Saturday, May 16, 2009

Liver 2/3

بسم الله الرحمن الرحيم

Liver 2/3


o Hepatic fibrosis, like fatty infiltration of the liver is a nonspecific response to various toxins, metabolic disorders, hepatitis
o Unlike fatty changes, hepatic fibrosis is irreversible and ultimately leads to cirrhosis.
o Hepatic fibrosis in infants may be associated with polycystic kidney disease.

o Hepatic fibrosis may cause only slight increase in hepatic echogenicity with increased priportal echogenicity.
o Hepatic fibrosis and fatty infiltration can coexist.

Causes of hepatic fibrosis:
o Alcohol abuse
o Hepatitis, usually viral.
o Toxins, drugs.
o Autosomal recessive polycystic kidneys.
o Hepatic venous obstruction Budd Chiari syndrome.


I- Schistosoma mansoni: is the most common type infecting humans, the cercariae enter the portal venous system through the gut and then lodge in the portal veins and liver where they mature into adult worms. The ova shed by these adult worms migrate into the portal radicles where they cause granulamatous perephlebitis leading to fibrosis, and portal hypertension
o Highly echogenic peri-portal band because of peri-portal fibrosis. There is often hepatosplenomegaly and thickened gallbadder wall.
II- Schistosoma japonicum: results in the formation of characteristic calcified sepatated appearances of the peri-portal and peri-capsular regions of the liver "tortoise-shell" appearance.


o It is the most common hepatic primary tumour (about 80-90% of the primary tumors of the liver).
o Predisposing factors are: cirrhosis, chronic hepatitis, hemochromatosis, Wilson's disease and Alpha 1 antitrypsin deficiency.
o H.C.C may appear by U/S as a solitary mass, multiple masses or diffuse infiltrative pattern which is almost always associated with cirrhosis.
o The hepatic mass may be hypoechoic or echogenic or of mixed echogenicity.

o Sonographic features suggestive of malignancy are-:
o Peripheral halos
o Refractive or edge shadows.
o Increased in tra-lesional flow by Doppler u/s.
o Vascular invasion (portal vein invasion or hepatic vein invasion. Other suggestive features are:

§ Irregularity or bulging of liver surface.
§ Displacement or compression of intra-hepatic blood vessels or segmental bile duct obstruction.
§ About 8% have lymphadenopathy.
§ About 10% show calcification.

Fibrolamellar H. C. C.
· It is a distinct subtype of primary HCC (2% of all primary hepatoma), it presents in younger patients.
· No underlying cirrhosis or elevation of alphafetoprotein and it has better prognosis than the more classic HCC.
· The tumor is slowly growing that calcify with central scar.
· Characheristic features by U/S are "central scar", punctate calcification.
· The tumor is very vascular by angiography.

Infantile Hemangioendothelioma:
· 90% of the tumor are discovered in the first 6 months of life.
· Clinically: hepatomegaly, cardiomegaly and CHF., thrombocytopenia and 40% have cutaneous hemangiomas
· Most frequently they spontaneously involute within 6-8 months.
· Ultrasonographically: single or multiple lesions in the liver. Hypoechoic or echogenic, 25% shows fine granular calcification. The lesions is vascular and large draining veins may be identified.

· It is always seen in the first three years of life.
· May be associated with renal anomalies, Meckel's deverticulum, diaphragmatic hernia, macroglossia, hemi-hypertrophy and sexual precocity.
Clinically: Abdominal enlargement, anorexia, anemia, thrombocytopenia, markedly elevated alpha-fetoprotein, and early metastases to the lung.
· Ultrasonographically: the Rt. Lobe is the most common site.
· Single or multiple however, large solid heterogonous mass is common.
· 50% shows coarse calcification.
· Cystic hepatolblastoma with multilocular cyst of the liver and fine internal septations can be seen.

Mesenchymal hamartoma:
· The second most common tumor in young children (mean age at presentaion 16 month)
· The size of the tumor varies from 1 to 20 cm.
Clinically: abdominal mass, hepatomegly or high output-cardiac failure.
Ultrasonographically: well defined tumor with large cystic spaces, septations and some echegenic foci.
Biliary Cyst Adenoma/Cyst Adenocarcinoma:
· These tumors arise from intrahepatic bile ducts (85%). More in females and middle age.
· The tumor is well encapsulated, multiloculated cystic mass.
· Large (size up to 25cm), solitary, complex mass that contains locules septaei papillary- projections and fluid levels.


· Is the most common neoplasm in the liver.
· They may have one of the following ultrasound appearances.
o Diffuse inhomogenecity 35%.
o Discrete echogenic masses 30%.
o Discrete hypoechoic masses 23%.
o Discrete anechoic masses 2%.
o Combination of the above 10%.

· Metastatic disease should be suspected when there are multiple abnormal focal lesions within the liver.
· A single lesion is more of a diagnostic problem since solitary metastases are possible.

