Ultrasound Of The Ultrasound Of The LiverLiver

Steve Geiersbach MS, RT(R), RDMS

Size And LocationSize And Location

Largest abdominal Largest abdominal organorgan

Intraperitoneal Intraperitoneal except for the except for the “bare area”“bare area”

Location: RUQLocation: RUQ Weighs from 1400-Weighs from 1400-

1600 grams 15-17 1600 grams 15-17 cms in lengthcms in length

Lobar AnatomyLobar Anatomy RIGHT LOBE RIGHT LOBE

Largest lobe Largest lobe makes up 80% of makes up 80% of the liverthe liver

LEFT LOBE LEFT LOBE Comprises 20% of Comprises 20% of the liverthe liver

CAUDATE LOBE CAUDATE LOBE Located posterior Located posterior to the porta to the porta hepatishepatis

BARE A

REA

Right Lobe

Left Lobe

R. Kidney

Liver

Anatomical BordersAnatomical Borders

POSTERIORPOSTERIOR: Right : Right kidney and IVCkidney and IVC

ANTERIORANTERIOR: Free : Free margin & GB fossamargin & GB fossa

POSTIOR/INFERIORPOSTIOR/INFERIOR: : DiaphragmDiaphragm

SUPERIORSUPERIOR: : Diaphragm outlines Diaphragm outlines this surfacethis surface

Cell TypesCell Types

BILIARY EPITHELIALBILIARY EPITHELIAL: : Line vascular sinusoidsLine vascular sinusoids

KUPFERKUPFER: Portion of the : Portion of the reticuloendothelial reticuloendothelial system; phagocytizes system; phagocytizes bacteria and foreign bacteria and foreign materialsmaterials

HEPATOCYTESHEPATOCYTES: : Synthesize, metabolize Synthesize, metabolize and excrete a variety of and excrete a variety of compoundscompounds

Double Vascular SupplyDouble Vascular Supply

PORTAL VEINPORTAL VEIN: : 80%80% of the blood of the blood supply is unfiltered coming from supply is unfiltered coming from the stomach, intestines, and the stomach, intestines, and pancreaspancreas

COMMON HEPATIC ARTERYCOMMON HEPATIC ARTERY: : 20%20% is clean oxygenated blood is clean oxygenated blood originates at the celiac axis of the originates at the celiac axis of the abdominal aorta runs adjacent to abdominal aorta runs adjacent to the PV and CBD at the porta the PV and CBD at the porta hepatishepatis

Double Vascular SupplyDouble Vascular Supply

AcinusAcinus: Terminal : Terminal branchesbranches of the portal of the portal veins & accompanying hepatic arterioles veins & accompanying hepatic arterioles and bile ducts.and bile ducts.

Branches Of CHABranches Of CHA

Proper Hepatic Artery (PHA) Proper Hepatic Artery (PHA) Continuation of the CHA at the Continuation of the CHA at the junction of the gastroduodenal junction of the gastroduodenal artery artery

Gastroduodenal Artery (GDA) Gastroduodenal Artery (GDA) Curves caudally and runs along the Curves caudally and runs along the RT anterolateral surface of the RT anterolateral surface of the pancreatic headpancreatic head

Branches of CHABranches of CHA

Right hepatic artery courses in Right hepatic artery courses in the rt. Intersegmental fissure.the rt. Intersegmental fissure.

