ULTRASOUND OF THE ABDOMEN PART I

LIVER LECTURES 2-3

HHHoldorf PhD, MPA, RDMS (Ob/Gyn, Ab), RVT, AS(LRT)

Outline Part 2

Granulomas Hepatitis Pyogenic (Bacterial) Abscess Amebic Abscess Fungal Abscess (Candidiasis) Echinococcal Cyst (Hydatid Disease) Schistosomiasis Sonographic findings related to AIDS Fatty Infiltration Cirrhosis Portal Hypertension Portal Systemic Collaterals

Granulomas

Present as small calcifications in the liver and spleen.

Caused by histoplasmosis or tuberculosis infection. Histoplasmosis is especially common in North America in the Great Lakes Basin in the mid-western US.

Homework: Show an image of a Granuloma.

Define Histoplasmosis.

Hepatitis Liver inflammation resulting from

infectious (viral, Bacterial, Fungal, and parasitic organisms) or noninfectious (medications, toxins, and autoimmune disorders) agents.

May result in elevation of ALT, AST, conjugated and unconjugated bilirubin.

Viral infections account for most cases of hepatitis.

Homework: Define ALT, AST, conjugated and unconjugated bilirubin.

Route of transmission for hepatitis infection:

Hepatitis A (HAV) – Fecal/oral Hepatitis B (HBV) – Blood/body fluids Hepatitis C (HCV) – Blood/body fluids

HCV – associated chronic liver disease is the most frequent indication for liver transplantation.

HAV, HBV, and HCV cause greater than 90% of acute hepatitis in the US. Other viruses include HDV, HEV, HFV, and HGV.

Acute Hepatitis

Hypoechoic liver parenchyma Liver enlargement Hyperechoic portal vein walls

Homework: Show an image of acute hepatitis.

Chronic Hepatitis

Hyperechoic liver parenchyma Small liver Decreased echogenicity of portal

vein walls

Homework: Show an image of Chronic Hepatitis.

Pyogenic (Bacterial) Abscess Occurs commonly in the right lobe of the liver Reaches the liver via the bile ducts, portal

veins, hepatic arteries, or lymphatic channels.Complex massEchogenic gasreverberation artifact

Varies Sonographic appearance. Differential diagnosis includes:Amebic abscess,Echinococcal cyst, Hemorrhagic cyst, Hematoma, Cystic neoplasm.

Pyogenic abscess cont. Symptoms

RUQ pain Leukocytosis Fever Elevated liver function tests

Aspiration is needed to confirm diagnosis

Homework: Show an image of a Pyogenic abscess.

HINT: Differentiation of Pyogenic abscess from an amebic abscess is difficult. If a patient has traveled out of the United States, an amebic abscess may be the correct diagnosis.

Amebic abscess Occurs when a parasite (amoeba) from

the intestines reaches the liver via the portal vein. An amebic abscess in the liver is the most common extra-intestinal complication of amoebic dysentery.

Symptoms and findings: Right upper quadrant pain Diarrhea Fever Leukocytosis Elevated liver function tests Elevated right dome of diaphragm by X-ray.

Ask where has the patient been? Out of the country?

Sonographic features: Round hypoechoic / complex mass Typically occurs in the right lobe (dome) Contiguous with the liver capsule.

Aspiration may be required for diagnosis.

Homework: Show an image of an Amebic Abscess.

Fungal Abscess (Candidiasis) A mycotic (fungal) infection of the

blood that results in small abscesses of the liver. The appearance of these lesions can change over the course of the disease process. “Wheel within a wheel” - is a lesion

with a peripheral hypoechoic zone, an inner echogenic wheel and a hypoechoic center. This is the earliest manifestation of a fungal infection and the most recognizable.

“Bull’s Eye”- lesion appears like this when the hypoechoic center calcifies

“Uniformly hypoechoic focus” – Most common presentation of lesion.

“Echogenic focus” – calcification representing scan formation seen late in the disease process.

Homework: Show an image of the these 4 fungal abscesses.

Echinococcal Cyst (Hydatid Disease)

An Echinococcal cyst is the result of a parasitic (tapeworm) infestation associated with sheep and cattle-raising countries. Eggs of Echinococcal granulosus are swallowed by the intermediate host (man). The eggs pass into the portal venous system where the larvae hatch and move into the liver.

