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Abdomen Ultrasound Course

Liver Ultrasound Part–1

By:
Dr/ Ismail Sayed Ismail
Quiz
 Case 1

• Name the arrowed structure (in Red) ?

 Case 2

• How to image the liver if the patient is cirrhotic with shrunken liver ?
 Case 3

• What is the nature of this hepatic lesion ?

 Case 4

• Any lesions in this image ?

 Case 5

• What is the normal caliber of CBD ?

Liver Kidneys Pancreas

GB UB Para-aortic
region
Spleen Pelvis Peritoneum
(Prostate & SV) &
Or (Region of
(Uterus & Adnexae) Interest)
Anatomy
• UV.
• DV.
• The liver is the largest solid organ in the human body, weighing
approximately 1500 g in the adult.
• Functionally, it can be divided into three lobes: right, left, and caudate.
 Ligaments

➢ The falciform ligament conducts

the umbilical vein to the liver
during fetal development.
After birth, the umbilical vein
atrophies, forming the
ligamentum teres.
➢ The fissure for the ligamentum teres acts as the most caudal division of the
left lobe.
➢ Contained fat helps in localization of falciform ligament.
➢ Fat is seen anterior to the ascending branch of the left ascending portal vein.
➢ Cephalad extent of the fat in the location of the ligament between the middle
and the left hepatic veins.
• Ligamentum Teres.
• Ligamentum Venosum.
➢ The ligamentum venosum carries the obliterated ductus venosus, which
until birth shunts blood from the umbilical vein to the IVC.
 Porta hepatis

➢ At the porta hepatis,

the main portal vein, the
proper hepatic artery, and the
common bile duct are contained
within investing peritoneal folds
known as the hepatoduodenal
ligament.
• It has a dual blood supply : arterial blood accounts for around 20 % of its
blood supply and the portal vein providing 80 %.

• Hepatic artery and portal vein enter the liver and the common hepatic duct
exits the liver at the hepatic hilum.

• Hepatic veins drain directly into the inferior vena cava, usually there are
three main veins (right, middle, and left) entering the inferior vena cava
immediately below the diaphragm, close to the right atrium.
• Porta hepatis.
• Porta hepatis.
 Segmental Anatomy

Couinaud classification
• It divides the liver into eight
functionally
independent segments.
• Each segment has its own vascular
inflow,
outflow and biliary drainage.
• In the center of each segment there
is
a branch of the portal vein, hepatic
artery
and bile duct.
• In the periphery of each segment
there is
vascular outflow through the hepatic
veins.
Right hepatic vein divides the right lobe into :-
anterior and posterior segments,
as hepatic veins run in-between the liver T.S
segments, high
(Inter-segmental course). level

Middle hepatic vein divides the liver into right

and left lobes.
This plane runs from the inferior vena cava to
the gallbladder fossa,
along main lobar fissure (red arrow).
VIII VIa
Left hepatic vein (superior segments) divides the
left lobe into :-
a medial segment IVa and VII II
a lateral segment II.
The portal vein divides the liver into
upper and lower segments.
T.S
The left and right portal veins branch mid
superiorly and inferiorly to project into the level
center of each segment,
as portal veins run inside the liver segments,
(Intra-segmental course).
The Falciform ligament (yellow arrow), seen at
inferior segments and divides the left lobe into :-
a medial segment IVb and T.S
a lateral segment III. low
level
Pancreas and RT kidney are seen on the
level of inferior segments.

Segment I (Caudate lobe) between,

IVC, PV and ligamentum venosum (blue arrow).

IVa / II / IVb III

IVb III

I
➢ A “recumbent H” is formed by the main left portal vein, the ascending branch of the left portal
vein, and the branches to segments, II, III, and IV
• Segmental anatomy.
➢ Left lobe divides into medial and lateral segments by :-
❑ Left hepatic vein.

❑ Umbilical (ascending) branch of portal vein.

❑ Ligamentum teres (Falciform ligament).

• TS views of Left lobe.
• TS views of Left lobe.
• TS views of Left lobe.
• TS views of Left lobe.
• LS of Left lobe.
• LS of Left lobe.
• LS of Left lobe.
• TS of Right Lobe.
• TS of Right Lobe.
• TS of Right Lobe.
• TS of Right Lobe.
• LS view of Right lobe.
• LS view of Right lobe.
• LS view of Right lobe.
• LS view of Right lobe.
• Oblique view at Porta Hepatis.
• Oblique view at Porta Hepatis.
• Oblique view at Porta Hepatis.
• Portal Vein.
• Oblique view at Porta Hepatis.
• CBD.
• Oblique view at Porta Hepatis.
• Hepatic Artery.
• Structures at Porta Hepatis.
• B-mode =
measurements =
Subcostal.

