Pathology of the Liver – Flashcards
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What is obstructive disease and how is it treated?
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excretion of bile is obstructed resulting in liver malfunction, treated surgically
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What is diffuse or hepatocellular disease and how is it treated?
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affects the hepatocytes and interferes with liver function, treated medically
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An obstruction proximal to the cystic duct or intrahepatic leads to what?
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intrahepatic duct dialation
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A lesion distal to the cystic duct leads to dilation of what?
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intrahepatic duct and/or gall bladder (hydropic)
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A lesion distal to the cystic duct at the area of the pancreas head leads to dilation of what?
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intrahepatic duct and/or gall bladder, possibility of pancreatic duct
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Biliary obstruction proximal to cystic duct can be caused by what?
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metastatic tumor invasion of porta hepatis, lymph nodes
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Biliary obstruction can cause what?
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jaundice and pruritis
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What LFTs increase with biliary obstruction?
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direct bilirubin and alkaline phophatase
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How does biliary obstruction proximal to cystic duct appear on ultrasound?
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dilated tubular branching of intrahepatic ducts, seen best in periphery of the liver, difficult to see discrete lesion in porta hepatis, gall bladder may be normal
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What might biliary obstruction distal to the cystic duct be cause by?
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stones in common bile duct or stricture of the common bile duct
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What are symptoms of biliary obstruction distal to the cystic duct?
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jaundice, pruritis, RUQ pain, increase in LFTs direct bilirubin and alkaline phosphatase
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What may cause a biliary obstruction distal to the cystic duct near the pancreas head?
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stones in the CBD, pancreatic head mass, pancreatic pseudo cyst
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How might Common Duct strictures be diagnosed?
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Patient is post cholecystectomy, presents with jaundice and increased direct bilirubin and alk phos, intrahepatic duct dilation with absence of porta hepatis mass
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How does Passive Hepatic Congestion appear on ultrasound?
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dilation of IVC, SMV, HV, PV, and splenic veins may decrease in size with expiration and increase with inspiration
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How is Hepatitis A transmitted and how long does it last?
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fecal contamination, lasts less than 6 weeks, complete recover or death
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How is Hepatitis B transmitted and how long does it last?
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Blood stream, bodily fluids, sexual contact Most common and lasts longer than A
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How is Hepatitis C transmitted?
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blood, 1/2 cases become chronic
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How does acute hepatitis appear on ultrasound?
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normal liver or decrease in echogenicity, increase in PV wall echogenicity, hepatomegaly, gallbladder wall thickening
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How does chronic hepatitis appear on ultrasound?
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Increased echogenicity, coarse texture, decreased PV wall echogenicity, normal size
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How long does hepatitis last for it to be considered chronic?
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6 months
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What can chronic hepatitis cause?
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non-obstructive jaundice cirrhosis and liver failure
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What is the definition of hepatitis?
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inflammation of the liver
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What are the symptoms of hepatitis?
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Flu like symptoms, jaundice with hepatomegaly or splenomegaly
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What are the lab values of a hepatitis patient?
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increase in AST, increase in ALT that falls rapidly after several days, and increase in bilirubin leukopenia
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Why are cysts from trauma, parasites, or inflammatory changes not true cysts?
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no epithelial lining
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What are some acquired cystic masses?
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abscesses, hepatic candiasis (fungal infection), chronic graulomatous, echinococcal cyst
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What are the features of an extrahepatic lesion?
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Internal invagiation of the liver capsule Formation of a triangular fat wedge Discontinuity of liver capsule Anteriormedial shift of IVC Anterior displacement of right kidney
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What are the features of an intrahepatic lesion?
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Displacement of hepatic vascular External bulging of liver capsule Posterior displacement of IVC
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What are the routes that bacteria can enter the liver and cause an abscess?
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Biliary tree, Portal Vein, Hepatic Artery adjacent infection, hepatic cyst, trauma w/ direct contamination
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Which route does bacteria most often enter the liver by?
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Biliary tree
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What can cause bacteria to enter the biliary tree?
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Cholangitis and cholecystitis
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Which bacteria usually enters the liver through the biliary tree?
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E. coli
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What usually causes bacteria to enter the liver through the portal vein?
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Diverticulitis Appendicitis
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What usually causes bacteria to enter the liver through the hepatic artery?
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Osteomyelitis bacterial endocarditis
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Where can a liver abscess be located?
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subhepatic, subphrenic, intrahepatic
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What are clinical symptoms of a pyogenic liver abscess?
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fever, pain, pleuritis, nausea, vomiting, diarrhea, malaise, anorexia, RUQ pain, jaundice
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What are lab values in a patient with pyogenic liver abscess?
