It’s a SURPRISE

Danielle
• A 59 year-old man presents to the emergency department complaining of
diffuse weakness. Five days ago he underwent a large volume paracentesis
for symptomatic relief of ascites. He has a long-standing history of
cirrhosis secondary to A chronic hepatitis B infection. His medications
include lactulose, furosemide, spironolactone, propranolol, and a multi-
vitamin. On physical exam, he is afebrile with a blood pressure of 98/52,
and a pulse of 62 bpm. He is alert and oriented. The paracentesis site is
dry and intact without any surrounding erythema. His creatinine is noted
to be 2.1, up from a baseline of 1.1. Other labs including CBC, liver
function tests, and sedimentation rate are comparable to the patient's
baseline. The patient is admitted to the medicine service. He is
aggressively hydrated with IV normal saline. The next day, his abdomen is
more distended and his creatinine is 2.5. A urinalysis and urine microscopy
are performed. There is no evidence of protein, casts, red cells, white
cells, or bacteria. A renal ultrasound is unrevealing. The patient continues
to be afebrile and to have a non-focal exam, and the remainder of his labs
are non-diagnostic. He is further hydrated. The following day, his
creatinine is 3.1.
• Which of the following mechanisms is likely responsible for the patient's
declining renal function?
– Glomerular subepithelial immune deposits
– Necrotizing inflammation of the renal arteries
– Renal interstitial edema with lymphocytic infiltrate
– Renal tubular ischemia
– Splanchnic vasodilation
• A 34-year-old woman presents to the emergency
department because of right upper quadrant abdominal
pain and nausea. Physical examination is positive for a
palpable, mildly tender, hepatic mass. Contrast-enhanced
CT of the abdomen reveals a well-demarcated solitary mass
without a fibrous capsule in the right lobe of the liver, and
with transient homogeneous enhancement during the
hepatic arterial phase. The patient's medical history is
negative, and her only medications are aspirin as needed
and oral contraceptive pills for the past 4 years. Laboratory
tests show a mild elevation in the y-glutamyl
transpeptidase level and a normal a-fetoprotein level.
• Which of the following is the most likely diagnosis?
– Focal nodular hyperplasia
– Hepatic hemangioma
– Hepatoblastoma
– Hepatocellular adenoma
– Hepatocellular carcinoma
 Patient 1
• 52 Year Old Male presents to the hospital with
a oliguria and increased creatinine. Personal
Hx of HTN(12 years, uncontrolled) and and
radiating back pain(1 year in duration, radiates
to leg).
 Pt 2
• 48 year old male presents with abdominal
swelling of 4 months duration, shortness of
breath, and decreased urination.
 Abdominal Ultrasound Indications
• Abdominal, flank, and/or back pain.
• Signs or symptoms that may be referred from the abdominal and/or
retroperitoneal regions such as jaundice or hematuria.
• Palpable abnormalities such as an abdominal mass or organomegaly.
• Abnormal laboratory values or abnormal findings on other imaging examinations
suggestive of abdominal and/or retroperitoneal pathology.
• Follow‐up of known or suspected abnormalities in the abdomen and/or
retroperitoneum.
• Search for metastatic disease or an occult primary neoplasm.
• Evaluation of suspected congenital abnormalities.
• Abdominal trauma.
• Pretransplantation and posttransplantation evaluation.
• Planning for and guiding an invasive procedure.
• Searching for the presence of free or loculated peritoneal and/or retroperitoneal
fluid.
• Suspicion of hypertrophic pyloric stenosis or intussusceptions.
• Evaluation of a urinary tract infection
 Liver Examination
• The examination of the liver should include long‐axis and transverse views.
The liver parenchyma should be evaluated for focal and/or diffuse
abnormalities. If possible, the echogenicity of the liver should be
compared with that of the right kidney. In addition, the following should
be imaged3–8
– The major hepatic and perihepatic vessels, including the inferior vena cava
(IVC), the hepatic veins, the main portal vein, and, if possible, the right and
left branches of the portal vein.
– The hepatic lobes (right, left, and caudate) and, if possible, the right
hemidiaphragm and the adjacent pleural space.
– For vascular examinations of the native or transplanted liver, Doppler
evaluation should be used to document blood flow characteristics and blood
flow direction. The structures that may be examined include the main and
intrahepatic arteries, the hepatic veins, the main and intrahepatic portal veins,
the intrahepatic portion of the IVC, collateral venous pathways, and
transjugular intrahepatic portosystemic shunt stents.
