Pathology

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1

Fatty infiltration:

Fatty liver is an acquired but reversible disorder of metabolism. Fatty filtration implies increased lipid accumulation in the hepatocytes.

2

What is the sonographic appearance of Fatty infiltration?

Increased echogenicity

Enlargement of the lobe

Decreased penetration

Difficult to image

Increased echo texture

3

What is the presentation of Fatty infiltration?

ETOH abuse

Diabetes Mellitis

Obsesity

steroids

Asymptomatic

jaundice

nausea, vomiting

4

What is the labs of Fatty infiltration?

↑Alk Phos

↑Direct Bilirubin

5

Acute Hepatitis

Inflammatory and infectious disease of the liver caused by complications of liver damage. May be mild to severe.

6

Acute Hepatitis Sonographic Appearance

Mild: Normal echogenicity

Slightly increased echogenicity

Prominent portal walls

Echogenic portal radicals

Hepatosplenomegaly

Thickened gallbladder wall

7

Acute Hepatitis presentation

Asymptomatic

jaundice

nausea, vomiting

abnormal tenderness.

8

Acute Hepatitis lab values

↑AST

↑ALT

↑Bilirubin

Leukopenia

9

Chronic hepatitis

Hepatitis becomes chronic when the inflammation lasts longer than 6 months.

10

Chronic hepatitis appearance

Increased echogenicity

Hypoechoic portal triads

Fibrosis

Soft posterior shadowing may be apparent.

Difficult to visualize liver structures

11

Chronic hepatitis presentation

nausea, vomiting

anorexia

weight loss

tremors

jaundice

dark urine

fatigue

and varicosities

12

Chronic hepatitis lab values

↑AST

↑ALT

↑Bilirubin

Leukopenia

13

Cirrhosis

A chronic degenerative disease in which there is parenchymal necrosis, regeneration and fibrous tissue resulting in disorganization of lobular architecture. Lobules are infiltrated with fat. Commonly caused by alcoholism.

14

Cirrhosis appearance

Hepatomegaly

Increased echogenicity and attenuation

Size decrease of right lobe

Size increase of left and caudate lobe

Nodularity

Fibrosis

Hepatosplenomegaly

Ascites

Portal hypertension

Hepatoma tumors

15

Cirrhosis labs

↑Alk Phos

↑Direct Bilirubin

↑AST

↑ALT

Leukopenia

16

Cirrhosis presentation

fatigue

bruises

jaundice

edema

dark urine

blood in stool

fever

flatulence

17

Glycogen storage disease

Characterized by the abnormal storage and collection of glycogen in the tissue of the liver and kidneys. Most common Type I – Von Gerke’s

18

Glycogen storage disease appearance

Hepatomegaly

Increased echogenicity and attenuation

Hepatic adenomas

Focal nodular hyperplasia

Round, homogenous, echogenic tumors

19

Glycogen storage disease

Disturbances of acid-base balance

20

Hemochromatosis

This is a rare disease involving excess iron deposits. May lead to cirrhosis and portal hypertension

21

Hemochromatosis appearance

Hepatomegaly

Cirrhotic changes

Increased echogenicity

22

Hemochromatosis presentation

Bronze skin

23

Hemochromatosis labs

↑Iron levels

24

Portal venous hypertension:

This is an increase in portal venous pressure (above 10mmHg) or hepatic venous gradient (above 5mmHg).

caused by cirrhosis

25

Portal venous hypertension: appearance

Portal vein measures greater than 13mm

Collateral circulation

Flow reversal

Ascites

Hepatosplenomegaly

26

Portal venous hypertension: presentation

Gastrointestinal bleeding, blood in the stools, or vomiting of blood, Encephalopathy

27

Portal venous hypertension: labs

↑Liver Enzymes

↓Platelet Count

28

Budd-Chiari Syndrome

A rare disease which is caused by a thrombosis of the hepatic veins or IVC. Has a high mortality rate.

29

Budd-Chiari Syndrome presentation

Ascites

Hepatomegaly

Enlarged caudate lobe

Atrophy of right lobe

Hyperechoic

Inhomogeneous

Fibrosis

Thick Gallbladder wall

Stenosis

Disrupted flow

30

Budd-Chiari Syndrome labs

Albuminuria

↑Alk Phos

↑AFT

31

Passive hepatic congestion

occurs with congestive heart failure

32

Simple hepatic cysts

A hepatic cyst is usually a solitary, non-parasitic cyst of the liver. Solitary or multiple. More common in females.