Left hepatic artery courses Left hepatic artery courses anterior to the lt. Hepatic duct anterior to the lt. Hepatic duct

Middle hepatic artery courses Middle hepatic artery courses in the mid intersegmental in the mid intersegmental fissure fissure

Venous Return ViaVenous Return ViaHepatic VeinsHepatic Veins

Valveless venous outflowValveless venous outflow Left hepatic veinLeft hepatic vein Middle hepatic veinMiddle hepatic vein Right hepatic veinRight hepatic vein

Ligaments Ligaments Ligament Of TeresLigament Of Teres: Originates as the : Originates as the

umbilical vein in embryology;umbilical vein in embryology; FalciformFalciform LigamentLigament Becomes the Becomes the

ligament of teres at termination point; ligament of teres at termination point; separates medial and lateral segments separates medial and lateral segments of the left lobeof the left lobe

Ligament Of Venosum Ligament Of Venosum Separates the Separates the left lobe from the caudate lobe left lobe from the caudate lobe originates from ductus venosum in originates from ductus venosum in embryologyembryology

Hepatic Veins (HV) - Anechoic structuresThin walls

Portal Vein (PV) -Echogenic walls from periportalfat

hv

IVC

PVHA

CHD

Hepatic FissuresHepatic Fissures Right Intersegmental Right Intersegmental

FissureFissure Left Intersegmental Left Intersegmental

FissureFissure Main Lobar FissureMain Lobar Fissure: :

Courses between the Courses between the right portal vein and right portal vein and the gallbladder / also the gallbladder / also referred to as the major referred to as the major hepatic fissure; useful hepatic fissure; useful to locate the to locate the gallbladder fossagallbladder fossa

Collagen fat greater in echogenicity Collagen fat greater in echogenicity than pancreas, liver, and kidneythan pancreas, liver, and kidney

PV walls very echogenic due to PV walls very echogenic due to collagen contentcollagen content

HV less echogenic HV less echogenic PV, HA, and CD = portal triad / PV, HA, and CD = portal triad /

portal hepatisportal hepatis Liver is Homogeneous ehotexture Liver is Homogeneous ehotexture

interspersed with tubular fluid filled interspersed with tubular fluid filled structuresstructures

Sonographic AppearancesSonographic Appearances

AnteriorRPV

Main PVPosteriorRPV

Sonographic AppearancesSonographic Appearances

Glisson’s CapsuleGlisson’s Capsule: : The capsule of The capsule of the liver. A layer of connective tissue the liver. A layer of connective tissue surrounding the liver and ensheathing the surrounding the liver and ensheathing the hepatic artery, portal vein, and bile ducts hepatic artery, portal vein, and bile ducts within the liver. Named for the British within the liver. Named for the British physician, anatomist, physiologist, and physician, anatomist, physiologist, and pathologist Francis Glisson (1597-1677). pathologist Francis Glisson (1597-1677).

Distinguishing PVs & HVsDistinguishing PVs & HVs

Portal VeinsPortal Veins– Very echogenic wallsVery echogenic walls– High collagen contentHigh collagen content– Course transverselyCourse transversely

Hepatic VeinsHepatic Veins– Less echogenic wallsLess echogenic walls– Low collagen contentLow collagen content– Course longitudinallyCourse longitudinally– Get larger as they course towards Get larger as they course towards

the IVCthe IVC

Distinguishing HVs & PVsDistinguishing HVs & PVs

Physiology Of The LiverPhysiology Of The Liver Metabolizes bile pigmentsMetabolizes bile pigments Synthesizes proteins as Synthesizes proteins as

albumin and fibrinogenalbumin and fibrinogen Bilirubin becomes water Bilirubin becomes water

solublesoluble Forms urea from ammoniaForms urea from ammonia Metabolizes fats and Metabolizes fats and

carbohydratescarbohydrates Phagocytizes bacteria Phagocytizes bacteria

Laboratory Function TestsLaboratory Function Tests

SGOT/ASTSGOT/AST SGPT/ALTSGPT/ALT Alkaline phosphataseAlkaline phosphatase Serum bilirubinSerum bilirubin Serum albuminSerum albumin Prothrombin timeProthrombin time

– Each LFT may rise or fall depending Each LFT may rise or fall depending on pathologic condition.on pathologic condition.

Scan PreparationScan Preparation

NPO After midnight or for at NPO After midnight or for at least six hours. This allows the least six hours. This allows the biliary system to distend and biliary system to distend and fill the gallbladder with bile. It fill the gallbladder with bile. It also reduces bowel gas. Bowel also reduces bowel gas. Bowel gas limits the exam.gas limits the exam.

