Hemapoietc functions begin at ___ and end at birth.
begins at 6 weeks, peaks at 12-24 weeks
Lymphocyte formation starts at week ___________ gestational age.
10
___________ starts at week 13-16 gestational age and does not end at birth.
bile production
The umbilical vein becomes what after birth?
ligamentum teres
What does the ductus venosus becomes what after birth?
ligamentum venosum
The liver occupies which regions of the abdomen?
most of right hypochondrium and epigastrium and part of left hypochondrium
The liver is covered by what?
glissons capsule
The normal superior/inferior size of liver is ___________ .
15-17 cm
The normal weight of the liver is ___________ .
1200-1600 grams
The fundus of the stomach is ___________ to the left lobe of liver.
posterior
The body and antrum of stomach are ___________ to liver.
inferior
The ___________ is medial to the right lobe of liver.
duodenum
The ___________ is inferior to left lobe and right anterior lobe and medial to right posterior lobe.
pancreas
The right kidney is ___________ to liver.
posteroinferior
The GB is ___________ to liver.
posterior
The IVC and AO are ___________ to liver.
posterior
The right lobe is bordered anterosuperiorly by the ___________.
falciform ligament
Right lobe is bordered ___________ by caudate lobe.
posterosuperiorly
Right lobe is bordered posteroinferiorly by ___________ .
viscera (stomach, RK, GB)
Right lobe is bordered anteriorly by ___________ .
umbilical notch
Right lobe is marked ___________ by porta hepatus, GB fossa, and IVC fossa.
inferoposteriorly
Right lobe functionally includes everything to the right of the ___________ .
main lobar fissur
The right lobe can be divided by:
RHV, MLF, RPV
The left lobe can be divided by:
LHV, Lig teres
The ___________ lobe is anatomically part of right lobe but functions in left lobe.
caudate
The caudate is bordered by ligamentum venosum anterior and left, and by the ___________ posterior and to the right.
porta hepatus
The ___________ borders the caudate posterior and to the right.
IVC
Coinaud Segment I is __________.
caudate
Coinaud Segment II is ___________ .
left posterolateral
Coinaud Segment III is ___________ .
left anterolateral
Coinaud Segment IVa is ___________ .
left superomedial
Coinaud Segment IVb is ___________ .
left inferomedial
Coinaud Segment V is ___________ .
right anteroinferior
Coinaud Segment VI is ___________ .
right posteroinferior
Coinaud Segment VII is ___________ .
right posterosuperior
Coinaud Segment VIII is ___________ .
right anterosuperior
The ___________ ligament attaches the liver to diaphragm (bare area).
coronary
What 2 aspects are part of the coronary ligament?
right triangular and left triangular
Which ligament surrounds portal triad, bounds the foramen of winslow, and is the right edge of gastrohepatic ligament?
hepatoduodenal ligament
Name 3 functions of the liver.
metabolism of food products, detoxification of waste products, storage of physiologic compounds
Describe a hepatocyte.
performs metabolic functions and is capable of regeneration
What lines the biliary system?
epithelial cells
Describe Kupffer cells.
phagocytic, part of RE, and breakdown hemoglobin (HGB) during bile production
hyperglycemia
increased blood sugar levels
hypoglycemia
decreased blood sugar levels
In which food product is sugar converted to glucose and used for energy or converted to glycogen and stored in liver cells?
carbohydrates
___________ are absorbed from the intestines as mono and diglycerides.
fats
Which food product is converted within hepatocytes to lipoproteins and stored until later converted to glucose?
fats
Fats cannot travel thru blood and may accumulate in ___________.
liver cells
Name the 3 proteins that are metabolized in kupffer cells and contribute to correct blood viscosity.
albumin, fibrinogen, and prothrombin
Which type of bilirubin is conjugated by hepatocytes, formed in spleen by breakdown of HGb, is water soluble, and increases during post hepatic and hepatic jaundice?
direct
Which type of bilirubin is not yet conjugated, water insoluble, and increases during hepatic and pre hepatic jaundice?
indirect
What can the liver store?
glycogen, fats, vitamins, iron, and copper
How much blood is supplied to the liver via the hepatic artery?
20%
Which normal variant is an inferior extension of posterior right lobe, past the lower pole of RK?
