first 1/2 of Liver Pathology PPT

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1

What 3 regions does the liver occupy?

*Relationship*: the liver like ______ to the diaphragm

Rt Hypochondrium, Lt Hypochondrium (to mamillary line), and greater part of the epigastrium

inferior

2

What are the fissures/ligaments/capsules that make up the liver? (5)

What is their echogenicity sonographically? Why?

Glisson capsule, Main lobar fissure, Falciform ligament, Ligamentum teres (round ligament), and Ligamentum venosum

Appear echogenic or hyperechoic because of the presence of collagen and fat within and around the structures

3

What are the four major functions of the liver?

Hepatic metabolic functions, role in digestion, storage function, and detoxification function

4

Describe the Hepatic metabolic functions of the liver. (9)

The major site for converting dietary sugars (carbohydrates) into glucose; Converts glucose to glycogen and stores it; when glucose is needed, it breaks down the glycogen and releases glucose into the blood; Major site for metabolizing fats; Stored fats may be transported to the liver and converted into energy; Manufactures plasma proteins; Converts excess amino acids to fatty acids and urea; Removes nutrients from the blood; Phagocytizes bacteria and worn-out red blood cells

5

Describes the livers role in digestion, storage function, and detoxification function.

Roll in Digestion: Secretes bile- digestion of fats; Bilirubin, a pigment when red blood cells are broken down, is excreted in the bile.

Storage function: Stores iron and vitamins

Detox function: Detoxifies many drugs and poisons and waste products of the body’s metabolic processes.

6

Describe the difference between hepatic vs obstructive disease.

Hepatocellular disease- Liver cells (hepatocytes) are the immediate problem. Usually treated medically with supportive measures and drugs

Obstructive disorders- Bile excretion is blocked. Usually treated surgically.

7

What is bilirubin?

Describe bilirubin detoxification. (4 steps)

Bilirubin, the breakdown product of hemoglobin, is also an important substance detoxified in the liver.

    • Liver excretes bilirubin into the gut
    • Worn out bred blood cells are trapped and broken down by reticuloendothelial cells, primarily in the spleen.
    • Hemoglobin is converted to bilirubin and is then released into the bloodstream.
    • Bilirubin attach to albumin in the blood and are transported to the liver.
8

During Metabolism of bilirubin in hepatocytes there is: Uptake, Conjugation, and Excretion. Describe each.

    1. Uptake: Bilirubin is separated from albumin
      at the cell membrane, and is taken inside the hepatocytes.
    2. Conjugation: Bilirubin molecule is combined with two glucuronide molecules, forming bilirubin diglucuronide.
    3. Excretion: Bilirubin released from the hepatocytes passes through the bile ducts with other components of bile and is delivered to the bowel.
9

With biliary obstruction, the hepatocytes pick up________ and conjugate it with glucuronide molecules; however, they cannot ______ it.

Conjugated form is then ___________ into the bloodstream, with resultant elevation of the ________ bilirubin.

_________ bilirubin may also rise slightly in biliary obstruction, but the direct bilirubin predominates.

bilirubin; dispose

regurgitated; direct-acting

Indirect-acting

10

The ___________ form predominates in hepatocellular disease.

What step of bilirubin detoxification is most affected when the hepatocytes are damaged? Therefore hepatocytes continue to take in and conjugate _______ but are unable to ________ it.

As in biliary obstruction, the accumulated conjugated bilirubin is _________ into the blood.

Direct (or conjugated)

Excretion; bilirubin; excrete

regurgitated

11

What is the excretory product of the liver?

It is formed continuously by the___________, and is transported to the gut via the __________.

Bile

hepatocytes; bile ducts

12

What are the four PRINCIPAL components of bile?

and the other three components?

What is the primary function of bile?

water, bile salts, and bile pigments (primarily bilirubin diglucuronide)

cholesterol, lecithin, and protein

Emulsification(breakdown) of intestinal fat

13

What are the 7 liver function tests?

Aspartate Amniotransferase (AST), Alanine Amniotransferase (ALT), Lactic Acid Dehydrogenase (LDH), Alk Phos (ALP), Bilirubin (indirect, direct, total), Prothrombin time (PT), Albumin and globulins

14

Where is AST found other than the liver?

Alanine Amniotransferase (ALT) is found exclusively in the ____.

LDH is measured to check for what? Its found where (7)?

Alk Phos (ALP) is found what four places?

Bilirubin is the byproduct of ________.

Prothrombin time (PT) is a _______ factor.

Albumin and globulins- _____ synthesis and fluid _______ in the body.

Muscles

Liver

Tissue Damage; the heart, liver, kidney, muscles, brain, blood cells, and lungs.

Bile ducts, liver, growing bones, and placenta.

RBC

Clotting

protein; regulation

15

For best sonographic evaluation of the liver--

what is the ideal patient prep?

patient position(s)?

Complete survey of what 4 scan planes?

What four things are assessed?

