This document provides information about a liver ultrasound presentation given by Prof. Dr. Ibrahim Nunow Cabdi, including his medical qualifications and areas of expertise. It outlines the techniques for performing ultrasound of the liver and assessing liver anatomy, vasculature, and segments. Common benign and malignant liver conditions are described, along with how they appear ultrasonographically. Diffuse liver diseases such as hepatitis, cirrhosis, and fatty infiltration are also discussed.

1. Prof. Dr. Ibrahim Nunow Cabdi
MD.MSc, MSc, MSc, and
on going MSc.

2. Prof. Dr. Ibrahim Nunow Cabdi
• MD = La Sapienza University, Rome, Italy
• MSc = Gastroenterology at Queen Marry and
West Field of London University, U.K.
• MSc = Emergency/Urgency Medicine at La
Sapienza University, Rome, Italy
• MSc = General Ultrasound at la Sapienza
University, Rome, Italy
• MSc (on going) Echocardiography at Medical
University of Vienna, Austria

3. 09/05/2016
Presents

4. Liver ultrasound

5. LIVER ANATOMY & DISEASES
• Ultrasound is the best initial imaging modality in evaluating
patients with suspected liver diseases. We can assess for
diffuse liver parenchymal changes and the detection of
smaller focal lesions is easy.
• Ultrasound can also helps in the characterization of focal
masses.
• Liver occupies most of the right hypochondrium,
epigastrium and part of left hypochondrium.
• Most part of the liver is intra peritoneal except the bare
area. It is covered by Glisson’s capsule. It is mostly covered
by ribs.
• Normal size of the liver is from 14.5 - 16.5 Cm in
superioinferior dimension in mid clavicular line.

6. ULTRASOUND OF LIVER TECHNIQUE
• Patient lies supine
• Transducer is positioned such that it nestles
under the sub-costal margin.
• Angle the transducer towards the right
shoulder.
• Right lobe of the liver is demonstrated

7. the sub-costal margin and the right
side of the liver

8. LEFT LOBE ANATOMY
• Patient lies supine
• Transducer is placed to the left of the
midline leading edge facing the head.
• Transducer is pressed down under the sub-
costal margin.
• On suspended inspiration the left lobe of the
liver is demonstrated.

10. RT. LOBE/RT. KIDNEY ANATOMY
• Patient is moved 45 degree to the left side.
• Transducer is positioned to nestle under the
sub-costal margin.
• On suspended inspiration the rt. Lobe of the
liver and the longitudinal plane of the upper
pole of the rt. Kidney is demonstrated.

11. Transducer is positioned to nestle
under the sub-costal margin.

12. NORMAL LIVER CRITERIA
• liver parenchyma should be more echogenic
( brighter then the kidney parenchyma).
• Their should be clear differentiation
between the portal vein radicals and the
hepatic sinusoids in the liver.
• Liver should demonstrate homogenous echo
texture.

15. COUINAUD’S ANATOMY
• Because sonography allows evaluation of liver
anatomy in multiple planes, the radiologist
can precisely localize a lesion to a given
segment for the surgeons.
• Each liver segment has its own blood supply
(arterial, portal, hepatic venous), lymphatics,
and biliary drainage.

16. • There are eight segments.
• The right, middle, and left hepatic veins divide
the liver longitudinally in to four sections i.e.
Lateral and medial section of left lobe and
anterior and posterior sections of right lobe.
• Each of these sections is further divided
transversely by and imaginary plane through
the right and left main portal pedicles.

18. • Segment I is the caudate lobe.
• II and III are the superior and inferior segments of left
lateral section, and
• segment IV, witch is further divided in to IVa and IVb, is
the medial section of the left lobe.
• The right lobe consists of segment V and VI, located
caudal to the transverse plane, and segment VII and
VIII, which are cephalad (forwards: towards the head or
anterior extremity of the body)
• The caudate lobe (segment I) may receive branches of
both right and left portal vein, in contrast to the other
segments, it has one or several hepatic veins which
drain directly in to the inferior vena cava.

20. Liver segments and lobules parietal
surface
COUINAUD’S TRADITIONAL
Segment I Caudate Lobe
Segment II Lateral segment of the left lobe superior
Segment III Lateral Segment of Left Lobe Inferior
Segment IV Medial Segment of Left Lobe
Segment V Anterior Segment of Right Lobe Inferior
Segment VI Posterior Segment of Right Lobe inferior
Segment VII Posterior Segment of Right Lobe superior
Segment VIII Anterior Segment of Right Lobe superior

21. Division into segments is based upon ramifications of bile ducts
and hepatic vessels. It does not entirely correspond with division
into lobes.

22. Liver segments and lobules visceral
surface

23. HEPATIC VASCULATURE
• 80 % of the blood to the liver is supplied by portal vein
branches while hepatic artery supplies 20 % of the
blood to the liver.
• The blood from the liver is drained via hepatic veins.
• There are four types of vessels in the liver, Hepatic
artery branches, Portal vein branches, Bile ducts and
hepatic veins.
• Normally portal vein branches and hepatic veins are
visible.
• The bile ducts become visible only when they are
obstructed.

