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Abdomen Binder ARDMS Abdomen Board Information Exam Questions and Complete Solutions Graded A+ Denning [Date] [Course title]
What does each segment of the liver have - Answer: Its own
- portal vein
- hepatic artery
- bile duct What are the three lobes of the liver - Answer: Right Left Caudate How is the right lobe of the liver divided - Answer: Anterior and posterior segments How is the left lobe of the liver divided - Answer: Medial and lateral The medial segment used to be called the quadrate lobe Caudate lobe - Answer: - lies on posterior superior surface of the liver between the IVC and the medial left lobe
- supplied blood from branches of left and right portal venous and hepatic arterial systems
- drained by small emissary veins which enter directly into the IVC What is the segmental anatomy based on - Answer: Distribution of the portal veins How do the hepatic veins divide the liver - Answer: Longitudinally into 4 sections. Each section is then divided transversely by an imaginary plan through the right and left portal veins
- segment 1: caudate lobe
- segment 2: left lateral superior
- segment 3: left lateral inferior
- segment 4a: left medial superior
- segment 4b: left medial inferior
- segment 5: right anterior inferior
- segment 6: right posterior inferior
- segment 7: right posterior superior
- segment 8: right anterior superior Blood supply to right lobe of liver - Answer: Right portal vein Blood supply to the left lobe of the liver - Answer: Left portal vein Blood supply to the caudate lobe of the liver - Answer: Right and left portal veins Intersegmental / hepatic veins - Answer: - hepatic veins course between the lobes and segments, interlobar and intersegmental
- the hepatic veins have NON echogenic walls Intrasegmental / portal triad - Answer: - the vessels of the portal triad course to the center of each segment (intrasegmental)
- the portal triad is encased by a fibrofatty sheath /Glisson's capsule giving it hyperechoic walls Vessels in the portal triad - Answer: - main portal vein
- prior hepatic artery
- common hepatic duct Main lobar fissure - Answer: - divides right and left hepatic lobes by an oblique plane between the inferior vena cava and the gallbladder fossa
- landmarks: gallbladder, inferior vena cava, middle hepatic vein
- the fissure May be identified between the gallbladder neck and the junction of the right and left portal veins
- it is also correct to say that the main lobar fissure divides the anterior segment of the right lobe from the medial segment of the left lobe
Right intersegmental fissure - Answer: Divides right lobe into anterior and posterior segments
- landmarks: right hepatic vein Left intersegmental fissure - Answer: Divides the left lobe into medial and lateral segments
- landmarks: left hepatic vein, ascending left portal vein, falciform ligament, ligamentum teres Ligamentum venosum - Answer: Remnants of the ductus venosus
- separates the left lobe from the caudate lobe Fetal circulation - Answer: - ligamentum teres is a remnant of the umbilical vein which runs from the umbilicus to the left portal vein
- shortly after birth, the umbilical vein contracts down forming the ligamentum teres
- with portal hypertension, the ligamentum teres recanalizes to form a portosystemic venous collateral
- ligamentum venosum is a remnant of the ductus venosus
- ligamentum venosum runs from the left portal vein to the inferior vena cava separating the left lobe from the caudate lobe of the liver Portal vein hepatopedal flow - Answer: Flow toward the liver, above baseline Portal vein hepatofugal flow - Answer: Flow away from the Liver, below baseline Portal vein - Answer: - hepatopedal flow: flow toward liver
- hepatofugal flow: flow away from liver
- low velocity continuous flow toward the liver with mild undulations. Flow velocity can increase after eating
- the main portal vein is a vessel of the portal triad along with the common hepatic ducts and the hepatic artery proper
- HEPATIC BLOOD FLOW: approx 1500mL/min
- 25-30% proper hepatic artery
- 70-75% portal vein
- HEPATIC OXYGENATION
- 45-55% proper hepatic artery
- 50-55% portal vein
- THE PORTAL VEIN SUPPLIES GREATER VOLUME AND OXYGEN TO THE LIVER
- 13mm is the upper limited of portal vein diameter: a larger diameter may be seen in patients with portal hypertension Petal - Answer: To seek Fugal - Answer: To flee Portal triad - Answer: Main portal vein, proper hepatic artery, common hepatic duct Hepatic veins - Answer: - scanning from the anterior abdominal surface, color Doppler demonstrates blood flow towards the IVC and away from the transducer. This is represented below the baseline in the normal Doppler spectral analysis presentation
- hepatic vein waveforms are typically triphasic reflecting right atrial filling, contraction, and relaxation
- normal spectral analysis presentation: flow toward transducer = above baseline, flow away from transducer = below baseline Hepatic artery - Answer: - The proper hepatic artery runs parallel to the main portal vein. It is located anterior to the left of the main portal vein. The classic anatomy of the right and left hepatic artery's arising from the proper hepatic artery is seen approximately 55% of patients
- The right hepatic artery may originate/replaced from the superior mesenteric artery. A replacement right hepatic artery is seen posterior to the main portal vein
- The left hepatic artery may originate from the left gastric artery
- Doppler waveforms demonstrates flow throughout diastole, indicating a low resistance system.