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increased WBC (leukocytosis) elevated LFT anemia
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What is the sonographic appearance of a liver abscess?
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round or ovoid, from 1cm to very large, anechoic to highly echogenic w/ most of abscess less echogenic than liver, right lobe 80% of the time, solitary 90% of the time, irregular wall, posterior enhancement 50% of the time, comet tail from air bubble in abscess or in biliary ducts
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What are differential diagnosis for pyogenic abscesses?
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amebic or echinococcal infection, simple cyst w/ hemorrhage, hematoma, necrotic cystic neoplasm, cystadenoma
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What is Candidiasis infection?
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Candia, a yeast like fungus, spreads to liver, kidneys, brain, and heart via bloodstream
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What patients are usually affected by candidiasis?
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Immunocompromised: chemotherapy, organ transplant, HIV, pregnancy
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What are clinical symptoms of candidiasis?
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fever, neutropenia, non specific abdominal pain
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What are the sonographic findings of a candidiasis infection?
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early stages: "wheel within wheel" later: multiple target "bulls eye" lesions and echogenic foci uniform hypoechoic lesions
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What is amebic infection most often caused by?
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protozoan parasite entamoeba histolytic, from ingestion of contaminated food and water (out of USA travel)
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How does an amebic infection reach the liver?
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travels through colon to mesenteric to portal vein to liver
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What are the symptoms and clinical findings of a patient with amebic infection?
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GI symptoms (pain, diarrhea, melena (black tarry stool)), leukocystosis, fever, possible abnormal LFTs
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What is the sonographic finding of a liver with with amebic abscess?
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Same as pyogenic abscess, usually in periphery of the liver
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What is the prognosis for amebic abscess?
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Amebicidal drugs effective within within 24-48 hours Drainage may be necessary if patient deteriorating Residual cyst and and focal lesions up to 23 months after treatment
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What is an echinococcal (hydatid) cyst caused by?
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Echinococcus granulosis tapeworm- eggs hatch in intestines of host and travel through mesenteric to portal veins
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What are the clinical symptoms of an echinococcal cyst?
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Acute RUQ pain usually right lobe, hepatomegaly, epigastric mass (round and mobile), elevated WBC, components-ectocyst, peri cyst, endocyst
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What is the sonographic appearance of an echinococcal cyst?
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Varies depending on stage of larvae -Discrete simple cyst with thick or calcified wall or large cyst with smaller cyst within (early disease) -Cystic mass with thick septi between fluid- honeycomb appearance, when germinal layer collapses can have the water lily sign or honeycomb look
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What does the complete wall calcification of an echinoccocal cyst usually indicate?
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inactive lesion
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What is the treatment for echinoccocal cysts?
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Usually surgery, sometimes drainage
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What is schistosomiasis?
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Most common parasite in humans, from wading in contaminated water Worms (cercaria from snails) puncture skin and travel through lymphatic and venous systems to urinary or portal system
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What can schistosomiasis cause?
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granulomatous reaction and fibrosis along portal branch
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What are the sonographic findings of schistosomiasis?
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Liver normal to small, portal vein walls increased thickness and echogenicity, terminal portals occulted leading to periportal fibrous, portal hypertension, splenomegaly portosystemic venous collaterals
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What is pneumocystitis carinii?
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Most common organism causing infection in AIDS patients, most life threatening
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How is pneumocystitis carinii spread to liver?
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extra pulmonary Pneumocystitis carinii can spread to liver especially in patients that used aerosolized pentamidine
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How does P. carinii appear sonographically?
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Diffuse, tiny, non shadowing, echogenic foci to echogenic clumps calcification
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What is fatty infiltration?
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An aquired reversible condition resulting from deposits/accumulation of fatty lipids within liver cells secondary to cell injury or impaired fat metabolism
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What is the most common cause of fatty infiltration?
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obesity
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What is fatty infiltration associated with?
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Diabetes mellitus, jejunoileal bypass, alcohol abuse, chronic illness or early cirrhosis, severe hepatitis, corticosteroid therapy, hyperlipidemia, glycogen storage disease, chemotherapy, pregnancy, starvation, Kwashiorkor, Reye syndrome
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What are the clinical signs of fatty infiltration?
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Normal to increased liver size, increased alk phos, increased direct bilirubin
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What is the sonographic appearance of fatty infiltration?
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Normal size or hepatomegaly, diffuse increase in liver echogenicity, increased attenuation making it difficult to image deeper, focal infiltrates patchy, focal sparing
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How does focal sparing appear?
