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Lucas Greiner
Wuppertal/Germany

Lucas Greiner, MD
Professor of Internal Medicine
Director, Medical Clinic 2
Helios-Clinics
University Witten/Herdecke
Heusnerstr. 40
D – 42283 Wuppertal
[email protected]
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9HVVHOV the hepatic artery, the left portion the

splenic artery).
The aorta and inferior vena cava are
visible in every patient (the latter The renal arteries are positioned dorsal
sometimes following a Valsalva‘ s to the renal veins with the right renal
maneuver only). They are landmarks in artery crossing under the inferior vena
abdominal ultrasound; whenever cava.
orientation is lost, one should return to
these well known and easily
identifiable organs. This is also true for &DYDLQIHULRULOLDFUHQDODQG
the vascular structures of the liver KHSDWLFYHLQV
hilum. Therefore, knowledge of
anatomy of the great vessels including The inferior vena cava is at the same
their main branches is indispensible level in the body as the aorta and
(for more details, see also Part I; Arab parallels its course on the right down to
J G Vol 2, No 2, October 2001, 358- the iliac bifurcation. The inferior vena
371). cava may be visible only in deep
inspiration or in right heart failure. It
shows typical double-pulsatory
$RUWDFHOLDFD[LVVXSHULRU movements in healthy people. Easily
PHVHQWHULFDUWHU\DQGUHQDODUWHULHV demonstrated by ultrasound are the big
venous afferent vessels: the iliac, renal
The abdominal Aorta is characterized and hepatic veins. The left renal vein is
by its position, pulsations and by the positioned ventral to the aorta.
typical branching of the celiac axis,
superior mesenteric artery and the iliac
arteries (positioned ventral to the 0HVHQWHULFYHLQV
concomitant veins). In longitudinal
sections, the aorta-slices are band The superior mesenteric vein and the
shaped with more or less well seen splenic vein join in the confluens to
main branches of the celiac axis and form the portal vein. The splenic vein
the superior mesenteric artery in the is the main landmark for detecting the
upper abdomen. The angle between pancreas. The other mesenteric veins
these two branches encompases the are not as easily seen in routine
portion of the pancreas which is examination.
scanned transverse to the organ axis.
In transverse sections, where the aorta
is seen as a circular structure, the 3RUWDKHSDWLVEORRGDQGELOH
celiac axis looks like a double hooked
structure (the right portion representing The ultrasound properties of blood and
bile are identical - since they do not
present any acoustic interfaces, their information. In the first group of
ultrasound appearance is black patients, more longitudinal sections (in
(assuming no possible interfering the supine position) will be sufficient,
artefacts). The plane of section whilst right lateral (maybe even
necessary to visualize the liver hilum intercostal) sections in left oblique
best may vary considerably from case position may be needed in the second
to case. As a rule, slim (and tall) group.
patients have a more or less
longitudinal course to the hilar The course of the portal vein is always
structures running in the hepato- dorsal to the course of the common
duodenal ligament, whereas more bile duct, with the hepatic artery (or
obese (and small) patients show a one of its main branches) crossing in
rather transverse course; again, between. Lymphatic vessels are not
adapting to these individual visible on ultrasound either in the liver
circumstances by variations in the hilum or elsewhere.
scanning plane will give the best

General view of the porta hepatis and Porta hepatis:

liver: 1 common bile duct,
1 inferior vena cava, 2 liver veins, 3 2 portal vein, 3 hepatic artery (note its
portal vein, 4 splenic vein, 5 common intercrossing right branch between 1
bile duct, 6 superior mesenteric vein; and 2)
liver segments
3DWKRORJ\VHOHFWHG - FKDQJHV in the wall structure
(e.g.,sclerosis, partial thrombosis,
The tubular structures of vessels or inflammation,
containing blood and bile can be - RFFOXVLRQ (complete thrombosis,
influenced by tumor, concretions), or by
- FKDQJHV in liquid pressure - FRPSUHVVLRQ (tumor, lymphoma,
(resulting in a more or less inflammation).
pronounced increase in vessel
diameter),

2
1

2 3

1 Infrarenal aneurysma, 1 Thoracoabdominal aneurysma,

2 normal aorta (longitudinal scan) 2 liver, 3 right ventricle (longitudinal
(longitudinal scan) scan)

