CAHE ABDOMEN II- LIVER PART I
Terms in this set (137)
INTRAperitoneal with bare area uncovered
4 hepatic liver lobes
right, left, caudate & quadrate
largest lobe of the liver
what divides the right lobe of the liver?
the right hepatic VEIN into anterior & posterior segments
what divides the left lobe of the liver?
the left hepatic vein into medial & lateral segments
how do the portal veins course the liver?
through the segments of the liver (INTRAsegmental)
normal blood flow in portal veins
-low velocity continuous flow
what provides 75% of the liver's blood flow?
the portal veins with nutrient rich blood
portal veins size as they approach diaphragm
they decrease in size
how do you get an image showing the IVC, MPV and LPV together?
just to the right of midline in a longitudinal axis
3 hepatic veins
right middle and left
where do hepatic veins drain into?
how do hepatic veins course in the liver?
intersegmental & interlobar
what happens to the size of hepatic veins as they approach diaphragm?
increase in size
blood flow pattern of hepatic veins
normal tissue of the liver
-medium grey shade
-equal to or slightly greater in echogenicity to parenchyma of right kidney
-slightly less echogenic than pancreas
-isoechoic or slightly hyperechoic compared to normal spleen
Aspartate aminotransferase (AST)
liver function test to see if there is any elevation of enzyme released with liver damage
Aspartate aminotransferase (AST) elevation is associated with what diseases?
Alanine aminotransferase (ALT) liver function test
-more specific than AST for evaluating liver function
-remains elevated longer than aspartate aminotransferase (AST).
diseases associated with ALT elevation
diseases associated with Alkaline phosphatase (ALP) elevation
Alpha-fetoprotein liver function test
a protein normally synthesized by the liver, yolk sac, and GI tract of the fetus
diseases associated with Alpha-fetoprotein liver function test increase
diseases associated with Lactic acid dehydrogenase (LDH) elevation
diseases associated with increase in Gamma Glutamyl Transpeptidase (GGT)
increased in diseases causing acute damage to liver/bile ducts
what does Increased GGT + increased ALP indicate?
what does Increased GGT + increased ALT indicate?
a product of the breakdown of hemoglobin in tired RBCs
causes of increase in serum bilirubin
excessive amount of RBC destruction & malfunction of liver cells
what gives skin a jaundiced coloration?
a rise in serum bilirubin leaking into the tissues
Indirect bilirubin (unconjugated bilirubin)
-elevation seen with increased red blood cell destruction (anemias)
what conditions is Indirect bilirubin (unconjugated bilirubin) associated with?
non obstructive conditions
Direct bilirubin (conjugated bilirubin)
elevation usually related to obstructive jaundice from stones or neoplasm obstructing ducts
Prothrombin time (PT)
seconds it takes for blood to coagulate
normal clotting time
when is Prothrombin time (PT) increased?
in presence of liver disease with cellular damage
what does a decrease in serum albumin suggest?
a decrease in protein synthesis
when might a striking elevation of AST and ALT be observed?
in severe hepatocellular destruction, such as acute, viral, or toxic hepatitis
a tongue like extension of the right hepatic lobe most common in women
how to differentiate reidel's lobe from hepatomegaly
examine left lobe for enlargement too
papillary process of the caudate lobe
liver variant where papillary process can appear to resemble a mass
appearance of the papillary process of the caudate lobe
may appear separate from liver mimicking lymph nodes or a pancreatic mass
hepatocellular liver disease classification
diseases affecting the liver when liver cells (hepatocytes) are destroyed & interferes with liver function causing disease
hepatocellular classification of liver disease example
obstructive liver disease classification
when something is blocking normal function of the liver causing disease
obstructive liver disease classification example
when bile excretion is blocked
organs reversed- liver is on the left and spleen is on right side
vascular anomalies of the liver- "replaced right hepatic artery"
right hepatic artery originates from SMA & is seen posterior to MPV
diffuse parenchymal liver disease
- fatty infiltration
-alcoholic liver disease
fatty liver disease
-acquired reversible disease characterized by deposits of fat within liver cells
causes of fatty liver disease
-diabetes mellitus (most common cause)
-glycogen storage disease
clinical findings of fatty liver disease
-some present with jaundice
-pain with elevated liver function tests
sonographic findings of fatty liver disease
-focal fatty infiltration
-focal fatty sparing
diffuse infiltration of fatty liver disease
-liver appears diffusely echogenic with walls of hepatic vasculature/diaphragm not easily imaged
-more difficult to penetrate
focal fatty infiltration
liver segment affected by focal infiltration of fat
how does focal fatty infiltration appear on sonogram?
appears as an area of increased echogenicity like a solid, hyperechoic mass
focal fatty sparing
entire liver is not affected & areas of liver may be spared from fatty infiltration
focal fatty sparing sonogram appearance
localized regions of decreased echogenicity within fatty echogenic liver
where is focal fatty sparing usually seen?
