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345 terms

Liver Pathology - Abd Son Test 2

crossword terms & lecture slideshow
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fibromellar carcinoma
a subtype of hepatocellular carcinoma that is found in adolescents and young adults without coexisting liver disease
core biopsy
a procedure in which a small piece of tissue is removed from an organ in order to examine it under a microscope. usually done to rule out malignancy of a tumor.
cholangiocarcinoma
a malignant (cancerous) growth in one of the ducts that carries bile from the liver to the small intestine. also known as bile duct cancer
fine needle aspiration
a procedure in which a thin needle is placed into a tissue or organ. cells are acquired by drawing them up into a syringe
lipoma
a benign tumor composed of fat
hypervascular
term that means "demonstrating excessive color flow when evaluated with color doppler."
microbubble enhanced sonography
the injection of a contrast (which consists of microbubbles in a suspension) for the purpose of enhancing the visualization of the vascularity of a mass on sonography
hemangioendothelioma
a true neoplasm of vascular origin, characterized by proliferation of endothelial cells in and about the vascular lumen; it is usually considered to be intermediate in grade between hemangioma and hemangiosarcoma but sometimes is used to denote the latter.
focal nodular hyperplasia
known as FNH, this is the 2nd most common benign mass of the liver
hemangioma
a benign tumor composed of blood vessels
hepatocellular carcinoma
accounts for the majority of all primary liver cancers. this type of cancer occurs more often in men than women, usually in people 50-60 years old. the disease is more common in parts of Africa and Asia than in north or south America and Europe. most common cause in America is alcoholic cirrhosis.
contrast agent
a substance injected into the blood stream that increases the contrast between tumors and normal liver tissue, making them more visible
angiomyolipoma
a benign tumor composed of blood vessel endothelium, smooth muscle tissue, and fat.
spelt
single-photon emission computed tomography (a special type of CT scan)
karposis sarcoma
a rare type of cancer seen in patients with immune deficiency. mainly seen in patients with AIDS.
candidiasis
a fungal infection by candida albicans (also known as thrush)
Glycogen
this is stored energy. it is made primarily by the liver and the muscles, but can also be made by glycogenesis within the brain and stomach. it is stored in the liver and when energy is needed it is converted into glucose and released in the blood.
pyogenic
refers to bacterial infections that make pus.
normal variant
an unusual property of an organ or tissue (ie shape, size, or form) which usually does not cause medical problems for the patient.
Liver Function Tests
include direct bilirubin, indirect bilirubin, serum protein, albumin, beta globulin, Alkaline Phosphate (ALP), Alpha Fetal Protein (AFP), Aspartate Aminotransferase (AST)/Serum Glutamic Oxaloacetic Transaminase (SGOT), Alanine Aminotransferase (ALT)/Serum Glutamic Pyruvic Transaminase (SGPT), cholestero, Lactic Dehydrogenase (LDH), and Prothrombin Time (PTT)
echinococcus granulosis
this is the parasite that causes hydatid disease (tapeworm 3-6mm long) most common in sheep and cattle herding countries.
situs inversus
a variant or anomaly in which the organs are located (by varying degrees) on the opposite side of the body
autosomal dominant traits
traits that are expressed if present on one gene. only one parent has to have the trait to have a child with the same trait
surgical jaundice
this type of jaundice occurs due to an obstruction of bile flow out of the liver which causes it to spill over into the blood.
liver flukes
Flatworms that can occur in bile ducts, gallbladder, and liver parenchyma. they feed on blood. adult flukes produce eggs which are passed into the intestine. it respires anaerobically. its life cycle contain two hosts: sheep and snail.
E.Coli
a bacteria that is commonly found in the lower intestine of warm-blooded organisms
TIPS
a shunt used in patients with portal hypertension. it connects the right portal vein to the right hepatic vein in order to relieve pressure in the portal vein system.
abscess
a collection of pus (dead neutrophils) that has accumulated in a cavity formed by the tissue in which the pus resides on the basis of an infections process (usually caused by bacteria or parasites or other foreign materials.
hamartoma
a benign, focal malformation that resembles a neoplasm in the tissue of its origin. this is not a malignant tumor, and it grows at the same rate as the surrounding tissues. it is composed of tissue elements normally found at that site, but which are growing in a disorganized mass. they occur in many different parts of the body and are most often asymptomatic and undetected unless seen on an image take for another reason.