• CF-mode =
direction =
Intercostal.
• Biliary Tree.
• Biliary Tree.
• Biliary Tree.
• Biliary Tree.
Technique
➢ Preparation. 1. Fasting for 6-8 hours.
2. Holding breath.
Planes :
1. LT lobe TS & LS.
2. RT lobe TS (subcostal) & LS.
3. For PV : oblique subcostal &
intercostal.
4. For GB : oblique subcostal
❑ LS. -T.S -Oblique
❑ Subcostal -Intercostal
❑ Midline - RT MCL -RT Axillary
• B-mode =
measurements =
Subcostal.

• CF-mode =
direction =
Intercostal.
• Tracing CBD.
Start at Porta hepatis
then follow the CBD
into
the pancreatic head.
• Segmental Anatomy at superior level.
• Liver is OK - Are you sure ?
• Always scan 2-3 cm beyond any organ margin.
• Transducer.
Linear probe is advisable in ?
• High resolution options :
Higher frequency, focusing and high DR.
When to need the Linear transducer for the liver ?
1. In suspected hepatic case, > to check the homogeneity / texture.
2. In oncologic case, searching for early Mets > to check subscapular region.
3. In traumatic case, searching for liver injury > to check the capsular integrity.
What if patient can not hold breath ?
• Ascites / comatosed patient or trauma ,…

• What to do Next ?
What if the patient can not take deep breath =
What if the liver is hidden in-between the ribs ?
>> Use sector or TVS probe (small foot print).
>> Through inter-costal window.
>> Decubitus position if possible.
When to need the Inter-costal Approach for the liver ?
1. To check the direction of portal vein.
2. In cirrhotic patient with shrunken liver + ascites.
3. If the patient can not hold breath as in ICU, Coma, Trauma, Old age, …
• Look like cyst !
• What is Next ?
• After Doppler - What is your DD ?
• Double barrel sign ?
• What is Next ?

• Dilated biliary tree.

• Double barrel sign ?

• After Doppler – What is Your DD ?

When to need the Doppler for the liver ?
1. To determine the patency of vessels.
2. Portal HTN, …
3. To differentiate cystic from vascular lesion.
4. To differentiate dilated biliary tree from dilated arterial tree.
5. To clarify the nature of any suspected solid lesion.
Protocol
 Liver Ultrasound

Comment on :- Reporting
1. Size.
▪ RT lobe.
▪ LT lobe. Liver is of average size.
▪ Caudate lobe.
2. Shape. Displaying homogenous
▪ Echotexture. echotexture.
▪ Echogenicity.
▪ Surface / capsule. No gross focal lesions.
3. Scan.
4. Biliary tree. No dilated intra-hepatic biliary
▪ IHBR.
radicles.
▪ CBD.
5. Vascular tree. CBD: normal caliber.
▪ Portal vein.
▪ Hepatic veins. PV: normal caliber & patent.
1 - Size
Right Lobe

• Normal size of the right lobe : up to 15 cm.

• Measured at the right MCL, LS view, diagonally.
Left Lobe

• Normal size of the left lobe : up to 10 cm. Measured in the midline.

• LS view, craniocaudally (if needed).
Caudate Lobe

• Normal size of caudate lobe : less than 0.65 of the right lobe.
• Measured subcostal, TS view (if needed).
Practical points regarding the RT lobe :-
• Inferior margin should be sharp pointed (not rounded, unless enlarged).
• Inferior margin should not pass lower pole of the right kidney, unless
enlarged or ptosed kidney.
• If enlarged RT lobe, look at LT lobe, if normal or small sized >>
Could be Riedel’s lobe (variant).
• 14 cm ?
• Inferior edge ?

• Age ?
• 12y = enlarged.
• Inferior edge ?

• Left lobe ?
• Rounded edge also = enlarged.
• Inferior edge ?

• Left lobe ?
• Normal = Riedel’s lobe
(Variant).
Practical points regarding the LT lobe :-
• Inferior margin should be sharp pointed.
• If enlarged LT lobe with normal or shrunken RT lobe >>
_ Cirrhosis,
_ Atrophic RT lobe (? Cancer) or
_ Hypolastic RT lobe (Chiladiti).
• Where is the right lobe ?