NPO for 6 hours to eliminate bowel gas and ensure fullness of gallbladder

Supine or right anterior oblique position, usually with deep inspiration to allow the liver to move inferior to the rib cage

Complete survey: transverse, coronal, subcostal oblique, and sagittal views

Size of liver (long), attenuation of liver parenchyma, texture/echogenicity, presence of hepatic vascular structures, ligaments and fissures.

16

What is the normal texture of the liver?

Echogenicity compared to kidney?

Echogenicity compared to spleen?

Homogeneous with fine-low level echoes

Minimally hyperechoic to isoechoic, when compared with the renal cortex of the kidneys

Hypoechoic, when compared with the texture of the spleen

17

What are the four developmental anomalies of the liver?

      • Agenesis
      • Anomalies of position- Situs inversus
      • Accessory fissures
      • Vascular anomalies
18

_______________ disease affects the hepatocytes and interferes with liver function. (LFTS)

Diffuse hepatocellular

19

The ___________ is a parenchymal liver cell that performs all the functions of the liver.

How is diffuse disease measured?

hepatocyte

through LFTs

20

__________is an acquired, reversible disorder of metabolism, resulting in an accumulation of ___________ (glycerol and three fatty acid groups) within the hepatocytes.

Fatty liver; triglycerides

21

_____________ implies increased lipid accumulation in the hepatocytes and is the result of major injury to the _____ or a systemic disorder leading to impaired or excessive metabolism of _____. (Storage disorders/medication issues)

Fatty infiltration; liver; fat

22

10 causes of fatty liver?

    • Obesity
    • Excessive alcohol intake
    • Poorly controlled hyperlipidemia
    • Diabetes (type II typically)
    • Excess corticosteroids
    • Pregnancy
    • Severe hepatitis
    • Glycogen storage disease
    • Cystic fibrosis
    • Pharmaceutical – Acetaminophen
23

What are the three classes of fatty infiltration?

    • Mild: Minimal diffuse increase in hepatic echogenicity with normal visualization of the ________ and ___________ vascular borders
    • Moderate: _________ echogenicity with slightly impaired visualization of the diaphragm and intrahepatic vascular borders
    • Severe: Significant increase in echogenicity of the __________, decreased penetration of the posterior segment of the _______, and decreased to poor visualization of the diaphragm and hepatic vessels

Mild, moderate, and severe

diaphragm, intrahepatic

increased

liver parenchyma; RLL

24

What is the general name for inflammatory and infectious disease of the liver?

Hepatitis

25

Hepatitis (viral) may result from _______, from an infection elsewhere in the body (mono, amebiasis), or from ______ or drug toxicity.

local infection; chemical

26

Mild inflammation impairs ________ function, whereas more severe inflammation and necrosis may lead to ______ of blood and bile flow in the liver and impaired liver cell function.

hepatocyte; obstruction

27

________ is considered to result from infection by a group of viruses that specifically target the hepatocytes

Hepatitis

28

What are the 6 types of hepatitis?

In the US approx 60% of acute viral hepatitis is type _____.

20% is ____.

and the remaining 20% is all other types.

  • Hepatitis A virus (HAV)-- 20%
  • Hepatitis B virus (HBV)-- 60%
  • Hepatitis C virus (HCV)
  • Hepatitis D virus (HDV)
  • Hepatitis E virus (HEV)
  • Hepatitis G
29

Patients with acute and chronic hepatitis may initially have flulike and gastrointestinal symptoms, including a loss of ________, _________, _________, and ________.

appetite, nausea, vomiting, and fatigue

30

_______ hepatitis may be fatal.

_________ hepatitis may lead to portal hypertension and cirrhosis.

Viral

Acute hepatic necrosis; chronic hepatitis

31

Without complications, clinical recovery from acute hepatitis usually occurs within ______ months.

Complications of hepatitis involving damage to the liver may range from________________ to ___________________.

four

mild disease to massive necrosis and liver failure

32

What three pathologic changes take place with acute hepatitis?

      • injury or swelling of the hepatocytes, hepatocyte degeneration, cell necrosis
      • Reticuloendothelial and lymphocytic response with Kupffer cells enlarging
      • Regeneration
33

Sono Appearance of Acute Hepatitis: Liver texture may appear _________, or portal vein borders may be ____________.

Liver parenchyma is slightly more _______ than normal.

________ may be present.

________megaly is present.

Normal; more prominent than usual

echogenic

attenuation

hepatosplenomegaly

34

Chronic hepatitis extends beyond ______ months.

What are the four possible causes of chronic hepatitis?

8 symptoms of Chronic hepatitis?

six

viral, metabolic, auto-immune, or drug induced

nausea, anorexia, weight loss, tremors, jaundice, dark urine, fatigue, and varicosities.

35

Chronic _________ hepatitis is a benign, self-limiting process.

Chronic _______ hepatitis usually progresses to cirrhosis and liver failure.

persistent

active

36

Sonographically:

Liver parenchyma is coarse with _________ brightness of the portal triads.

Liver does not _______ in size with chronic hepatitis.

________ may be evident, which may produce “soft shadowing” posteriorly.

decreased

increase

Fibrosis

37

_________ is a chronic degenerative disease of the liver.

      • Lobes are covered with________ tissue.
      • Parenchyma _________.
      • Lobules are infiltrated with _____.

