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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
6.10 Jaundice
Schmidt, Ultrasound © 2007 Thieme
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n
Sonographic findings :
x
Enlarged liver
x
Diffuse, homogeneous increase in echogenicity (“white liver”)
x
The liver is markedly hyperechoic to the normal kidney or psoas muscle
x
The portal vessels appear hypoechoic (reversal of contrast)
n
Accuracy of sonographic diagnosis: Ultrasound can establish the presence of a
fatty liver in more than 90 % of cases, but it cannot determine the cause of the
excessive fat deposition.
Cholecystitis
..............................................................................................................
n
See Upper Abdominal Pain, Acute Cholecystitis, p. 63; Gallbladder, Acute cholecystitis, p. 339; Mural abscess, p. 341; Chronic cholecystitis, p. 344.
Budd–Chiari Syndrome
..............................................................................................................
n
See Ascites, p. 162; Hepatosplenomegaly, p. 148; Search for Occult Tumors, Deformation and infiltration of vessels, p. 447.
Secondary Biliary Cirrhosis
..............................................................................................................
n
Clinical manifestations: lethargy, decreased exercise tolerance, feeling of upper
abdominal pressure or fullness; nausea, vomiting; jaundice; pruritus with scratch
marks, spider nevi, telangiectasis, palmar erythema, glossitis, hormonal disorders
n
Diagnosis:
x
History
x
Clinical findings: liver feels hard and initially enlarged; later it is decreased in
size.
x
Laboratory findings: low cholinesterase, Quick PT, albumin; elevated AP, LAP,
GGT, and conjugated bilirubin
x
Sonography (comparable to CT)
x
Biopsy: Histology establishes the diagnosis
n
Sonographic findings :
x
Typical signs of hepatic cirrhosis (see p. 236, 330)
x
Demonstrable cause of biliary obstruction:
– Signs of chronic pancreatitis
– Common duct obstruction, gallstone
– Choledochal cyst
n
Accuracy of sonographic diagnosis: Diagnostic accuracy is only about 85 %. Sono-
graphic findings are least rewarding in the early phase of the disease.
Biliary Atresia
..............................................................................................................
n
See Ascites, p. 155.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
147
6.11 Hepatosplenomegaly
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6
6
6.11 Hepatosplenomegaly
Basic Principles
..............................................................................................................
n
Principal signs and symptoms: abdominal tenderness in the right and left upper
quadrants, palpable organ enlargement
Table 26.Differential diagnosis of hepatosplenomegaly
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hepatic cirrhosis (p. 149)
Principal Signs and Symptoms
Principal Signs and Symptoms
Cardiac inflow stasis (p. 149)
Fatty liver (p. 149) Enlarged, echogenic, homogeneous liver with rarefied
Hepatic tumor or metastasis
(p. 150)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Less common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
High-grade lymphoma, lymphogranulomatous infiltrates in
Hodgkin disease (p. 150)
Cystic liver (p. 151) Numerous anechoic nodules (may be echogenic due to
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Rare
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Portal vein thrombosis (p. 151)
Splenic vein thrombosis (p. 151) Dilated splenic vein with no detectable flow
Budd–Chiari syndrome (p. 152) Occlusion of the large hepatic veins; the veins usually
Constrictive pericarditis (p. 152) Hypoechoic enlargement of the liver, obstruction of the
Echinococcal cyst of the liver
(p. 153)
Hepatic fibrosis (p. 153) Coarse parenchymal pattern, periportal fibrosis, signs of
Conditions that cannot be diagnosed with ultrasound
Common: Sepsis due to various pathogens, infectious mononucleosis, epidemic hepatitis,
toxic liver damage
Less common: Familial hyperlipidemia, hemochromatosis, subacute infectious endocarditis,
sarcoidosis, blood diseases (hemolytic anemia, chronic myeloid leukemia, thrombocytosis,
osteomyelofibrosis), malaria
Rare: Amyloidosis, hematologic diseases (polycythemia vera, Waldenström macroglobulinemia, acute erythromyelosis, erythropoietic porphyria), tropical diseases, other infectious
diseases (Weil disease, Bang disease, relapsing fever, etc.), salmonellosis, paratyphoid fever,
miliary tuberculosis, cytomegalovirus infection, metabolic diseases (storage diseases such as
148
Gaucher disease, Wilson disease, fructose intolerance), rubella
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
hepatic veins
Hypoechoic or echogenic masses, enlarged liver and
spleen, biliary stasis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Enlarged liver and spleen, enlarged lymph nodes
intralesional hemorrhage)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Enlarged spleen, venous collaterals (recanalized umbilical
vein, convoluted veins)
show increased echogenicity with no detectable flow
vena cava
Anechoic round lesion with echogenic wall, calcifications
portal hypertension
6.11 Hepatosplenomegaly
Schmidt, Ultrasound © 2007 Thieme
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n
Differential diagnosis: The possible diagnoses are listed in Table 26 in order of
their frequency in the general hospital setting.