 Ultrasound of the Liver
• Size
• Capsular contour (smooth, coarse, lobulated)
• Parenchymal echogenicity
• Vascularity
• Biliary tree
• Masses or collections
 Size
• MIDCLAVICULAR
• If the measurement is made
from the ant diaphragm to
the lower edge of the liver
in the midclavicular line it
should be no >13cm
• MIDHEPATIC
• Measured in the midhepatic
line with a large field of
view it should measure
<16cm from the post
diaphragm to the lower
anterior edge.
 Common Pathology Found on Liver
Ultrasound
• Fatty liver
• Liver cysts
• Haemangioma
• Portal hypertension
• Portal vein thrombosis
• Hepatic vein thrombosis
• Liver abscess/collection
• Cirrhosis
• Trauma
• Metastases
• HCC
• Abscess
What if you see this?
What about this?
 Findings seen on Ultrasound
• Focal
– hyperechoic liver lesions
– hypoechoic halo sign / target
lesions
– simple hepatic cyst
– hepatic haemangioma
– focal nodular hyperplasia
– hepatic adenoma
– hepatic metastases
– cystic hepatic metastases
– hepatic abscess
– periportal hyperechogenicity
– periportal hypoechogenicity
• Other
– hepatic trauma on ultrasound
• Diffuse
– acute hepatitis
– Cirrhosis
– hyperechoic liver
– diffuse hepatic steatosis
– grading of hepatic steatosis
– coarsened hepatic echotexture
– generalised decrease in hepatic
echogenicity
– "starry sky appearance" of the liver
• Hepatic vasculature
– normal hepatic vein Doppler
– portal hypertension
– portal vein thrombosis
– developed collaterals /
portosystemic shunts
 Focal Lesions of the Liver
• Benign Lesions • Malignant Lesions
– Cysts – Hepatic metastases
– Hemangiomas – Hepatocellular
– Focal nodular hyperlasia Carcinoma
– Hepatic adenoma – Cholangiocarcinoma
– Biliary cystadenomas
– Peliosis hepatis
 Malignant Liver Lesions
• Hepatocellular • picture
Carcinoma
– Massive (focal)
– Nodular (multifocal
– Infiltrative (diffuse)
 Metastases
• Hypoechoic- 65% • Peripheral halo- bull’s eye
– Lung sign
– Breast – Lung cancer
– Pancreatic adenocarcinoma – Mucinous adenocarcinoma
– Lyphoma – Gastrointestinal
• Hyperechoic – Ovarian mucious
adenoucarcinoma- Cystic
– CRC
– Squamous cell carcinoma
– RCC
– Ovarian cancer
– Choriocarcinoma
– Pancreatic adenocarcinoma
– Kaposi sarcoma
– CRC
– Neuroendocrine tumors
– Carcinoid • Poorly defined/infiltrative
– Pancreatic islet cell tumors – Breast
– Lung
• Intrahepatic biliary dilation
– Colorectal carcinoma
 Benign liver lesions
• Cysts
• Hemangiomas
• Focal nodular hyperlasia
• Hepatic adenoma
• Biliary cystadenomas
• peliosis hepatis
 Cysts
• Present in 2.5%
population
• Asymptomatic F>M
• On ultrasound- sharply
defined margins with
acoustic enhancement
w/ or w/o septations
• Typically well-defined hyperechoic
lesions
Hemangiomas
• a small proportion (10%) are
hypoechoic, which may be due to a
background of hepatic steatosis,
where liver parenchyma itself is of
increased echogenicity.
• colour Doppler: may show peripheral
feeding vessels
• contrast-enhanced ultrasound
• arterial phase: peripheral nodular
discontinuous enhancement
• portal venous and delayed phases:
continued “filling in” of the lesion,
until the entire haemangioma is
hyperechoic relative to background
liver
 Focal Nodular Hyperplasia
• Some lesions are well marginated
and easily seen whereas other are
isoechoic with surrounding liver.
• Detectable lesions characteristically
will demonstrate a central scar with
the displacement of peripheral
vasculature on colour Doppler
examination.
• contrast-enhanced ultrasound :
– arterial phase
• FNH will enhance relative to
background liver
• prominent feeding vessel may be seen
– portal venous phase
• centrifugal filling (opposite to
haemangioma and adenoma)
• sustained enhancement in the portal
venous phase (as opposed to adenoma)
• unenhanced scar may be present
 Hepatic Adenoma
• A hepatic adenoma usually
presents as a solitary well-
demarcated heterogeneous mass.
Echogenicity is variable :
• hypoechoic: 20-40%
• hyperechoic: up to 30%, often
due to fat .
• colour Doppler: may show
perilesional sinusoids
• contrast-enhanced ultrasound
– arterial phase
• hypervascular (similar to FNH,
although adenomas are usually less
enhancing)
– portal venous and delayed phases
• centripetal filling in (opposite of FNH
which shows centrifugal filling)