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hypoechoic area, anterior to porta hepatis, usually smooth borders, mistaken for metastases, vessels are undisturbed, rapid change
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What is cirrhosis?
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Chronic end stage disease of the liver from loss of functioning cells of the liver that are replaced by fibrosis and liver cell nodules
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What is the most common cause of micronodular cirrhosis?
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ETOH
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What is the most common cause of macronodular cirrhosis?
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Chronic viral hepatitis
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What is the 6th leading cause of death in USA?
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cirrhosis
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Cirrhosis causes increased incidence of what?
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hepatoma
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What are the causes of cirrhosis?
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drugs, viruses, alcohol abuse, heredity, and unkown
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What are the clinical presentations of cirrhosis?
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nonobstructive jaundice, abdominal pain, ascites, nausea, weight loss, weakness, spider angiomas of the face, hepatomegaly, increase in bilirubin, AST, ALT, and alk phos, leukopenia
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What is the sonographic appearance of cirrhosis?
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hepatomegaly early, small liver later coarse echo texture, nodular surfaces, regenerating nodules, dysplastic nodule (adenomatous hyperplastic nodules), portal hypertension, increased HA flow, splenomegaly, ascites
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How does cirrhosis affect the Doppler characteristics of hepatic veins?
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abnormal decreased amplitude, loss of reversed flow and flattened waveform, luminal narrowing
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What is the sonographic appearance of late stage cirrhosis?
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Echogenic coarse liver texture with surface nodularity (heterogeneous), smaller atrophied liver, causate lobe enlargement, poss IVC compression
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What is glycogen storage disease?
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Autosomal recessive genetic disorder of carbohydrate metabolism
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What is the most common type of glycogen storage disease?
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Type 1 Von Gierke's
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What does glycogen storage disease do?
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Increased glycogen in hepatocytes, kidneys, and intestines, but LFTs normal
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What is glycogen storage disease associated with?
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liver cell adenomas, focal nodular hyperplasia, nephromegaly
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What is the sonographic appearance of glycogen storage disease?
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hepatomegaly, fatty inflitrate with increases attenuation
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What is hematochromatosis?
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Rare disease that causes excessive iron deposits throughout body
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What may hematochromatosis lead to?
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cirrhosis and portal hypertension
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What are the sonographic findings of hemochromatosis?
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nonspecific, hepatomegaly and cirrhotic changes, increased chance of hepatocellular carcinoma
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What are benign hepatic neoplasms?
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They originate from the hepatic parenchymal cells or bile duct epithelium and do not spread or invade surrounding areas
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What are some examples of benign hepatic neoplasms?
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cavernous hemangioma, focal nodular hyperplasia (FNH), liver cell adenoma, hepatic lipoma, angiomyolipomas
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What is the most common benign tumor of the liver?
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Cavernous hemangioma
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What are cavernous hemangiomas composed of?
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Large network of vascular endothelium lined spaces filled with RBC and may contain thrombi
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What is the usual location and size of a cavernous hemangioma?
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Right lobe, less than 3 cm, in females
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How do cavernous hemangiomas appear on ultrasound?
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Small, round, echogenic, homogeneous, sharply marginated solid mass Degeneration and fibrotic changes cause it to appear heterogeneous Subcapsular or peripheral location Acoustic enhancement in larger hemangiomas (slow blood flow not usually demonstrated with US without contrast)
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How are cavernous hemangiomas diagnosed?
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2 confirmatory studies: CT, MRI, SPECT, US, micro bubble contrast
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What is the second most common benign liver mass?
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Focal nodular hyperplasia (FNH)
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What is FNH and what is it composed of?
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Rare benign tumor composed of abnormally arranged hepatocytes, Kupffer cells, bile ducts, and fibrous connective tissue
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What are the risk factors for FNH?
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Females under 40 Use of oral contraceptives (increased chance of hemorrhage)
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What can FNH cause?
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Displacement of normal blood vessels
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What are the sonographic findings of FNH?
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Right lobe or lat left usually, up to 20 cm in size but usually less than 5 cm Central scar from fibrous septation if multiple nodules (hypoechoic linear stellate area) Variable echogenicity, can be "stealth lesion" May have large feeder vessel
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What is hepatic adenoma?
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Normal or slightly atypical hepatocytes can contain areas of bile stasis and hemorrhage or necrosis
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What is the difference between hepatic adenoma and FNH?
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Few or absence of bile ducts and Kupffer cells
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What are the risk factors for hepatic adenoma?
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Woman using long term oral contraceptives Men using anabolic steroids Patients with Von Gierke's
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What are the sonographic findings of hepatic adenoma?