24. Biliary system

25. • The portal and hepatic veins can be differentiated
by the fact the portal veins have echogenic walls
because of more fibrous tissue while hepatic
veins have anechoic walls.
• Moreover portal vein branches get smaller as we
move away from porta hepatis while hepatic
veins get larger as they are drained in to the IVC.
• Portal vein branch with bile duct and hepatic
artery branch is called portal triad.

27. HEPATIC VASCULATURE
• The bile ducts run sagitally and in somewhat oblique
fashion.
• Small bile ducts of each hepatic lobe join together to form
right and left hepatic ducts which in turn join to form the
common hepatic duct.
• The common hepatic duct is joined by the cystic duct from
the GB to form the CBD.
• CBD is extra hepatic and opens in the duodenum at the
ampulla either independently or after joining with the
pancreatic duct.
• Bile ducts are visible when obstructed. These are tortuous
vessels having echogenic walls and visible in areas where
normally there are no vessels.

28. LIVER PATHOLOGIES
• Liver is involved by two types of disease
processes.
- Hepatocellular that affect the hepatocytes and
are treated medically and
- Obstructive that affect the flow of bile and are
treated surgically.

31. Focal hepatic diseases
A) Focal Cystic diseases
• Focal benign cystic lesions of liver are fairly common in
clinical practice and are typically anechoic and have
posterior acoustic enhancement. These include
- Simple Cysts
- Pyogenic abscesses (producing pus)
- Amaebic abscesses
- Hydatid cyst (cyst filled with liquid; forms as a result of
infestation by tape worm larvae (as in echinococcosisi)
- Haematoma

32. 1) Simple Hepatic cysts
• Simple hepatic cysts may be single or multiple.
• These are typically round or oval in shape,
anechoic (not having or producing echoes;
sound absorbent), have thin smooth walls and
show acoustic enhancement (improvement
sweetening)

35. 2) Pyogenic abscesses:
• These are typically in Right hepatic lobe,
Round or ovoid in shape, have thick Irregular
walls with Variable internal echogenicity and
show acoustic enhancement.

37. 3) Amaebic abscess
• Amoebic abscesses typically lack significant
wall echoes, have a lower reflectivity than
liver with homogenous pattern of internal
echoes and are generally located in the right
hepatic lobe peripherally

39. 4) Hydatid cysts:
• Hydatid cysts may present in number of ways on
ultrasound including:
- Detached Membrane (isolated membrane)
- Purely cystic
- Multi-loculated Complex heterogenous mass
- Mass with calcified walls
• The characteristic findings of hydatid cyst is
‘Ultrasound water lily sign’ which results from
detachment and collapse of inner germinal layer.
• It is seen as undulating linear membrane either floating
in the cyst or lying in most dependent portion.

43. 5) Haematoma
• These are the usually associated with trauma.
• The appearances depend upon the age.
• Fresh haematomas are echogenic and with
the passage of time they become hypoechoic
and finally anachoic.

45. B) Focal benign solid masses
• These include
- Cavenous Haemangioma
- Focal nodular hyperplasia
- Hepatic adenoma
- Regenerating Nodule

46. HAEMANGIOMA
• It is the most common benign liver mass.
• These are vascular tumours that are more
common in females.
• These are small well defined solid masses that
are echogenic.

49. FOCAL NODULAR HYPERPLASIA
• It is more common in females and female to
male ratio is 2 : 1.
• These may be due to vascular thrombosis with
regeneration.
• They have variable echogenecity but mostly
are hypoechoic.
• These show variable echotexture but are
usually homogenous.

51. ADENOMAS:
• These are also rare solid benign masses more
common in females and are probably related
to the taking of contraceptive pills.
• These are large well defined encapsulated
solid masses measuring from 8-15 cm.
• Adenomas typically have a hypoechoic halo
around them.

53. REGENERATING NODULE:
• These are associated with cirrhosis and
represent regeneration of the hepatic
parenchymal cells after injury and
inflammation.
• These are typically small in size and
peripherally located.

55. MALIGNANT MASSES:
• The liver is the site for many primary malignant
lesions as well as metastases from different
masses.
• Primary liver cancer includes the more common
hepatocellular carcinoma, cholangiocarcinoma,
and Hepatoblastoma which is common in
children.
• Metastases to the liver are also fairly common
from neoplasms of kidneys, bowel and breasts.
• The liver may also be involved by infiltrations
from lymphomas and leukemias.

56. HEPATOCELLULAR CARCINOMA:
• This can be nodular with well defined single or
multiple nodules measuring more than 5.0 cm.
• The mass can present as diffuse when the mass is
indistinct and large portions of liver parenchyma
are involved by tumors.
• Various degrees of reflectivity are found in
hepatocellular carcinoma depending on the size
and duration and other pathological
characteristics.
• The mass may show reflectivity less than, equal
too greater than normal liver.