Ringdown
an artifact commonly seen in the presence of gas. It appears as bright white vertical lines on the US images. See in cases of biliary hamartoma from the cholesterol crystals that are trapped in the mass during development.
diffuse hepatocellular disease
a disease that involves the entire liver
omphalocele
a type of abdominal wall defect in which the intestines, liver, and occasionally other organs remain outside the abdomen in a sac because of a defect in the development of the muscles of the abdominal wall
incubation period
the time elapsed between exposure to a pathogenic organism, a chemical, or radiation, and when symptoms and signs are first apparent
compensatory hypertrophy
the enlargement of an organ (or part of an organ) due to damage or agenesis of an organ (or part of an organ)
hypoglycemia
low blood sugar
anomaly
a discrepancy or deviation from an established appearance or shape. these may eventually cause problems for the patient.
autosomal recessive traits
traits not expressed unless the gene is present on both autosomal chromosomes. both parents must be carriers to produce a child with this type of hereditary disease.
varices
enlarged distended veins
hyperglycemia
elevated blood sugar
medical jaundice
this type of jaundice occurs due to hepatocellular disease
agenesis
failure of an organ to develop during embryonic growth and development
recannalization
re-opening of a vein such as the paraumbilical vein in the liver
target lesion
a bull's eye lesion composed of rings of varying echogenicity resembling a bull's eye pattern
diaphragmatic slip
occurs when the diaphragm invaginates into the liver during embryological development and remains stuck there
cavernous transformation
multiple tube-like structures appearing around the portal vein which represent collaterals in the presence of portal vein obstruction or impedance to portal vein flow into the liver
triglycerides
an ester derived from glycerol and three fatty acids. it is the main constituent of vegetable oil and animal fats
schistosome
a parasite commonly known as blood-flukes and bilharzia, includes flatworms which are responsible for the most significant parasitic infection of humans by causing the disease schistosomiasis.
collateral circulation
an alternate route for blood flow when the primary artery or vein is blocked
accessory fissure
an in-folding of peritoneum into the liver.
Complete Agenesis of Liver
incompatible with life
With Right Lobe Agenesis,
Caudate lobe is usually also absent
What is result of agenesis of a lobe?
Compensatory Hypertrophy of remaining lobe
Congenital Diaphramatic Hernia
varying amounts of liver herniated into the thorax
Do development anomalies affect LFTs?
NO - except for total agenesis b/c there wouldn't be any
Most common location for accessory fissure?
inferior accessory fissure - stretches from RPV to inferior surface of the R lobe of Liver
How many fissures = accessory fissure
more than 4
Are accessory fissures common?
NO
What do diaphragmatic slips look like on US?
Accessory fissures or pseudomass
3 types of Vascular Anomalies
Variations in the
1. Hepatic Artery
2. Hepatic Veins
3. Portal Vein
Do vascular anomalies affect LFTs?
Not usually
True liver cysts are believed to result from
defects in the bile duct formation
Can patient develop a true cyst in liver?
NO - they are congenital (born with it)
Can patient develop a cystic mass in liver?
Yes
What are causes of cystic masses in liver?
trauma, parasites, inflammatory change (i.e. hepatitis)
Where do liver cysts typically occur?
Right Lobe
True liver cysts contain
clear serous fluid & bile duct epithelial lining
Appearance of liver cyst
anechoic, round or oval
thin well defined wall
good thru transmission
Large liver cysts can cause
liver enlargement
biliary obstruction and /or
epigastric pain
(bleeding & infection also cause pain)
Do LFTs elevate with liver cysts?
NO
Liver cysts most commonly seen in patients
over 80 yrs old
Will liver cysts recur?
Yes if not removed or ablated
Hemorrhaged cysts will appear
to have internal echoes,
septations,
a thick wall
may appear solid or have solid components (complex)
Peribiliary cysts are usually seen in patients with
severe liver disease
Size of prebiliary cysts?
small, .2-2.5 cm
Location of prebiliary cysts
porta hepatis, junction of RHD & LHD
Prebiliary cysts may cause
Biliary Obstruction
Sono appearance of prebiliary cysts
Discrete cluster cysts
tubular anechoic areas paralleling bile ducts & PV
On doppler, prebiliary cysts...
demonstrate no flow
Prebiliary cysts impact on LFTs?
No elevation unless biliary obstruction
Types of polycystic disease
Autosomal Dominant
Autosomal Recessive
Effect of Polycystic disease on LFTs?
Usually normal
Which type of polycystic disease is more aggressive - recessive or dominant?
Recessive
Recessive polycystic disease has association with:
hepatic fibrosis, portal hypertension
In dominant polycystic disease, what % of patients have liver cysts?