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Solitary, well encapsulated from 8-15 cm Echogenicity- hypoechoic, isoechoic, mixed, echogenic, calcific Difficult to distinguish from FNH
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What are biliary hematomas von Meyenburg complexes?
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Small focal benign liver formation, developmental lesion of groups of dilated biliary ducts
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How do von Meyenburg complexes appear on ultrasound?
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Bright echogenic foci, usually less than 1 cm and hypoechoic Can be confused with metastatic cancer
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What is infantile hemangioendothelioma?
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Benign overgrowth of endothelium of minute capillary vessels in infants
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What is the most common symptomatic vascular tumor in infancy?
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Infantile hemangioendothelioma
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What are the risk factors for infantile hemangioendothelioma?
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Females 2:1 85% before six months of age
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What are the clinical signs of infantile hemangioendothelioma?
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Abdominal mass, normal AFP (excludes hepatoblastoma), CHF common due to shunting Can also develop: thrombocytopenia, angiopathic anemia, GI bleeding, and intra-abdominal rupture with hemorrhage
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What are the sonographic findings of infantile hemangioendothelioma?
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hyperechoic, hypoechoic, or mixed Multiple hypoechoic lesions 1-3 cm with hyperechoic margins and low level internal echoes Large draining vein and dilated proximal aorta may be seen in lesion with AV shunting Aorta distal to celiac usually normal size
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What is mesenchyma harmartoma?
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Rare developmental unencapsulated cystic tumor of the liver occurring in children under 2
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What are the sonographic findings of mesenchyma harmartoma?
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Well defined large complex mass 5-30 cm More common in right lobe Mostly anechoic with lace like configuration If multiple small cysts may appear more solid or hyperechoic
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What are hepatic lipomas?
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Rare, associated with renal angiolipomas and tuberous sclerosis
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How do hepatic lipomas appear sonographically?
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Well defined echogenic mass Differentials- metastasis, hemangioma, focal fat
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How do hepatic angiomyolipomas appear on ultrasound?
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Well defined echogenic mass on ultrasound Difficult to differentiate on CT due to less fat content
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What is the most common malignant tumor in children and infants?
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hepatoblastoma
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What is hepatoblastoma?
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Malignant germ cell tumor- either epithelial or mix epithelial and mesenchymal cell
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What increases the incidence of hepatoblastoma?
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Beckwith syndrome and hemihypertrophy
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What are the clinical signs of hepatoblastoma?
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abdominal enlargement, hepatomegaly, weight loss, nausea, vomiting, precocious puberty, high AFP
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What are the sonographic findings of hepatoblastoma?
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heterogeneous, hyperechoic mass or cystic with internal echoes (septations), occasional calcifications
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What are some malignant tumors of the liver?
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Hepatocellular carcinoma (HCC) (hepatoma), Hepatic angiosarcoma, hepatoblastoma, metastasis, lymphoma- hodgkins and nonhodgkins
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What is HCC?
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hepatocellular carcinoma aka hepatoma primary liver cancer attacks portal venous wall, invades vessel lumen
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What is the most common primary liver cancer?
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HCC
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What percent of cases of HCC have cirrhosis?
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80%
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What is HCC related to?
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Cirrhosis in the west Hep B and C, food carcinogens, and metabolic disorders more worldwide
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What are the clinical signs of HCC?
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RUQ pain, abd swelling (ascites), palpable mass Rapid increasing hepatomegaly Weight loss More in 6th decade women Signs of cirrhosis, jaundice, portal hypertension, ascites
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What are the lab values in HCC?
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LFTs normal except AFP increased in 70%
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How does HCC affect the veins?
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Can invade hepatic veins causing budd chiari Thrombosis or invasion into portal system 30-68% of the time Can invade hepatic veins and biliary tree 13% of the time
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What are 3 sonographic patterns of HCC?
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Solitary tumor Multiple nodules Diffuse parenchymal invasion
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What is the sonographic echogenicity of HCC?
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Smaller masses tend to be hypoechoic Larger masses more hyperechoic Isoechoic possible
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What are other sonographic findings of HCC?
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ascites, portal/hepatic/duct invasion, difficult to distinguish from metastasis, rarely calcification, hypervascular
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What is the fibrolamellar carcinoma form of HCC?
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Found in young patients without coexisting liver disease and with normal AFP
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How does fibrolamellar carcinoma form of HCC appear sonographically?
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solitary well defined 6-22 cm variable echogenicity May see punctate calcification with central echogenic scar which is not usual in HCC
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What is hepatic hemangiosarcoma/angiosarcoma?