57. • Hepatocellular carcinoma invades vessels and
invasion of hepatic veins, portal veins and IVC
can be picked up on routine ultrasound but is
best demonstrated on color doppler.
• Doppler also shows typical flow patterns in
the mass that is arterial vascularisation within
portal vein.
• Typically at the periphery of the lesion are
seen high velocities and within the tumour are
seen vessels which show high diastolic flow
because of low impedance

59. HEPATOBLASTOMA:
• It is the most common malignant tumour of
the liver in children.
• It is one of four blastomas seen in childhood.
• The others are neuroblastoma,
Retinoblastoma and nephroblastoma (Willm’s
Tumour).
• It is usually well defined solid mass measuring
up to 6 Cm and is typically hypoechoic.

61. CHOLANGIOCARCINOMA:
• It is the primary bile duct carcinoma and is
usually confined to the intrahepatic ducts
• Some patients develop tumors whose
appearance mimics hepatocellalar carcinoma.
• The most typical sonographic finding is a solitary
mass of mixed or increased echogenicitv.
• It may also present as multiple masses. or
infiltrating tumor.
• The right hepatic lobe is most commonly involved
and peripheral bile duct dilatation is usually

63. METASTASES
• The most common liver metastases originate from lung,
colon, pancreas, breast, and stomach carcinomas.
Metastatic disease is multifocal in approximately 90
percent of patients.
• The ultrasound pattern of liver metastases include multiple
hypoechoic, hyperechoic, or isoechoic masses.
• Hypoechoic halos are frequently seen.
• Target or bull's eye patterns with varying rings of hypo-and
hyper echogenenicity are common.
• An anechoic area indicates necrotic or hemorrhagic
component.
• Some metastases, especially the ones arising from
mucinous adenocarcinoma of colon may calcify. ”

66. LYMPHOMAS AND LEUKEMIAS:
• Poorly reflective lesions may be from any
primary but are typical of lymphomas.
• Lymphomas and leukaemia usually cause
diffuse involvement of liver with
hepatomegaly and overall reduction in
reflectivity, but these can present as multiple
well defined small hypoechoic masses.

68. LIVER CALCIFICATIONS.
• The liver may show multiple small focal
lesions in the form of echogenic foci with
acoustic shadowing.
• These represent benign calcifications.

70. DIFFUSE LIVER DISEASES
• Acute Hepatitis
• Sonographic patterns of acute hepatitis may appear
normal.
• There may be hepatomegaly with an overall decreased
echogenicity due to inflammation and oedema.
• Acute Hepatitis . Liver may show increased
visualization and brightness of portal vein radicles
(Starry Sky Appearances).
• There may also be thick echogenic bands surrounding
portal vein branches called “ Peri-portal Cuffing”

71. Acute hepatitis

73. Acute Hepatitis
• There is also associated gallbladder wall
thickening that is thought to be due to direct
invasion of the GB wall by the virus causing
inflammation.

75. Chronic Hepatitis
• In chronic hepatitis the liver demonstrates a
coarse echopattern throughout the
parenchyma.
• Typically there is mild thickening of the GB
wall.
• Minimal to mild splenomegaly is also noted.

76. Chronic Hepatitis

77. Cirrhosis
• In patients with cirrhosis, the liver
parenchyma is coarsened with surface
nodularity, well seen in the presence of
ascites.
• The size of the right lobe is found to shrink in
comparison to the caudate lobe.
• Portal hypertension may be present with
ascites, splenomegaly and varices.

82. • Liver is also a common site of various
infiltrative lesions including fatty infiltration,
and depositions of copper and Iron.

83. Fatty Infiltration
• Fatty liver is an acquired and reversible metabolic
disorder which results from accumulation of
triglycerides within the hepatocytes.
• The common cause is obesity, however, pregnancy,
diabetes and excessive alcohol intake can be
responsible.
• On Ultrasound fatty liver is usually enlarged with
increased echogenecity.
• Due to increased brightness of the liver the echogenic
walls of the portal vein branches are not well seen.
• Fatty liver also shows increased attenuation with
decreased visualization of echogenic Diaphragm.

86. • In few instances the liver may show either
patchy infiltration or patchy spared areas.
• These areas are typically located anterior to
the porta hepatis and in the medial segment
of left hepatic lobe.
• These patchy areas are identified by there
characterestic of not disturbing the hepatic
vasculature in addition to their site.

91. WILSON’S DISEASE
• It is an autosomal recessive disease of copper metabolism.
• In Wilson's disease the liver does not release copper into
bile and copper builds up in the liver injuring the liver
tissue.
• Symptoms usually appear between the ages of 6 and 20
years.
• The symptoms of Wilson’s disease include enlargement of
liver and spleen, abnormal liver enzymes, and finally liver
cirrhosis with protal hypertension.
• The characterestic finding on ultrasound are innumerable
small echogenic foci in the liver parenchyma.

93. HEPATIC CONGESTION
• The liver may also be involved by congestive
diseases causing right heart failure or
congestive cardiac failure.
• Typically there is hepatomegaly with reduced
echogenecity due to veneous congestion.
• The Hepatic veins and IVC are dilated with loss
of phasicity in the IVC.

100. Thanks 4 your attension