Ultrasound Of The Liver

Steve Geiersbach MS, RT(R), RDMS

Size And Location

Largest abdominal organ Intraperitoneal except for the bare area Location: RUQ Weighs from 14001600 grams 15-17 cms in length

Lobar Anatomy

RIGHT LOBE Largest lobe makes up 80% of the liver LEFT LOBE Comprises 20% of the liver CAUDATE LOBE Located posterior to the porta hepatis

Left Lobe Right Lobe

Liver

R. Kidney

Anatomical Borders

POSTERIOR: Right kidney and IVC ANTERIOR: Free margin & GB fossa POSTIOR/INFERIOR: Diaphragm SUPERIOR: Diaphragm outlines this surface

Cell Types

BILIARY EPITHELIAL: Line vascular sinusoids KUPFER: Portion of the reticuloendothelial system; phagocytizes bacteria and foreign materials HEPATOCYTES: Synthesize, metabolize and excrete a variety of compounds

Double Vascular Supply

PORTAL VEIN: 80% of the blood supply is unfiltered coming from the stomach, intestines, and pancreas COMMON HEPATIC ARTERY: 20% is clean oxygenated blood originates at the celiac axis of the abdominal aorta runs adjacent to the PV and CBD at the porta hepatis

Double Vascular Supply

Acinus: Terminal branches of the portal veins & accompanying hepatic arterioles and bile ducts.

Branches Of CHA
Proper Hepatic Artery (PHA) Continuation of the CHA at the junction of the gastroduodenal artery Gastroduodenal Artery (GDA) Curves caudally and runs along the RT anterolateral surface of the pancreatic head

Branches of CHA
Right hepatic artery courses in the rt. Intersegmental fissure. Left hepatic artery courses anterior to the lt. Hepatic duct Middle hepatic artery courses in the mid intersegmental fissure

Venous Return Via Hepatic Veins

Valveless venous outflow Left hepatic vein Middle hepatic vein Right hepatic vein

Ligaments

Ligament Of Teres: Originates as the umbilical vein in embryology; Falciform Ligament Becomes the ligament of teres at termination point; separates medial and lateral segments of the left lobe Ligament Of Venosum Separates the left lobe from the caudate lobe originates from ductus venosum in embryology

Hepatic Veins (HV) Anechoic structures Thin walls

Portal Vein (PV) Echogenic walls from periportal fat

CHD
HA PV IVC

hv

Hepatic Fissures

Right Intersegmental Fissure Left Intersegmental Fissure Main Lobar Fissure: Courses between the right portal vein and the gallbladder / also referred to as the major hepatic fissure; useful to locate the gallbladder fossa

Sonographic Appearances
Collagen fat greater in echogenicity than pancreas, liver, and kidney PV walls very echogenic due to collagen content HV less echogenic PV, HA, and CD = portal triad / portal hepatis Liver is Homogeneous ehotexture interspersed with tubular fluid filled structures

Anterior RPV

Posterior RPV

Main PV

Sonographic Appearances

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

Distinguishing PVs & HVs

Portal Veins
Very echogenic walls High collagen content Course transversely

Distinguishing HVs & PVs

Hepatic Veins
Less echogenic walls Low collagen content Course longitudinally Get larger as they course towards the IVC

Physiology Of The Liver

Metabolizes bile pigments Synthesizes proteins as albumin and fibrinogen Bilirubin becomes water soluble Forms urea from ammonia Metabolizes fats and carbohydrates Phagocytizes bacteria

Laboratory Function Tests

SGOT/AST SGPT/ALT Alkaline phosphatase Serum bilirubin Serum albumin Prothrombin time

Each LFT may rise or fall depending on pathologic condition.

Scan Preparation

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

Indications For Exam

RUQ Pain Nausea Vomiting Palpable mass Jaundice Abnormal LFTs

SCAN PLANES PATIENT POSITIONS

SCAN PLANES:
SAGITTAL TRANSVERSE

PATIENT POSITIONS SUPINE LPO LATERAL UPRIGHT

Liver
Longitudinal
RIGHT LOBE

RT. KIDNEY

Liver
RIGHT LOBE OF LIVER

Longitudinal

Longitudinal PVs
HEPATIC VEINS DIAPHRAGM

RIGHT LOBE OF LIVER

Left Lobe
Longitudinal

Caudate Lobe
Longitudinal
LEFT LOBE LIGAMENT OF VENOSUM CAUDATE LOBE

Ultrasound Of The Abdomen

SPLEEN

Size And Location

Intraperitoneal located in the Lt. hypochondrium between fundus of stomach and diaphragm
Bare area anterior to Lt. kidney

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

Varies 80-300 gms

Structure
Red Pulp - Venous sinuses serving as blood reservoir, resembles a lymph gland White Pulp - Malpighian corpuscles / lymph tissue

Blood Exchange
Splenic Artery - Originates at the celiac trunk Splenic Vein - Tributaries to the SV connect with the sinus pulp

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

Physiology
Hemopoiesis Protection Blood Reservoir Culling Function Pitting Function

Indications For Study

Palpable splenomegaly Lt. Upper quadrant trauma Focal and congenital abnormalities Solid masses HIV / AIDS

Terminology
Leukopenia Decrease in WBCs Leukocystosis Increase in WBCs Leukemia - Abnormal numbers and forms of WBCs

Sonographic Techniques

Patient Positions
SUPINE RPO LATERAL UPRIGHT

Sonographic Techniques

Scan Planes
SAGITTAL TRANSVERSE CORONAL

Spleen
Longitudinal
Spleen

Lt Kidney
Adrenal

Splenic Hilium
Longitudinal
Splenic hilum

Longitudinal Spleen

Diaphragm