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Rare and in older adults, associated with carcinogens like arsenic, thorotrast, and polyvinyl chloride, malignant tumor originating from blood vessels, rapidly metastasizes
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What are the US findings of hepatic angiosarcoma?
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Large mass of mized echogenicity, sold mass with areas of decreased echogenicity secondary to hemorrhage and necrosis
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What is EHE?
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Hepatic epithelioid hemangioendothelioma rare vascular origin, nodules coalesce and foci may be seen diagnosed with biopsy
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What is the most common site of metastasis?
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Liver
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What is a more common malignancy in the liver than HCC?
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metastasis
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How does metastasis present?
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Jaundice, pain, and hepatomegaly 50% of time Abnormal hepatocellular function (increased alk phos, direct bilirubin, LFTs)
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How is metastasis spread to the liver?
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Portal veins (from GB, colon, breast, lung) Lymphatic (from stomach, pancreas, ovary, uterus)-often causes hepatomegaly Hepatic artery and direct invasion less often
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What are the sonographic characteristics of metastasis?
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Multiple nodules throughout the liver common, sometimes calcification, sometimes cystic degeneration, usually discrete multiple lesions
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What are anechoic findings of metastasis suggestive of?
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lymphomatous
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What are hypoechoic findings of metastasis suggestive of?
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breast and lung
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What are hyperechoic findings of metastasis suggestive of?
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renal cell, carcinoid, choriocarcinoma, islet cell
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What are echogenic findings of metastasis suggestive of?
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GI anechoic or diffuse patterns
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What are bulls eye findings of metastasis suggestive of?
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edema around tumor lung
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What are calcified findings of metastasis suggestive of?
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mucinous adenocarcinoma, colon, pancreatic tumor, leiomyosarcoma, adenocarcinoma, neuroblastoma, osteogenic ovarian cystadenoma
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How is ultrasound used for metastasis?
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Follow progress: no change, size or spreading, pattern change
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How is ultrasound used in hepatic blunt trauma?
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Follow up from CAT, right posterior lobe most common, hepatic infarct rare because dual blood supply
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What are the three categories of liver trauma?
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Rupture of liver and capsule, separation of capsule/subscapular hematoma, central rupture of liver
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What is the echogenicity of liver hematoma based on age?
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Less than 24 hours: fresh hemorrhage, echogenic echodense due to fibrin and erythrocytes layering 7 days: more hypoechoic reabsorption 2-3 weeks: indistinct, anechoic, more reabsorption
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What are the clinical signs of liver trauma?
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decrease in hematocrit, collapse and shock, decrease in BP and heart rate
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Why are portasystemic shunts done?
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To decompress patients with portal hypertension: mesocaval, distal splenorenal, mesoatrial, portal caval Identify for patency: anastomosis or hepatofugal flow
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What are TIPS?
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Transjugular Intrahepatic Portosystemic Shunts metal stent inserted between hepatic vein usually RHV to RPV or MPV (intrahepatic portal)
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How are TIPS evaluated with US?
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Doppler: stent in 3 location w/ angle corrected, hepatic arteries and veins, portal veins Indicate failure: stent occlusion, stenosis, hepatic venous stenosis
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What is a Percutaneous Liver Biopsy?
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percutaneous drainage and aspiration and ethanol injection
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What are the contraindications of percutaneous liver biopsy?
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bleeding disorders, unsafe access route, patient who cannot cooperate
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What is the accuracy rate of percutaneous liver biopsy?
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90%
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How is US used in operation?
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Sterile 7.5 mhz transducer in open abdomen, can identify lesions to small to be seen TA, can help with identification for resection
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What is the hallmark sign of budd chiari?
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massive ascites
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What are other signs of budd chiari on US?
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hepatomegaly, enlarge caudate and atrophy of the right lobe due to different vascular supplies, extensive hepatic or IVC thrombosis, difficult to visualize HV due to invasion and lack of flow, hypoechoic early, hyperechoic later
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How is budd chiari treated?
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liver transplant (only in non malignant cause) otherwise fatal
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How does lymphoma appear on ultrasound?
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hepatomegaly, change in parenchyma, focal mass, diffuse, splenomegaly or retroperintoneal node
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How does hodgkin's lymphoma appear on US?
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hypoechoic and diffuse pattern in liver
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How does non hodgkins lymphoma appear on US?
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target and echogenic mass
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How does Burketts lymphoma appear on US?
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intrahepatic and lucent
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How does leukemia appear on US?
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small multiple discreet masses, bullseye lesion due to necrosis
