Geir Folvik, MD Division of Gastroenterology Department of Medicine, Haukeland University Hospital Bergen, Norway

Transcription

1 Benign liver diseases Geir Folvik, MD Division of Gastroenterology Department of Medicine, Haukeland University Hospital Bergen, Norway

2 Agenda Benign focal liver lesions Fatty liver disease Liver cirrhosis Budd-Chiari and Congestive heart failure Other benign liver disorders 2

3 Cavernous hemangioma most common benign tumour of the liver (prevalence 5-10%) small (< 2-3 cm) homogeneous hyperechogenic lesion well defined, often with irregular margins often found in a subcapsular or perivascular position most often discovered by coincidence larger hemangiomas can be atypical with heterogeneous echogenicity typical vascular pattern peripheral nodular arterial enhancement followed by centripetal filling contrast-enhanced ultrasonography(ceus) and MRI > CT DD: metastases/ HCC/ FNH /adenomas/ focal fatty changes/ lipomas 3

4 Hemangioma 4

5 Hemangioma typically peripheral nodular contrast enhancement on CEUS centripetal fill-in 5

6 Focal nodular hyperplasia/ Adenoma FNH second most common benign liver tumour (incidence of 1-3%) often almost isoechoic with a central stellate scar non-encapsulated, but well defined typical centrifugal vascular filling to the periphery in the arterial phase on Color Doppler(CDS),CEUS, CT and MRI DD: adenoma, HCC, metastases Liver cell adenoma adenomas less frequent than FNH» young women using contraceptive pills encapsulated larger adenomas often inhomogeneous due to bleeding, necrosis and fibrosis RUQ pain due to mass effect or bleeding CEUS biopsy seldom indicated DD: HCC/ FNH/ abscess 6

7 FNH 7

8 FNH -CEUS 8

9 Adenoma 9

10 Adenoma 10

11 Liver cysts ultrasound is highly accurate in diagnosing liver cysts anechoic with a clear posterior demarcation (but no wall) posterior enhancement often round in shape and smooth occasionally RUQ pain due to mass effect or bleeding DD: abscess, echinococcal cysts, tumours with central necrosis, hematomas polycystic liver disease autosomal dominant disorder often multiple renal cysts (>50%) variation in size and shape hepatomegaly, cholestasis and portal hypertension (PHT) 11

12 Liver cysts ultrasound is highly accurate in diagnosing liver cysts anechoic with a clear posterior demarcation (but no wall) posterior enhancement often round in shape and smooth occasionally RUQ pain due to mass effect or bleeding DD: abscess, echinococcal cysts, tumours with central necrosis, hematomas polycystic liver disease autosomal dominant disorder often multiple renal cysts (>50%) variation in size and shape hepatomegaly, cholestasis and portal hypertension (PHT) 12

13 Liver cysts 13

14 Liver cysts 14

15 Polycystic liver disease 15

16 Liver abscess cystic pattern on ultrasound often contain echogenic material including bubbles of gas abscess wall more irregular than in simple cysts fever, leucocytosis, CRP elevation and elevated LFT`s DD: hematomas, necrosis in metastases/tumours, bloodcontaining cysts, infarction, parasitic cysts 16

17 Liver abscess 17

18 Liver abscess on CT-scan 18

19 Liver abscess CEUS 19

20 Lipoma and Fatty liver disease Lipoma a highly reflective hyperechogenic tumour with sharp demarcation ( very bright ) Fatty liver disease steatosis or diffuse fatty liver -hyperechogenic liver focal fatty infiltration -hyperechogenic area in focal sparing you will find a hypoechogenic area or lesion in a diffuse fatty liver 20

21 Fatty liver alcohol NAFLD (obesity/ DM/ hyperlipidaemia) drugs/ toxic substances TPN pregnancy malnutrition/ bypass surgery inborn errors of metabolism ( metabolic diseases) hepatomegaly hyperechogenic with fine, closely packed echoes/ bright liver blood vessels and diaphragm often less distinct increased attenuation => reduced visualisation in depth sensitivity % (depends of severity) lower specificity (fibrosis ) 21