• Transplanted left lobe.

Practical points regarding the Caudate lobe :-
• Should not bulge beyond contour of liver unless enlarged.
• If enlarged > cirrhosis or Budd Chiari.
LS midline.
• Normal vs enlarged caudate lobe.

TS midline.
 1
Comment on :- Practically
About RT lobe:-
1. Size. # Inferior margin should be sharp
▪ RT lobe. pointed (not rounded, unless enlarged).
▪ LT lobe. # Inferior margin should not pass lower
▪ Caudate lobe. pole of R.K, unless enlarged or ptosed K
Normal size of the right lobe : up to 15 # If enlarged RT lobe, look at Lt lobe, if
cm. Measured at the right MCL, normal or small sized > could be
LS view, diagonally. Riedel’s lobe (variant).
About Lt lobe:-
Normal size of the left lobe : up to 10
# Inferior margin should be sharp
cm. Measured in the midline,
pointed.
LS view, craniocaudally (if needed).
# If enlarged LT lobe with normal or
Normal size of shrunken RT lobe > Cirrhosis, atrophy
caudate lobe : (?Cancer) or hypolastic (Chiladiti)…
less than 0.65 of About Caudate lobe:-
the right lobe. # Should not bulge beyond contour of
Measured subcostal, liver unless enlarged.
TS view (if needed). # If enlarged > cirrhosis or Budd Chiari..
2 - shape
Echotexture

• Homogenous (intermediate level echoes).

• If in doubt > Linear probe.
• Zoomed image.
When to need the Linear transducer for the liver ?
1. In suspected hepatic case, > to check the homogeneity / texture.
2. In oncologic case, searching for early Mets > to check subscapular region.
3. In traumatic case, searching for liver injury > to check the capsular integrity.
Echogenicity

• Slightly higher than the right renal parenchyma.

• Slightly lower than spleen (compare with the spleen, if ectopic or removed
RT K.
• Lower than pancreas.
• FATTY.
Capsule

• Smooth (not nodular).

• Better assessment by Linear probe.
• Increase frequency (better resolution).
• Adjust focal zone to capsule.
• Smooth surface.
• Nodular surface (Cirrhosis).
 2
Comment on :- Homogen. Coarse In oncologic
2. Shape. Echotexture Echotexture case, searching
for early Mets >
▪ Echotexture.
use linear probe
▪ Echogenicity. for subscapular
▪ Surface / capsule. region
Echotexture :
# Homogenous (intermediate level echoes).
# If in doubt > Linear probe.
# Zoomed image.
Echogenicity : (In Adults).
# Slightly higher than RT renal parenchyma Normal Increased
# Slightly lower than spleen (compare with echogenicity echogenicity Beaver tail liver
spleen, if Beaver tail liver,
ectopic or removed RT K. In traumatic
# Lower than pancreas. case, searching
Surface / capsule : smooth (not nodular). for liver injury >
# Better assessment by Linear probe. use linear probe
# Increase frequency (better resolution). Smooth Irregular for capsular
# Adjust focal zone to capsule. capsule capsule integrity
3 - scan
• The level of hepatic veins.
TS view.
• Where is this lesion ?
TS view.

• Right lobe.
• Segment 8.
• Where is this lesion ?
LS view.

• Right lobe.
• Segment 7 ?
 3
Comment on :-
3. Scan.

Scan for solid or cystic focal lesions &

localization according to segmental anatomy.

Couinaud classification
• It divides the liver into eight functionally
independent segments.
• Each segment has its own vascular inflow,
outflow and biliary drainage.
• In the center of each segment there is
a branch of the portal vein, hepatic artery
and bile duct.
• In the periphery of each segment there is
vascular outflow through the hepatic veins.
4 – biliary tree
• At the porta hepatis, the main portal vein, the proper hepatic artery, and the
common bile duct are seen.
• Within the hepatic parenchyma,
Look at portal tracts !
• Single tract.
• Dilated CBD.
• Double tracts ?

• Dilated IHBR ?

• Enlarged hepatic artery ?

• Dilated duct or artery ?

• Dilated biliary tree.

• Dilated duct or artery ?

• Dilated hepatic arteries.

 Double barrel sign
= Intra-hepatic biliary dilatation, BUT,
Bil

After confirmation with doppler.