The Sonographic appearance can vary depending on the stage of Hydatid disease: Simple cyst

Cyst with detached endo-cyst (cyst within a cyst

Cyst with multiple daughter cysts Cyst with detached membrane (Water Lilly

Sign) Calcified mass.

Homework: Submit images of the four types of Hydatid disease.

Tests used to diagnosis Hydatid disease include: Casoni skin test (70% sensitivity) Detection of antibodies (Echinococcal

Arc 5) Indirect hemagglutination Indirect florescent antibody test

Homework: Describe the Casoni skin test.

Hydatid Disease is associated with anaphylactic shock

The Echinococcal cysts contain active larvae; can see the cyst move.

Schistosomiasis Schistosomiasis is one of the most

common parasitic infections in humans. Schistosomiasis is the genius of several species of parasitic trematodes (an extensive order of parasitic worms).

It is a major cause of portal hypertension world-wide. The unique life cycle of Schistosomiasis is limited to specific areas: tropical zones around the world.

Eggs reach the liver through the portal vein inciting a granulomatous reaction resulting in periportal fibrosis.

The intrahepatic portal veins occlude resulting in portal hypertension. Sonographic findings include:

Occluded intrahepatic portal veins. Thickening and increased echogenicity of

the portal vein walls.

Secondary signs of portal hypertension include: Splenomegaly Ascites Esophageal variceal bleeding Portosystemic collaterals Absence of Portal Vein Flow

Although Schistosomiasis infections are not common in the United States, It is estimated that 400,000 infected persons have immigrated to this country.

Homework: Show images of Periportal fibrosis Several signs of portal hypertension as

described.

Sonographic Findings related to Acquired Immunodeficiency Syndrome (AIDS)

The following are Sonographic findings associated with AIDS: Fatty liver infiltration Hepatomegaly Hepatitis Candidiasis (Infection with a fungus of

the genus Candida. Cholangitis (inflammation of the bile

ducts) A-calculous cholecystits Kaposi’s Sarcoma – specific to Africa.

Pneumocystic carinii is the most common organism causing infection in AIDS patients. This organism is usually responsible for pneumoccystis pneumonia.

The Sonographic findings of P. Carinii organism involvement of the liver is that of diffuse, nonshadowing, hyperechoic foci.

Infectious agents may cause the bile ducts (cholangitis) and the gallbladder wall (cholecystitis) to be thickened.

AIDS cholangitis Sonographically appears as thickening biliary ducts. Thickening may compromise the lumen causing biliary obstruction.

Lymphoma and Kaposi’s sarcoma may be seen as an infiltration without visualization of a Sonographic abnormaltiy.

Homework: Show images of the following

Pneumocystis carinni Cholecystitis (Gallbladder wall thickening

without gallstones) Lymphoma

Fatty Infiltration

Fatty liver is the accumulation of triglycerides within the 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.

There are two patterns of fatty infiltration: FOCAL FATTY INFILTRATION

Focal regions of increased echogenicity within normal liver parenchyma. Focal fat commonly occurs at the porta hepatis.

FOCAL FATTY SPARING Focal regions of normal liver parenchyma within

a fatty infiltrated liver. Sparing commonly occurs adjacent to the gallbladder, in the porta hepatis, in the caudate, and at the liver margins.

Glycogen Storage Disease- A genetically acquired disorder that results in

the excess deposition of glycogen in the liver. It is associated with diffuse fatty infiltration and hepatic adenomas.

Differential diagnosis of hyperechoic masses within the liver include: Focal fatty infiltration Cavernous Hemangioma Echogenic metastasis Hepatic Lipoma

Homework: Show images of the following: Focal fatty infiltration Focal fatty sparing

Cirrhosis

Cirrhosis is the diffuse process of fibrosis and distortion of normal liver architecture.

Initially, there is liver enlargement, but continued insult results in hepatic atrophy.

Parenchymal changes produce symptoms related to blood coagulopathy, hepatic encephalopathy (disorder of the brain caused by a liver disorder) or portal hypertension.

Alcoholic liver disease once was considered to be the predominant cause of cirrhosis ion the United States. Hepatitis C has emerged as the nation’s leading cause of both chronic hepatitis and cirrhosis.

Clinical presentation of cirrhosis is Hepatomegaly Jaundice Ascites Portal hypertension

Abnormal (increased) liver functions include: AST (SGOT) ALT (SGPT) LDH (Lactate dehydrogenase) Conjugated bilirubin.