Hepatic Cirrhosis (Fig. 193)
..............................................................................................................
n
See also Ascites, p. 156; and Liver, pp. 236 and 238.
Fig. 193 Marked splenic enlargement
in hepatic cirrhosis due to portal hypertension
Cardiac Inflow Stasis
..............................................................................................................
n
See Renal Insufficiency, Heart Failure, p. 127; Shock Kidney, p. 136; Liver, Congestive Cirrhosis, p. 236; Vena Cava and Peripheral Veins, Congestion, p. 208.
Fatty Liver (Fig. 194)
..............................................................................................................
n
See also Liver, Alimentary or diabetic fatty liver, p. 127; Toxic fatty liver, p. 238.
n
Clinical manifestations: enlarged, palpable liver that may be tender to pressure;
also signs and symptoms of the precipitating illness
n
Diagnosis: history; laboratory tests: liver values, lipids, blood sugar, HbA1c
n
Sonographic findings :
x
Enlarged, bulbous, echogenic, homogeneous liver (markedly hyperechoic to the
healthy kidney)
x
Rarefied hepatic veins
x
Posterior (distal) acoustic shadowing
n
Accuracy of sonographic diagnosis: Ultrasound can show only that fatty infiltra-
tion has probably occurred, producing a circumscribed area having the appearance of a fatty liver. The diagnosis can be confirmed by percutaneous biopsy,
but this is rarely indicated. It is important to exclude other causes of echogenic
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
Fig. 194 Fatty liver: enlarged liver (L)
with a dense, homogeneous echo pattern. The hepatic veins are only faintly
visible, and there is dense posterior
acoustic shadowing. GB = gallbl adder,
D = diaphragm
149
6.11 Hepatosplenomegaly
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6
6
liver enlargement (see p. 234, 235). Therapeutic implications relate to the prevention or treatment of the precipitating cause (diabetes mellitus, glycogen storage
disease, lipid metabolism disorder, alcohol-related disorders, etc.). Often no specific cause can be identified.
Hepatic Tumor or Metastasis (Fig. 195)
..............................................................................................................
n
See also Jaundice, p. 145; Liver, Primary hepatic carcinoma, p. 249; Metastases,
p. 250.
n
Clinical manifestations : Early metastases may be clinically silent. As the intrahe-
patic pressure rises and bile ducts are compressed, jaundice may develop. Enlargement of the liver may lead to significant complaints (e.g., inferior vena cava
obstruction and tenderness).
n
Sonographic findings :
x
Principal Signs and Symptoms
Principal Signs and Symptoms
Hypoechoic or echogenic masses (usually rounded) with more or less welldefined margins
x
Enlarged liver
x
Biliary stasis
n
Accuracy of sonographic diagnosis: The masses are clearly visualized in most
cases. Ultrasound contrast agents can be helpful in locating and differentiating
hepatic masses. Ultrasound-guided percutaneous biopsy establishes the diagno sis.
Fig. 195 Considerably enlarged liver with
multiple round lesions, some showing a bull’seye pattern p “metastatic liver”, compressing
and obstructing the inferior vena cava
(vena cava compression syndrome)
High-Grade Lymphoma, Lymphogranulomatous Infiltrates
in Hodgkin Disease (Fig. 196)
..............................................................................................................
n
See also Palpable Masses, p. 101; Enlarged Lymph Nodes, Malignant Lymphoma,
p. 113; Spleen, Splenic lymphoma, p. 316; Liver, Hematologic malignant systemic
diseases, p. 239.
n
Clinical manifestations : enlarged, palpable lymph nodes; lethargy, fever, night
sweats, weight loss
n
Diagnosis:
x
Laboratory tests : differential blood count, ESR; LDH; tuberculin test (e.g., Tine
test)
x
Sonography with staging
x
Search for superficial lymph nodes
x
Lymphadectomy or percutaneous biopsy
n
Sonographic findings :
x
Enlarged liver
x
Enlarged spleen
x
Other enlarged lymph nodes in the abdominal cavity and in peripheral soft
150
tissues
6.11 Hepatosplenomegaly
Schmidt, Ultrasound © 2007 Thieme
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Fig. 196 High-grade non-Hodgkin
lymphoma of the spleen (S)
n
Accuracy of sonographic diagnosis: Multiple organ manifestations and multiple
enlarged lymph nodes suggest a diagnosis of lymphoma. Splenic involvement is
particularly suggestive, as other primary tumors rarely metastasize to the spleen.
