Liver

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Author:
Digigirl333
ID:
153900
Filename:
Liver
Updated:
2012-05-15 00:56:32
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Liver Ultrasound
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Description:
Abdomen Exam
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  1. What are the four functions of the liver?
    • 1) Metabolism
    • 2) Storage
    • 3) Detoxification
    • 4) Digestion
  2. What are three types of cells in the liver?
    • 1) Hepatocytes
    • 2) Kupffer cells
    • 3) Biliary epithelium
  3. What is the purpose of hepatocytes?
    Metabolic functions
  4. What is the purpose of biliary epithelium?
    Allows for exchange of nutrients and hepatocyte product exchange
  5. What is the purpose of Kupffer cells?
    Phagocytosis
  6. How many portal triads are around each central vein?
    6
  7. What does the liver metabolize?
    • Carbohydrates - glucose -> glycogen -> glucose
    • Fats - absorbed from intestines -> lipoproteins
    • Proteins - Albumin, fibrogen, prothrombin, etc
  8. What does the liver store?
    • Vitamins A, D, B12
    • Glycogen
    • Fats
    • Amino Acids
    • Iron
    • Poisons/Drugs unable to be broken down
  9. What is ALT?
    • Alanine aminotransferase
    • Enzyme produced by liver
    • AKA SGPT
  10. When is ALT elavated?
    • Hepatocellular disease and obstructive jaundice
    • All forms of hepatitis
    • chock and drug toxicity (cell death)
  11. What is AST?
    • Aspertate aminotransferase
    • Produced by liver, muscle, and other tissues with high metabolic rates
    • AKA SGOT
  12. When is AST elavated?
    • Hepatocellular disease
    • Significantly incresed with cirrhosis and acute hepatitis
    • Fatty changes, mets, injury
  13. What causes AST elavation not associated with the liver?
    • Mononucleosis
    • Myocardial infarction
  14. What is ALP?
    • Alkaline phosphatase
    • Enzyme in the cells lining the biliary ducts
    • Also present in bone, kidneys, intestines and placenta
    • Most sensetive indicator of obstruction
  15. When is ALP elvated?
    • Diseases of bile ducts (Obstruction, Sclerosing cholangitis, Biliary cirrhosis) - Severe
    • Hepatocellular disease (Abscesses, Carcinoma, Cirrhosis) - Mild to Moderate
  16. When is Conjugated/Direct Bilirubin increased?
    Obstruction
  17. When is Unconjugated/Indirect Bilirubin increased?
    • Hemolytic diseases
    • Trauma (Hematoma)
  18. When is Total Bilirubin increased?
    • Mets
    • Lymphoma
    • Cholestasis secondary to drugs
    • Cirrhosis
    • Hepatitis
  19. What is LDH?
    • Lactic Dehydrogenase
    • Produced in liver, skeletal muscle, kidneys, etc
    • Primarily used to detect pulmonary and myocardial infarctions
  20. When is LDH elavated?
    • May increase with chronic hepatocellular disease or obstructive jaundice
    • Moderate increase with Mono
    • Mainly used to detect myocardial and pulmonary infarctions
  21. What is Albumin?
    • Transport protein synthesized by the liver
    • Helps maintain oncotic pressure
  22. When is Albumin decreased?
    Hepatocellular disease (Decreased protein synthesis)