Homework: Define SGOT and SGPT

Hepatocellular dysfunction Inability to conjugate (join) – leads to jaundice Inability to synthesis bile. Inability to synthesis protein- albumin Inability to synthesis blood clotting factors Inability to convert ammonia to urea

Sonographic findings include: Hepatomegaly (acute Stage) Small liver (Chronic Stage) Caudate lobe hypertrophy Fatty infiltration- increased echogenicity Changes related to portal hypertension Increased incidence of Hepatocellular Ca

Cirrhosis

Homework: Show images of the following

Acute stage cirrhosis Chronic stage cirrhosis Hepatocellular Carcinoma

Portal Hypertension

Increased pressure in the portal venous system. Normal portal pressure is 5 to 10 mm Hg 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 suggest portal hypertension.

Cirrhosis and Schistosomiasis are the two major causes of portal hypertension.

Portal hypertension is asymptomatic. Patients typically present with sudden, painless, upper GI hemorrhage due to rupture of esophageal varices.

Four types of portal hypertension: Extrahepatic presinusodial (before the

liver) Example: Portal vein thrombosis

Intrahepatic presinusodial Example: Schistosomiasis

Intrahepatic (most common) Example: Cirrhosis

Intrahepatic postsinusoidal Example: Hepatic vein thrombosis

Sonographic findings of portal hypertension include the secondary signs of: Splenomegaly Ascites Portal systemic venous collaterals

Surgical techniques to lower portal pressure Portacaval shunt TIPS (transjugular intrahepatic

portosystemic shunt)

Portal Systemic Collaterals BY DEFINITION: Venous collaterals

are created, connecting the portal system to the inferior vena cava, bypassing the liver.

How? 1. Gastroesophageal varices – collaterals

of the distal esophagus and gastric fundus. May lead to life-threatening gastrointestinal hemorrhage.

2. 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.

3. Spleno-renal varices- tortuous collateral veins seen in the splenic and left renal hilum.

4. Intestinal varices – the veins of retroperitoneal structures such as the colon, duodenum and pancreas anastomoses with systemic tributaries.

5. 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- Tortuous collaterals around umbilicus Hemorrhoids Ascites

Homework: Show images of the following:

Recanalized umbilical vein Spleno-renal varices An image or diagram of gastro-

esophageal varices.

AND Covered in Section 3 Webinar- SDMS

JDMS Collection Series Liver Hemangioma

Approval number 12815

Outline Part 3

Surgically Created Portosystemic Shunts Liver Transplantation Portal Vein Thrombosis Budd-Chiari Syndrome Portal Vein Gas Liver cysts Cavernous Hemangioma Focal Nodular Hyperplasia Hepatic Adenoma Hepatic Lipoma Hepatocellular Disease Hepatoblastoma Laboratory Values

Surgically Created Portosystemic Shunts Portosystemic shunts are created to

decompress the portal system to avoid the development or rupture of gastroesophageal varices.

Intrapoerative shunts includes: Mesocaval-shunting of the SMV to the proximal

end of the IVC Portacaval-shunting between the Portal V and the

IVC Distal Splenorenal (Warren) – Shunting between

the distal splenic vein and the renal vein All are done to avoid bleeding and Ascites

Intraoperative shunting in most cases has been replaced by Transjugular intrahepatic portal systemic shunting (TIPS). This shunt is placed by using a jugular access. It is placed between a hepatic vein and a portal vein (typically the RHV and RPV).

Routine Doppler evaluation (3 to 6 month intervals) is utilized to detect early shunt compromise for prompt shunt revision.

Criteria for TIPS malfunction include: Focal velocity increase within the TIPS. Hepatopetal flow direction (towards the

liver) of the LPV or RPV. Hepatofugal flow direction of the MPV

(Away from the liver)

With a recanalized umbilical vein, the flow direction of the left portal vein may be in either direction (Hepatopetal or hepatofugal).

Liver Transplantation

Orthotopic (occurring in same place as original organ) liver transplantation 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 etiologies: (Hepatitis C is the leading

cause of chronic hepatitis and cirrhosis).

Indications for transplantation in Children:Biliary atresia

Preoperative Sonographic evaluation Is aimed at appropriate patient

selection. This includes the assessment of: Liver size and extent of pathology Portal vein patency Hepatic artery patency Hepatic vein patency Inferior Vena Cava patency Presence of venous collaterals Presence of complicating factors

Aortic aneurysms Extrahepatic malignancy

Postoperatively, the hepatic artery provides the only blood supply to the biliary tree.

