Sunday, June 22, 2008

LIVER DISEASES

LIVER
HEPATOMEGALY.
A. LARGE TENDER HEPATOMEGALY.
1.Congestive cardiac failure.
2.Amoebic Abscess./Hepatitis.
3.Infective Hepatitis.
4.Secondaries in Liver.
5.Infected Cyst.
B. NON TENDER HEPATOMEGALY.
1.Cirrhosis of Liver
2.Fatty Infilteration/Amyoloidosis.
3.Hepatoma
4.Lymphomas( Hodgekins.non Hodgekins lymphoma)
5.kalazar
6. Malaria
7. Hydatid cyst
8. Myelofibrosis.
C.Other causes are.
1.Tuberculosis
2.Typhoid
3 Lymphosarcoma.
4 Biliary cirrhosis
5Multiple myeloma
6.Lipoid Storage diseases( Gauchers disease)
7.Polycystic Disease.
8.Diabetes Mellitus
9.Toxic Hepatitis(Anaesthetic Drugs,Gold ,Dilantin)
10.Fungal Disease( Actinomycosis,Histoplasmosis)
11. Infectious mononucleosis.

BRIGHT LIVER.

Characteristic features are.

1.Strong echoes from liver parenchyma which is equal to peri portal structures
2.Liver appears flat,ground glass texture as normal peri vascular markings are
lost, all vessels appears as wall less cleft.
3.when compared with renals,renal parenchyma appears almost echo free
while liver is highly echogenic.
4.Echogenicity of liver parenchyma and ligamentum teres is same.

Causes are.
1.Micronodular cirrhosis of liver
2.Fatty infilterations..
3 .Chronic hepatitis.
4.Granulomas.
DARK LIVER

1.Liver parenchyma is of lower echogenicity than renal cortex
2. peri portal structures echoes are exaggerated.
3.Darkness of liver is due to more fluid present in parenchyma.

Causes are.

1Congestive cardiac failure.
2Acute infective hepatitis
3 Malignancy of liver
4 Lymph reticular tumour.


FATTY INFILTRATION OF LIVER

Causes are –
Diabetes Mellitus
Glycogen storage disease (Gauchers disease)
Obesity
Starvation & kwashiorkor
Alcoholic hepatitis
Others
Pregnancy
Corticosteroid
Hallothane / Tetracycline
Ulcerative Colitis


CIRRHOSIS OF LIVER

Sonological features of cirrhosis liver are very variable.

1. Liver may be enlarged with fatty change / may be normal in size /shrunken & scarred in late stages.
2. Highly echogenic(bright liver) seen in early cases where periportal structures are in apparent & appears like hepatic veins, while in others it may be normal.
3. Liver surface smooth but large regenerating nodule could be seen in post hepatitis cases.
4. Caudate lobe often enlarged which is a good index for cirrhosis of liver. Usually caudate lobe is half of the width of right lobe.
5. Ascites is seen which is transudate, no debris seen & bowel floats normally.
6. Portal vein more than 15 mm .
7. Splenic vein more than 10 mm in inspiration.
8. Portocaval anastomosis
· Oesophageal, splenic varices appears tortuous like bag of worms.
· Umbilical appears due to canalization of ligamentum teres.


AMOEBIC ABSCESS

Early cases are hyper echoic due to solid nature of abscess & it could be confused with meta static lesion of liver.
As liquefaction starts hypo echoic area appears due to collection of puss & necrotic debris. Occasionally mass is an echoic with floating debris inside cavity of abscess.
Initially abscess wall is irregular & shaggy but later it becomes smooth & outlined.
Post acoustic shadowing(PAS) often seen depending upon attenuation of puss.
Amoebic abscess cavity usually disappears in three months but occasionally it may last for one year or even more.
Usually amoebic abscess are single.
Site of the abscess is in right lobe superiorly close to diaphragm.

PYOGENIC ABSCESS

Pyogenic abscess are usually multiple.
Echo texture is similar to amoebic abscess varying from anechoic to highly echogenic.
Usually right lobe of liver due to streaming effect of portal vein.
Size vary from 1cm to any size.
Shape rounded are ovoid.
Walls irregular.
Posterior acoustic enhancement present.

HYDATID CYST

Commonly seen in right lobe of liver & is sub-capsular.
Well circumscribed, multilocular “cysts within cyst” i.e. daughter cysts within mother cyst.
Budding of germinal inner layer forming irregularities of cystic wall.
Hydatid sand(imperfectly formed daughter cyst) & calcification observed occasionally.
Many of daughter cysts are anechoic while some may have low level echoes due to debris.
If no daughter cysts seen then difficult to diagnose from simple cyst.


HEPATIC TUBERCULOSIS

1. Hepatic texture is non-homogeneous with scattered areas of increased & decreased reflectivity.
2. Some nodules could be located.
3. Caudate lobe may be enlarged.
4. Liver is enlarged.


HAEMANGIOMA

Cavernous type(where large sinusoidal blood vessels present)
Echo free focal lesions.
Irregular or lobulated wall.
No distal enhancement.
Occasionally complex lesion due to internal echoes are fluid- fluid level.

Capillary type(numerous small vessels present)
Echogenic(homogenous echo dense) masses.
Ill defined margin / sharply marginated.
Post acoustic shadowing present in masses more than 2.5 cm
Note- Haemangioma are to be confirmed by doppler study / angiography / biopsy(often catastrophic haemorrhage).


LIVER CELL ADENOMA

Solitary, marginated, encapsulated mass.
Common in woman taking oral contraceptives.
May present as palpable mass or pain in right hypochondrium.
If bleeding occurred it appears anechoic / hypo echoic or of greater density than surrounding liver parenchyma.




HEPATOCELLULAR CARCINOMA (HCC)



Found in preexisting post necrotic or macro nodular cirrhosis who are hepatitis B positive and alpha fetoprotein is raised.

Sonological features are.
Multiple nodules through out the liver
Diffuse infiltration.
solitary massive tumour
Discrete echogenic/discrete echo free /isoechoic / mixed echo texture / hypo echoic
Hepatomegaly.

Tip.
Any macro nodular cirrhotic patient who suddenly shows progressively enlargement of liver or suddenly deteriotes & there is haemorrhagic ascites,one should suspect hcc.

METASTATIC DISEASE OF LIVER
1 Multiple echogenic mass are due to breast carcinoma
2 Cystic masses are due to ovary/pancreas/stomach/colon/Leiomyosarcoma
squamous cell carcinoma

3 Hypo echoic mass( solitary) are due to Colorectal carcinoma
“HALO”
4 Heterogenous/ coarse structure are due to Renal lesion


5 Mixed echogenic masses are due to Urogenital./GIT lesion

7 Mass with target appearance are due to any where lesion(BULLS EYE)
7 Uniformly echogenic mass are due to Any where lesion
8 Calcified focal/multiple deposit due to GUT/Ovary lesion
9 Necrotic multiple deposit are due to Any tumour
10 Generalised Involvement
Fine Texture due to Miliary Metastasis
Echo poor due to Lymph reticular tumour
Moth eaten due to Any tumour
11 Multiple echo poor deposit due to Breast. Bronchus lesion






COMMON LIVER TUMOUR PATTERN
Primary site
1 Cystic deposit Mucin secreting tumour deposit colorectal tumour
4 Echo poor deposit any tumour



HODGEKINS LYMPHOMA

1 . Hypo echoic and Diffuse pattern of liver seen.

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