DD Art

= Dilated hepatic artery branches as in PV

thrombosis, HCC, HHT,…

Art
 4
Comment on :- ▪ Common hepatic/common bile ducts
lying anterior to the portal vein (V) and
4. Biliary Tree.
hepatic artery (arrow).
CBD.
IHBR. ▪ Right and left hepatic ducts (short
arrows) are normally seen lying anterior
to the portal veins,(less than 3 mm in
newborn, otherwise suspect biliary
atresia in proper clinical setting).

▪ CBD (intra-pancreatic portion) is seen in

the posterior aspect of pancreatic head
(yellow arrow) while the gastroduodenal
artery (red arrow) is seen in the anterior
aspect.
Comment on :- ▪ A normal CBD should measure less
than 7 mm, 1 mm is added for each
4. Biliary Tree.
decade of life after 50 years .
CBD. Mild dilatation is accepted after
IHBR. cholecystectomy.

▪ A normal intra-hepatic duct is 2 mm, or

no more than 40% of the portal vein.

▪ The portal triad contains a portal vein, a

bile duct, and a hepatic artery.
The hepatic artery and bile duct are not
readily visible unless they are dilated.
4 – vascular tree
• Normal portal vein.
• Dilated portal vein.
• Thrombosed portal vein.
• Absent portal vein !

• Portal venous cavernoma.

• Normal hepatic veins.
• Dilated hepatic veins.

• Congestive HF.
• Attenuated hepatic veins.

• Cirrhosis.
• Thrombosed hepatic veins.

• Acute
Budd-Chiari ?
• Absent hepatic veins.

• Chronic
Budd-Chiari ?
 5
Comment on :- ➢ Main portal vein divides into RT & LT branches.
Normal diameter : ≤ 13 mm , and up to
5. Vascular 16 mm postprandial (inner to inner).
Normal flow : Hepatopetal (towards the liver),
▪ PV. On upper side of color map.
▪ HV. Same as hepatic artery, but darker (slower).
Normal velocity : 10- 25 cm/sec.
▪ HA. Showing respiratory phasicity (variations).

➢ The right portal vein has an anterior branch lying

centrally within the anterior segment of the right
lobe and a posterior branch lying centrally within
the posterior segment of the right lobe.
Intercostal
approach (not ➢ The left portal vein initially courses anterior
subcostal) to the caudate lobe (C).
The ascending branch (umbilical branch)
of the left portal vein then travels anteriorly C
in the left intersegmental fissure to divide the
medial and lateral segments of the left lobe.
Comment on :- ➢ Normal IVC diameter: < 18 mm.
Normal HV diameter : < 6-8 mm.
5. Vascular Normal flow : Hepatofugal (away from liver)
▪ PV. On down side of color map.
Opposite color of hepatic artery & portal
▪ HV. vein.
▪ HA. Normal PW pattern : Showing triphasic
flow.

➢ Hepatic veins, the right, middle, and left

hepatic veins. All drain into the IVC in
the superior aspect of the liver, sharing
in the segmental anatomy of the liver.
 Liver Ultrasound

Comment on :- Reporting
1. Size.
▪ RT lobe.
▪ LT lobe. Liver is of average size.
▪ Caudate lobe.
2. Shape. Displaying homogenous
▪ Echotexture. echotexture.
▪ Echogenicity.
▪ Surface / capsule. No gross focal lesions.
3. Scan.
4. Biliary tree. No dilated intra-hepatic biliary
▪ IHBR.
radicles.
▪ CBD.
5. Vascular tree. CBD: normal caliber.
▪ Portal vein.
▪ Hepatic veins. PV: normal caliber & patent.
 Case 1

• Name the arrowed structure (in Red) ?

 Answer 1

• Aorta.
 Case 2

• How to image the liver if the patient is cirrhotic with shrunken liver ?
 Answer 2

• Sector probe (small footprint probe).

• Through inter-costal approach.
• With/without decubitus position.
 Case 3

• What is the nature of this hepatic lesion ?

 Answer 3

• B-mode : cyst.
• CF-mode : vascular lesion.
• History : Pseudoaneurysm.
 Case 4

• Any lesions in this image ?

 Answer 4

• Fat within falciform ligament.

 Case 5

• What is the normal caliber of CBD ?

 Answer 5

• CBD up to 6/7 mm.

• 1 mm for each decade after 50s.
• Post-cholecystectomy up to 9/10mm.