Faroes Lectures 2019

1. www.mhb-fontane.de
Dieter Nuernberg
WFUMB – WFUMB COE TF Director
WFUMB Secretary & Vice President 2013-17
WFUMB Repres. WHO (NGO) 2013-17
Delegate of EBGH (European Board of Gastro & Hep)
EFSUMB – Delegate & Education Committee 2006-15
DEGUM – President 2008-2010
Brandenburg Medical School Theodor Fontane
Neuruppin, Germany
20-21 June 2019
Tórshavn
WFUMB & DSDU

2. Dieter Nuernberg
Brandenburg Medical School Theodor Fontane
Neuruppin, Germany
www.mhb-fontane.de
US liver,
gall bladder
and bile ducts
- Nice to know, Need to master
Ultrasound update 2018 – a course in Tórshavn, Faroe Islands
20-21 June 2019, WFUMB & DSDU

3. Untersuchungsgang

4. scanning
gliding
rotating
pressing
angulation

5. diagnostics in liver diseases
– diffuse changes
D. Nürnberg
 anamnesis
 clinic
 laboratory
 imaging = sonography
 histology

7. Block B.: Sono-Trainer, Thieme 2001
use like flashlight

8. Diagram
Subcostal and upper abdominal transverse slices
Please click to start animation! © JK

9. Diagram
Subcostal and upper abdominal transverse slices
Contents
Information
Please click to start animation! © JK

10. Block B.: Sono-Trainer, Thieme 2001
I
II
III

15. l

18. diffuse liver changes:
D. Nürnberg
back side position + side position
subcostal + intercostal
inbreathing + „Sono“-palpation
3.5 MHz + 7.5 MHz
problem: near area, lat. ri. LL.
liver + spleen + vessels + bil
free fluid ?

19. Most frequent questions:
• hepatomegalia ?
• diffuse parenchym disease ?
• focal leason ?
• DD icterus
• puncture guiding

20. Most frequent questions:
• hepatomegalia ?
• diffuse parenchym disease ?
• focal leason ?
• DD icterus
• puncture guiding

21. When is the liver to big ?

22. D. Nürnberg
Rettenmaier* Schmidt**
MC long cm cm
normal 9-11 12-13
moderate 12-13 14-16
strong 15-18 17-20
*1990 **1999
When is the liver to big ?

23. D. Nürnberg
Niederau***
MC long 10,5 / 12,6
MC sagg 8,1 / 11,3
ML long 8,3 / 10,9
ML sagg 5,7 / 8,2
***1983
When is the liver to big ?

24. diffuse liver changes:
sonographical signs
D. Nürnberg
direct signs:
size (hepatomegalia)
conture (surface)
border
form, consistence
structure
parenchyma ?
vessels
US-guidance
indirect signs:
splenomegalia
ascites
portal hypertension

26. Rettenmaier 1990
fatty liver:
size: ++
conture: konvex
border: blunt, round
structure: echorich
US-guidance: dorsal --
vessels: -
form changing: -
Prevalence 12 - 22 %
fatty liver –
fatty infiltration

27. Rettenmaier 1990
degree LCFI: size cm border ang Echo ves.
low (+) 10-11 sharp 30-50 + ++
midle + 12 blunt > 60 ++ (+)
FL - high ++ 12-15 round >> +++ -
fatty liver –
fatty infiltration

28. Regional/focal fatty differences

29. fatty liver :
size: ++
conture: konvex
border: blunt
structure: echorich
n. Rettenmaier, 90
fatty liver –
fatty infiltration

30. right heart failure

31. D. Nürnberg
direct signs:
hepatomegalia, > lobus caudatus
konvex + irregulaer contur
blunt + round border
echorich, inhomogeneous, macronodulaer structur
reduced elasticity
rareficated veins, vessel signs
large portal border
indirect signs:
portal hypertension
splenomegalia
ascites
liver cirrhosis

33. D. Nürnberg
Blunt border
No vessels
Portal hypertension

36. ©JS

37. Cruveilher-v.
Baumgarten-Syndrom

39. liver cirrhosis & HCC

40. Focal leason Diffuse changes

41. Overview
Segmental division of the liver (according to Couinaud)
I
II
III
IV
V
VI
VII
VIII
The numbering
of the segments
is clockwise, starting
from dorsal-medial.
Vena cava-gallbladder line
(+ Vena hepatica media) = border
between the functionally separated
right and left half of the liver.
Posterior
double segment
Anterior
double segment
Medial
double segment
Lateral
double segment
V. hep. dextra V. hep. sinistra
Segment I =
caudate lobe
V. hep.
media
Vena cava inf.
Vesica fellea
Dct. hepatocholedochus (DHC)
Vena portae
Ligamentum
teres hepatis
© JK

42. D. Nürnberg
liquide / zystic: solid:

44. Cyst:
Smooth wall
echofree
dorsal echo +

46. D. Nürnberg
FNB
atypic cyst
abszess
necrot. metacyst

51. Gallbladder

55. Gallstones

56. Cholecystitis

60. Bile duct system

61. Porta hepatica
 Vena portae
 common bile duct (DHC)
 Arteria hepatica

69. • Glisson Trias
Double gun sign

71. W. Ch., w, 93 a, pT2N1M0
21 a no rezidiv !

73. Dieter Nuernberg
Brandenburg Medical School Theodor Fontane
Neuruppin, Germany
www.mhb-fontane.de
US liver,
gall bladder
and bile ducts
- Nice to know, Need to master
Ultrasound update 2018 – a course in Tórshavn, Faroe Islands
20-21 June 2019, WFUMB & DSDU

74. Thanks for your attention !