54-74%
Autosomal recessive polycystic disease presents itself
very early, in infants
Autosomal dominant polycystic disease usually presents
in adulthood
APKD
Adult Polycystic Kidney Disease
Occurence of adult polycystic disease
1:1000 (rare)
APKD prevelance
4:1 females to males
Adult Polycystic Kidney Disease usually detected at this age:
50-70 years
APKD may also involve these organs:
Kidneys, spleen, pancreas, ovaries, testicles
Correlation between severity of renal disease and # of liver cysts?
NO correlation
What % of patients with liver cysts also have renal cysts?
over 50%
Biliary Hamartoma
Solid focal mass composed of bile duct tissue
Biliary hamartomas benign or malignant?
Usually benign, but hamartomas can change from benign to malignant.
Biliary hamartoma sonographic appearance
single, multiple or innumerable
well defined, solid
ring down from cholesterol crystals
bright foci
Biliary hamartoma often mistaken for
METS
Treatment for Cysts
surgical removal or ablation (if symptomatic)
Treatment for Partial Agenesis
None Required
Treatment for Prebiliary Cysts
Surgery if obstruction present
Treatment for Polycystic Disease
Transplant
Treatment for Situs Inversus
None
Treatment for Diaghragmatic Hernias
Surgery
Treatment for Omphalocele
Surgery
Treatment for Accessory Fissures
Non required
Treatment for Hamartoma
Surgical Removal
Treatment for Complete Agenesis
Transplant
Diffuse Hepatocellular Disease
disease process that affects hepatocytes and interferes with liver function
4 types of diffuse liver disease:
1. Fatty Infiltration
2. Cirrhosis
3. Glycogen Storage Disease
4. Hepatitis (Infectious)
Fatty Infiltration
acquired, results in accumulation/deposition of fatty triglycerides with the liver cells secondary to cell injury or impaired fat metabolism from systemic disorders
Is fatty infiltration reversible?
Yes
Fatty Infiltration is associated with
diabetes mellitus
ethanol abuse
obesity
gastric bypass
chemotherapy
& many other diseases
Lab values of moderate-severe fatty infiltration
Elevated LFTs
Elevated Bilirubin
lab values of Mild fatty infiltration
Normal
Clinical Presentation of Fatty Infiltration
Usually asymptomatic
Mild hepatomegaly
Lab values vary depending on severity
Appearance of Mild grade fatty infiltration
slightly diffuse increase in the fine echoes in parenchyma
can see the diaphragm and hepatic veins normally
Appearance of moderate fatty infiltration
diffuse increase in fine echoes with slightly impaired visualization of intrahepatic vessels and diaphragm
Appearance of severe fatty infiltration
marked increase in fine echoes, no intrahepatic vessels or diaphragm seen
Focal fatty infiltration results in
non-uniform areas of increased echogenicity and attenuation within otherwise normal liver texture
Focal Fatty Sparing
focal area of normal liver tissue that has been spared from fatty infiltration. focal normal section of liver in an otherwise fatty infiltrated liver. (island of normal tissue in sea of fatty infiltration)
Focal fatty sparing commonly appears as
hypoechoic liver texture in the medial segment of left lobe anterior to porta hepatis
Cirrhosis
diffuse process characterized by fibrosis and conversion of normal liver architecture into strucxturally abnormal nodules
Essential feature of cirrhosis
generalized involvement of liver by parenchymal necrosis, regeneration and diffuse fibrosis
Scarring caused by cirrhosis is
irreversible and often progressive
Cirrhosis is the #__ cause of death in the US
6th
60-70% of cirrhosis cases in the Western hemisphere are secondary to
Alcohol Abuse
Cirrhosis causes / leads to:
liver cell failure
portal hypertension
leads to caput medussae
varices
GI Bleeding
It is not uncommon for patients with cirrhosis to have
HCC - hepatocellular carcinoma
Caput Medussae
Enlarged abdominal veins
Cirrhosis starts asymptomatic and progresses to
1. abnormal LFTS
2. elevated biliruben
3. elevated Alkaline Phosphatase
4. Hepatomegaly (early stages)
5. Jaundice (yellow skin)
6. Ascites
7. Portal Hypertension Symptoms
8. May have no symptoms
Most common cause of cirrhosis in Eastern Hemisphere
Biliary Disease
Various Causes for cirrhosis
alcohol
drugs
viruses
heredity
Diagnosis of Cirrhosis is made by
blood test
imaging
liver biopsy
Early stage sono appearance of cirrhosis
hepatomegaly
fatty infiltration with increase in liver echogenicity and sound attenuation
Later stage appearance of sono appearance cirrhosis:
1. smaller heterogenous liver
2. relative caudate enlargement
3. echogenic coarse liver texture w/ poss IVC compression
4. ascites
5. may see HCC
6. doppler consistent with PVH
With chronic cirrhosis, may see hepatofugal flow b/c...