Riedel’s lobe
Which normal variant is a medial extension of the caudate lobe?
caudate process
Which disease process affects hepatocytes and is treated medically?
hepatocellular
Which disease process is treated surgically and the flow of bile is prevented?
obstructive
What is bile?
an excretory product of the liver
Where is bile formed?
in hepatocytes
Bile is collected in ducts, stored in ___________ and released to___________ where its emulsified and removes liver by products.
GB; duodenum
Bile salts absorb fats and may cause:
steatorrhea (fatty stools) or prevent absorption of fat soluble vitamins (A, D, E, K)
Name 5 things that can be stored in the liver.
glycogen, fats, vitamins, iron, copper
What percentage of blood is supplied by the hepatic arteries?
20 %
What percentage of blood is supplied by the portal veins?
80%
Blood is drained by the ____________.
hepatic veins
PVs are ____________.
intrasegmental
PV's have brightly echogenic walls and get _____ as the move away from the porta hepatus.
smaller
The MPV is formed by the union of the ____________and ____________.
SV; SMV
The MPV enters the liver where?
at the porta hepatus
The ____________ has a mostly transverse course and enters the liver at the porta hepatus.
MPV
The MPV is surrounded by what ligament?
hepatoduodenal
The MPV immediately divides into what?
right and left branches
The ____________ is the larger branch of the MPV and has anterior and posterior branches.
RPV
The ____________ lies more superoanterior and can be seen to course superiorly to enter the left lobe.
LPV
A right, middle, and left vein converge to drain directly into what?
IVC
Are HV's intra or intersegmental?
intersegmental
HV's have hyperechoic walls and get ____________ as you move towards the IVC.
larger
What is small left lobe is also called?
Riedel’s lobe
An inferior extension of posterior right lobe, Riedel’s lobe, is past which pole of the kidney?
lower
What is a medial extension of the caudate lobe?
caudate process
Which disease process affects hepatocytes and is treated medically?
hepatocellular
Which disease process prevents the flow of bile and is treated surgically?
obstructive
Hepatic enzymes present in ____________ and leak into blood during cellular damage.
hepatocytes
SGOT
serum glutamic exaloacetic transaminase.
What is SGOT now called?
AST (aspartate aminotransferase)
SGPT
serum glutamic pyruvate
What is SGPT now called?
ALT (alanine aminotransferase)
ALP
alkaline phosphatase
What does LDH increases with?
heart disease
What does GGTP increases with?
alcoholic liver disease
What does PT(prothrombin) increase with?
vitamin K deficiency
Which enzyme decreases during chronic liver disease, GI tract inflammatory processes and increases during dehydration?
albumin
Which enzyme increases due to hepatoblastoma?
AFP
Biliary obstruction is a mild increase of SGOT, SGPT and a major increase of what?
ALP, direct bilirubin
Which disease causes a major increase of SGOT, SGPT, and a minor increase of ALP and indirect bilirubin?
cellular disease
Both SGOT and SGPT may increase due to what?
heart disease
Which enzyme may increase due to pregnancy or bone disease?
ALP
Where is bile, an excretory product of the liver, formed?
hepatocytes
Bile is collected in ducts, stored in GB and released to the what?
duodenum
Bile is composed of what?
water, bile salts, bile pigment, cholesterol, lecithin, and proteins.
Bile salts absorb ____________.
fats
The absence of bile salts may cause what?
steatorrhea, prevent absorption of fat soluble vitamins
In general, for liver pathology you should set your machine how?
set field of view to enable you to see all liver parenchyma and set gains to avoid drop out or bending. (Follow orderly protocol)
Describe a simple cyst.
smooth walls, no internal echoes (anterior cystic noise) and posterior enhancement
Describe an abscess.
irregular walls, varying internal echogenicity, some posterior enhancement
What would the patients symptoms be for an abscess?
fever, elevated WBC
What are intrahepatic abscess' caused by?
infection or trauma
Where are subhepatic abscess' located?
in morrison's pouch
What causes subphrenic liver abscess'?
surgical infection, trauma or ulcers
What results from infection within the protozoan parasite?
amebic liver abscess
What does a pt with amebic liver abscess' present with?
fever, anorexia, and abdominal pain
What is a hyatid cyst?
parasitic tapeworm (cyst within a cyst)
Patients with what kind of cyst present with increasing abdominal girth and/or abdominal pain?
hyatid cyst
What arises in the liver or in the extrahepatic bile ducts?
Cystadenoma
________ are most commonly seen in middle aged women.
Cystadenoma
Describe a cystadenoma.
well encapsulated, multiloculated, have septations with varying degrees of mural and septal thickening and nodularity.