- In a post liver transplant a high resistance/no flow in diastole, hepatic artery waveform may suggest organ rejection
Hepatic ligaments - Answer: - ligamentum teres
- falciform ligament
- coronary ligament
- right and left triangular ligament Ligamentum teres - Answer: - remnant of the umbilical vein
- extending from the umbilicus to the left portal vein
- recanalizes in cirrhosis to function as a venous collateral Falciform ligament - Answer: - Peritoneal reflection or fold created by the passage of the embryonic umbilical vein from the umbilicus to the left branch of the portal vein Coronary ligament - Answer: - peritoneal reflection which suspends the liver from the diaphragm
- the coronary ligaments surround the bare area
- the diaphragm is in direct contact with the liver
- this area is not a part of the peritoneal space, thus ascites is not seen in this area Right and left triangular ligament - Answer: - peritoneal reflections to the far right and left of the bare area Right Hepatic Vein / RHV - Answer: Location
- right intersegmental fissure Usefulness
- divides anterior and posterior segments of right lobe Middle hepatic vein / MHV - Answer: Location
- main lobar fissure
Usefulness
- separates right and left lobes Left hepatic vein / LHV - Answer: Location
- left intersegmental fissure Usefulness
- divides medial and lateral segments of the left lobe Right Portal vein anterior branch / RPV - Answer: Location
- intrasegmental in anterior segment of the right lobe Usefulness
- courses centrally in anterior segment of right lobe Right portal vein posterior branch / RPV - Answer: Location
- intrasegmental in posterior segment of the right lobe Usefulness
- courses centrally in posterior segment of right lobe Left portal vein horizontal segment / LPV - Answer: Location
- anterior to caudate lobe Usefulness
- separates caudate lobe from medial segment of left lobe Left portal vein ascending segment - Answer: Location
- left intersegmental fissure Usefulness
- divides medial from lateral segment of left lobe Gallbladder fossa - Answer: Location
- main lobar fissure Usefulness
- separate right and left lobes Ligamentum teres - Answer: Location
- left intersegmental fissure Usefulness
- divides caudal aspect of left lobe into medial and lateral segments Ligamentum venosum - Answer: Location
- left anterior margin of the caudate lobe Usefulness
- separates caudate lobe from medial left lobe Liver size - Answer: - measured in the superior inferior dimension on the mid clavicular sagittal plane
- vary with weight height, and body surface area
- hepatomegaly when greater than 15 cm superior inferior dimension or when right lobe extends inferior to the lower pole of the right kidney
- Riedels lobe is an inferior projection of the right lobe which is commonly seen in women, it can be mistaken for hepatomegaly when only measuring the superior inferior dimension of the liver
Liver echogenicity - Answer: - normal is homogeneous and slight hyperechoic to normal renal cortex Echogenicity of normal structures hyperechoic to hypoechoic
- renal sinus
- pancreas
- spleen/ liver
- renal cortex Granulomas on the liver - Answer: - granulomas are small calficiation in the liver and spleen
- caused by: histoplasmosis, tuberculosis infection
- histoplasmosis is common in north America in the Great Lakes basin and in the mid western US Hepatitis on the liver - Answer: - liver inflammation resulting from infectious (viral, bacterial, fungal, and parasitic organism) or noninfectious (medications, toxins, and autoimmune disorders) agents
- may result in ELEVATED ALT, AST, Conjugated and unconjugated bilirubin
- viral infections account for most cases of hepatitis
- hepatitis A: HAV, spread fecal/oral
- hepatitis B; HBV, spread blood/body fluids
- hepatic C: HCV, spreads blood/body fluids
- today most people becomes infected by sharing needles to inject blood
- acute hepatitis: hypoechoic liver parenchyma, liver enlargement, hyperechoic portal vein walls
- chronic hepatitis: hypoechoic liver parenchyma, small liver, decreased echogenicity of portal vein walls Pyogenic / bacterial abscess - Answer: - occurs commonly in right lobes of the liver