the PV blood cannot pass through the liver due to extensive fibrosis
WIth chronic cirrhosis, flow will back up into the____ causing ____
PV system causing venous congestion
With chronic cirrhosis, the size of the PV will exceed
13 cm
With chronic cirrhosis, varices can...
rupture & cause death, especially in alcholics
In chronic cirrhosis, these may be seen on Doppler:
collaterals
In chronic cirrhosis, this can prevent espophageal varices
recannalization of paraumbilical vein
In chronic cirrhosis, may see this tangle of worms appearance
Carvernous Transformation of PV
With chronic cirrhosis may see increased flow in the
Hepatic Artery
Jaundice
condition which causes the skin and sclera of the eyes to turn yellow due to back up if biliruben in the blood
How do you determine amt of jaundice in dark skinned people?
look at sclera of eye
Glycogen Storage Disease
Autosomal recessive genetic disorder of carbohydrate metabolism characterized by a derangement of either the synthesis or degradation of glycogen and its utilization
Type 1 glycogen storage disease AKA
Von Gierke's Disease
Most common type of Glycogen Storage Disease
Type 1
Where does excessive glycogen accumulate with Glycogen Storage Disease?
hepatocytes
kidneys
intestines
With GSD, the body can't convert
glycogen back into glucose
GSD manifests itself during
Infancy to young adulthood
GSD Symptoms
1. hypoglycemia
2. may have hypoglycemia convulsions
3. Hepatomegaly
4. Hyperlipidemia (high cholesterol)
GSD Sonographic appearance
hepatomegaly
fatty infiltration
associated liver cell adenomas or FNH
possible HCC (if adenomas or FNH present)
Nephromegaly (enlarged kidneys)
Exam of choice for imaging metabolic liver disease
CT
Can be used to test the liver for function and malignancy
NM
Treatment for Fatty Infiltration
Depends on the cause
Treatment for Cirrhosis
Liver Transplant, TIPS & Treatment of Symptoms
Treatment for GSD
Depends on complications --
usually restriction of all types of sugar
Liver transplant
Sources of Liver Infections
Viral
Bacterial
Fungal
Parasitic
Viral Infection of Liver
Hepatitis
Hepatitis Definition
Inflammation of the liver
Types of Hepatitis
Types A-E
Rare Types of Hepatitis
D & E
Acute hepatic necrosis or chronic hepatitis causes how many deaths?
Millions
Acute Hepatic Necrosis
Destroys liver hepatocytes
Natural Progression of Hepatitis
1. Acute Hepatitis (Necrosis)
2. Chronic Hepatitis
3. Portal Hypertension
4. Cirrhosis
5. Hepatocellular CA
How is Hep A Spread?
Fecal to Oral route
Incubation period for HAV?
2-6 weeks
Symptoms of HAV
mild flu-like symptoms
may never know you have it
Can Hep A Cause Death?
Rare; usually patients completely recover
Incubation period for HBV?
2-6 months
How is Hep B Spread?
Parenterally (by blood transfusions, need punctures, sexual contact, body fluids)
Most AIDS patients also have
Hepatitis B
Hepatitis attacks ___
Hepatocytes
In hepatitis, liver sinusiouds become filled with
Kupffer Cells and Lymphocytes / Monocytes
Hepatitis results in liver cell
swelling & necrosis
Clinical Presentation of Acute Hepatitis
sudden severe onset of symptoms
resolves completely within 4-6 months
elevated LFTs
Elevated Ammonia
Decreased levels of Urobilinogen
Jaundice
Hepatomegaly
RUQ pain
Nausea, vomiting & diarrhea
Fever
Clinical presentation of Chronic Hepatitis
Varies with length and severity
Persists longer than 6 months
Can have non-viral causes
Major indicator of acute hepatitis
Elevated Ammonia
Increase in direct biliruben (conjugated) may indicate:
sub-acute choleycystitis
choledocholithiasis
GB cancer
bile duct injury or obstruction
Leukocyte (WBC) count
Increases with infection
Elevated Serum Alakaline Phosphatase
May indicate obstruction or prolonged liver disease
Elevated LFTs,refers to SGOT (AST) and SGPT (ALT)
Increases with active primary liver disease, especially acute onset
Prothrombin Time (PT/PTT)
Cholecystitis, GB Cancer, Prolonged duct obstruction, bile duct injry
Acute Hepatitis - Sono Appearance
*Normal in most cases
*Diffusely hypoechoic with increased echogenicity of portal triads
*Hepatomegaly
*Thickening of GB Wall
Starry Night Appearance
diffusely hypoechoic with increased echogenicity of the portal triads
Chronic Hepatitis Sonographic Appearance
*Normal appearance in most cases
*May show increased liver echogenicity due to fatty change and fibrosis (pre-cirrhosis)
*If cirrhosis developed, then liver echotexture may become coarse from nodular degeneration