Indications For ExamIndications For Exam

RUQ PainRUQ Pain NauseaNausea VomitingVomiting Palpable massPalpable mass JaundiceJaundice Abnormal LFTsAbnormal LFTs

SCAN PLANESSCAN PLANESPATIENT POSITIONSPATIENT POSITIONS

SCAN PLANES:SCAN PLANES: SAGITTALSAGITTAL� TRANSVERSETRANSVERSE

PATIENT POSITIONSžSUPINEžLPOžLATERALžUPRIGHT

LiverLiver

RIGHT LOBE

RT. KIDNEY

Longitudinal

LiverLiver

RIGHT LOBEOF LIVER

Longitudinal

RIGHT LOBE OF LIVER

PVs

HEPATICVEINS

DIAPHRAGM

Longitudinal

Left LobeLeft Lobe

Longitudinal

Caudate LobeCaudate Lobe

LIGAMENT OFVENOSUM

CAUDATELOBE

LEFT LOBE

Longitudinal

Ultrasound Of The Ultrasound Of The AbdomenAbdomen

SPLEENSPLEEN

Size And LocationSize And Location Intraperitoneal located in the Lt. Intraperitoneal located in the Lt.

hypochondrium between fundus of hypochondrium between fundus of stomach and diaphragmstomach and diaphragm– Bare area anterior to Lt. kidneyBare area anterior to Lt. kidney

Ovid in shapeOvid in shape 12 cm in length;12 cm in length; 7 cm in breadth7 cm in breadth 4 cm in thickness4 cm in thickness Weighs 150 gm Weighs 150 gm

– Varies 80-300 gmsVaries 80-300 gms

StructureStructure

Red Pulp - Venous sinuses Red Pulp - Venous sinuses serving as blood reservoir, serving as blood reservoir, resembles a lymph glandresembles a lymph gland

White Pulp - Malpighian White Pulp - Malpighian corpuscles / lymph tissuecorpuscles / lymph tissue

Blood ExchangeBlood Exchange Splenic Artery - Originates at Splenic Artery - Originates at

the celiac trunkthe celiac trunk Splenic Vein - Tributaries to Splenic Vein - Tributaries to

the SV connect with the sinus the SV connect with the sinus pulppulp– Joins the superior mesenteric Joins the superior mesenteric

vein to form the portal vein and vein to form the portal vein and is considered a sonographic is considered a sonographic landmark (portal venous landmark (portal venous confluence)confluence)

PhysiologyPhysiology

HemopoiesisHemopoiesis ProtectionProtection Blood Blood ReservoirReservoir Culling FunctionCulling Function Pitting FunctionPitting Function

Indications For StudyIndications For Study

Palpable splenomegalyPalpable splenomegaly Lt. Upper quadrant traumaLt. Upper quadrant trauma Focal and congenital Focal and congenital

abnormalitiesabnormalities Solid massesSolid masses HIV / AIDSHIV / AIDS

TerminologyTerminology

Leukopenia - Decrease in Leukopenia - Decrease in WBCsWBCs

LeukocystosisLeukocystosis - Increase in - Increase in WBCs

Leukemia - Abnormal numbers and Leukemia - Abnormal numbers and forms of WBCsforms of WBCs

Sonographic Sonographic TechniquesTechniques

Patient PositionsPatient Positions– SUPINESUPINE– RPORPO– LATERALLATERAL– UPRIGHTUPRIGHT

Sonographic Sonographic TechniquesTechniques

Scan PlanesScan Planes– SAGITTALSAGITTAL– TRANSVERSETRANSVERSE– CORONALCORONAL

SpleenSpleen

Longitudinal

Lt Kidney

Adrenal

Spleen

Splenic HiliumSplenic Hilium

Longitudinal

Splenic hilum

Spleen

Longitudinal

Diaphragm