Which pathology is intrahepatic or subcapsular and its appearance depends on age?
Hematoma
How does a new hematoma appear?
sonolucent
How does a hematoma appear as it ages?
clot forms and it becomes echogenic
How does a chronic hematoma appear?
begins to liquefy (hygroma formation) as it resolves
Patients with hematomas have decreased what?
Hematocrit
What is a neoplasm?
Any new growth of abnormal tissue (may be benign or malignant)
True or False. Calcifications are often symptomatic.
False, they are asymptomatic.
What is the most common causes of a calcification?
calcified granuloma (eg, tuberculosis and histoplasmosis) and hydatid disease
An adenoma is typically ____________.
benign
A ____________ and ____________ both have increased incidence in women taking birth control pills and both tend to be small, focal lesions with increased echogenicity.
adenoma, hamartoma
Where in the liver are adenoma and hamartoma often seen?
inferiorly
Can an adenoma or hamartoma hemorrhage?
yes
What is a hemangioma?
Tend to be small, focal lesions with increased echogenicity
Larger hemangioma's may cause what?
nausea and vomiting
Name 3 things about hemangioma's.
they are vascular, more common in women, and most common benign liver mass
What is a lipoma?
a benign fatty tumor of the liver.
Describe a hepatoma.
arises from hepatocytes, poorly defined, often occur after long term cirrhosis or hepatitis
Which liver enzymes increase when you have a hepatoma?
ALP, AST, prothrombin, and AFP (fetal cells gone crazy)
Are hepatomas more common in women or men?
men
What else is a hepatoma called?
hepatocellular carcinoma (HCC)
What pathology presents in the first 3 yrs of life?
hepatoblastoma
A hepatoblastoma is the most common symptomatic liver tumor occurring under the age of what?
5 yrs
What does a hepatoblastoma present with?
a large palpable mass
What is the most common liver neoplasm?
mets
The primary of mets (metastatic disease) may be:
colon, breast, lung, pancreas, stomach, lymphoma or melanoma
What does the bowel tend to look like in mets?
hyperechoic with a bullseye appearance.
What are the 3 appearances of mets?
well defined hypoechoic mass, well defined hyperechoic mass, diffuse parenchymal changes
Mets is hypoechoic in nature unless they come from the ____________, then they tend to be hyperechoic.
GI tract
Tendencies: poorly defined means its mainly ____________, and well defined means it mainly ____________.
malignant; benign
More tendencies: post. enhancement means ______, and post. shadow means its ______.
benign; malignant
True or false. In liver mets, shadows tend to be bad if post. to a calcification.
true
What is a lymphoma?
a well defined hypoechoic malignancy of lymphatic tissue within an organ
Which malignant tumor has hepatomegaly with paranchymal changes and generally no target sign?
lymphoma
Where does a lymphoma typically occur?
anywhere in your body
When a lymph node gets big its called a ____________.
lymphadenopathy (enlargement of a node)
Lymphatic tissue is almost always ____________.
hypoechoic
Normal to decreased echogenicity with hepatomegaly is common is which form of hepatitis?
acute
Increased echogenicity and decreased size due to scarring and fibrosis is common in ____________ hepatitis.
chronic
Hepatitis has 3 increased liver enzymes, what are they?
ALT, AST, and bilirubin
Symptoms of hepatitis include:
Nausea, vomiting and fatigue
True or false. Acute hepatitis can look totally normal.
true
Which infiltrating liver disease is often secondary to heart failure, obesity, and alcohol abuse and has hepatocytes that are damaged w/ fat accumulates?
fatty infiltration
Fatty infiltration has ____________ sound penetration due to increased attenuation.
decreased
Liver echogenicity is slightly increased, with normal visualization of the diaphragm and the intrahepatic vessel borders. Which fatty infiltration is this?
grade 1 (mild)
Echogenicity is moderately increased, with slightly impaired visualization of the diaphragm or intrahepatic vessels.
Grade 2 (moderate)
Echogenicity is markedly increased, with poor or no visualization of the diaphragm, the intrahepatic vessels, and posterior portion of the right lobe. Which fatty infiltration is this?