*Decreased echogenicity of portal vein walls compared to liver echotexture
*Portal HTN and Cirrhosis signs may be visualized
Pyogenic
Bacterial
Bacterial Infection
Localized collection of pus (abscess)
bacteria feed on liver parenchyma and give off gas a by-product
can spread to adjacent organs
Most common types of bacteria that infect liver
E. Coli
Anaerobic
Bacterial Infections can kill patient if not
drained
Clinical presentation of Bacterial Infections
Fever
Pain
Leukocytosis
Nausea
vomiting
Diarhhea
Elevated LFTs
Pleuritic Pain
Anemia
Exam of choice for bacterial infections
CT
Location of bacterial liver infections
Mostly located in Right Lobe and dome of liver near diaghragm (but can occur anywhere in liver)
Sonographic Appearance of bacterial infections
*Usually solitary
*Usually round or oval
*Irregular thick poorly defined walls
*variable echogenicity (usually hypoechoic)
*may have bright echogenic foci with shadows represting microbubbles of air (or gas)
*50% will have posterior acoustic enhancement
*cannot be differentiated from a simple cyst or hemorrhagic cyst on ultrasound with certainty
*if echogenic foci with dirty shadowing is seen...this is diagnostic of an abscess
Echogenic foci with dirty shadowing is diagnostic of an
abscess
Fungal Infection
Infection of the liver by fungus cadidiasis albicans.
Prevalance of Fungal Infections
Uncommon
usually seen in immunnocompromised patients
Clinical presentation of Fungal Infections
Fever
Pain
Nonspecific
Low Leukocycte Count
Normal LFTs
Why do patients with fungal infections present with low leukocytes?
immunocompromised
Sonographic appearance of Fungal Infections
Hepatomegaly
Wheel within a wheel type lesion (early stage)
Multiple bulls-eye target lesions
Uniform Hypoechoic lesions
echogenic foci with variable posterior acoustic shadowing (late stage)
Types of parasitic infections
1. amoebiasis (amoebic abscess)
2. Hydatid Disease
3. Schistosomiasis
Amoebiasis
A localized cavity caused by parasite Entamoeba histolytica
How do amoebic parasites reach liver
through portal vein, usually from an infected color
amoebiasis can spread from the colon to the
liver, lungs and brain
Patients acquire amoebiasis from
fecal-oral route (contaminated food / water)
after amoebiasis parasites deposit in PV radicles, they cause
subsequent liquifaction necrosis of the hepatocytes with some leukocytic and fibrotic response
amoebic abscess formation is usually located
peripheral in the liver b/c that is where the portal radicles are located
Clinical Presentation of Amoebiasis
May be asymptomatic at first
abdominal pain
diarrhea
melena (black vomit & stools)
leukocytosis
elevated / abnormal LFTs
Special Dangers of Amoebic Abscesses
1. rupture into the pleuropulmonary structures
2. rupture into the periotneal cavity (peritonitis)
Sonographic Findings - Amoebiasis
40% have lack of significant wall echoes
round or oval configuration
echogenicity less than liver
has low level fine homogenous internal echoes
distal acoustic enhancement
contiguous with liver capsule and/or diaphragm
Amoebiasis is diffiult to distinuish from ______ without a biopsy
pyogenic infection
Hydatid Disease
parasitic infection caused by Echincoccus Granulosis
Hydatid Disease is most common in these countries
sheep and cattle herding countries
Echinococcus Granulosis is found
where dogs herd sheep
% of hydatid disease cysts found in liver
50%
Other locations where hydatid cysts are found
lungs
bones
brain
These types of cysts also form with Hydatid Disease
Daughter cysts (big cyst will have little cysts around it)
How does Hytadid disease reach liver?
sheep ingest the eggs from dog feces. humans eat sheep. eggs hatch in small intestines & travel by PV to liver where they slowly grow
Clinical presentation of Hydatid Disease
Jaundice
Abdominal Pain
Fever
Leukocytosis
Elevated LFTs (biliary obstruction)
Sonographic Findings with Hydatid Disease
Simple cysts with fine textured particles within
Mother & Daughter cysts
Calcified cyst or mass
Honeycomb cysts (fluid collection with septae)
Solid appearing masses
Hydatid cysts have 2 layered membrane wall consisting of:
Ectocyst - sometimes calcifies
Endocysts - may separate and float within cyst
Water Lily sign
when endocyst separates and floats within a cyst
Schistomiasis
Granulomatous PV reaction to parasitic invasion - liver flukes-schistosomes
Most common parasitic infection in the world (though not common in the U.S.)
