Liver Powerpoint

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1

Budd-Chiari

What disease is caused by thrombosis of the hepatic veins or IVC?

It may present as acute or chronic lasting from a few weeks to years.

It can be classified as primary or secondary.

Has a poor prognosis

2

Budd Chiari

Presents with symptoms of: ascites, abdominal pain, hepatosplenomegaly, jaundice, vomiting and diarrhea.

3

Budd Chiari

____ primary type is caused by congenital obstruction of the hepatic veins or IVC by membranous webs across the upper IVC or just above the entrance of the left and middle hepatic veins.

4

Budd Chiari

____ secondary type results from thrombosis in the hepatic veins or IVC.

5

Glycogen Storage Disease

___ is an inherited disease characterized by the abnormal storage and accumulation of glycogen-especially the liver and kidneys.

6 categories- most common is type 1 or von Gierke disease

Are associated with adenomas

6

Hemochromatosis

is a rare disease of iron metabolism characterized by excess iron deposits throughout the body.

May lead to cirrhosis and portal hypertension

Sonographic findings include: hepatomegaly, cirrhotic changes, increased echogenicity throughout the hepatic parenchyma.

7

Diffuse abnormalities of the liver parenchyma

Biliary obstruction, common duct stones and stricture, extrahepatic mass, and passive hepatic congestion

8

Proximal Biliary Obstruction

___ is obstruction proximal to the cystic duct.

Can be caused by gallstones, carcinoma of the CBD, and metastatic tumor invasion of the porta hepatis.

9

Proximal Biliary Obstruction

___ presents as a jaundiced patient with pruritus (itching)

LFTs show an elevation in the direct bilirubin and alkaline phosphatase levels with ___.

10

Distal Biliary Obstruction

___ is obstruction distal to the cystic duct.

Caused by stones in the CBD, extrahepatic mass in the porta hepatis, and stricture of the common duct.

11

Distal Biliary Obstruction

___ causes RUQ pain, jaundice, and pruritus, as well as an increase in direct bilirubin and alkaline phosphatase.

12

Focal Hepatic Disease

___ is a solitary nonparasitic cyst of the liver.

May be congenital or acquired

May be solitary or multiple

13

Focal Hepatic Disease

___ patients are often asymptomatic and require no treatment

Sonographic findings of a benign cyst show the lesion to be well-demarcated, thin walled with anechoic posterior enhancement.

14

Simple Hepatic Cysts

___ are usually incidental because most patients are asymptomatic. As the cyst grows, it may cause pain or a mass effect to suggest a more serious condition such as infection, abscess, or necrotic lesion.

More common in women

15

Polycystic Liver Disease

___ is inherited and affects 1 in 500 individuals.

At least 50-74% of patients with with polycystic renal disease have one to several hepatic cysts. Of patients with ___, 60% have associated polycystic renal disease.

16

Polycystic Liver Disease

___ appears as small cysts, less than 2-3 cm, and multiple throughout the hepatic parenchyma.

May enlarge and cause biliary obstruction in the porta hepatis.

17

Hepatic Abscesses

___ are usually complications of biliary tract disease, surgery or trauma.

3 types: intrahepatic, subhepatic and subphrenic (below diaphragm)

Present with fever, elevated WBCs, and RUQ pain. Presents as multiple lesions in the liver, abnormal fluid collections in Morison's pouch, or subphrenic space.

18

Pyogenic Abscess

pus forming

May enter the liver through the biliary tree, portal vein or hepatic artery; direct extension from a contiguous infection; and rarely hepatic trauma

19

Pyogenic Abscess

___ serious infections include cholagitis; portal pyemia secondary to appendicitis, diverticulitis, inflammatory disease, or colitis; direct spread from another organ; or infarction after embolization or from sickle cell anemia.

20

Hepatic Candidiasis

___ is a fungal disease caused by a species of Candida. Occurs in immunocompromised hosts, such as patients undergoing chemotherapy, organ transplant recipients, or individuals with HIV.

Invades the bloodstream and may affect any organ, with the more perfused kidneys, brain and heart affected the most.

21

Amebic Abscess

___ usually affects the colon and cecum. If the organism invades the colonic mucosa, it may travel to the liver via the portal venous system.

Patients may be asymptomatic or may show the GI symptoms of abdominal pain, diarrhea, leukocytosis, and low fever.

22

Amebic Abscess

___ is a collection of pus formed by disintegrated tissue in a cavity, usually the liver.

Caused by the protozoan parasite, Entamoeba histolyica

Is contracted by ingesting the cysts in contaminated food and water.

23

Echinococcal Cyst

___ is an infectious cystic disease common in sheep-herding areas.

A worm that is ingested through canine feces in the environment.

Typically seen on ultrasound in the GB.

24

Echinococcal Cyst

___ has 2 layers: 1) the inner layer and 2) the outer, or inflammatory reaction, layer. Smaller daughter cysts may develop from the inner layer.

Cysts may enlarge and rupture.

Cysts may also impinge on the blood vessels and lead to vascular thrombosis.

25

Cavernous Hemangioma

Benign congenital tumor consisting of large, blood-filled cystic spaces (but does not appear cystic)

The most common benign tumor of the liver

More frequent in women

26

Cavernous Hemangioma

Patients are usually asymptomatic, although a small percentage may bleed, causing RUQ pain

Enlarges slowly and undergoes degeneration, fibrosis, and calcification

Found more in the dome or in the posterior right lobe than the left lobe.