1 1

1 Lumen of a giant infrarenal 1 Single arteriosclerotic plaque,

aneurysma, 2 thrombotic portions infrarenal abdominal aorta
(transverse ! scan) (longitudinal scan)
 1
1 2

1
1

Right heart failure with 1 dilated cava

1 Multiple plaques, abdominal aorta
inferior and 2 dilated hepatic veins
(longitudinal scan)
(right subcostal scan)

2
1a
3
1b
1
2

Membranous dissection of abdominal

1 cava inferior with 2 tumor spread
aorta with 1a, 1b lumen portions and
(thrombus-like) in renal adenocarcinoma
2 dissection membrane (transverse
3 caudate lobe (longitudinal scan)
scan)

1
2

2
1

1 thrombosis of superior mesenteric 1 thrombosis of left iliacal vein (no

vein (no colour flow), 2 aorta colour flow), 2 iliacal artery (left lower
(longitudinal scan) abdominal scan)
/\PSKQRGHVDQGO\PSKRPD malignant) can be detected, usually
adjacent to the great vessels (aorta,
With the advent of more sophisticated celiac axis, inferior vena cava). They
ultrasound devices even normal are less pronounced in the liver hilum.
paravascular lymphnodes in the The spleen - as a specifically big
abdomen may be visible in slim lymphnode - deserves special attention
patients. Routinely however only (see 3.7.).
enlarged lymphnodes (either benign or

2
2
1
1 3
6 5 7 1
1 5
1 4
3

1 multiple lymphnodes, 2 liver, 3 aorta, 1, 2 lymhnodes adjacent to 3 head of

4 vertebral body, 5 celiac axis with 6 pancreas, 4 splenic vein, 5 superior
hepatic and 7 splenic artery mesenteric artery (transverse scan)
(transverse scan)

4
2
3

arrow: retroaortal lymphnode

1 multiple lymphnodes anterior and
enlargement (metastatic), 1 abdominal
posterior to 2 aorta (longitudinal
aorta, 2 celiac axis, 3 superior
scan)
mesenteric artery, 4 liver, arrowhead:
left kidney vein (longitudinal section)
3DQFUHDV 5 cm, which in turn will deflect
interfering gas-containing intestinal
*URVVPDFURVFRSLFDQDWRP\ structures. The main anatomical
landmarks used for visualising the
The pancreas appears as a more or pancreas are the mesenteric vascular
less carrot-shaped organ without a structures which adhere to it, the
capsule lying transversely across the splenic and mesenteric vein and their
aorta and the spinal column. Its main junction ( the confluens), forming the
portion - the head - is generally to the portal vein. In gross anatomy, there are
right of the second lumbar vertebra. no fixed demarcations between the
The junction of the head and the body three portions of the pancreas (head,
is curved around the vertebral column body and tail), and the same is true of
and the abdominal aorta and the tail course on ultrasound scanning.
lies in the left upper abdomen touching
the splenic hilum. The visualisation of the non-distended
The uncinate process as a part of the main pancreatic duct as it passes
pancreatic head surrounds the superior along the body of the pancreas serves
mesenteric vein. The head of the as a marker of ultrasound machines
pancreas itself is surrounded by the which have high resolution capabilties.
duodenal C-loop, and penetrated by The normal organ shows soft passive
the intrapancreatic portion of the movements caused by aortic and
common bile duct. venous pulsations.
The pancreas is covered by intestinal
structures (stomach, small and large The head and body of the pancreas
intestine) and the left lobe of the liver. are detectable in nearly all patients.
The latter serves – in deep inspiration - The tail region (usually less important)
as an acoustic window. is somewhat more difficult for the
ultrasonographer due to its small size,
angulated course (with a high
([DPLQDWLRQWHFKQLTXHDQG variability ) and sometimes hidden
XOWUDVRXQGVHFWLRQDODQDWRP\ position behind the gas filled gastric
fundus. If necessary, filling the gastric
With the scanning probe in a fundus with non-sparkling water can
transverse position high up in the create a good acoustic window for
epigastrium, a deep inspiration will visualisation of the pancreatic tail.
move the liver downwards for some 3-
 Ventral view of the extrahepatic bile Dorsal view of the extrahepatic bile
duct: 1 portal vein, 2 common bile duct, duct: 1 portal vein, 2 common bile duct,
3 pancreatic duct, 4 duodenum 3 pancreatic duct, 4 duodenum