I- Echogenic Metastasis:
· Colon, pancreas and stomach.
· Cholangio carciroma.
· Carcinoid, Kaposi's sarcoma.
· Breast cancer after treatment.
II- Calcified metastasis:
· Mucinous adenocarcinoma from the colon.
· Ovarian cyst adenocarcinoma.
· Osteogenic sarcoma.
· Medullary carcinoma of the thyroid, neuroblastoma, leiomyosarcoma and pancreatic islet cell tumor.
III- Cystic metastasis:
· Ovarian cystadenocarcinoma.
· Pancreatic cystadenocarcinoma.
· Biliary cystadenocarcinoma.
· Cystic hepatoblastoma.
IV- Hypoechoic metastasis:
· Breast.
· Lung.
· Lymphoma.
V- Complex hepatic metastasis:
· Any metastasis may have a complex appearance, particularly if complicated by hemorrhage.


· Is the most common benign tumor of the liver.
· The tumor is made of vascular channels lined by endothelium separated by fibrous stroma.
· It is common in adults and in females (female to male ratio of 5:1).
· Usually solitary, but 10- 20% of cases are multiple.
· Mostly seen in Rt-lobe, and 25% are found in the left lobe.
· The majority are subcapsular (70%) usually in the posterior segment of Rt. Lobe.
Important Features are:
· They are sharply marginated, well - defined.
· Uniformely echogenic (Atypical hypoechoic lesion seen in 15-20% of cases) the multiple interfaces of the endothelial channels result in the highly echogenic sonographic appearance.
· No peripheral halos.
· Rarely change in size.
· Giant hemangioma (more than 8cm) are large, complex masses:
· Giant cavernous hemagioma can rupture and severe hemorrhage result.
· Oestrogens may affect hemangioma's growth and they can enlarge with pregnancy.
· Involution has been described with corticosteroid therapy.
· Association with focal nodular hyperplasia and Rendu Osler Weber syndrome is known.


· It is a benign tumor (hamartoma) consisting of all normal cellular elements of the liver i.e. Kupffer cells, hepatocytes and bile ducts, but lack normal hepatic architexture and are thus poorly functioning.
· Common in the third to fifth decade of life and more common in females.
· They are usually less than 5cm in diameter.
· Usually solitary, (multiple in 7-20% of cases).
· The tumor is well- defined with sharp margin.
· Usually on the surface of the liver.
· 40% of the tumors are isoechoic, 40% are hypoechoic and in 20 % of cases the tumor are hyperechoic.
· Central stellate scar and radiating fibrous septa are usually seen.
· There is no malignant potential, but if the mass is pedunclulated, it can undergo torsion.
· The majority of patients are asymptomatic with normal liver function tests.
· Association with hepatic haemangioma is described. Other conditions associated with FNH are vascular anomalies and neuroendocrine tumors.


· It is a rare benign tumor.
· Almost seen in women taking oral contraceptives.
· It can also occur in patients with glycogen storage disease (Von Gierke's disease), Fanconi's anemia, and exogenous hormone intake
· Hepatic adenoma consists of sheets of normal or atypical hepatocytes, they are very vascular and have tendency to rupture and bleed causing hemoperitoneum.
· They are usually solitary in the Rt. Lobe.
· Most frequent appearance (80%) is an echogentic, well defined uniform mass and often large in size (8-15 cm).
· Atypical adenoma may appear poorly defined, hypoechoic (20%) and inhomogenous.
· Pregnancy may increase tumor growth and may rarely lead to rupture.
· Percutaneous biopsy is risky as hemorrhage may follow.


I- Simple Hepatic Cyst:
· Non - parasitic hepatic cysts are usually discovered incidentally by U/S and they are believed to be congenital defects.
· They are usually asymptomatic unless complicated by hemorrhage or infection.
· More common in females in the 50-80 year age group.
· May be solitary or multiple.
· They are anechoic.
· Well defined, thin smooth wall.
· Posterior enhancement.
· Septations and soft tissue nodularity may be seen after internal hemorrhage.
Polycystic Kidney Disease With Hepatic Involvement:
· Hepatic involvement is seen in 40% of patients with autosomal dominant poly cystic kidney disease. Hepatic cysts are multiple and small with smooth walls and no septations or mural nodules.

III- Carolis Disease:

· Non obstructive saccular dilatation of intra-hepatic biliary tree.
· By U/S the intra hepatic cystic spaces may be seen communicating with the branching biliary tree, calculi may be seen with debris within the sacular dilatation, it may be associated with infantile polycystic disease.
· Usually presents itself in childhood with recurrent cholangitis.

IV- Hydatid Cyst: Echinococcus granulosus" cyst.
· The live ris the most common organ affected (70%).
· The Rt. Lobe of the liver is the most common site.
· In 20% of cases the cysts are multiple.
Ultrasonographically it depends upon the stage of evolution and maturity:
o Early stages: simple fluid filled cyst.
o Cyst with undulating membrane occur it the endocyts rupture (sonographic water lilly sign).
o Daughter cysts may appear within the mother cyst.
o Multilocular cyst with echogenic matrix may form.
o Complex mass with both solid and cystic elements can be seen.
o The cyst may be densely calcified with distal acoustic shadowing.
o Solid cysts may occur (17% of cases) giving ball of wool' appearance or Spin or whorl' sign representing collapsed parasitic membrane.

V- Echinococcus "Multilocularis" cyst:
· The infection is less common but more aggressive than the E. granulosus.
· The cyst of E. multilocularis is multilocular rather than unilocular and is has echogenic solid looking, single or multiple ill-defined masses and is difficult to differentiate between it and HCC.
· Calcification is common (68%).

15/05/2009 06:10 PM
To Be Completed.... ان شاء الله