Cirrhosis

fibrous

degenerates

fat

38

The essential features of Cirrhosis are: simultaneous parenchymal _______, regeneration, and ______ fibrosis, resulting in a disorganization of _______ architecture.

necrosis; diffuse; lobular

39

Cirrhosis may be both ________ and_________, with liver cell failure and portal hypertension as the end stage.

___________ cirrhosis is most commonly the result of chronic alcohol abuse, whereas ___________ cirrhosis is caused by chronic viral hepatitis or other infection.

Other causes of cirrhosis include______ cirrhosis, Wilson disease (copper), primary sclerosing cholangitis, and __________ (disorder where you absorb too much iron).

Chronic & progressive

Micronodular; macro-nodular

biliary; hemochromatosis

40

Patients with acute cirrhosis may be asymptomatic or may have what other symptoms?

What are the three classic clinical presentations of cirrhosis?

nausea, flatulence, ascites, light-colored stools, weakness, abdominal pain, varicosities, and spider angiomas.

hepatomegaly, jaundice, and ascites.

41

Chronic cirrhosis symptoms (7)?

Chronic cirrhosis may progress to____________ and ____________.

nausea, anorexia, weight loss, jaundice, dark urine, fatigue, or varicosities.

liver failure; portal hypertension

42

Doppler Characteristics of Cirrhosis:

The _________ velocity waveform reflects the hemodynamics of the right atrium.

The ________ pattern has two large antegrade diastolic and systolic waves and a small retrograde wave that corresponds to the atrial kick (from the heart).

_________ easily receive the transfer of flow via the collaterals from the portal veins in a normal liver.

hepatic vein

triphasic

Hepatic veins

43

Doppler Characteristics of Cirrhosis:

In patients with ________ cirrhosis (no portal hypertension), the Doppler waveform is abnormal.

As cirrhosis advances, the hepatic veins develop_________ narrowing with increased velocities and turbulence of the flow patterns.

Hepatic artery waveform also shows altered flow dynamics in cirrhosis and chronic liver disease.

Resistive index is________ after a meal in patients with liver disease.

compensated

luminal

blunted

44

Hepatic Vascular Flow Abnormalities: Portal Venous Hypertension

Increase in portal venous _________ or hepatic venous gradient present

pressure

45

Acute or chronic hepatocellular disease can block the flow of blood throughout the liver, causing it to back up into the ________________.

Hepatocellular disease causes the blood pressure in the hepatic circulation to increase and leads to the development of ______________.

hepatic portal circulation

portal hypertension

46

In an effort to relieve the pressure from Portal Venous Hypertension, _______ veins are formed. These are known as varicose veins and occur most frequently in the area of the_______, ________, and _________.

Rupture of these veins can cause massive bleeding that may result in death.

collateral

esophagus, stomach, and rectum

47

_________ is most common cause of intrahepatic portal hypertension.

_________ liver disease may also produce portal hypertension.

Other causes include thrombotic diseases of the inferior vena cava and hepatic veins, constrictive pericarditis or other right-sided heart failure over time.

Cirrhosis

Diffuse metastatic

48

Porta venousl hypertension may develop when hepatopetal flow (toward the liver) is impeded by ______ or _______ invasion.

The blood becomes obstructed as it passes through the liver to the hepatic veins and is diverted to _______ pathways in the upper abdomen.

thrombus or tumor

collateral

49

Portal hypertension may develop from increased resistance to flow (cirrhosis). It is difficult for the blood to _____.

Portal hypertension may develop from _______ portal flow.

Patients with increased portal blood flow may have an ___________ or splenomegaly secondary to a ________

perfuse

increased

arteriovenous fistula; hematologic

50

In Portal Hypertension,___________ circulation develops when the normal venous channels become obstructed.

Diverted blood flow causes embryologic channels to reopen ie. recanalized ________ vein; blood flows__________ and is diverted into collateral vessels.

Most common collateral pathways are through the ________ and __________ veins.

Collateral

umbilical (paraumbilical); hepatofugally

coronary and esophageal

51

What is the primary complaint of portal vein thrombosis?

With PV Thombus,patient has neither________ nor a tender, enlarged liver.

Splenomegaly and bleeding varices may be present.

Portal vein thrombosis may develop secondary to trauma, sepsis, cirrhosis, or hepatocellular carcinoma.

Ascites

jaundice

52

If portal hypertension becomes extensive, the portal system can be __________ by shunting blood to the systemic venous system.

decompressed

53

What are the three types of portacaval shunts? Describe location of each.

      • Portacaval- superior mesenteric vein-splenic vein confluence to the anterior aspect of the inferior vena cava
      • Mesocaval-mid-distal superior mesenteric vein to the inferior vena cava
      • Splenorenal- splenic vein to the left renal vein
54

What does TIPS stand for?

Transjugular Intrahepatic Porosystemic Shunt

55

TIPS are created percutaneously with the use of metallic expandable stents.

_________ may occur at the hepatic vein level or within the shunt.

Stenosis