Schistomiasis
Schistomiasis is aquired due to exposure to
contaminated water
Schistomiasis process
ova puncture skin and migrate via lyphatics and venous routes. mature worms travel to urinarty or PV systems and incite a granulomatous reaction and fibrosis along the PV branches. Process may take years to develop
Clinical presentation of schistomiasis
Pain
Fever
Leukocytosis
Elevated LFTs
Terminal PV branches become occluded leading to presinusoidal portal HTN, hepatomegaly, splenomegaly, varices and ascites
With schistomiasis, terminal PV branches become occluded leading to
presinusoidal portal HTN, hepatomegaly, splenomegaly, varices and ascites
Sonographic Findings in patient with schistomiasis
widened portal tracts up to 2cm
echogenic PV wall radicles
porta hepatis is most common area affected
hepatomegaly early
contracted fibrotic liver later on
use doppler to evaluate patency of portal veins
Treatment for Schistomiasis
abscesses are drained
treated with antibiotics afterward
other infections receive drug therapy
Pneumocystis Carinii
type of fungal pneumonia infection

causes cysts to form
Pneumocystis Carinii is common in patients with
HIV (low immunity)
Penumocystis Carinii travels in body from ____ to liver
lungs
Sonographic appearance of Pneumocystis Carinii
diffuse, tiny nonshadowing echogenic foci
may see clusters of calcifications
Commonly found in lungs of healthy people
Pneumocystis
Which is more common - primary liver tumors or metastatic tumors?
Metastatic Tumors
Benign liver tumors originate from
hepatic parenchymal cells
or
bile duct epithelium
or
a mixture of the two
neoplasms grow due to
cell replication
cysts enlarge due to
fluid secretion
What determines if a neoplasm will be visualized on sonography
echogenicity of the mass due to difference in impedence from surrounding tissue
if impedence is equal the echogenicity of a mass will be
isoechoic (equal to that of surrounding tissue) and we will not be able to see it
List the benign neoplasms
hepatic adenomas
cavernous hemangiomas
Focal Nodular Hyperplasia
Hemangioendothelioma
Hepatic Lipomas
Do benign neoplasms interfere with liver function?
No - LFTs are normal b/c hepatocytes are not being destroyed
Hepatic Adenoma
benign neoplasm of normal or slightly atypical hepatocytes frequently containing areas of bile stasis and focal hemorrhage or necrosis
Which neoplasm contains Kuppfer Cells and/or bile duct tissue?
Focal Nodular Hyperplasia (FNH)
Can hepatic adenomas become malignant?
Yes
Hepatic Adenomas are prone to
rupture & hemorrhage
Treatment for Hepatic Adenoma
Surgical Removal due to high rupture rate
If hepatic adenomas become malignant they are called
adenocarcinoma
Incidence of hepatic adenoma
uncommon, less than 1% of population
Hepatic Adenomas are most prevalant in
women taking oral contraceptives
Hepatic Adenomas can develop in men who
are taking anabolic steroids or estrogen therapy for prostate cancer
Hepatic Adenoma is associated with
Type 1 Glycogen Storage Disease
It is believed that adenomas are linked to
hormones
Patients with adenoma and GSD have a higher incidence of
HCC
Clinical Presentation of Hepatic Adenoma
Often asymptomatic yet palpable
If hepatic adenoma is bleeding, patient will experience
pain, rupture, shock
hepatic adenomas are covered by a
thin capsule - likely to rupture
Sonographic appearance of hepatic adenomas
variable echogenicity
well defined
usually solitary
well encapsulated
may have fluid component due to hemorrhage, old blood
hard to distinguish from FNH
Most often seen in right lobe and usually subscapular
Hepatic Adenoma appearance on doppler
demonstates blood flow around and /or inside the mass (hyperemic)
Cavernous Hemangioma
a benign tumor composed of a large network of vascular endothelium lined spaces filled with RBCs
Cavernous Hemangioma Incidence
most common benign neoplasm in liver
Prevalance of cavernous hemangioma
5:1 female to male
older women