- reaches the liver via the bile ducts, portal veins hepatic arteries or lymphatic channels
- sonographic appearance: complex mass, echogenic gas, reverberation artifact
- symptoms: RUQ pain, leukocytosis, fever, elevated liver function tests
- aspiration is needed to confirm diagnosis
- Differentiation of a pyogenic abscess from am amoebic abscess is difficult. If a patient has traveled out of the United States and amebic abscess may be the correct diagnosis Amebic abscess - Answer: - occurs when a parasite (amoeba) from the intestines, reaches the liver via the portal vein
- most common EXTRAINTESTINAL complication of amoebic dysentery
- Symptoms: RUQ pain, diarrhea, leukocytosis, elevated liver function tests, elevated right dome of diaphragm Sonogrpahic apprarance
- round hypoechoic / complex area
- typically occurs in right lobe dome
- contiguous with the liver capsule
- aspiration may be required for diagnosis Fungal abscess / candidiasis - Answer: - mycotic / fungal infection of the blood that results in small abscesses in the liver
- appearance changes over the length Appearance
- wheel within a wheel: A lesion with a peripheral hypoechoic zone, an inner echogenic wheel and a hypo quick center. This is the earliest manifestation of a fungal infection and most recognizable
- Bulls eye: lesion appears like this when the hypoechoic Center calcifies
- uniformly hypoechoic focus: most common presentation of lesion
- echognenic focus: calficiation representing scar formation seen late in the disease process Echinococcal Cyst / Hydatid disease - Answer: - an echoinoccal cyst is the result of a parasitic/tapeworm infestation associated with sheep and cattle raising countries
- eggs do echinococcus granulosus are swallowed by the intermediate host like man/Shepard.
- egg pass into portal venous system where the larvae hatch and move into the liver
- sonographic appearance: vary depending on the stage. Simple cyst, cyst with detached endocyst/ cyst within a cyst, cyst with multiple daughter cysts, calcified mass
- test used to diagnose hydatid disease: casoni skin test which has 70% sensitivity, detection of antibodies/ ecchinococcal arc 5 including indirect hemagglutination and indirect fluorescent antibody test
- associated with anaphylactic shock Schistosomiasis - Answer: - most common PARASITIC infection in humans
- Schistosomiasis is the genius of several species of parasitic trematodes
- major cause of portal hypertension worldwide
- unique lifestyle limits endemic areas to tropical zones around the world
- eggs reach liver through portal vein inciting a granulomatous reaction resulting in periportal fibrosis
- intrahepatic portal veins occlude resulting in portal hypertension
- Sonographic appearance: occluded intrahepatic portal veins, thickening and increased echogenicity of the portal vein walls
- Secondary Signs: splenomegaly, ascites, esophageal variceal bleeding, portosystemic collaterals
- roughly 400,000 people have immigrated to the US with this disease Sonographic findings related to Acquired Immunodeficiency Syndrome/ AIDS - Answer: - Sonographic appearance: pneumocystis carinii/ hepatic, fatty liver infiltration, hepatomegaly, hepatitis, non Hodgkin lymphoma, cardidiasis, kaposi sarcoma
- pneumocytic carinii: most common organism causing infection in AIDS patients, usually responsible for pneumocystis pneumonia
- sonographic findings for P carinii involvement of the liver are that of diffuse, non shadowing, hyperechoic foci
- infectious agents may cause bile ducts/ cholangitis and the gallbladder wall/ cholecystitis to be thickened
- sclerosing and AIDS cholangitis sonographically appear as thickened biliary ducts. Thickening May compromise the lumen causing biliary obstruction
- lymphoma and Kaposki's sarcoma May be seen as an intrahepatic mass or possibly diffuse infiltration without visualization of a sonographic abnormality Fatty infiltration - Answer: - fatty liver is the accumulation of triglycerides witching hepatocytes
- alcohol abuse and obesity are leading causes of hepatic fatty infiltration
- sonographically infiltration of fat within the liver appears as increased echogenicity and decreased acoustic penetration. Increased attenuation makes it difficult to visualize the posterior liver and diaphragm
- 2 patterns of fatty infiltration: focal fatty infiltration and focal fatty sparing
- focal fatty infiltration: focal regions of increased echogenicity within normal liver parenchyma. Focal fatty com,only occurs at the porta hepatis
- focal fatty sparing: focal regions of normal liver parenchyma within a fatty infiltrated liver, commonly occurs adjacent to the gallbladder in the porta hepatis in the caudate lobe and at the liver margins
- glycogen storage disease: a genetically acquired disorder that results in the excess deposition of glycogen in the liver. Associated with diffuse fatty infiltration and hepatic adenoma
- differentiation between hyperechoic masses within the liver include: focal fatty infiltration, cavernous hemangiomas, echogenjc metastasis, hepatic lipoma Cirrhosis - Answer: - diffuse process of fibrosis and distortion of normal liver architecture
- initially there is enlargement, but continued insult results in hepatic atrophy resulting in blood coagulopathy, hepatic encephalopathy, and portal hypertension CAUSES
- hepatitis C
- alcoholic liver disease
- non alcoholic fatty liver disease
- non alcoholic steatihepatitis
- hepatitis B
- autoimmune hepatitis
- primary biliary cirrhosis
- primary sclerosing cholangitis
- hemochromatosis: iron deposition
- Wilson Disease: copper deposition
- drug induced liver disease
- venous outflow liver disease like Budd Chiari, right sided heart failure, tricuspid regurgitation Abnormal increased liver function tests
- AST/ SGOT
- ALT / SGPT
- GGT
- LDH, lactate dehydrogenase
- conjugated bilirubin SONOGRAPHIC APPEARANCE
- hepatomegaly with acute
- liver atrophy with chronic
- caudate lobe enlargement
- surface nodularity /. Regeneration nodules
- fatty infiltration, increased echogenicity changes related to portal hypertension
- increased incidence of hepatocellular cancer
- hep C is now the nations leading cause of chronic hepatitis and cirrhosis
Portal hypertenison - Answer: — increased pressure in the portal venous system. Normal portal pressure is 5 to 10 mmHg which is slightly higher than the normal inferior vena cava pressure. When this pressure gradient increases, it is considered portal hypertension
- portal vein diameter >13mm suggests portal hypertension
- cirrhosis is the major causes of portal hypertension
- portal hypertension is asymptomatic. Patients typically present with sudden painless upper GI hemorrhage due to rupture of esophageal varices 4 TYPES OF PORTAL HYPERTENSION
- extrahepatic presinusoidal like portal vein thrombosis
- intrahepatic presinusoidal like schistosomiasis
- intrahepatic: most common, like cirrhosis
- intrahepatic postsinusdoidal like the hepatic vein thrombosis
- Sonographic findings of portal hypertension include the secondary signs of splenomegaly, ascites, and portal systemic venous collaterals
- surgical techniques to lower portal pressure include a porta cavalshunt, splenorenal shunt/ lentos shunt, distal splenorenal shunt/ Warren shunt to scare me, TIPS Portal systemic collaterals - Answer: - venous collaterals are created, connecting the portal system to the inferior vena cava bypassing the liver
- gastroesophageal varices: collaterals of the distal esophagus and gastric fundus. May lead to life threatening gastrointestinal hemorrhage
- recanalized umbilical vein: re opening of the umbilical vein/ligamentum teres to act as a collateral from the left portal vein to epigastric veins to the inferior vena cava
- splenorenal varices: tortuous collateral veins seen in the splenic and left renal hilum
- intestinal varices: the veins of retroperitoneal structures such as the colon, duodenum, and pancreas anastomose with systemic tributaries
- rectal varices/hemorrhoids: a collateral path in which the inferior mesenteric vein drains into the rectal veins which connect with systemic tributaries
- physical signs of collaterals: dilated veins on anterior abdominal wall, Caput Medusa which is tortuous collaterals around the umbilicus, hemorrhoids, ascites which is fluid wave
Transjugular Intrahepatic Portal-Systemic Shunt / TIPS - Answer: - Portosystemic shunt are created to decrease portal pressure/portal hypertension avoiding the development or rupture of gastroesophageal varices and reducing the accumulation of ascites
- Intraoperative shunting in most cases has been replaced by transjugular intrahepatic portal systemic shunting/TIPS. This shunt is placed using a jugular access. It is placed between the hepatic vein in the portal vein, typically the right hepatic vein and right portal vein
- routine Doppler evaluation at six month intervals is utilized to detect early shunting compromise for prompt shunt revision
- with a widely patent TIPS, the right portal vein and left portal vein should demonstrate hepatofugal flow
- criteria for tips malfunction includes:
- focal velocity increases within the TIPS
- hepatopetal flow of the left portal vein or right portal vein
- hepatofugal flow of the main portal vein that can be from an occluded TIPS
- exception: with a recanalized umbilical vein, the flow direction of the left portal vein may be in either direction Liver transplantation - Answer: Orthotopic liver transplantation / OLT, Occurring in the same place as original organ is performed to eliminate irreversible disease. Approximately 5000 liver transplants are performed in the US each year
- indications for transplantation in adults: cirrhosis of many etiologids including hepatitis C, which is the leading cause of chronic hepatitis and cirrhosis
- viral hepatitis is the leading cause of liver cancer in the most common reason for liver transplantation
- indications for transplantation in children include biliary atresia
- pre-operative sonographic evaluation includes
- portal vein patency
- hepatic artery patency
- hepatic v in patency
- inferior vena cava patency
- presence of venous collaterals
- postoperative sonographic evaluation includes
- biliary tree
- portal vein patency
- hepatic artery patency
- hepatic vein patency
- inferior vena cava patency
- perihepatic fluid collections
- postoperatively, the hepatic artery provides the only blood supply to the biliary tree
- thrombosis or stenosis is the hepatic artery will result in biliary complications Portal vein thrombosis - Answer: - SONOGRAPHIC APPEARANCE
- hypoechoic thrombus within the portal vein
- increased portal vein caliber
- cavernous transformation
- portal systemic collaterals
- CAUSES OF PORTAL VEIN THROMBOSIS
- Tumeral causes: hepatocellular carcinoma, metastatic liver disease, pancreatic carcinoma
- non-tumoral causes: pancreatitis, cirrhosis or hepatitis, inflammatory bowel disease, trauma, splenectomy, hypercoagulation, portal lymphadenopathy
- cavernous transformation: numerous work like venous collaterals that parallel the chronically thrombosed portal vein. Cavernous transformation is typically seen with benign causes of portal vein thrombosis Budd Chiari Syndrome - Answer: -disorder characterized by hepatic vein obstruction by thrombus or tumor. Typically seen in young adult women taking birth control pills
- patient presents with signs associated with portal hypertension: ascites hepatomegaly, splenomegaly
- causes include: membranous obstruction of inferior vena cava, hypercoagulation, hepatic vein compression, tumor invasion, majority of cases are undetermined
- The caudate lobe is often spared because the emissary veins drain directly into the inferior vena cava. Thus, the caudate lobe and enlarges with atrophy of the right and left lobes
Portal vein gas - Answer: - uncommon condition where air is noted within the intrahepatic portal veins
- associated with ischemic bowel disease, ulcerative colitis, or Crohn's
- High mortality rate due to ischemic or gangrenous bowel
- in infants, intrahepatic portal vein gas is due to necrotizing enterocolitis Liver cyst - Answer: A liver cyst is defined as a fluid filled space lined by biliary epithelium. Liver cyst usually referred to non-parasitic simple cysts
- sonographic criteria: anechoic, thin walled, acoustic enhancement
- estimated to occur in 5% of the population. Typically do not appear until the 5th decade of life. If liver cysts are seen at an earlier age, kidneys should be evaluated for autosomal dominant polycystic kidney disease -!!! A hemorrhaging cyst will appear as a cyst with internal echoes accompanied by right upper quadrant pain and a decrease in hematocrit!!!
- differential diagnosis includes simple cyst, polycystic liver disease, hydatid cyst, cystic tumors, abscess Cavernous hemangioma - Answer: - MOST COMMON BENIGN TUMOR OF THE LIVER
- majority of hemangiomas are asymptomatic and discovered incidentally. Hemangiomas consist of multiple vascular channels that create multiple sonographic interfaces which give this mass its characteristic hyperechoic appearance
- sonographic finding: hyperechoic, posterior enhancement
- may enlarge with pregnancy or administration of estrogen
- hemangiomas May appear hypoechoic within the background of a fatty infiltrated liver
- color or duplex Doppler does not typically demonstrate flow within the hemangioma
- contrast enhanced imaging demonstrates characteristic centripetal flow Focal nodular hyperplasia - Answer: A benign solid liver mass that is believed to be a developmental type of hyperplastic lesion related to an area of congenital vascular malformation
- typically an incidentally detected liver mass in an asymptomatic patient. They are more common in women than men
- Sonographic findings: solid mass with varying echogenicity, central fibroid scar, stellate vascularity
- may appear as iso attenuating and blend in with surrounding liver parenchyma also called Stealth lesions
Hepatic adenoma - Answer: - associated with use of contraceptive agents
- patient may present with pain due to tumor hemorrhage
- associated with glycogen storage disease
- survival resection is recommended due to the risk of malignant
- Sonographic appearance: nonspecific echogenicity , tumor hemorrhage Hepatic lipoma - Answer: - Hepatic lipomas are extremely rare fatty tumors. Tuberous sclerosis is a congenital familiar disease, is associated with hepatic lipomas and angiomyolipomas
- sonographic findings: hyperechoic mass, propagation speed artifact. Propagation speed artifact: decreased speed of sound in fat which is 1450 m/s result in a prolonged sound return time. Does objects posterior to the fatty mass will be placed further away from the transducer. This may be seen as a broken diaphragm posterior to the fatty mass.
- CT scan can confirm fatty nature of the mass by the negative Hounsfield units List of hyperechoic hepatic masses - Answer: - hepatic lipoma -, angiolyplipoma -hemangioma
- echogenic metastasis Hepatocellular carcinoma - Answer: - most common PRIMARY malignancy of the liver
- occurs in 10-25% of patients with cirrhosis
- commonly invades venous structures like the portal veins, hepatic veins, and IVC
- Sonographic appearance: variable, most are hypoechoic
- associated with increased AFP, AST/SGOT, and ALT/SGPT Metastatic Disease of the Liver - Answer: - most commonly encountered solid masses of the liver
- The most common source of metastatic involvement is from the gastrointestinal, breast, or lung cancer
- SONOGRAPHIC APPEARANCE
- hypoechoic metastases
- bulls eye or target metastases
- calcified metastases
- cystic metastases
- diffuse metastases
- ultrasound cannot correlate to sonographic appearance of a hepatic metastases with the primary originating organ There are some more common sonographic patterns
- hyperechoic metastases= gastrointestinal tract
- hypoechoic metastases= lymphoma
- bulls eye of target metastases= lung
- calcified metastases= mucinous adenocarcinoma
- cystic metastases= sarcoma -due to the nonspecific sonographic appearance of metastatic liver disease, ultrasound guided biopsy is needed to determine the primary tissue diagnosis Hepatoblastoma - Answer: - most common malignant liver tumor in EARLY CHILDHOOD
- 3rd most common intra-abdominal childhood malignancy after adrenal neuroblastoma and Wilm's tumor
- most occurrences are prior to two years of age.
- Patient presents with an enlarging asymptomatic abdominal mass 10 to 12 cm at diagnosis
- associated genetic conditions: Beckwith-Wiedemann syndrome, familial adenomatous polyposis
- increased levels of serous AFP
- associated with lung metastases and portal vein invasion
- nonspecific sonographic appearance Amniotransferases /transaminases - Answer: - One of the first lab test to assess the liver in determining the presence of liver enzymes in the blood.
- When liver cells are damaged they spill these enzymes into the blood stream.