33

Congenital hepatic cysts

A rare lesion that caused by developmental defects in the formation of bile ducts.

34

Peribiliary Cysts

Very small cysts that range from .2 to 2.5 cm. They are most common in patients with severe liver disease.

35

Polycystic liver disease

This is an autosomal dominant genetic disease in which multiple small cysts cover the liver. 60% of patients with polycystic liver disease will have polycystic kidney disease.

36

Polycystic liver disease appearance

Anechoic

Thin well-defined walls

Posterior enhancement

Multiple

Varying in small size

Fever of unknown origin

37

Polycystic liver disease presentation

abdominal pain

bloating or swelling in the abdomen

feeling full, fever

38

Polycystic liver disease labs

↑WBC

39

Pyogenic abscess:

A pus-forming abscess caused by bacteria. The most common bacteria is Escherichia coli and anaerobes.

40

Pyogenic abscess: appearance

Varying size

Hyperechoic

Round or Oval

Internal debris

Posterior enhancement

Shadowing

41

Pyogenic abscess: presentation

fever, pain, pleutitis, nausea, vomiting, diarrhea. Elevated liver function tests, leukocytosis, and anemia. The most frequent organism causing the infection is Escherichia coli or anaerobes.

42

Pyogenic abscess: labs

↑WBC

LFT

43

Hepatic candidiasis

This is caused by a type of Candida fungus usually in immunocompromised patients.

44

Hepatic candidiasis appearance

Multiple

Small

Bull’s-eyes or target lesions

Hypoechoic mass

Echogenic core

45

Hepatic candidiasis presentation

persistent fever and localized pain Lab Values: ↑WBC

46

Chronic granulomatous disease

a genetic disorder in which phagocytes are unable to kill certain bacteria.

47

Chronic granulomatous disease appearance

Poor borders

Hypoechoic mass

Posterior enhancement

Calcifications

Shadowing

48

Chronic granulomatous disease presentation

reoccurring respiratory infections

49

Amebic abscess

A collection of pus formed by disintegrated tissue. Primarily a disease of the colon

50

Amebic abscess appearance

Hypoechoic

Ill-defined walls

Round or oval

Internal echoes

Posterior enhancement

51

Amebic abscess presentation

asymptomatic

abdominal pain

diarrhea leukocytosis

and fever.

52

Amebic abscess labs

↑Leukocytes

53

Echinococcal cyst

Infectious cystic disease common in sheep herders, a tapeworm that infects.

54

Echinococcal cyst appearance

Simple

Complex cyst

Posterior enhancement

Round

Oval

Calcifications

Septations

Water lily sign (cyst within cyst)

55

Echinococcal cyst presentation

asymptomatic, abdominal pain, abnormal abdominal tenderness, hepatomegaly, abdominal mass, jaundice, fever and/or anaphylactic reaction

56

Echinococcal cyst labs

↑WBC

57

Liver cell adenoma

tumor of glandular epithelial tissue. More commonly in women taking oral contraceptives.

58

Liver cell adenoma appearance

Well defined

Hyperechoic with central hypoechoic area

Solitary

Multiple

Fluid may be present

59

Liver cell adenoma presentation

RUQ pain

60

Hepatic cystadenoma

rare neoplasm in middle aged women

61

Hepatic cystadenoma appearance

Multi – loculated lesion

Mucinous fluid

62

Hepatic cystadenoma presentation

palpable mass

63

Focal nodular hyperplasia

This is the second most common benign liver mass in women over 40 years of age.

64

Focal nodular hyperplasia appearance

Subtle contour abnormalities

Hyperechoic to linear areas

Multiple nodules

65

Hepatocellular carcinoma

HCC: This is the most common primary malignant neoplasm.

66

Hepatocellular carcinoma appearance

Hepatomegaly

Appearance varies

Solitary

Multiple

Hypoechoic

Hyperechoic

Vessel with tumor invasion

67

Hepatocellular carcinoma presentation

palpable mass

appetite disorder, fever

68

Hepatocellular carcinoma labs

↑alpha-protein test

Liver function test

↑Alk Phos

↑Direct Bilirubin

↑AST

↑ALT

Leukopenia

69

Metastatic disease

This is the most common form of neoplastic involvement of the liver. The primary sites include colon, breast, and lung.