22 Lipoma -US og CT 22

23 Focal fatty infiltration hyperechogenic area vessels are normal without displacement no mass effect can respect anatomical margins DD: tumours 23

24 Steatosis 24

25 Fatty liver with focal areas of sparing 25

26 Fatty liver with focal areas of sparing 26

27 Liver cirrhosis ultrasonographic signs in more than 2/3 of cases increased echogeneity (increased reflection due to fibrosis) portal vein walls often not defined no significant increase in attenuation as in fatty liver coarse and irregular echo-structure irregular contour because of surface nodularity -Lelio et al. Radiology 1989 especially with high-frequency transducers and ascites atrophy of the right lobe and hypertrophy of the caudate lobe large regenerative nodules (DD: metastases/tumours) 27

28 Liver cirrhosis hepatic veins: often flattened flow-curve thickened and layered wall of the gallbladder ascites (Morrison`s pouch) portal hypertension (PHT) alteration in or reversal of portal vein flow portal vein diameter increase in size to > 13-15mm splenomegaly collaterals/ recanalized paraumbilical vein increased risk of HCC US screening and AFP every 6-12 months? CEUS 28

29 Liver cirrhosis 29

30 Liver cirrhosis 30

31 Enlarged caudate lobe 31

32 Flow-curve of the hepatic veins Normal Cirrhosis 32

33 Portal hypertension Dilated portal vein Reversed flow in the portal vein Open umbilical vein 33

34 Open umbilical vein 34

35 Splenomegaly and collaterals 35

36 Budd-Chiari and VOD partial or complete thrombosis of hepatic veins asymptomatic to acute liver failure hepatomegaly and ascites visible thrombotic material inside the veins? reversal of blood flow in portal vein (Duplex Doppler/ Color Doppler) later on: hypertrophy of the caudate lobe with progressive splenomegaly 36

37 Budd-Chiari all degrees echoic thromb anechoic thromb absence of flow (CDS) absence of vessels hepatomegaly ascites collaterals 37

38 Budd-Chiari 38

39 Intrahepatic portal vein thrombosis 39

40 Congestive liver failure dilatation of the hepatic veins dilatation of vena cava compression/ Valsalva hepatomegaly ascites portal hypertension ESLD 40

41 Other benign disorders acute viral hepatitis cholestatic liver disease hematomas hydatid disease (echinococcal cysts) amoebic abscess hypoechogenic (history!) schistosomiasis regenerative nodules in cirrhosis Caroli`s disease biloma (bile leakage) sarcoidosis (granulomas usually not visualised) 41

42 Acute viral hepatitis exclude obstructive jaundice, tumour and cirrhosis hepatomegaly occasionally dark liver sign / starry night liver hyperechogenic portal vein walls ( periportal cuffing ) hypoechogenic liver parenchyma (edema) layered gallbladder wall periportal lymph node enlargement but, most often US is normal 42

43 Acute viral hepatitis 43

44 Lymph node enlargement 44

45 Primary biliary cirrhosis -Primary sclerosing cholangitis periportal fibrosis periportal lymph nodes stones in the gallbladder or bile ducts end stage liver disease (cirrhosis +/- PHT) irregular bile ducts in PSC 45

46 PBC and PSC 46

47 PSC 47

48 PSC 48

49 Stones in the gallbladder (PSC) 49

50 Hematoma acute; highly reflective later; often inhomogeneous or hypoechogenic depends on age and severity of bleeding 50

51 Echinococcal cyst like a simple cyst in stadium I» most frequent finding (50-80%)» irregular lokalized wall thickening thickened, layered cyst wall wall calcification echogenic matrix with daughter cysts» cysts enclosed within a cyst classification: Gharbi type I-V 51

52 Ultrasound in Schistosomiasis periportal fibrosis PHT splenomegaly 52

53 Schistosomiasis male 24 year of age (Etiopia 2012) 53

54 Sarcoidosis Hepatomegaly on US 54 CT-scan shows multiple small focal lesions

55 What is the diagnosis? 55