  23. What is PT?
    • Prothrombin time
    • Clotting factor affected by level of vitamin K
  24. When is PT prolonged?
    • Cirrhosis
    • Mets
  25. When is PT shortened?
    • Extrahepatic obstruction
    • GB carcinoma
    • Cholecystitis
  26. What is AFP?
    • Alpha fetoprotein
    • Produced in fetal liver
  27. When is AFP elavated?
    • HCC
    • Hepatoblastomas
  28. What should be assesed during liver scan?
    • 1) Size
    • 2) Texture
    • 3) Ligaments/Fissures
    • 4) Vasculature
    • 5) Attenuation
  29. What is Diffuse liver disease?
    • Affects hepatocytes
    • Includes fatty changes, cirrhosis, hepatitis,
    • Evaluated through LFTs
  30. What is fatty infiltration?
    • Accumulation of lipids in hepatocytes
    • Results in cell injury and impaired fat metabolism
    • Often asymptomatic
    • Can be reversible
  31. What does fatty infiltration look like on u/s?
    • Hyperechoic (fat in cells)
    • Hepatomegaly over time
    • Increased attenuation (difficult to see posterior)

    • Focal Fatty Infiltration: Non-uniform
    • Focal Sparing: Hyperechoic w/hypoechoic sparing, usually in medial left lobe anterior to PH
  32. What is Hepatitis?
    • Inflammation of the liver
    • A - fecal route
    • B - blood
    • C - non A, non B
  33. What are characteristics of acute hepatitis?
    • Recovery within 4 months
    • Flu-like GI symptoms
    • Elavated AST and Total Bilirubin
    • Elavated ALT w/rapid decrease after several days
  34. What are characteristics of chronic hepatitis?
    • Lasts > 6 months
    • Fatigue
    • Jaundice (Non-obstructive)
    • Can progress to cirrhosis or liver failure
  35. What is the sonographic appearance of acute hepatitis?
    • Normal
    • Decreased echogenicity
    • Increased Portal wall appearance
    • Possible hepatomegaly
    • GB wall thickening
  36. What is the sonographic appearance of chronic hepatitis?
    • Increased echogenicity (fatty changes and fibrosis)
    • Coarse texture
    • Decreased PV echogenicity
  37. What is cirrhosis?
    • Scarring - irreversible
    • Fibrosis, necrosis and regeneration of parenchyma (disorganized appearance)
    • 60-70% caused by alcoholism
  38. What are characteristics of cirrhosis?
    • Elavated AST, ALT, Total Bilirubin
    • Ascites
    • Portal hypertention
    • Splenomegaly
    • Jaundice
  39. What is the sonographic appearance of cirrhosis?
    Early - hepatomegaly, fatty infiltration, increased echogenicity, increased attenuation

    Late - atrophy of right lobe, caudate enlargement, echogenic coarse texture w/nodules, heterogenous
  40. What is glycogen storage disease?
    • Von Gierke Disease - most common
    • Abnormally large amounts of glycogen deposited in liver and kidneys
    • Diagnosed w/blood tests
  41. What is the u/s appearance of glycogen storage disease?
    • Hepatomegaly
    • Increased echogenicity
    • Slightly increased attenuation
    • Associated with adenomas and FNH
  42. What are the characteristics of congenital liver cysts?
    • simple
    • solitary
    • small - 20mm
    • asymptomatic
    • from defect in bile ducts
    • anterior right lobe
  43. What are the characteristics of polycystic liver?
    • associated with PCKD
    • autosomal dominant
    • multiple, simple cysts <3cm
  44. What are the characteristics of pyogenic abcess?
    • variable, puss filled cysts
    • solitary
    • irregular, round/ovoid
    • dirty shadowing, comet tail, microbublbles
    • associated with biliary obstruction and infection
  45. What are the characteristics of candidiasis?
    • fungal infection
    • immunocomprimised patients (AIDS, chemo)