-adjacent to porta hepatis or right portal vein
-left medial segment of left lobe
what fatty liver changes can occur in the same places?
focal fatty sparing & infiltration
sonographic findings for focal fatty infiltration and sparing
1. location in area= characteristic of fat deposition or sparing
2. absence of mass effect on vessels and other liver structures
3. geographic configuration rather than round/oval
4. poorly delineated margins
5. fat content
classification of fatty infiltration
grade I classification of fatty infiltration
increased hepatic echogenicity with normal visible periportal/diaphragmatic echogenicity
grade II classification of fatty infiltration
increased hepatic echogenicity with imperceptible periportal echogenicity, without obscuration of diaphragm
grade III classification of fatty infiltration
increased hepatic echogenicity with imperceptible periportal echogenicity and obscuration of diaphragm
inflammation of the liver that can lead to cirrhosis, portal hypertension & hepatocellular carcinoma
what does hepatitis result from?
infection (viral bacteria) or non infectious (medication, toxin or autoimmune disorder)
most common types of hepatitis
symptoms of hepatitis
what might elevate from hepatitis
elevation of ALT, AST, conjugated and unconjugated bilirubin
-a contagious liver disease resulting from infection with hepatitis A virus
-ranges in severity from mild to severe illness
how is hepatitis a usually spread?
when a person ingests fecal matter with food or drinks contaminated by feces or stool of infected person
how is hepatitis B spread?
-by blood, semen or another bodily fluid
-through sexual contact or sharing needles/syringes
-can be passed from infected mother to infant at birth
results of chronic hepatitis B
increases patient's risk for developing cirrhosis or a carcinoma (hepatoma)
how is hepatitis C spread?
usually by blood
results of chronic hepatitis C
can result in long-term health problems or death
sonographic findings of acute hepatitis
-liver appears normal in echo texture but may be enlarged & show decreased echogenicity
thickening of portal vein walls appearing more hyperechoic than normal
"starry sky" appearance of liver
walls of portal veins appear more hyperechoic than normal from periportal cuffing
what might happen to the GB from acute hepatitis
GB wall = thickened & appear prominent b/c of accumulation of fluid within hepatocytes
exists when clinical or biochemical evidence of hepatic inflammation extends beyond 6 months
Sonographic findings of chronic hepatitis
-liver texture = coarse & hyperechoic with decreased brightness of portal triads
-DOES NOT increase in size or it may be small
-fibrosis may be evident producing "soft shadowing" posteriorly
defined as hepatocyte death, fibrosis and necrosis of liver with subsequent development of regenerating nodules
process of cirrhosis
-chronic and progressive
-liver cell failure and portal hypertension @ end stage
nodules 0.1 to 1 cm in diameter
results from chronic alcohol abuse
nodules up to 5 cm in diameter
results from chronic viral hepatitis or other infection
what is the predominant cause of cirrhosis in the US?
alcoholic liver disease
cirrhosis leads to an increase risk of developing what other diseases?
-hepatocellular carcinoma (HCC)
clinical presentation of cirrhosis
what liver function tests are abnormal (increased) with cirrhosis?
sonographic appearance of liver cirrhosis
-dismorphic liver with nodular surface
-anechoic peritoneal fluid outlines falciform ligament attaching to anterior liver surface
first sonographic finding of cirrhosis
in early stage = hepatomegaly
what happens to the liver lobes with advancing cirrhosis?
-right lobe = decreases in size (small in chronic stage)
-caudate lobe = often spared (hypertrophied) & possibly have normal echogenicity
sonographic findings with advancing cirrhosis
-increased echogenicity & coarsening of hepatic parenchyma secondary to fibrosis
-fatty infiltration causing attenuation with decreased vascular markings
-hepatosplenomegaly possibly present with ascites surrounding liver
what stage does surface nodularity of the liver edge appear with cirrhosis?
with chronic cirrhosis especially if ascites is present
sonographic appearance of surface nodularity of the liver edge
nodules = often too small to be seen but appear hypoechoic compared to surrounding liver
what type of transducer may be used to demonstrate the surface of the liver?
a higher frequency 10 MHz - 12 MHz linear array transducer
characteristics of glycogen storage disease
-abnormal storage & accumulation of glycogen in tissues especially liver/kidneys
most common type of glycogen storage disease
type I- Von Gierke disease
sonographic findings of glycogen storage disease
-slightly increased attenuation
what diseases are linked to glycogen storage disease?