Grade 3 (severe) fatty infiltration
How does focal fat infiltration appear?
appears as a hyperechoic area within normal or relatively normal liver parenchyma
Areas of focal fatty infiltration may also be seen within a liver, with what else?
scattered areas of patchy fatty infiltration and patchy focal sparing
In fat sparing the etiology is unclear but is may be related to what?
decreased regional portal flow
is the area of focal sparing usually solitary or multiple?
usually solitary, may be multiple
How does focal sparing appear?
hypoechoic area with relatively distinct margins within hyperechoic fatty liver
Focal sparing is most commonly seen in which 3 areas?
in the medial segment of the left lobe adjacent to the main lobar fissure, anterior to the portal vein bifurcation, medial and anterior to the neck and proximal body of the gallbladder
Fibrotic Liver DX:
small, echogenic liver
Focal Nodular Hyperplasia:
diffuse or localized fat sparring or scarring
Cirrhosis symptoms include:
anorexia, dyspepsia, nausea, vomiting, increasing jaundice and abdominal girth
Liver becomes nodular due to cell death, fibrosis and regeneration in what disease?
cirrhosis
What is cirrhosis caused by?
alcohol (ETOH) abuse and hepatitis
How doe cirrhosis appear?
Increased liver echogenicity and distorted parenchyma with decreased penetration
what are the Sonographic Signs of Cirrhosis?
Coarse echo pattern, diffusely inhomogeneous echo pattern, increased echogenicity, surface nodularity-Volume redistribution, enlarged caudate and left lobe/small right lobe, caudate: right lobe ratio > 0.65, right lobe: left lobe ratio < 1.3, left portal vein diameter right portal vein diameter, signs of portal hypertension
Liver flow is ____________ or towards the liver.
hepatopedal
Liver flow away from the liver is?
hepatofugal
paraumbilical vein varices
ligamentum teres becomes a collaterol pathway for blood and its pretty stable
coronary vein varices
collaterols that develop to get rid of blood in liver. high risk of rupture.
What is a varice?
enlarged vessel, usually a vein
Collaterol flow vessels include:
splenorenal and gastrorenal-splenorenal collaterol veins
Portal vein thrombosis is due to:
tumor invasion (HCC), inflammatory disease, blood clotting, and chronic hepatitis or cirrhosis
What does PV thrombosis look like sonographically?
enlarged PV and filled with echogenic clot
Acute PV thrombosis appears:
PV is big and filled with newly clotted blood. hypoechoic
Chronic PV thrombosis appears:
small PV filled with clotted blood and is hyperechoic
In PV thrombosis, the liver only get what % of blood: then what happens?
20%; liver will atrophy and collapse in on itself. Will look heterogeneous and nodular
What is cavernous transformation of the PV?
adjacent collaterol veins enlarge to span the obstruction and permit continued hepatopetal flow of blood. (PV may reopen and the thrombosis begins to resolve.)
What is budd-chiari syndrome?
is obstruction to HV outflow due to tumor invasion or thrombus
What may be congenital or secondary to portal hypertension?
intrahepatic portosystemic venous shunts
what is TIPS?
transjugular intrahepatic portosystemic shunts. the placement of an expandable metallic stent inserted thru the IJV into the liver between the intrahepatic PV & HV
In TIPS, blood is shunted from the portal circulation to where?
to the systemic circulation thru the stent, thereby diverting blood away from the varices.
In TIPS, where is the risk for getting a thrombus at?
at ends of shunt (From MPV to HV)
DIPS
direct intrahepati portocaval shunt. goes from IVC to PV and excludes HV's. in research only
What is the most common procedure for liver transplants?
to use cadaveric orthotopic transplantation of entire liver to recipient.
What are the variations of liver transplants?
segmental transplant from living related donor (usually left lobe). or segmental transplant of cadaveric liver
What are the 5 anastomoses performed in liver tranplantation?
donor IVC to recipient IVC 2 cm from right atrium; caudal end of IVC to recipient IVC; donor PV to recipient PV; HA to HA; CBD to CBD
What is prehepatic jaundice?
prevents hepatocytes from taking up bilirubin and conjugating it
What is hepatic jaundice?
cellular liver damage prevents bilirubin from either being conjugated or being further processed
What is posthepatic jaundice?
biliary obstruction prevents the outflow of bile
What is cholangiocarcinoma and what are the symptoms?
is a malignancy of the ducts. symptoms include: intermittent jaundice, weight loss, nausea, and vomiting
Which enzymes increase with cholangiocarcinomas?
increased direct bilirubin, ALP, and AST
A primary adenocarcinoma of the bile duct epithelium which may distort the porta hepatus is:
