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Questions and Answers
What is the most common organism causing pyogenic abscess?
What is the most common organism causing pyogenic abscess?
Which source is the most common for pyogenic abscess?
Which source is the most common for pyogenic abscess?
What are the sonographic findings of a pyogenic abscess?
What are the sonographic findings of a pyogenic abscess?
Complex mass with irregular walls, gas, and reverberation artifact.
Amebic abscess usually occurs from contaminated food and water.
Amebic abscess usually occurs from contaminated food and water.
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What is a major complication of schistosomiasis?
What is a major complication of schistosomiasis?
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What is the most common opportunistic infection in HIV-infected persons?
What is the most common opportunistic infection in HIV-infected persons?
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Which of these infections is the most common opportunistic infection associated with HIV?
Which of these infections is the most common opportunistic infection associated with HIV?
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Focal Nodular Hyperplasia (FNH) is more common in women in __________ years.
Focal Nodular Hyperplasia (FNH) is more common in women in __________ years.
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What is the most significant lab test associated with Hepatocellular Carcinoma (HCC)?
What is the most significant lab test associated with Hepatocellular Carcinoma (HCC)?
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Hepatic adenoma is strongly associated with the use of oral contraceptives.
Hepatic adenoma is strongly associated with the use of oral contraceptives.
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In the case of metastatic liver disease, which primary cancers most commonly contribute?
In the case of metastatic liver disease, which primary cancers most commonly contribute?
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What is hepatocellular disease?
What is hepatocellular disease?
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What is the most common cause of acute liver failure in the United States?
What is the most common cause of acute liver failure in the United States?
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What does steatosis refer to?
What does steatosis refer to?
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What is the incidence of fatty infiltration in the U.S.?
What is the incidence of fatty infiltration in the U.S.?
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What is glycogen storage disease?
What is glycogen storage disease?
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What are the routes of transmission for Hepatitis B?
What are the routes of transmission for Hepatitis B?
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Chronic hepatitis shows an enlarged liver with hypoechoic appearance.
Chronic hepatitis shows an enlarged liver with hypoechoic appearance.
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What is a common sonographic finding in cirrhosis?
What is a common sonographic finding in cirrhosis?
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What is portal hypertension?
What is portal hypertension?
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What is Budd-Chiari syndrome associated with?
What is Budd-Chiari syndrome associated with?
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What is the common cause of echinococcal cysts?
What is the common cause of echinococcal cysts?
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Acquired liver cysts can occur due to trauma.
Acquired liver cysts can occur due to trauma.
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Study Notes
Diffuse Hepatocellular Disease
- Hepatocellular disease affects liver function.
- Disease severity ranges from fatty changes to cirrhosis.
- Disease progression can affect the liver’s size and echo density.
- Increased attenuation makes the liver difficult to penetrate with ultrasound.
- Acetaminophen overdose is a common cause of acute liver failure.
Fatty Infiltration
- The accumulation of triglycerides within hepatocytes.
- Common causes include metabolic syndrome and alcoholism.
- Occurs in 30% of the US population.
- Reversible and can be mild to severe.
Sonographic Findings: Fatty Infiltration
- Increased liver echogenicity.
- Decreased acoustic penetration.
- Difficulty visualizing the posterior liver and diaphragm.
Focal Fatty Infiltration
- Focal areas of increased echogenicity within normal liver.
- Commonly found near the porta hepatis.
Focal Fatty Sparing
- Focal areas of normal liver within a fatty infiltrated liver.
- Hypoechoic areas within a hyperechoic liver.
- Commonly seen adjacent to the gallbladder, in the porta hepatis, caudate lobe, and at the liver margins.
Glycogen Storage Disease (GSD)
- Autosomal recessive disorder.
- Excess glycogen deposits in the liver.
- Deficiency of enzymes involved in glycogen metabolism.
- Associated with fatty infiltration and hepatic adenomas.
- Eleven different types of GSD.
- GSD type 1, Von Gierke’s Disease, is caused by a defect in the glucose-6-phosphatase enzyme.
- GSD type 1 can cause hypoglycemia, abdominal distension, fatigue, and irritability.
Hepatitis
- Liver inflammation.
- Caused by infectious or non-infectious agents.
- Infectious agents include viruses, bacteria, fungi, and parasites.
- Non-infectious agents include medications, toxins, and autoimmune disorders.
- Can increase liver function tests like ALT, AST, conjugated and unconjugated bilirubin.
Viral Hepatitis
- Accounts for most hepatitis cases.
- Transmitted via fecal-oral, blood, and body fluids.
- Five main types: A, B, C, D, and E.
- Hepatitis A: Highly contagious, caused by the hepatitis A virus.
- Hepatitis B: Serious liver infection, caused by the hepatitis B virus, preventable by vaccine.
- Hepatitis C: Chronic, caused by the hepatitis C virus, associated with chronic liver disease and liver transplantation.
Hepatitis C
- Transmitted through sharing needles, blood transfusions, and organ transplants before 1992.
Alcoholic Hepatitis
- Liver inflammation caused by excessive alcohol consumption.
Autoimmune Hepatitis
- Immune system attacks the liver.
Viral Hepatitis Pathology
- Liver cell damage, swelling, degeneration, possible necrosis, immune response, and regeneration.
Fulminant Hepatitis Pathology
- Extensive liver necrosis.
- Decrease in liver size (acute yellow atrophy).
- Sudden onset leading to shock, coma, and death.
Acute Hepatitis
- “Starry Night” sign.
- Hypoechoic liver.
- Enlarged liver.
- Hyperechoic portal vein walls.
Chronic Hepatitis
- Small liver.
- Decreased echogenicity of portal vein walls.
Cirrhosis
- Destruction of normal liver lobule architecture.
- Initial liver enlargement followed by atrophy.
- Results in blood coagulopathy, hepatic encephalopathy, and portal hypertension.
Cirrhosis Causes:
- Hepatitis C: Leading cause in the US.
- Alcoholism.
- Non-alcoholic fatty liver disease (NAFLD).
- Non-alcoholic steatohepatitis (NASH).
- Hepatitis B.
- Other causes: Autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis, Wilson disease, drug-induced liver disease, venous outflow disease, right-sided heart failure, and tricuspid regurgitation.
Cirrhosis Sonographic Findings:
- Acute: Hepatomegaly.
- Chronic: Liver atrophy.
- 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.
Cirrhosis Secondary Findings:
- Portal hypertension.
- Splenomegaly.
- Varices.
- Collaterals.
- Ascites.
Common Collaterals or Varices:
- Recanalization of the paraumbilical vein.
- Esophageal varices.
- Splenic varices.
- Splenorenal shunt.
Portal Hypertension
- Cirrhosis causes increased pressure in the portal vein.
- Normal vein pressure is 5-10mmHg.
- Portal hypertension is asymptomatic but can lead to upper GI bleeding from esophageal varices.
- Portal vein diameter exceeding 13mm suggests hypertension.
Portal Hypertension Secondary Signs:
- Splenomegaly.
- Ascites.
- Portal systemic venous collaterals.
Clinical Signs of Portal Hypertension:
- Hematemesis.
- Hepatic encephalopathy.
- Caput medusa (dilated abdominal wall veins).
Hepatofugal flow
- Blood flowing away from the liver.
- Occurs in the portal vein during portal hypertension.
Hepatofugal Flow Secondary Signs:
- Dilated veins on the anterior abdominal wall (Caput Medusa).
- Hemorrhoids.
- Ascites.
Budd-Chiari Syndrome
- Hepatic vein obstruction.
- Possible IVC involvement.
- Presents with signs of portal hypertension: Ascites, hepatomegaly, splenomegaly.
- Clinical triad: Ascites, hepatomegaly, and abdominal pain.
Budd-Chiari Syndrome Causes:
- Often idiopathic.
- Congenital: IVC membranous obstruction, hepatic vein stenosis or hypoplasia.
- Hypercoagulable states: Polycythemia vera, paroxysmal nocturnal hemoglobinuria, Factor V Leiden deficiency, Protein C & S deficiency, Antithrombin III deficiency, Antiphospholipid antibody syndrome, Sickle cell disease, oral contraceptives.
- Infections.
- Pregnancy/postpartum.
- Tumors: Hepatocellular carcinoma, renal cell carcinoma, adrenal carcinoma.
Budd-Chiari Syndrome Sonographic Findings:
- Hepatic veins may be invisible, narrowed, or demonstrate reversed flow.
- Hypertrophy of the caudate lobe.
- Enlarged caudate veins draining into the IVC.
Liver Cysts
- Classified as congenital or acquired.
Congenital Liver Cysts
- True hepatic cysts.
- Simple cysts or related to hereditary disorders like polycystic liver disease.
- Result from developmental anomalies in the formation of intrahepatic bile ductules.
- Incidence increases with age.
Acquired Cystic Lesions:
- Traumatic (hematoma, biloma).
- Parasitic (echinococcal).
- Inflammatory (abscess).
Sonographic Appearance of Liver Cysts:
- Anechoic.
- Thin-walled.
- Acoustic enhancement.
Echinococcal Cyst
- AKA Hydatid disease.
- Caused by the Taenia echinococcus or Echinococcus granulosus (parasitic tapeworm).
- Daughter cysts develop within the original cyst.
- Sonographic appearance depends on cyst maturation.
Echinococcal Cyst Sonographic Appearances:
- Solitary cyst with possible calcification.
- Mother cyst with daughter cysts.
- Fluid collections with septa (honeycomb appearance).
- Solid-looking cysts.
- “Cyst within a cyst” or “water-lily sign” (detached endocyst membrane).
Echinococcal Cyst Diagnosis:
- Casoni skin test for anti-echinococcus antibodies.
Acquired Cyst: Hematomas
- Fresh hematomas: Hypoechoic, with acoustic enhancement.
- Older hematomas: Hyperechoic, with possible calcification.
Liver Abscesses
- Three main types: Pyogenic, amebic, and fungal.
Pyogenic Abscess
- 80% of cases.
- Escherichia coli is the most common organism.
- Biliary tract is the most common source.
- Right lobe is more affected than the left.
Pyogenic Abscess Sonographic Findings:
- Complex mass with irregular walls.
- Gas.
- Reverberation artifact.
Pyogenic Abscess Symptoms;
- Leukocytosis.
- Fever.
- Elevated liver function tests.
Pyogenic Abscess Diagnosis:
- Aspiration.
Amebic Abscess
- Caused by Entamoeba histolytica.
- Usually occurs in people who live or have visited areas with poor sanitation.
- Often involves the right lobe of the liver.
Amebic Abscess Sonographic Findings:
- Round or oval shaped.
- Fluid-filled with internal echoes.
- May have a thin wall.
Fungal Abscess
- Less common than pyogenic or amebic abscesses.
- Caused by fungi such as Candida or Aspergillus.
- Can occur in people with weakened immune systems.
Fungal Abscess Sonographic Findings:
- Complex masses with irregular walls.
- May contain gas.
- Often have a peripheral rim of calcification.
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