Thrombosis or stenosis of the hepatic artery will result in biliary complications.

Homework: Show images of a transplanted liver

showing hepatic vein and portal vein patency.

Portal Vein Thrombosis

Sonographic findings Hypoechoic thrombus within the portal vein Increased portal vein caliber Cavernous transformation** Portal systemic collaterals

Causes of portal vein thrombosis Tumoral causes Hepatocellular carcinoma Metastatic liver disease Pancreatic carcinoma

Non-Tumoral causes of Portal Vein Thrombosis Pancreatitis Cirrhosis/hepatitis Inflammatory bowel disease Trauma Splenectomy Hypercoagulation Portal lymphadenopathy

Homework Show images of several thrombosed

portal veins Tumor causal Non-tumor causal

** Cavernous Transformation Numerous worm-like venous

collaterals that parallel the chronically thrombosed portal vein.

Cavernous transformation is typically seen with benign causes of portal vein thrombosis.

Homework: Show an image of a Cavernous

Transformation.

Budd-Chiari Syndrome A disorder characterized by hepatic

vein obstruction by thrombus or tumor. Typically, seen in young adult woman

taking birth control pills (causing hyper-coagulation).

Patient presents with Ascites Hepatomagaly Splenmegaly

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 (valveless) veins drain directly into the inferior vena cava. Thus, the caudate lobe enlarges with atrophy of the right the left lobes.

Homework: Show an image of Budd-Chiari

syndrome.

Portal vein Gas

Air within the intrahepatic portal veins is typically located in the periphery of the liver.

Associated with ischemic bowel disease (ulcerative colitis, or Crohn’s disease…which can cause neurotic bowel and abscesses).

In infants, intrahepatic portal vein gas is due to necrotizing enter-colitis (the death of intestinal tissue, most often affecting premature or sick babies).

Liver Cysts

A liver cyst is defined as a fluid-filled space lined by biliary epithelium.

Liver cysts usually refer to non-parasitic simple cysts.

Sonographic criteria include: 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 hemorrhagic cyst will appear as a cyst with internal echoes accompanied by pain and a decreasing hematocrit.

Differential diagnosis includes: Simple cyst Polycystic liver disease Hydatid cyst Cystic tumors Abscess

HOMEWORK: Show several images of Liver cysts.

Cavernous Hemangioma

Most common benign tumor of the liver.

The majority of hemangiomas are asymptomatic and discovered incidentally.

Hemangiomas consist of multiple vascular channels which create multiple sonographic interfaces.

Sonographic findings: Hyperechoic Posterior enhancement

May enlarge with pregnancy or administration of estrogens.

Hemangiomas may appear hypoechoic within the background of a fatty infiltrated liver.

Color or duplex Doppler does not routinely demonstrate flow within a hemangioma.

Contrast enhanced imaging demonstrates characteristic central flow.

Homework: Show an image of a Cavernous

Hemangioma

Focal Nodular Hyperplasia

This is a benign solid liver mass that is believed to be a developmental hyperplastic lesion related to an area of congenital vascular malformation.

FNH is typically an incidentally detected liver mass in an asymptomatic patient. They are more common in women than in men.

Sonographic findings Solid mass with varying echogenicity Central fibrous scar Star-shaped vascularity

FNH may appear as iso-attenuating and blend in with the surrounding liver parenchyma (Stealth lesion).

Homework: Show an image of a know FNH

Hepatic Adenoma

Associated with use of contraceptive agents. Patient may present with pain due to tumor

hemorrhage. Associated with glycogen storage disease. Surgical resection is recommended due to the

risk of malignant transformation. Sonographic findings

Nonspecific echogenicity Tumor hemorrhage

Note: It is often difficult to distinguish hepatic adenomas from FNH sonographically.

Homework: Show an image of a hepatic aden.oma

Hepatic Lipoma Hepatic lipomas are extremely rare

fatty tumors. Tuberous sclerosis (a congenital

familial disease which affects multiple systems and causes non-malignant tumors to grow in the brain and other vital organs) is associated with hepatic lipomas .

Sonographic findingsHyperechoic massPropagation speed artifact

Propagation speed artifact Decreased speed of sound in fat (1450

m/s) results in a prolonged sound return time.

Thus, objects posterior to a fatty mass will be placed farther away from the transducer.

This may be seen as a broken diaphragm posterior to a fatty mass.