27

Liver Cell Adenoma

___ consists of normal or slightly atypical hepatocytes and frequently contains areas of bile stasis and focal hemorrhage or necrosis.

Found more commonly in women and has been related to birth control

Symptoms include RUQ pain, secondary to rupture with bleeding in tumor. Incidence increased in patients with type 1 glycogen storage disease.

28

Focal Nodular Hyperplasia

Second most common benign liver mass

Found in women under 40

Aysymptomatic

Mass related to an area of congenital vascular formation

29

Focal Nodular Hyperplasia

Lesions occur more in the right lobe of the liver, many in dome. Typically, one well-circumscribed lesion; may be more than one mass. Some are pedunculated. May have a central scar.

Consist of normal hepatocytes, Kupffer cells, bile duct elements, and fibrous connective tissue.

Multiple nodules are separated by bands of fibrous tissue. Increased bleeding may occur within the tumor in these patients.

30

Hepatocellular Carcinoma

AKA Hepatoma or HCC

Most common primary malignant neoplasm

Its pathogenesis is related to cirrhosis (80% of patients with preexisting cirrhosis develop ___), chronic hepatitis B virus infection, and hepatocarcinogens in foods.

Occurs more in men

31

Hepatocellular Carcinoma

Clinically presentation includes a previous history of cirrhosis or hepatitis B and C, a palpable mass, hepatomegaly, appetite disorder and fever. Solitary and massive; multiple nodules throughout; diffuse infiltrative masses in the liver.

Well defined "bull's eye" lesion

Pathology presents as: focal lesion, invasive lesion with necrosis & hemorrhage, and poorly defined lesion

32

Hepatocellular Carcinoma

___ can be invasive

Has been known to invade the hepatic veins to produce Budd Chiari

The portal venous system may also be invaded with tumor or thrombosis.

Has a tendency to destroy the portal venous walls

33

Metastatic Disease

METS

The most common form of neoplastic involvement of the liver

Primary sites are colon, breast and lung.

Patients with short survival rate after initial detection of ___ are those with hepatocellular carcinoma and carcinoma of the pancreas, stomach and esophagus.

34

Metastatic Disease

METS

Patients with longer survival rates are those with head and neck carcinoma and carcinoma of the colon.

Metastatic spread to the liver occurs as the tumor erodes the wall and travels through the lymphatic system or through the blood stream to the portal vein or hepatic artery.

35

Lymphoma

A malignant neoplasm involving lymphocyte proliferation in the lymph nodes. 2 main: Hodgkin and non-Hodgkin, are differentiated by biopsy

Patients have hepatomegaly with a normal or diffuse alteration of parenchymal echoes.

36

Lymphoma

Focal hypoechoic mass is sometimes seen

Symptoms may be: enlarged, nontender lymph nodes, fever, fatigue, night sweats, weight loss, bone pain, or an abdominal mass

Splenomegaly or retroperitoneal nodes may help confirm a diagnosis of __

37

Hepatic Trauma

The liver is the 3rd most commonly injured abdominal organ after the spleen and kidney.

Laceration occurs in 3% of trauma patients and its frequently associated with other injured organs.

Need for surgery is determined by the size, degree of hemoperitoneum and patient's clinical status.

38

Hepatic Trauma

The right lobe is affected more often than the left.

The degree of trauma can vary, small laceration/large laceration with a hematoma, or a subcapsular hematoma, to a capsular disruption.

Buzz word: automobile accident

39

Liver Transplant

Performed in patients with end-stage liver disease to eliminate irreversible disease when more conservative medical and surgical treatments.

40

Liver Transplant

Most common indications in adults in Hepatitis C, followed closely by: alcoholism liver disease and crypotogenic cirrhosis, fulminant active hepatitis, congenital metabolic disorders, sclerosing cholangitis, Budd Chiari syndrome, and unresectable HCC.

41

Liver Transplant

Many centers consider ____ only in patients with early stage hepatocellular carcinoma.

Guidelines use the Milan criteria of no lesion greater than 5 cm in diameter or no more than 3 lesions of greater than 3 cm in diameter.

42

Liver Transplant

Contraindications: compensated cirrhosis without complications, extrahepatic malignancy, cholanginocarcinoma, active untreated sepsis, advanced cardiopulmonary disease, active alcoholism or substance abuse, and anatomic abnormality precluding the surgical procedure.

43

Liver Transplant

Normal Sonographic Appearance

Primary function is to evaluate the portal venous system, hepatic artery, IVC and liver parenchymal pattern. Vascular structures are assessed, liver parenchyma, and also the biliary system for dilation and collateral vessels.

44

Complications of Transplant

Rejection, thrombosis/leak, biliary stricture, infection and neoplasia.

Hepatic artery thrombosis is the most serious complication. Color doppler may show an absence of flow in the porta hepatis.

Associated with: hepatic arterial occulsion, pretransplant primary sclerosing cholangitis, choledochojejunostomy, cholangitis at liver biopsy, and young age

45

Complications of Transplant

Biliary strictures may be asymptomatic, have painless jaundice, or abnormal LFTs. Anastomotic strictures are the most common cause of biliary obstruction after transplant.

Other complications: sclerosising cholangitis, biliary sludge and stones, dysfuntion of the sphincter of Oddi