Clinical presentation of Cavernous Hemangioma
usually asymptomatic, incidental
large ones can cause symptoms (acute abdominal pain due to hemorrhage)
usually reaches maximum size by adulthood with no change over time except with pregnancy or estrogen hormone therapy
possible hormone dependent
Sonographic appearance of Cavernous Hemangioma
*usually right lobe
*usually subscapular
*usually solitary
*well defined contours
*can be multiple
*round, oval or lobulated in shape
typically echogenic, homogenous sharply marginated and solid but may occasionally have posterior acoustic enhancement if larger than 2.5mm due to blood
most are less than 3cm in size
*can become large and show evidence of degeneration, fibrosis and calcification which will give a complex appearance
Doppler appearance of Cavernous Hemangioma
very slow flow, often no color
Best Exam for Cavernous Hemangioma
Nucelar Medicine - Red Blood Cell Tagged Scintogram
Correlative Imagining for Cavernous Hemangioma
1. NM RBC Tagged Scintogram
2. f/u with U/S in 6 months
3. CT & MRI can also be done
Focal Nodular Hyperplasia (FNH)
Benign neoplasm composed of normal hepatocytes that are abnormally arranged Kuppfer cells, bile duct elements, and fibrous connective tissue
Prevalance of FNH
Female predominance
Under 40 yrs of age
Incidence of FNH
rare, but the 2nd most common benign tumor of liver
increased incidence in women with use of oral contraceptives
Clinical presentation of FNH
Asymptomatic and incidental
Sonographic Appearance of FNH
*most commonly isoechoic
*look for subtle contour abnormalities and displacement of vascular structures
*usually right lobe or lateral segment left lobe
*large variation in sizes
*most less than 5cm
*Well circumscribed
*solitary
*central scar
*like normal lobule except lacks portal venous circulation
FNH
Focal Nodular Hyperplasia
treatment for FNH
surgery if symptomatic
follow up serial imaging scans if not symptomatic
Doppler appearance of FNH
well developed peripheral and central blood vessels - stelate arterial pattern (star like)
Hemangioendothelioma
a benign vascular liver tumor that occurs in infants
Incidence of hemangioendothelioma
most common benign liver tumor in an infant
Prevalance of hemangioendothelioma
femal predominance - 2:1
Clinical presentation of hemangioendothelioma
hepatomegaly
palpable mass
CHF is high and due to AV shunting through tumor
Why is CHF rate high in hemangioendothelioma?
due to AV shunting through tumor
Treatment for hemangioendothelioma
surgery
may also regress spontaneously
Cutenous hemangiomas may be observed in patients with
hemangioendothelioma
Sonographic Appearance of hemangioendothelioma
Variable echogenicity
Hepatomegaly
Large draining veins & dilated proximal abd aorta possibly seen in lesion with AV shunting
AO distal to Celiac Axis is eithe normal or slightly decreased in size
Doppler appearance of hemangioendothelioma
Hypervascular
Hepatic Lipoma Incidence
Extremely Rare
Hepatic Lipoma
well defined mass composed of fat
Sonographic Appearance of Hepatic Lipomas
discontinuous or broken echoes in the diaphragm behind the mass due to different propagation speed of fat (Propagation Speed Artifact)
Hepatic Trauma
Hematoma due to trauma, post biopsy or rupture of neoplasm
Primary imaging for Hepatic Trauma
CT then US to follow up
Hepatic Trauma location
typically Rt Posterior Segment of Liver
Three categories of Hepatic Trauma
1. Rupture of liver and capsule
2. Separation of capsule and a subscapular hematoma
3. central rupture of the liver
Clinical Presentation of Hepatic Trauma
RUQ Pain
Hepatomegaly
Hypotension
Drop in hematocrit
Sonographic appearance of Hepatic Trauma
Subscapular, Periscapular or Isolated Hematomas
Varied appearance depending on ago of hematoma
With capsular rupture, may see free fluid in the peritoneal cavity
Sonographic appearance of acute hepatic trauma (<24 hrs)
hemorrhage is sonolucent, then more hyperechoic as it resolves.