70

Metastatic disease appearance

Appearance varies

Multiple nodes

Solitary

Well defined

Echogenic to hypoechoic mass

Homogenous

Calcification

Necrosis

71

Metastatic disease presentation

jaundice

hepatomegaly

weight loss

decreased appetite

abnormal LFTs

72

Metastatic disease labs

Abnormal LFT

73

Lymphoma

This is a malignant neoplasm which involves a rapid increase of lymphocytes in the lymph nodes. Hodgkin’s and Non-Hodgkin’s lymphoma.

74

Lymphoma appearance

Hepatomegaly

Hypoechoic target lesions

Anechoic

Solid with no enhancement

Hepatosplenomegaly

75

Lymphoma labs

abnormal LFTs

76

Mirizzi Syndrome

Impacted stone in the cystic duct.

77

Mirizzi Syndrome appearance

Shot gun sign

Dilated intrahepatic ducts

GB unvisualized

78

Acute Cholecystitis

Inflammation of the gallbladder.

Presentation: RUQ Pain.

79

Acute Cholecystitis appearance

Dialation

Rounding of Gallbladder

Thick Wall

Stones

Pericholecystic Fluid

80

Acute Cholecystitis labs

↑Serum Amylase,

Abnormal Liver Function Test

81

Acute Cholecystitis cause

Gallstones

82

Cholelithiasis

Gallstones

83

Cholelithiasis appearance

Dilation

Thick Walls

WES sign

Gravity dependent

Posterior shadowing

Hyperechoic intraluminal echoes

84

Cholelithiasis presentation

Asymptomatic

RUQ pain

nausea, vomiting

85

Cholelithiasis labs

↑ Serum Amylase,

↑Alkaline Phosphatase

↑Bilirubin

Abnormal Liver Function Test

86

Cholelithiasis cause

Five F’s, Obesity

87

Hydrops of the Gallbladder

Mucus filled gallbladder. AKA: Mucocele

88

Hydrops of the Gallbladder appearance

Enlarged gallbladder

Thin walls

89

Hydrops of the Gallbladder presentation

RUQ pain

90

Hydrops of the Gallbladder labs

Abnormal Liver Function Test

91

Hydrops of the Gallbladder cause

obstruction of cystic duct

92

Courvoisier’s gallbladder

gallbladder enlargement from obstruction at the level of the distal common bile duct.

93

Courvoisier’s gallbladder appearance

Enlarged gallbladder

Thin walls

94

Courvoisier’s gallbladder

mass at the head of the pancreas

95

Porcelain Gallbladder

Rare, Calcium incrustation of the gallbladder wall

96

Porcelain Gallbladder apperance

Looks like eclipse

Thick wall calcification

Shadowing

97

Porcelain Gallbladder presentation

Asymptomatic, Female, over 60

98

Cholangitis

Medical Emergency, Inflammation of the bile ducts with pus within the ducts

99

Cholangitis appearance

Dilated biliary tree

CBD smooth or irregular thickening

Sludge

Hepatic abscess

100

Cholesterolosis

Cholesterol is deposited in the lumen of the gallbladder, Strawberry gallbladder

101

Cholesterolosis appearance

Polyps (Do not shadow)

102

GB Ademomas

Benign neoplasms, overgrowth of gallbladder epithelium. Most common of benign neoplasms usually near fundus

103

GB Ademomas appearance

hyperechoic

Flat elevations in body

Near fundus

Not gravity dependent

No shadow

104

Adenomyomatosis

hyperplastic change in the gallbladder wall sometimes with papillomas Stones get lodged.

105

Adenomyomatosis apperance

Single or groups

Comet tail

Fixed

No shadow

Comet tail

106

Gallbladder Carcinoma

Rare cancer with almost 100% mortality rate

107

Gallbladder Carcinoma appearance

Heterogeneous solid mass

Thick wall

Dilated biliary bucts

108

Gallbladder Carcinoma presentation

stones

women over 60 years

109

Choledochal Cysts:

This is a cystic dilatation of the common bile duct due to an abnormal insertion of the duct into the pancreatic duct.

