Liver Pathology Part 2
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What is the most common cause of acute liver failure in the United States?

  • Chronic alcohol abuse
  • Metabolic syndrome
  • Severe hepatitis
  • Acetaminophen overdose (correct)

    • Which of the following factors is NOT a common cause of fatty infiltration in the liver?

  • Hypertension (correct)
  • Obesity
  • Alcohol abuse
  • Type 2 diabetes

    • What is the characteristic ultrasound finding associated with fatty infiltration of the liver?

  • Normal liver size
  • Decreased echogenicity
  • Increased acoustic penetration
  • Increased echogenicity (correct)

    • Where are focal areas of fatty sparing most commonly located?

    <p>Adjacent to the gallbladder</p> Signup and view all the answers

    What is the primary feature of focal fatty infiltration observed on ultrasound?

    <p>Focal regions of increased echogenicity</p> Signup and view all the answers

    What does increased sound attenuation in the liver indicate?

    <p>Fatty infiltration</p> Signup and view all the answers

    What is a common sonographic finding when a liver is fatty infiltrated compared to a normal liver?

    <p>Difficulty visualizing the diaphragm</p> Signup and view all the answers

    Which of the following is considered a reversible condition?

    <p>Fatty infiltration</p> Signup and view all the answers

    What is a common characteristic of HCC as seen in imaging studies?

    <p>It is often associated with large, tortuous vessels.</p> Signup and view all the answers

    In which patient demographic is HCC more commonly confirmed through biopsy?

    <p>Middle-aged males with a history of alcohol abuse.</p> Signup and view all the answers

    Which statement about metastatic liver disease is accurate?

    <p>LFT values can be normal despite the presence of metastatic disease.</p> Signup and view all the answers

    What is a plausible reason why the liver is vulnerable to metastases?

    <p>The liver receives a large volume of blood and has extensive lymphatic drainage.</p> Signup and view all the answers

    Which primary cancers are most commonly associated with metastatic liver disease?

    <p>Colon, stomach, and breast cancers.</p> Signup and view all the answers

    What is currently the leading cause of chronic hepatitis and cirrhosis in the US?

    <p>Hepatitis C</p> Signup and view all the answers

    Which liver function test is NOT typically associated with cirrhosis?

    <p>Total protein</p> Signup and view all the answers

    Which of the following is a secondary finding of cirrhosis that can be observed via sonography?

    <p>Hepatomegaly</p> Signup and view all the answers

    What type of liver disease does non-alcoholic steatohepatitis (NASH) fall under?

    <p>Non-alcoholic fatty liver disease</p> Signup and view all the answers

    Which of the following conditions is associated with decreased liver size, indicative of chronic cirrhosis?

    <p>Liver atrophy</p> Signup and view all the answers

    What is one of the most common vascular complications of cirrhosis due to portal hypertension?

    <p>Esophageal varices</p> Signup and view all the answers

    Which of the following is NOT considered a miscellaneous cause of cirrhosis?

    <p>Alcoholism</p> Signup and view all the answers

    Which finding indicates the presence of increased echogenicity in the liver associated with fatty infiltration?

    <p>Internal textural changes</p> Signup and view all the answers

    What is the most common cause of echinococcal cysts?

    <p>Parasitic tapeworm</p> Signup and view all the answers

    Which appearance is characteristic of a simple liver cyst?

    <p>Anechoic with acoustic enhancement</p> Signup and view all the answers

    What is a characteristic feature of echinococcal cysts during larval maturation?

    <p>Presence of multiple daughter cysts</p> Signup and view all the answers

    What condition can lead to acquired cysts in the liver?

    <p>Traumatic events such as hematoma</p> Signup and view all the answers

    What does the 'water-lily sign' indicate in echinococcal cysts?

    <p>Detachment of the endocyst membrane</p> Signup and view all the answers

    In which scenario would a Casoni skin test be utilized?

    <p>To identify anti-echinococcus antibodies</p> Signup and view all the answers

    What imaging characteristic is associated with inactive echinococcal cysts?

    <p>Rim calcifications around the cyst</p> Signup and view all the answers

    What type of liver cysts are categorized as congenital?

    <p>Cysts present in asymptomatic patients</p> Signup and view all the answers

    What is the typical appearance of a focal nodular hyperplasia (FNH) on sonography?

    <p>Solid mass with varying echogenicity</p> Signup and view all the answers

    Which characteristic is NOT associated with hepatic adenoma?

    <p>More common in older men</p> Signup and view all the answers

    In which demographic is focal nodular hyperplasia (FNH) most commonly found?

    <p>Women in reproductive years</p> Signup and view all the answers

    What sonographic finding is most indicative of a hepatic adenoma?

    <p>Typically iso- or hypoechoic relative to surrounding liver</p> Signup and view all the answers

    What imaging characteristic is typically associated with a focal nodular hyperplasia?

    <p>Central fibrous scar</p> Signup and view all the answers

    What potential effect can FNH have during physiological changes?

    <p>Can enlarge with pregnancy and estrogen intake</p> Signup and view all the answers

    Which finding is least likely to be associated with focal nodular hyperplasia?

    <p>May present with abdominal pain</p> Signup and view all the answers

    Which statement about the vascular supply of focal nodular hyperplasia is correct?

    <p>Supplied by the hepatic artery, drained by hepatic veins</p> Signup and view all the answers

    What characteristic of liver metastases is common when originating from the gastrointestinal tract?

    <p>Hyperechoic metastases</p> Signup and view all the answers

    Which primary tumor is most commonly associated with cystic liver metastases?

    <p>Leiomyosarcoma</p> Signup and view all the answers

    What is the primary age group affected by hepatoblastoma?

    <p>Aged 2 years or younger</p> Signup and view all the answers

    Which syndrome is associated with hepatoblastoma?

    <p>Beckwith-Wiedemann syndrome</p> Signup and view all the answers

    What unusual discovery was made in the patient presented with infiltrative liver metastases?

    <p>Left renal cell carcinoma</p> Signup and view all the answers

    What type of liver metastases are described as 'Bull’s-eye' lesions?

    <p>Hypoechoic lesions</p> Signup and view all the answers

    In what scenario is a biopsy particularly necessary for liver metastasis diagnosis?

    <p>When the sonographic appearance is nonspecific</p> Signup and view all the answers

    What finding(s) might be associated with hepatoblastoma in addition to elevated AFP levels?

    <p>Liver enlargement and lung metastases</p> Signup and view all the answers

    Study Notes

    LIVER PATHOLOGY PART 2

    • Diffuse Hepatocellular Disease:
      • Hepatocellular disease causes hepatocyte dysfunction and interferes with normal liver function.
      • Disease severity ranges from simple fatty changes to severe cirrhosis.
      • Parenchymal disease changes echo density and often affects liver size. As disease progresses, penetration becomes harder due to sound attenuation.
      • Acetaminophen overdose, typically as a suicide attempt, is a common cause of acute liver failure in the US.

    FATTY INFILTRATION

    • AKA Steatosis, is the accumulation of triglycerides in hepatocytes.
    • Common causes include metabolic syndrome (type 2 diabetes, obesity), alcohol abuse, drug use, nutritional status, and severe hepatitis.
    • Incidence is 30% in the United States.
    • Reversible, ranging from mild to severe.
    • Sonographic Findings: Increased echogenicity, decreased acoustic penetration, and increased attenuation make the posterior liver and diaphragm difficult to see.
    • Focal Fatty Infiltration: Increased echogenicity within normal liver tissue, commonly seen at porta hepatis and other regions.
    • Focal Fatty Sparing: Regions of normal liver tissue within a fatty infiltrated liver, appearing hypoechoic, often adjacent to gallbladder, porta hepatis, caudate lobe, and liver margins.

    GLYCOGEN STORAGE DISEASE (GSD)

    • Autosomal recessive disorder where glycogen deposits excessively in the liver.
    • Patients typically lack enzymes responsible for making or breaking down glycogen.
    • Associated with fatty infiltration and hepatic adenomas.
    • Eleven different types of GSD exist.
    • GSD type 1 (Von Gierke's Disease) is a glucose-6-phosphatase deficiency, causing hypoglycemia, abdominal distension, fatigue, and irritability.

    HEPATITIS

    • Inflammation of the liver, from infections (viral, bacterial, fungal, parasitic) or noninfections (medications, toxins, autoimmune disorders).
    • Can elevate ALT, AST, conjugated and unconjugated bilirubin.
    • Viral hepatitis can be mild or extensive.
    • Types A, B, C, D and E account for 95% of all acute hepatitis cases.
    • Hepatitis A: Highly contagious liver infection (fecal-oral transmission).
    • Hepatitis B: Serious liver infection (blood/body fluid transmission), preventable by vaccine.
    • Hepatitis C: Infection from a virus causing liver inflammation and potentially chronic liver disease (blood/body fluid transmission).
    • Hepatitis C often spread through blood transfusions and organ transplants before 1992, and is the most frequent indication for liver transplantation.
    • Alcoholic hepatitis: Liver inflammation caused by alcohol consumption.
    • Autoimmune hepatitis: Inflammation because the immune system attacks the liver.
    • Viral hepatitis pathology: Liver cell injury, swelling, varying cellular degeneration, possible necrosis, immune response and regeneration.
    • Fulminant hepatitis pathology: Massive liver parenchyma necrosis, decrease in liver size (acute yellow atrophy), sudden, severe onset, leading to shock, coma, and possible rapid death from marked liver necrosis.
    • Acute Hepatitis:
      • "Starry Night" or Periportal Cuffing
      • Hypoechoic liver
      • Liver enlarged
      • Hyperechoic portal vein walls
    • Chronic Hepatitis:
      • Hyperechoic liver
      • Small liver
      • Decreased echogenicity of portal vein walls