-focal nodular hyperplasia
rare disease of iron metabolism marked by deposits throughout the body
what can hemochromatosis result in?
cirrhosis and portal hypertension
sonographic findings of hemochromatosis
-does NOT show specific findings other than hepatomegaly & cirrhotic changes
-some increased echogenicity seen uniformly throughout hepatic parenchymaportal hypertension
elevation of BP within portal venous system above 10 mmHg
normal portal pressure
most common cause of portal hypertension
what does portal hypertension result from?
-from liver becoming fibrotic/more difficult to perfuse from cirrhosis causing greater resistance of blood traveling into MPV increasing pressure within portal veins
how do patients usually present with portal hypertension?
they are asymptomatic with sudden, painless, upper GI hemorrhage resulting in caput medusa
tortuous collaterals around umbilicus
clinical findings of portal hypertension
-abnormal liver function tests
sonographic findings of portal hypertension
secondary signs of:
-portal systemic venous collaterals
-enlargement & reversed flow within the coronary vein (left gastric vein) is seen
what causes the development of collaterals?
abnormal blood flow patterns & varicosities near splenic hilum, renal hilum & gastroesophageal junction
most commonly identified collaterals with portal hypertension
recanalization of the paraumbilical vein
AP diameter of vessel with portal hypertension
exceeds 13 mm
portal hypertension blood flow
-irregular & often stagnant flow which increases chances of portal vein thrombosis development
-eventually becomes hepatofugal flow (reversed)
Transjugular Intrahepatic Portal-systemic Shunt (TIPS)
created to temporarily relieve portal hypertension by avoiding development or rupture of gastroesophageal varices
placement of TIPS for treatment of portal hypertension
a stent is placed between right portal veins & right hepatic veins to bypass liver & drain directly into IVC reducing portal systemic pressure
what does the interventional treatment with TIPS replace the treatment of?
sonographic appearance of a TIPS
strong echogenic walls & an anechoic lumen
pulsed doppler examination of normal functioning TIPS
-should demonstrate flow toward the IVC
-average velocity = 100- 190 cm/s (above 190 = high-grade stenosis within shunt)
TIPS flow with a velocity of less than 90 cm/s indicates what?
decreased flow through the stent (shunt) and may be the result of thrombosis in the shunt
criteria of malfunctioning TIPS
-focal velocity increase within the TIPS
-hepatopetal flow direction of the LPV or RPV
-hepatofugal flow direction of the MPV
portal vein thrombosis
development of clot within portal vein
what conditions is a portal vein thrombosis seen in?
hepatocellular carcinoma, pancreatic carcinoma, metastasis, portal hypertension, pancreatitis, cholecystitis, pregnancy, oral contraceptive use, inflammatory bowel disease, cirrhosis, hepatitis and trauma
cavernous formation of the portal vein
a mesh of tiny blood vessels in area of portal vein resulting from thrombosis (usually benign)
numerous worm-like venous collaterals that parallel the chronically thrombosed portal vein
symptoms associated with portal vein thrombosis
abdominal pain, low grade fever, leukocytosis, hypovolemia, elevated liver function tests, nausea, and vomiting
portal vein thrombosis sono findings
-isoechoic to surrounding blood becoming more echogenic over time
-increase portal vein caliber
-the cavernous transformation
-portal systemic collaterals
the occlusion of the hepatic veins with possible coexisting occlusion of IVC seen in young adult women taking birth control pills
Budd-Chiari syndrome is seen secondary to what conditions?
to a coagulation abnormalities, tumor invasion, thrombosis, oral contraceptive use, pregnancy and trauma
clinical symptoms of budd-chiari syndrome
ascites, right upper quadrant pain, hepatomegaly and possibly splenomegaly
sonographic features of budd-chiari syndrome
1.Nonvisualization of the hepatic veins
2.Thrombus within the hepatic veins
3.Enlarged caudate lobe
4.Lack of flow within the hepatic veins with color Doppler
5.Narrowing of the inferior vena cava
portal vein gas
Air is noted within the intrahepatic portal veins located peripherally
what is portal vein gas associated with?
ischemic bowel disease
AKA aerobilia- accumulation of gas in the biliary tree located centrally