- Amniotransferases catalyze/transfer the chemical reaction of amino groups
- the level of Amniotransferase does not correlate with extent of damage or prognosis REASONS FOR ELEVATION
- fatty liver
- drug induced
- hepatitis A
- hepatitis B
- hepatitis C
- autoimmune hepatitis
- inherited disorders like hemachromatosis, Wilson's disease, alpha one antitrypsin deficiency Other liver enzymes include: alkaline phosphatase, gamma glutamyl, transpeptidase, and 5'- nucleotidase Aspartate amniotransferase / AST /SGOT/ serum glutamic oxaloacetic transaminase - Answer: - has a wide tissue distribution
- present in the liver, heart, skeletal muscle, kidney, and brain
- elevation of AST by itself is nonspecific for liver disease
- very sensitive, being elevated and almost all significant hepatocellular disease
- an increase in AST without ALT is seen with myocardial infarction, heart failure, muscle injury, central nervous system disease, and other non-hepatic disorders
- Serum AST and ALT are elevated to some extent in almost all liver disease. The highest elevation occurs with viral hepatitis Alanine amniotransferase / ALT / SGPT / serum glutamic pyruvic transaminase - Answer: - ALT is present in high concentrations within the liver tissue, therefore, AL T is more specific for liver disease than AST
- elevated AST and lactic dehydrogenase/LDH with normal ALT rules out hepatic disease
Gamma Glutamyl Transpeptidase / GGT - Answer: - GGT is present in hepatocytes and bile duct epithelium, therefore an elevation indicates hepatocellular disease and biliary obstruction
- GGT is increased in most diseases that cause acute damage to the liver or bile duct
- GGT is also typically elevated in patients with acute or chronic alcohol abuse
- increased GGT + increased ALP = biliary obstruction
- Increased GGT + increased ALT = hepatocellular disease Lactic dehydrogenase/ LDH - Answer: - Enzyme found in the cells of many body tissues.
- Because LDH is widely distributed throughout the body cellular damage/tissue breakdown causes an elevation of the total serum LDH
- as a result the diagnostic usefulness of the enzyme by itself is not as valuable as determination of its five isoenzymes -individual isoenzyme elevation can indicate specific organ or tissue damage
- LDH levels can be used to monitor treatment of some cancers
- Examples of conditions which cause LDH elevation are: hemolysis, myocardial infarction, cancers like lymphoma and bacterial or viral meningitis Alpha fetoprotein - Answer: - proteins synthesized by the liver and levels decrease during the first year of life
- elevated levels also occur with hepatocellular carcinoma/hepatoma, germ cell tumor's/ovaries and testes, metastatic liver cancer, hepatoblastoma/childhood
- moderate levels of AFP can be seen with non-cancerous liver disease high levels of AFK are very suggestive of the hepatocellular carcinoma.
- The serum level of AFP loosely correlates with the extent of the HCC and maybe used to monitor treatment Prothrombin time/PT - Answer: - The time/seconds it takes for plasma to coagulate
- 12 blood fighting factors/proteins are needed to clot blood -prothrombin/factor II is one of the clotting factors produced by the liver vitamin K is needed to produce prothrombin
- prothrombin time measures the activity of five different clotting factors including I, II, V, VII, X
- abnormal/long prothrombin time is often due to liver disease or warfarin/Coumadin treatments.
- Other uses of PT include determining cause of abnormal bleeding, monitor warfarin/Coumadin usage, screen for blood clotting factor deficiency, screen for vitamin K deficiency and, monitor liver International normalized ratio / INR - Answer: Due to variations in prothrombin time, INR corrects for variations that would occur with different thromboplastin regiment, thus standardize is the prothrombin time test so that values may be compared between different labs normal range is 0.9 to 1.3, range on warfarin is between 2.0 and 3.0
- prothrombin time, INR, and platelets are monitored prior to an invasive procedure to ensure proper clotting Normal anatomy biliary tract - Answer: - Intrahepatic bile ducts converge to form the right and left hepatic duct
- The right and left hepatic ducts join to form the common hepatic duct
- The gallbladder is located at the inferior end of the main lobar fissure
- The gallbladder neck tapers to form the cystic duct which joins with the common hepatic duct to form the common bile duct
- common bile duct in the main pancreatic duct/duct of Wirsung join to form the ampulla of Vater
- it is uncommon to see the cystic duct on ultrasound, thus we use the term common duct to refer to the extrahepatic ductal system
