper abdominal pain
 

26

Sonographic findings of Budd-Chiari Syndrome


—Nonvisualization or reduced visualization of the hepatic veins
—Thrombus within the hepatic veins
—Enlarged caudate lobe
—Lack of flow within the hepatic veins with color Doppler
—Narrowing of the inferior vena cava
 

27

Focal Abnormalities


—Must differentiate between intrahepatic or extrahepatic
—Extrahepatic-anterior displacement of the RK. Anteromedial shift of the IVC. Discontinuity of the liver capsule,
—Intrahepatic-Posterior displacement of the IVC. Displacement of the hepatic vascular radicles. External bulging of the liver capsule
 

28

Focal Liver Disease


—Hepatic cysts
—Hydatid Liver cyst
—Pyogenic Hepatic Abscess
—Amebic Hepatic Abscess
—Hepatic Candidiasis
—Hepatocellular Adenoma
—Hepatic Hematoma
—Cavernous Hemangioma
—Focal Nodular Hyperplasia
—Hepatic Lipoma
 

29

Hepatic cysts


—Congenital,traumatic,parasitic, or inflammatory in origin
—Well defined borders,anechoic,good posterior acoustic enhancement
—Symptoms-generally asymptomatic, may have epigastric pain
—Rt lobe more often affected
—Women more effected than men
 

30

Clinical findings of Hepatic Cysts


—Asymptomatic
—Normal liver function tests
—Polycystic kidney disease
 

31

Sonographic findings of Hepatic Cysts 


—Anechoic mass or masses with smooth walls and posterior acoustic enhancement
—May have irregular shapes
—Clusters of cysts may be noted
 

32

Infection
Pyogenic Abscess


—Results when bacteria enters the liver from the biliary tree,portal vein or hepatic artery
—Pyo(pus filled)
—Most common source is E Coli, but often the etiology is unknown
—Symptoms- fever,pain,n/v,diarrhea,and pleuritic pain
—100% mortality if left untreated
—Appears as round or oval mass,irregular walls,internal echoes
 

33

Clinical findings of a pyogenic hepatic abscess


—Fever
—Hepatomegaly
—Leukocytosis
—Possible abnormal liver function tests
—Right upper quadrant pain
 

34

Sonographic findings of a pyogenic abscess


—Complex cyst with thick walls
—Mass may contain debris,septations, and/or gas
—The air within the abscess may produce dirty shadowing or ring-down artifact
—Results from a spread of infection from an inflammatory condition such as appendicitis, diverticulitis, endocarditis, .. Bacteria enters the liver through the PV, HA, or from a surgery
 

35

Pneumocystis Carinii


—Most often associated with AIDS, but also affects bone marrow and organ transplant patients
—Appears as diffuse micro-echogenic foci without shadowing to macro-echogenic clusters of dense calcifications
 

36

Parasitic Disease


—Amebic abscess
—Parasites reach the liver  via the portal vein
—Amebiasis is contracted by eating contaminated food or water
—The organism often will remain confined to the GI tract and patient is asymptomatic, those who are symptomatic will present with diarrhea, and abd pain, increased WBC’s
—Appears as round or oval mass with internal echoes 
—Echinococcal cyst
—Parasite is found in areas of the world where dogs assist in cattle and sheep herding
—Daughter cysts develop within a parent cyst
 

37

Clinical findings of an Amebic Hepatic Abscess


—Recent travel out of the country
—This infection is caused by the protozoa E histolytica, which ascends the portal venous system
—Hepatomegaly
—Right upper quadrant or general abdominal pain
—General malaise
—Diarrhea (possibly bloody)
—Fever
—Leukocytosis
—Elevated liver function tests
—Mild anemia
 

38

Sonographic findings of amebic hepatic abscess


—Round, hypoechoic or anechoic mass or massed
—May contain debris
—Acoustic enhancement
 

39

Clinical findings of Hydatid Liver cyst


—Leukocytosis
—Low-grade fever
—Nausea
—Obstructive jaundice
—Right upper quadrant tenderness
—Sheep herding countries
 

40

Sonographic findings of hydatid liver cysts


—Anechoic mass containing some debris(hydatid sand)
—“Water lily” sign-wall of the endocyst seen floating within the pericyst
—“Mother” cyst containing one or more smaller “daughter” cyst
—Mass may contain some elements of dense calcification
 

41

Tumors-Benign- Pediatric


—Infantile hemangioendothelioma
—Most frequently see symptomatic vascular tumor of the liver in infants
—Most common in females <6 months old
—Symptoms, abdominal mass and high cardiac output due to av shunting throughout the tumor
—Appears as hyperechoic,hypoechoic or complex mass AV shunting may contribute to large draining veins and dialated prox aorta
 

42

Tumors-Benign- Adult


—Focal nodular hyperplasia (FNH)
—Second most common benign tumor seen in women < 40 years old
—Asymptomatic
—Appears as a subtle liver mass usually <5cm
—Has a well developed central and peripheral blood vessels coursing through seen with Color Doppler
 

43

Tumors-Benign


—Liver cell adenoma
—More frequently seen in women taking oral contraceptives
—Symptoms are palpable mass, severe RUQ pain due to rupture of the mass
—Appearance is variable ranging from hypoechoic to hyperechoic.  Solitary, well defined margins. Range in size to 15 cm
—Surgical resection recommended since these may become malignant
 

44

Tumors-Benign


—Lipomas
—Rare,comprised of mesenchymal elements
—All fatty liver tumors are not lipomas and differentials include angiomyolipoma and hepatoma.  Confirmation is made by CT
 

45

Tumors-Malignant-Pediatric 


—Hepatoblastoma
—Most common malignant tumor of childhood
—High incidence with children who have Beckwith-Wiedemann syndrome
 

46

Tumors-Malignant-Adult


—Hepatocellular carcinoma HCC
—Related to cirrhosis, hepatocarcinogens in food, and hepatitis B and C
—Symtoms – unexplained mild fever and weight loss, hepatomegaly
—Appearance varies from solitary mass to diffuse infiltration or multiple tumors
—Invades portal venous system and hepatic veins
 

47

Clinical findings of Hepatocellular Carcinoma


—Elevated alpha-fetoprotein
—Abnormal liver function tests
—Cirrhosis
—Chronic hepatitis
—Unexplained weight loss
—Hepatomegaly
—Fever
—Palpable mass
—Ascites
 

48

Sonographic findings of Hepatocelluar Carcinoma
 


—Solitary, small hypoechoic mass
—Heterogenous masses scatered throughout the liver
—Mass with a hypoechoic halo
 

49

Metastasis


—Primary source is from colon,lung and breast
—Spread to the liver via the portal vein,hepatic artery and lymphatics
—Appears as one of four patterns discrete echogenic, target or bullseye,discrete hypoechoic, cystic or diffusely inhomogenous
 

50

Sonographic findings of Hepatic Metastasis


—GI tract and pancreas tend to be calcified tumors
—Hypoechoic masses may be from the breast, lung, or lymphoma
—Hyperechoic masses may be from the kidney and pancreas
—“Target” or “bulls-eye” lesion may be from lung or colon
 

51

Liver Transplants


—Ultrasound is used for pre and post-op evaluation
—Pre-op, main focus is to evaluate portal vein size and patency. Patency of hepatic veins and hepatic artery
—Most common post op complication is hepatic artery thrombosis and infection