    CIRRHOSIS

    • General term for a diffuse process that destroys normal liver lobule architecture.
    • Initial changes cause liver enlargement, but ongoing insult leads to hepatic atrophy, coagulopathy, hepatic encephalopathy, and portal hypertension.
    • Causes:
      • Hepatitis C
      • Alcoholism (once major cause, but Hepatitis C is now leading in the US).
      • Alcoholic liver disease
      • Non-alcoholic fatty liver disease (NAFLD)
      • Non-alcoholic steatohepatitis (NASH)
      • Hepatitis B
      • Autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis, iron deposition, Wilson disease, drug-induced liver disease, venous outflow disease, Budd-Chiari syndrome, right side heart failure/tricuspid regurgitation.
    • Liver Function Tests associated with cirrhosis:
      • Increased AST (SGOT)
      • Increased ALT (SGPT)
      • Increased GGT
      • Increased LDH (lactate dehydrogenase)
      • Increased conjugated bilirubin
    • Sonographic Findings:
      • Hepatomegaly (acute)
      • Liver atrophy (chronic)
      • Caudate lobe enlargement
      • Surface lobe enlargement (regenerative nodules)
      • Fatty infiltration (increased echogenicity)
      • Internal textural changes (fine to coarse, hypoechoic to hyperechoic)
      • Loss of delineation of intrahepatic vasculature
      • Changes related to portal hypertension
      • Increased incidence of Hepatocellular Cancer
      • Common collateral varices: Recanalization of the paraumbilical vein, Esophageal varices, Splenic varices, Splenorenal shunt.

    PORTAL HYPERTENSION

    • Most common cause is cirrhosis and destruction of liver cells.
    • Normal vein pressure is 5-10mmHg.
    • Fibrosis causes resistance to liver profusion, increasing portal vein pressure.
    • Portal vein diameter > 13mm suggests portal hypertension.
    • Portal hypertension is typically asymptomatic.
    • Patients usually present with upper GI hemorrhage due to rupture of esophageal varices (branches of the portal vein).
    • Secondary signs of portal hypertension: Splenomegaly, Ascites, Portal systemic venous collaterals
    • Surgical techniques to lower portal pressure: Portacaval shunt, Splenorenal shunt, Distal splenorenal shunt/Warren shunt, TIPS

    BUDD-CHIARI SYNDROME

    • Hepatic vein obstruction, possibly involving IVC.
    • Patients present with signs of portal hypertension (ascites, hepatomegaly, splenomegaly).
    • Non-specific clinical triad is ascites, hepatomegaly, and abdominal pain.
    • Causes: Idiopathic (approx. 50% cases), congenital causes (IVC membranous obstruction, hepatic vein stenosis or hypoplasia), hypercoagulable states, infections, pregnancy/postpartum, tumors.
    • Sonographic Findings: Occluded/narrow/reversed flow in hepatic veins, possible hypertrophy of the caudate lobe as liver directs venous blood to caudate lobe due to direct venous drainage into the IVC, enlarged caudate veins draining into IVC.

    LIVER CYSTS

    • Classified as congenital or acquired.
    • Congenital Cysts:
      • True hepatic cysts: Simple cysts, Polycystic liver disease (result from developmental anomalies in intrahepatic bile ductules or proper involution of those ductules).
      • Incidence increases with age.
    • Acquired Cysts: Traumatic (hematoma, biloma), parasitic (echinococcal), or inflammatory (abscess).

    ECHINOCOCCAL CYST

    • AKA Hydatid Disease.
    • Parasitic infection from tapeworm.
    • Larvae encyst in the liver and develop into multiple cysts of varying sizes.
    • Sonographic appearance depends on the stage of maturation (single cyst with calcification, cysts with daughter cysts and fluid collections with septa).
    • Cyst within a cyst or water lily sign observed when endocyst detaches from cyst-wall.
    • Confirm diagnosis with Casoni skin test, looking for anti-echinococcus antibodies.