3DWKRORJ\ - YDVFXODUDUFKLWHFWXUH (with respect

VHOHFWHG to the main pancreatic duct, the
common bile duct, the splenic and
As in all parenchymatous organs, an mesenteric vein and their junction,
ultrasound examination of the the confluens),
pancreas gives information relating to - IRFDOOHVLRQV, and adjacent
changes in its structures (e.g.lymphnodes).
- SRVLWLRQ, VKDSH, and VL]H,
- overall UHIOH[LELOLW\ and

1
5
1
6
2 3 2

8 4

Acute pancreatitis with 1 swollen head

Acute pancreatits with 1 spotted head
of pancreas obstructing, 2 common
of pancreas and 2 too good visibility of
bile duct (note 3 distended cystic duct)
lumen and * of wall layers of duodena C
and 4 fluid filled duodenum, 5 hepatic
(transverse scan)
artery, 6 portal vein, 7 liver, 8 right
renal artery,inferior vena cava
 3
1
1

2
2

1
1
3

1 enlarged head of pancreas (two 1 pathological fluid collection,

weeks after inflammatory episode), 2 right liver lobe, 3 right perirenal fatty
2 splenic vein, 3 liver (transverse tissue (right lateral scan)
scan)

3
1

5
6 4

1 pancreatitis 2 liver, 3 gastric antrum, Acute pancreatitis: diminuished

4 superior mesenteric artery, 5 splenic delineability of pancreas, +...+ swollen
vein /confluens, 6 duodenal C duodenal wall, 1 duodenal lumen
(transverse scan) (transverse scan)
 4 1 2

2 3

1
1p

1 acute pancreatitis with

1 huge pseudocyst with 1p penetration
2 pseudocyst and 3 splenic vein,
into the 2 spleen (left lateral scan)
4 liver, 5 aorta (longitudinal scan)

7 6
3

2 4 2
1
6 1
3

5 4
5

Highly reflexible spots (probably

1 pseudocyst (color-artifact, no
calcifications in chronical pancreatitis)
bleeding), 2 confluens, 3 gastro-
in 1 head and body of pancreas,
duodenal artery, 4 reduced panreas
2 gastroduodenal and 3 superior
parenchyma, 5 inferior cava, 6
mesenteric artery, 4 aorta, 5 cava
duodenal C, 7 liver (2nd scans)
inferior, 6 liver
 1
4 5
3
1
1
6
2
3

4 1

1 chronical calcifying panreatitis 1 multiple pseudocysts, 2 aorta,

(confirmed by ERCP) with slight 3 hepatic artery, 4 cava inferior, 5 liver,
compression of 2 portal vein/superior 6 confluens (transverse scans)
mesenteric vein, 3 gastroduodenal artery,
4 liver (modified longitudinal scan)




 




 

 




1 reduced pancreas parenchyma in
chronic inflammation with 2 marked duct 1 marked dilatation of main pancreatic
dilatation, 3 splenic vein/confluens, duct in chronical inflammation with 2
4 superior mesenteric artery, 5 hepatic, reduced parenchyma, 3 confluens, 4
6 gastroduodenal and 7 renal artery, superior mesenteric artery, 5 aorta,
8 aorta, 9 left renal vein, 10 liver 6 duodenal C, 7 gastric corpus
(transverse scan)
 E

 
 
K 

 


1 pancreas tumour with 2 splenic
vein, 3h head, 3b body of pancreas,
+,* slightly dilated main pancreatic duct
4 superior mesenteric artery,
1 confluens, 2 posterior antrum wall,
5 aorta (transverse scan)
3 gastric lumen (with highly reflexible
ingested material), 4 uncinate process
(transverse scan)

 
 
  

1 stent in the stenotic main

1 tumour of pancreas head with 2 tip pancreatic duct in chronic
of fine needle for aspiration cytology; pancreatitis (note the reduced
3 gastroduodenal artery 4 liver parenchyma) 2 superior mesenteric
(transverse scan) artery 3 confluens (transverse scan)