The diagnosis is confirmed by histologic examination (preferably of an excised
lymph node).
Cystic Liver
..............................................................................................................
n
See also Liver, p. 242.
n
Clinical manifestations : frequently asymptomatic; possible nonspecific feeling of
abdominal pressure and fullness
n
Diagnosis:
x
History, especially the family history
x
Physical examination: palpably enlarged liver with a tense, nodular consistency
x
Laboratory findings: unrewarding, as there is no change in liver function.
Laboratory values are altered only when complications arise.
x
Sonography: liver and kidney. Screening of family members may also be
advised. Follow-ups
x
Percutaneous biopsy of an enlarged liver after the exclusion of hydatid disease
(echinococciasis)
n
Sonographic findings :
x
Numerous anechoic round lesions
x
Cyst contents may become echogenic as a result of intralesional hemorrhage.
x
Cysts may be flattened because of their close proximity to one another.
n
Accuracy of sonographic diagnosis: The ultrasound findings are clear-cut. The
presence of cysts in other organs and a positive family history establish the diagnosis, and no additional studies are needed.
Portal Vein Thrombosis and Splenic Vein Thrombosis
..............................................................................................................
n
Portal vein thrombosis: see Ascites, Portal Hypertension, p. 158; Diffuse Abdom-
inal Pain, Mesenteric Vascular Occlusion, p. 84; Portal Veins, Luminal Widening
(Portal Hypertension), p. 257; Chronic portal vein thrombosis, p. 260.
n
Splenic vein thrombosis: see Ascites, Portal Hypertension, p. 158.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
151
6.11 Hepatosplenomegaly
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6
Budd–Chiari Syndrome (Fig. 197)
..............................................................................................................
n
See also Ascites, p. 162; Search for Occult Tumors, Deformation and infiltration of
vessels, p. 447.
n
Example (Fig. 197) : hepatic vein occlusion associated with oral contraceptive use.
The patient had an elevated GGT. Hepatic ultrasound and ERCP were initially normal. Four weeks later she showed hypertrophy of the caudate lobe and partial
occlusion of the hepatic veins.
Principal Signs and Symptoms
Principal Signs and Symptoms
ab
Fig. 197a–c Budd–Chiari syndrome.
a Enlarged caudate lobe (cursors).
b CDS: occluded left hepatic vein
(arrow) containing no color flow signals.
c CDS : The hepatic veins are barely
visualized in the periphery, showing very
few color pixels. The liver is nonhomogeneous and shows hazy increased
c
echogenicity in areas of venous
occlusion
Constrictive Pericarditis
..............................................................................................................
n
Clinical manifestations: weakness, fatigue, weight loss, anorexia; inflow stasis
with dilated neck veins, exertional dyspnea, frequent orthopnea. Signs of stasis
include hepatomegaly, ascites (more pronounced than peripheral edema), and
splenomegaly. Exudative enteropathy is seen with obstructed lymphatic drainage
from the small bowel.
n
Diagnosis:
x
Laboratory tests : simple blood count, HCT, hypalbuminemia, proteinuria, liver
function values (abnormal: Quick PT, CHE)
x
ECG: low voltage
x
Chest radiograph or fluoroscopy shows pulmonary congestion with a normalsized or slightly enlarged heart. Calcifications are visible in 50 % of cases.
x
Sonography and echocardiography
x
Thoracic CT
n
Sonographic findings :
x
Free fluid in the abdominal cavity (ascites)
152
6.11 Hepatosplenomegaly
Schmidt, Ultrasound © 2007 Thieme
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x
Hepatic changes:
– Hypoechoic enlargement due to congestion, with good through-transmission
of sound
– Later: hepatic cirrhosis
x
Splenic enlargement due to congestion (differential diagnosis: infectious endocarditis, tricuspid valve disease)
x
Obstruction of the vena cava, etc.
x
Possible renal enlargement due to congestion
x
Echocardiography: pericardial thickening (hyperechoic band behind the left
ventricle). The ventricular volumes are approximately normal.
n
Accuracy of sonographic diagnosis : The ultrasound findings are typical and easily
recognized but are not conclusive. Other causes can be excluded by sonography
and laboratory testing. The clinical examination is important: finding decompensated hepatic cirrhosis in a patient with congested neck veins is very suspicious for
constrictive pericarditis. Congestion of the neck veins is unresponsive to forced
diuresis.