    LIVER ABSCESSES

    • Pyogenic Abscess:
      • Infection from bacteria (Escherichia coli) with biliary tract being the common source.
      • Right lobe typically affected more than left.
      • Characterized by complex mass with irregular walls and gas.
      • Presents with RUQ pain, leukocytosis, fever, and elevated LFTs.
    • Amebic Abscess:
      • Caused by parasite (from contaminated food/water).
      • Extraintestinal complication of amoebic dysentery.
      • Usually presents as rounded hypoechoic mass in the right lobe, often continuous with the liver capsule.
    • Fungal Abscess: Mycotic infection that can result in liver abscesses over time and whose appearance changes. "Wheel within a wheel" is the earliest stage often recognizable with outer hypoechoic fibrosis surrounding a central hypointense region.

    SCHISTOSOMIASIS

    • Parasitic infection.
    • Contaminated water exposure.
    • Infection travels via lymphatics and bloodstream to the mesenteric veins.
    • Common in specific geographic areas.
    • Major cause of portal hypertension and periportal fibrosis.
    • Can result in thickening of the portal vein walls.
    • Complications of HIV include Pneumocystis infection (and pneumonia), tuberculosis, cytomegalovirus, candidiasis, cryptococcal meningitis, toxoplasmosis, cryptosporidiosis, or Kaposi's sarcoma.
    • Multiple tiny, focal calcifications (starry sky) can be a marker of HIV infection, though more definitive diagnosis required. Other types of infection might cause similar echogenic patterns.

    FUNGAL CANDIDIASIS

    • Mycotic (fungal) infection of the blood that results in small abscesses in the liver.
    • Appearance evolves and includes hypoechoic regions, and wheel within a wheel-pattern (earliest stage).
    • Infection and presentation is affected by the immune status of the host.

    CAVERNOUS HEMANGIOMAS

    • Most common benign liver tumor.
    • Usually incidental finding and often asymptomatic.
    • Multiple vascular channels with endothelium result on sonography in the hyperechoic appearance of the mass.
    • Posterior enhancement.
    • Can enlarge with pregnancy and estrogen intake.
    • May appear hypoechoic within the background of fatty liver.

    FOCAL NODULAR HYPERPLASIA

    • 2nd most common benign liver tumor.
    • Lack normal hepatic architecture.
    • Arterial supply is from hepatic artery and venous drainage is into hepatic veins.
    • Commonly appears as a solid mass with varying echo-genicity.
    • Solitary lesion (80-95% cases).
    • Central fibrous scar.
    • Often in right lobe or left lateral segment.

    HEPATIC ADENOMA

    • Mostly in women of childbearing age, associated with (oral) estrogens.
    • Often asymptomatic but may present with pain due to tumor or hemorrhage (potentially requiring surgical resection), associated with glycogen storage disease.
    • Sonographic appearance: Well-circumscribed, encapsulated, hyperechoic mass with a hypoechoic halo (or isoechoic) relative to normal liver parenchyma (and potentially increased vasculature). Flow in center and around the periphery.

    HEPATIC LIPOMA

    • Extremely rare fatty tumor, potentially associated with tuberous sclerosis.
    • Sonographic appearance: Hyperechoic mass with a speed of sound artifact (decreased speed of sound in fat—1450 m/s).
    • Broken diaphragm.

    HEPATOCELLULAR CARCINOMA

    • AKA Hepatoma, most common primary malignancy of the liver.
    • Usually occurs in patients with underlying chronic liver disease & cirrhosis, and may increase in prevalence in patients 40-60 year olds.
    • Common structures venous invasion frequently.
    • Elevated AFP, AST, and ALT are potential markers.
    • Treatments include hepatic resection, transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection, radiofrequency ablation, cryoablation, or liver transplant.

    METASTATIC DISEASE

    • Metastases of lymph nodes to liver is common site for metastasis from various cancers.
    • Cancer involvement contributes to liver complications, often 18–20 times more common than hepatocellular carcinoma.
    • Vulnerable to metastases from gallbladder, colon, stomach, pancreas, kidney, ovaries, breast and lung (large blood volume and lymphatic drainage).
    • 40% of patients with cancer have liver metastases.

    HEPATOBLASTOMA

    • Rare malignant tumor in infants and children.
    • Hepatomegaly.
    • Calcifications may be present.
    • Elevated AFP.
    • Associated with Beckwith-Wiedemann syndrome and familial adenomatous polyposis, as well as associated lung metastases and portal vein invasion.

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