Irregular walls
Some through transmission (less than cyst but more than solid structure)
Benign Causes for Hyperechoic Foci in Liver
1. Calcification
2. Air in Bile Ducts
3. Foriegn Objects
Calcification in Liver
a. granulomatous change
b. healed abscess or hematoma
c. causes posterior acoustic shadowing
Air in bile ducts
a. post operative biliary surgery or ERCP
b. infection causing gas (like an abscess)
c. causes comet-tail and /or ring down artifact
d. may move with change in pt position
ERCP
endoscopic retrograde cholangiopancreatography
Foreign Objects that cause hyperechoic foci
a. surgical clips
b. buck shot
5 Types of Malignant Neoplasms
1. Hepatoblastoma
2. Hepatocellular carcinoma
3. Hemangiosarcoma (Angiosarcoma)
4. Metastatic Disease
5. Lymphoma
Hepatoblastoma
A malignant germ cell tumor comprised of
epithelial or mixed with epithelial & mesenchymal tissues
Prevalance of Hepatoblastoma
occurs in pediatric patients - infancy & childhood
malignant hepatic tumors seldom occur in children but of those hepatoblastoma is most common
RIsk factors for hepatoblastoma
All 3 are congenital:
Beckwith Syndrome
Hemihypertrophy
Sporadic Aniridea
Beckwith Syndrome
causes abnormal growth
Hemihypertrophy
one side of body larger than other
Sporadic Aniridea
no irises in eye
Clinical presentation of Hepatoblastoma
Abdominal enlargement
hepatomegaly
weight loss
nausea
vomiting
precocious puberty (early onset)
Elevated AFP (alphafetoprotein)
AFP is a marker for
cancer
A common cancer symptom
weight loss
Sonographic appearance of hepatoblastoma
Heterogenous
Complex
Poorly marginated
occasional calcifications seen
Doppler appearance of hepatoblastoma
flow may be seen on color flow
Hepatocellular Carcinoma (HCC)
aka Hepatomas
primary live cancer that has a common tendency to invade the PV system.
also has tendency to invade HVs causing budd-CHairi syndrome
can also invade biliary tree
most common primary malignancy
hepatocellular carcinoma
Diffuse infiltrative HCC
appears like pepper and salt
Focal HCC
appears like grapes in salt - can be single or multiple
3 forms of HCC
1. solitary
2. multiple
3. diffuse infiltrative
Main cause / predisposing factor in HCC Cases
alcoholic cirrhosis - 80% of all cases
Typical progression to HCC
1. fatty infiltration
2. cirrhosis
3. HCC
___ found in food is also related to HCC
Carcinogens
In Eastern World, HCC mostly occurs due to
Chronic Hepatitis B & C
These disorders are also linked to HCC
Metabolic Disorders - Fatty infiltration, GSD
Clinical Presentation of HCC
Palpable mass
Weight Loss
Rapid Liver enlargement
Abdominal Swelling if Ascites present
Possible RUQ pain with extensive Ascites
Unexplained mild fever
Signs and symptoms associated with Cirrhosis
Elevated AFP
Sonographic Findings in HCC
*variable echogenicities
*solitary tumor, multiple nodules or diffuse
*small tumors tend to be hypoechoic with fibrous capsule
*with increase in size, tend to become more echogenic and then mixed
*hepatomegaly
*possible ascites
*may see PV, HV or bile duct invasion
HCC Doppler Appearance
high velocity signals in the mass
Hemangiosarcoma
aka Angiosarcoma
A malignant tumor that originates from the blod vessels in the liver
Hemangiosarcoma is a malignant version of
cavernous hemangioma
Hemangiosarcoma progesses rapidly and metastisizes to
PV, Spleen, Lungs, Lymph nodes, peritoneal cavity, thyroid
Prevelance of Hemangiosarcoma
usually patients in their 60s-70s
Incidence of Hemangiosarcoma
Extremely rare
Risk factors for hemangiosarcoma
Associated with exposure to thorotrast, arsenic and polyvinyl choride (PVC plumbing pipes, plastics)
Sonographic Appearance of Hemangiosarcoma
Large mass with mixed echogenicity due to hemorrhage and necrosis
Liver Metastasis
occurs from dissemination of tumor cells from a primary malignant neoplasm to the liver via the PV, lymphatics, HA routes and less often by direct extension.
Primary sites causing liver metastasis are
GI tract, breast and lung
Incidence of Liver Metastases
Common - Most common liver malignancy
18-20x more common than HCC
More common than benign masses or primary cancer
Clinical presentation of Liver Metastases
Hepatomegaly
Jaundice (very suspicious)
Possible Pain
Weight Loss
Abnormal Labs (depends on primary)
Can be asymptomatic or have painless jaundice
Sonographic findings with liver metastasis
variance echogenicities and patterns
hypoechoic or hyperechoic
various size masses
solitary rare, multiple masses common
bullseye/target sign
diffusely heterogenous
calcifications
cystic degeneration
RF (radio frequency) Ablation
new procedure being performed under US guidance
probe is placed with its tip inside metastatic lesion
RF waves are applied which "COOK" lesion killing it.
best performed in patients with 3-4 lesions
Treatment for Metastasis
RF Ablation
Ethanol Ablation
Lymphoma appearance on US
hepatomegaly
may see hypoechoic masses in liver
splenomegaly
Retripoteneal Nodes (draped around AO & IVC)
Most common disease of liver
Hepatitis (with A being most common)
Most common benign mass
Cyst
Most common benign
Hemangioma
Most Common Malignancy
Mets