Echinococcal (Hydatid) Cyst of the Liver (Echinococcus granulosus)
..............................................................................................................
n
See also Liver, cystic lesions, p. 244.
n
Organ involvement : liver, lung, bone, CNS, heart
n
Clinical manifestations: The patient may be asymptomatic for some time,
depending on the pattern of involvement. Pain eventually occurs as the cysts
enlarge and exert pressure on the organ capsule. A palpable mass is noted in
the right upper quadrant. Intermittent bile duct compression can mimic recurrent
cholelithiasis. Jaundice may occur. Discharge of hydatid fluid leads to fever, pruritus, urticaria, eosinophilia, and anaphylaxis. Pulmonary involvement is marked by
cough, chest pain, and hemoptysis.
n
Diagnosis:
x
Laboratory tests: differential blood count, antibodies (may be false-negative)
x
Sonography
x
Chest radiograph: irregular round lesions
x
CT if required.
n
Sonographic findings :
x
Round, more or less anechoic lesion meeting all the criteria for a cyst (E. granulosus, type CE 1 of the WHO classification of cystic echinoccosis cysts), or
x
Multiple cysts arranged in a rosette-like pattern (type CE 2)
x
Sharply circumscribed
x
Echogenic wall
x
Complex structure, calcification (types CE 3, 4)
x
Alveolar echinococcus disease (E. multilocularis) : blurred, limited, complexstructured mass
n
Accuracy of sonographic diagnosis: Calcified walls can be clearly visualized and
suggest the correct diagnosis. Finding daughter cysts within a larger cyst confirms
the diagnosis. The diagnosis could be proved by aspirating the cyst contents and
identifying scolices, but this is not advised because of the risk of spreading the
infection. The definitive diagnosis is made during therapeutic drainage of the
cysts followed by alcohol instillation or after possible surgical intervention.
Hepatic Fibrosis (Figs. 198–200)
..............................................................................................................
n
See also Liver, p. 235.
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
153
6.11 Hepatosplenomegaly
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6
Fig. 198 Congenital hepatic fibrosis.
The liver (L) appears normal sized with
a somewhat coarse internal echo
Principal Signs and Symptoms
Principal Signs and Symptoms
pattern. Fibrotic encasement of the
portal vessels (arrows) is clearly
visualized
Fig. 199 Congenital hepatic fibrosis.
The portal venous trunk (PVT), cut
approximately in cross-section by the
scan plane, shows even clearer evidence
of fibrotic encasement (same patient as
in Figs. 198 and 200)
Fig. 200 Splenomegaly in congenital
hepatic fibrosis. The spleen (S) is markedly enlarged in this slender patient,
measuring 16 cm long by 6 cm deep
n
Classification: congenital form, or secondary fibrotic transformation due, for
example, to collagen deposition resulting from an infectious disease (e.g., schistosomiasis).
n
Clinical manifestations: The patient feels well. Later, a pattern of complaints may
emerge that resembles portal hypertension (see Ascites, Portal Hypertension,
p. 158).
n
Diagnosis:
x
Laboratory tests are unrewarding (normal liver values); liver cells are undamaged.
x
Physical examination, palpation: small, hard, nodular liver
x
Sonography; biopsy is rarely necessary
n
Sonographic findings :
x
Liver exhibits a somewhat coarse internal echo pattern.
x
Periportal fibrosis, echogenic encasement (fibrotic transformation of the portal
branches, echogenic bands)
x
No regenerative nodules as in cirrhosis
x
Signs of portal hypertension (see Ascites, p. 158)
x
Splenomegaly is less common than with hepatic cirrhosis.
x
Congenital form may be associated with polycystic kidneys or liver.
n
Accuracy of sonographic diagnosis: The sonographic features are so characteris-
tic that biopsy is generally unnecessary.
154
6.12 Ascites
Schmidt, Ultrasound © 2007 Thieme
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6.12 Ascites
Basic Principles
..............................................................................................................
n
Principal signs and symptoms: possible abdominal distention with prominent
flanks, slender extremities, free fluid in the abdominal cavity (as little as 30 mL
can be detected sonographically); feeling of tension and fullness, possible dyspnea
and tachycardia
n
Differential diagnoses: These are listed in Table 27 according to their frequency in
the general hospital setting.