    • elevated wbc
    • ruq pain
    • multiple small hypoechoic lesions
    • may have target/bull's eye appearance w/echoigenic center
  46. What are the characteristics of granulomatous disease?
    • autosomal recessive
    • congenital defect in leukocytes
    • children
    • recurrant respiratory infections
    • Poorly marginated, hypoechoic
    • possible post enhancement or calcification w/shadowing
  47. What are the characteristics of amebic abcesses?
    • asymptomatic or GI sypmtoms w/leukocytosis and fever
    • non-specific appearance
    • hypoechoic, lack of wall echoes, internal echos from debris
  48. What are the characteristics of echinococcal (hydatid) cysts?
    • common in sheep-herding areas
    • caused by a tapeworm
    • daughter cysts
    • "water-lily" sign / cyst within a cyst
    • possible calcifications
    • septations, honeycomb appearance
  49. What are characteristics of portal hypertension?
    • >10mmHg in portal vein
    • PV >13mm
    • possible collaterals
    • acites
    • splenomegaly
    • GI bleeding - vomit blood, blood in stool
    • Jaundice
    • Elavated LFTs
  50. What is the most common cause of portal hypertension?
    cirrhoisis
  51. What does TIPS stand for?
    Transjugular-intrahepatic-portosystemic-shunt
  52. Portal vein thrombosis is associated with _______ ?
    Malignancy
  53. What are two causes for Budd-Chiari syndrome?
    Congenital obstruction or thrombus in IVC or main hepatic veins
  54. What are characteristics of Budd-Chiari?
    • Thrombus in IVC/HVs
    • hepatomegaly and splenomegaly
    • ascites
    • enlarged caudate and eventual atrophy of rt lobe
    • portal hypertension
    • associated with HCC (invades Hepatics)
  55. What can a arterial-portal fistula result from?
    percutaneous liver biopsy or trauma
  56. What can cause porto-hepatic venous shunts?
    Congenital or related to portal hypertension
  57. What does an intrahepatic-portosystemic shunt fistula look like on ultrasound?
    • complex vascular channels connecting portal vein to hepatic vein or IVC
    • bidirectional flow
  58. What are characteristics of beinign tumors?
    • Originates from liver parenchyma or bile duct epithelial
    • Slow growing
    • Asymptomatic
    • Low vascular flow
    • Doesn't invade surrounding structures
  59. What are characteristics of cavernous hemangiomas?
    • collection of blood vessels
    • solitary, "solid" mass
    • <5 cm
    • very echogenic
    • right lobe along periphery
    • Women > Men
  60. What is the most common benign tumor of the liver?
    Cavernous hemangioma
  61. What are characteristics of adenomas?
    • Associated w/birth control and glycogen storage disease
    • Hypoechoic mass w/possible hyperechoic center w/bleed
    • Pain w/rupture
  62. What is the second most common benign liver mass?
    Focal nodular hyperplasia (FNH)
  63. What are characteristics of FNH?
    • Composed of abnormally arranged liver parenchyma (vascular malformation)
    • Asymptomatic
    • Women <40 yrs
    • Subcapsular area
    • Well-defined, hyperechoic to isoechoic mass with depressed center
  64. What are characteristics of malignant tumors?
    • Grow rapidly
    • vascular
    • invade surrounding structures
    • Usually from mets
  65. What is the most common primary malignant liver tumor?
    Hepatocellular carcinoma (HCC)
  66. What is another name for HCC?
    Hepatoma
  67. What are the 3 main types of malignancies in the liver?
    • HCC
    • Hepatoblastoma
    • Mets from colon, breast or lung
  68. What is a predisposing factor of HCC in the US?
    Cirrhosis
  69. What are predisposing factors of HCC outside of the US?
    Hepatitis B and Aflatoxin exposure
  70. What are clinical characteristics of HCC?
    • Men
    • History of cirrhosis or hep B or C
    • Palpable mass
    • hepatomegaly
    • appetite disorder
    • fever
    • Possible AFP increase (70% of patients)
  71. What are the three presentations of HCC?
    • 1) solitary, massive tumor
    • 2) multiple nodules throughout liver
    • 3) diffuse infiltrative masses in liver
  72. What is the ultrasound appearance of HCC?
    • Variable
    • hypoechoic to hyperechoic
    • isoechoic w/hypoechoic halo
    • diffuse heterogenous texture invading parenchyma
    • Invasion into hepatic veins/IVC
  73. What lab values are expected with mets?
    Increased AFP, ALP, and direct bilirubin
  74. What are clinical characteristics of mets?
    • Jaundice
    • Hepatomegaly
    • Weight loss
    • Increased LFTs (AFP, ALP, DB)
  75. How does mets appear on u/s?
    • Multiple
    • Anechoic to hyperechoic
    • Complex, target lesions
  76. What are characteristics of lymphoma?
    • Night sweats
    • Bone pain
    • Fever
    • Weight loss
    • Fatigue
    • Abdominal mass
  77. How does lymphoma appear on u/s?
    • enlarged lymph nodes around aorta (cluster of grapes)
    • variable appearance of lesions depending on type of lymphoma
  78. What are characteristics of hepatoblastomas?
    • Most common liver malignancy in children
    • Precocious puberty
    • Palpable mass
    • Elavated AFP
    • Heterogenous, hyperechoic or cystic w/internal septations
    • Occasionally calcify
  79. What are the two most common reasons for liver transplants?
    • Cirrhosis
    • Sclerosing Cholangitis

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