- at the portahepatis, the portal triad consist of the main portal vein, common hepatic duct, and proper hepatic artery this is known as the Mickey Mouse sign How was the gallbladder divided - Answer: Neck, body, fundus Valve of heister's - Answer: Spiral fold which controls bile flow into the cystic duct Hartmann's pouch - Answer: An abnormal sacculation/diverticulum of the neck of the gallbladder Phrygian cap - Answer: Fold in the fundus of the gallbladder Junctional fold - Answer: A fold between the body and the infundibulum of the gallbladder. True gallbladder septations are rare
Describe the direction of the CBD - Answer: The CBD passes posterior to the first part of the duodenum and pancreatic head joining the main pancreatic duct/of Wirsung at the ampulla of Vater Where does the ampulla to Vater empty - Answer: The ampulla of Vater empties through the duodenal papilla, controlled by the sphincter of Oddi Diffuse Wall Thickening - Answer: -Gallbladder wall thickness less than 3 mm is considered normal
- most common cause of gallbladder wall thickening is cholecystitis
- other causes of diffuse wall thickening include: hypoalbuminemia, ascites, hepatitis, congestive heart failure, pancreatitis Pre hepatic causes of jaundice - Answer: Hemolytic jaundice
- pathology occurring prior to liver hemolysis/RBC breakdown
- Examples: sickle cell and anemia Hepatic causes of jaundice - Answer: -Pathology occurring in the liver
- reduces livers ability to metabolize bilirubin
- Examples: hepatitis, primary biliary cirrhosis, Gilbert syndrome, Crigler-Najjar syndrome Post hepatic causes of jaundice - Answer: - obstructive jaundice
- results in increased conjugated bilirubin
- causes pale stool and dark urine
- examples is anything that blocks the bile ductsincluding choledocholithiasis, pancreatic cancer, bile duct stricture, biliary atresia, cholangiocarcinoma, Mirizzis Syndrome Sludge - Answer: - calcium bilirubinate granules and cholesterol crystals
- associated with biliary stasis secondary to prolonged fasting, parenteral nutrition, hemolysis, cystic duct obstruction, cholecystitis
- appears as non-shadowing, echogenic material which layers and shifts with patient position
- tumefactive sludge/sludge balls is organization of sludge Cholelithiasis - Answer: SONOGRAPHIC CRITERIA INCLUDE
- mobile
- strongly echogenic
- acoustic shadowing GALLSTONES ARE COMPOSED OF
- calcium bilirubinate
- calcium carbonate CYSTIC DUCT OBSTRUCTION MAY RESULT IN
- acute cholecystitis
- empyema
- gallbladder perforation
- pericholecystic abscess
- bile peritonitis
- A gallbladder filled with stones may be seen as a strong shadow in the right upper quadrant this is called the double arc or WES sign the wall echo shadow sign Acute Cholecystitis - Answer: - gallbladder wall inflammation due to cystic duct obstruction by a gallstone
- associated with right upper quadrant pain, fever, and leukocytosis
- Features of a cute cholecystitis: gallstones, Murphy's sign, diffuse wall thickening, gallbladder dilatation, sludge
- complications: empyema, gangrenous cholecystitis, perforation, pericholecystic abscess, bilioenteric fistula
- bacterial infection is secondary to initial obstruction and ischemia
- associated with cholelithiasis in 90-95% of patients, acalculous in 5-10% of patients
- amylase elevation suggests obstruction at the level of the ampulla of Vater Chronic cholecystitis - Answer: - defined clinically as chronic gallbladder disease characterized by reoccurring symptoms of biliary Colic due to multiple previous episodes of acute cholecystitis
- sonographically does not appear different from acute cholecystitis. Findings may include thick walled, fibrotic, contracted gallbladder, sludge and an obstructing cystic duct stone may be present emphysematous cholecystitis - Answer: - acute cholecystitis due to gallbladder wall ischemia and infection
- thought to be different pathogenesis/cause than calculus cholecystitis
- occurs more commonly in diabetic men
- gas produced by aneorbic bacteria like clostridium and E Coli
- gas found in the wall of the gallbladder, the gallbladder lumen or biliary tree. Comets tail/reverberation artifacts or seen due to the presence of gas
- higher rate of gangrene and perforation
- with gangrenous cholecystitis, perforation is inevitable resulting in pneumoperitoneum and peritonitis Empyema of the gallbladder - Answer: Purulent material within the gallbladder due to bacteria containing bile associated with acute cholecystitis
- initiated with obstruction of the cystic duct
- symptoms are the same as the acute cholecystitis with the addition of fever
- sonographically it should be suspected if atypical bile echoes are seen Gallbladder perforation - Answer: A complication of acute cholecystitis
- localized fluid collection in the gallbladder fossa
- complications include peritonitis, pericholecystic abscess, biliary fistula Acalculous cholecystitis - Answer: - acute cholecystitis without the presence of gallstones. It is typically a secondary event and a critically ill hospitalized patient