Table 27.Differential diagnosis of ascites
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hepatic cirrhosis (p. 156)
Peritoneal carcinomatosis
(p. 157)
Peritonitis (p. 158) Echogenic thickening of the peritoneum, loculated fluid, local or
Portal hypertension
(p. 158)
Abdominal tumor (p. 159) Variable appearance, usually hypoechoic or hyperechoic to
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Less common
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Pancreatitis (p. 159)
Right heart failure (p. 160) Enlarged, congested liver; dilated hepatic veins; expanded vena
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Rare
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Pericardial effusion
(p. 161)
Bowel obstruction,
paralytic ileus (p. 161)
Meigs syndrome (p. 162) Free fluid in the abdominal cavity, pleural effusion, hypoechoic
Mesenteric vascular
thrombosis (p. 162)
Budd–Chiari syndrome
(p. 162)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Enlargement of the caudate lobe, wavy surface contours with
apparent breaks in the capsule, peripheral pruning of the portal
vessels
Anechoic deposits in the abdominal cavity, thickened echogenic
peritoneum, possible tumor mass
diffuse intestinal paralysis
Enlarged spleen, venous collaterals (recanalized umbilical vein,
convoluted veins)
surroundings, sharply circumscribed or with ill-defined
infiltrating margins
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Appearance varies with the stage of the disease: normal,
echogenic, hypoechoic, possible cysts or calcifications
cava
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic masses in the pericardial sac; ventricles usually empty
and hyperactive
Dilated bowel loops, circumscribed or diffuse absence of
peristalsis, frequent hypoechoic thickening of bowel wall;
contents may be increased or decreased
enlargement of the ovary (usually unilateral)
Doppler shows absence of flow in the artery (embolism) or in
the dilated hypoechoic veins (thrombosis)
Liver greatly enlarged and tender with hypertrophic caudate lobe;
large hepatic veins are not visualized and show no flow by CDS
6
6
Principal Signs and Symptoms
Principal Signs and Symptoms
155
6.12 Ascites
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6
6
Table 27.Differential diagnosis of ascites – continued
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diagnosis Sonographic signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hepatic tumor or
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hepatitis mass of variable echogenicity (depending on its origin)
metastases (p. 249, 250)
Biliary atresia (p. 163) Bile ducts cannot be visualized
Conditions that cannot be diagnosed with ultrasound
Less common: Hypoproteinemia (nephrotic syndrome, malabsorption), primary biliary
hepatic cirrhosis
Rare: Mesenteric tuberculosis, hemorrhagic diathesis, fulminating hepatitis, acute liver dystrophy, intestinal lymphangiectasia, Wilson disease, galactosemia
Hepatic Cirrhosis (Figs. 201 and 202)
Principal Signs and Symptoms
Principal Signs and Symptoms
..............................................................................................................
n
See also Liver, Severe chronic hepatitis with fibrosis or cirrhosis, p. 236, 239.
n
Classification:
x
Hepatitic (same features as in siderocirrhosis and autoimmune cirrhosis)
x
Toxic
x
Secondary biliary
x
Primary sclerosing cholangitis
n
Clinical manifestations: lethargy, decreased exercise tolerance, weight loss
(rarely, weight gain due to copious ascites), feeling of upper abdominal pressure
or fullness, nausea, vomiting; abdominal distention, jaundice, pruritus with
scratch marks, spider nevi, telangiectasis, palmar erythema, glossitis; hormonal
disorders, edema, hepatic insufficiency with gastrointestinal bleeding, coma
n
Diagnosis:
x
History: alcohol consumption, viral hepatitis, medications
x
Examination: liver is hard and initially enlarged, later diminished in size
x
Laboratory findings: decreased CHE, Quick PT, albumin; elevated AP, LAP, GGT,
and bilirubin (conjugated = direct). Hepatitis serology, coagulation status, etc.
x
Sonography is of equivalent diagnostic value as CT
x
Biopsie (e.g., with Menghini needle), histology
n
Sonographic findings :
n
Note: Initial structural and contour changes in a cirrhotic liver are followed by
vascular changes (in hepatitic and toxic forms). First the liver is enlarged, and
later it becomes small and atrophic. The right lobe of the liver tends to shrink,
while the left lobe tends to enlarge and may come in contact with the spleen
(“kissing liver and spleen” sign).
x
Enlargement of the caudate lobe
x
Rounded hepatic border, wavy surface, apparent breaks in the capsule
Fig. 201 Hepatic cirrhosis. The liver
presents a coarse, mottled internal echo
pattern. The inferior border shows
coarse nodularity (arrows) with
apparent “breaks ” in the liver capsule.
156
PV = portal vein