CT scanning can confirm the fatty nature of a mass by the negative Hounsfield units (-30HU)

Recap-List of hyperechoic Hepatic masses Hepatic lipoma Hemangioma Echogenic metastasis Focal fatty infiltration

Homework: Show an image of a hepatic lipoma

Hepatocellular Carcinoma Hepatocellular Carcinoma (AKA Hepatoma) is the

most common primary malignancy of the liver. HCC occurs in 10-25% of patients with cirrhosis in

the US Hepatocellular carcinoma commonly invades

venous structures (portal veins and hepatic veins). Sonographic findings

Variable appearance Most are hypoechoic

Associated with Increased Alpha fetoprotein AST (SGOT) ALT (SGPT)

Homework: Show an image of Hepatocellular

Carcinoma.

Metastatic Disease Metastatic tumors are the most commonly

encountered solid masses of eh liver. The most common source of metastatic

involvement is from gastrointestinal, breast, or lung cancer.

Sonographic appearances include: Hyperechoic metastases Hypoechoic metastases Bull’s eye or target metastases Calcified metastases Cystic Metastases Diffuse metastases

Ultrasound can not correlate the sonographic appearance of the hepatic metastases with the primary originating organ.

There are some common sonographic patterns: Hyperechoic Metastases

Gastrointestinal tract Hypoechoic Metastases

Lymphoma Bull’s eye or 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.

Homework: Show images of liver metastatic disease with confirmed tracts of the following Gastrointestinal Lymphoma Lung Mucinous adenocarcinoma

Hepatoblastoma

Most common malignant liver tumor in early childhood.

Third 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 (10-12 cm at diagnosis.

Increased levels of serum alpha fetoprotein

Associated lung metastases and portal vein invasion.

Nonspecific sonographic appearance.

Homework: Show an image of Hepatoblastoma.

Laboratory Values

AST Aspartate Aminotransferase. Formally known as

serum glutamic oxaloacetic Transaminase (SGOT), AST has a wide tissue distribution. It is present in the liver, heart, skeletal muscle, kidney, and brain.

Elevation of AST, by itself, is non-specific for liver disease. It is, however, very sensitive, being elevated in almost all significant hepato-cellular diseases. An increase in AST without ALT, is seen with myocardial infarction, heart failure, muscle injury, CNS disease and other non-hepatic disorders. Serum AST and ALT are elevated to some extent in almost all liver diseases. The highest elevations occur with viral hepatitis.

Alanine Aminotransferase (ALT) Formally known as serum Glutamic

pyruvic transaminase (SGPT). ALT is present in high concentrations

within the liver tissue, therefore, ALT is more specific for liver disease than AST. Elevated AST and lactic dehydrogenase (LDH) with normal ALT rules out hepatic disease.

Gamma Glutamyl Transpepidace (GGT) GGT is present in hepatocytes and bile

duct epithelium. Therefore, an elevation indicates hepato-cellular disease and biliary obstruction.

GGT levels parallel those of alkaline phosphatase (ALP).

GGP is absent in placenta and bone: Therefore it is not elevated in pregnancy or childhood.

GGT is utilized to distinguish hepatocellular disease in these individuals.

Lactic Dehydrogenase (LDH) Enzyme found in the cells of many body

tissues. It converts pyruvate (which supplies

energy to living cells) to lactate (helps with metabolism).

Because LDH is widely distributed throughout the body, cellular damage causes an elevation of the total serum LDH. As a result, the diagnostic usefulness of this enzyme by itself is not as valuable as determination of its five isoenzymes. Individual iosenzyme elevations can indicate specific organ or tissue damage.

Alpha Fetoprotein (AFP) AFP is synthesized by the fetal liver and

levels decrease during the first year of life.

Marked elevations occur with hepatocellular carcinoma and hepatoblastoma.

AFP is a useful screening test for hepatocellular carcinoma because few other conditions cause levels to rise to high.

Prothrombin time PT PT is the time (seconds) it takes to blood

to coagulate. At least a dozen blood clotting factors

(proteins) are needed to clot blood. Prothrombin 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. Abnormal (long) prothrombin time is

often due to liver disease or warfarin (Coumadin) treatment.

Prothrombin time is measured to: Determine cause of abnormal bleeding Monitor Coumadin usage Screen for blood clotting factor

deficiency Screen for vitamin K deficiency Monitor liver function.

Partial Prothrombin time (PPT) Measures the function of several other

clotting factors. The PT and PTT tests together screen for

problems with coagulation due to blood clotting factors.