110

Choledochal Cysts: appearance

True cyst

Dilated cystic CBD

Diverticulum of CBD

CBD in duodenum

Dilated CBD and CHD

Appearance of a true cyst

Large, cystic mass in the porta hepatis

111

Choledochal Cysts: presentation

Gallstones

pancreatitis

cirrhosis

112

Klatskins tumor

Occurs at the bifurcation of the common hepatic duct.

113

Caroli’s Disease

Rare congenital recessive abnormality, dilatation of the intrahepatic bile ducts

114

Caroli’s Disease appearance

Multiple cystic structures

Near ductal system

Converge toward porta hepatis

Sludge in the ducts

115

Caroli’s Disease presentation

Renal disease,

congenital hepatic fibrosis

cramps in upper abdomen

ductal stones, stones

cystic kidney disease.

116

Emphysematous Cholecystitis

Rare complication of Acute Cholecystitis, more common in men, gas forming bacteria in the Gallbladder.

Often fatal- Surgical Emergency.

117

Emphysematous Cholecystitis appearance

Bright echoes

Ringdown

Comet trail

WES

Stone

118

Emphysematous Cholecystitis presentation

diabetes,

RUQ pain

nausea

vomiting

119

Emphysematous Cholecystiti labs

Abnormal Liver Function Test

120

Gangrenous Cholecystitis

Rare complication of Acute Cholecystitis, Gallbladder undergoes necrosis.

Sonographic Appearance:

121

Gangrenous Cholecystitis presentation

RUQ pain

122

Gangrenous Cholecystitis appearance

Echogenic density with absence of obstruction

No Shadow

Not gravity dependent

No layers

123

Gangrenous Cholecystitis labs

Abnormal Liver Function Test

124

Gangrenous Cholecystitis cause

Prolonged infection

125

Acalculous Cholecystitis

Rare acute inflammation of the gallbladder

126

Acalculous Cholecystitis appeance

Dilation

Murphy’s sign

Thick wall

Sludge

Pericholecystic Fluid

Subserosal Edema

127

Acalculous Cholecystitis labs

↑ Serum Amylase

Abnormal Liver Function Test

128

Acalculous Cholecystitis cause

decreased blood flow through the cystic artery

129

Torsion of the Gallbladder

Twisting of Gallbladder, more common in elderly females

130

Torsion of the Gallbladder Appearance

Massively inflames

Distended

Cystic artery and cystic duct twisted

Presentation:

Lab Values:

131

Torsion of the Gallbladder presentation

RUQ Pain.

132

Torsion of the Gallbladder labs

↑Serum Amylase

Abnormal Liver Function Test

133

Chronic Cholecystitis

Numerous attacks of acute Cholecystitis

134

Chronic Cholecystitis appearance

Contraction

Stones

WES sign

135

Chronic Cholecystitis presentation

RUQ Pain

136

Chronic Cholecystitis labs

↑Serum Amylase

Abnormal Liver Function Test

137

Gallbladder Polyps

Small, well-defined, soft tissue projection.

138

Gallbladder Polyps appearance

Small, Smooth, Ovid

Multiple

No shadow

Fixed

Comet tail

139

Biliary Obstruction

Blockage in the tubes that carry bile from the liver to the gallbladder and small intestine.

140

Biliary Obstruction appearance

Duct Dilation

141

Biliary Obstruction presentation

Jaundice

Pancreatitis,

142

Biliary Obstruction cause

tumor or thrombus within the ducts

143

Choledocholithiasis

Formation of calcium stone in the bile ducts

144

Choledocholithiasis appearance

Impacted stones in the ampulla of vater

Dilated duct

Posterior shadowing

145

Ascariasis

20-30 cm long parasitic round worm that uses oral fecal route.

146

Ascariasis

Enlarged duct

Moving tube

Transverse plane shows bullseye

147

Ascariasis

asymptomatic, biliary colic, pancreatitis

148

Intrahepatic Cholangiocarcinoma

Biliary Neoplasm

149

Intrahepatic Cholangiocarcinoma appearance

Large hepatic mass

Varied hyperechoic/hypoechoic

Ductal dilation

Solid mass within the cystic structure

150

Distal Cholangiocarcinoma

Biliary Neoplasm

151

Distal Cholangiocarcinoma appearance

Nodular tumor

Focal irregular ductal stricture

Wall thickening

152

Distal Cholangiocarcinoma presentation

Jaundice