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Ultrasound & doppler ultrasound in liver transplantation

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Role of ultrasound and Doppler ultrasound in the diagnosis of complications of liver transplantation

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Ultrasound & doppler ultrasound in liver transplantation

  1. 1. Ultrasound & Doppler Ultrasound in Liver Transplantation Samir Haffar, MD
  2. 2. US & Doppler US in liver transplantation  Surgical techniques of LT  Normal US & Doppler US in LT  Reversible Doppler findings in post-operative period  Doppler US of LT complications  US of LT complications
  3. 3.  Surgical techniques of LT
  4. 4. Types of liver graft • Full cadaveric graft • Split cadaveric graft • Reduced cadaveric graft • Living donor graft • Domino transplantation
  5. 5. Liver transplant anatomy Singh AK et al. RadioGraphics 2010; 30: 339 – 351 Orthotopic liver transplant Living donor liver transplant
  6. 6. Surgical techniques of LT • Surgical procedure Whole liver, single lobe, segmental • Gallbladder Normally removed • PV, HA, & BT End-to-end anastomoses usually • IVC Piggy-back technique Avoids clamping IVC during surgery • Conduit vessels Discrepancies in vessel diameter Portal vein thrombosis Increased risk of thrombosis It is important to know type of surgical procedure performed, but it is rarely available
  7. 7. Vascular complications are the most frequent adverse events after LT Early correction of vascular complications could permit complete recovery or may save the graft Timely detection is important
  8. 8. Complications of liver transplantation • Vascular Hepatic artery Stenosis, thrombosis, PA Portal vein Stenosis, thrombosis IVC & HV Stenosis, thrombosis Splenic artery Splenic artery steal synd • Biliary Obstruction Stenosis, stones, biliary cast • Others Abscess Collections Hematoma, biloma Neoplasms HCC – PTLPD* Recurrent disease PSC Cirrhosis & its complications *PTLPD: Post Transplant Lympho-Proliferative Disease Singh AK et al. RadioGraphics 2010; 30: 339 – 351.
  9. 9. Imaging evaluation of LT Disease Initial study Subsequent study Final invasive study Vascular Doppler US MR angiography CT angiography CEUS Angiography Biliary Doppler US MRCP CT scan Scintigraphy ERCP PTC Ajay K. Singh RadioGraphics 2010; 30: 339 – 351.
  10. 10.  Normal US & Doppler US in LT
  11. 11. Frequency of Doppler US exam • First exam 24 – 48 hour after transplantation Confirm patency of hepatic vessels • Then Every 3 – 5 days for first 2 weeks • Additional exam 4 week after transplantation Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. No RCT investigates optimal frequency Each centre decides its own policy More frequent exam in patients at higher risk
  12. 12. US & Doppler US of LT • US exam Hepatic parenchyma Bile ducts • Doppler exam Hepatic vessels Hepatic artery Portal vein Hepatic veins & IVC Splenic artery Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  13. 13. Normal hepatic artery Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. Intercostal approach Epigastric approach Right hepatic artery Left hepatic artery
  14. 14. Normal hepatic artery Resistance index (RI) or Pourcelot’s index RI: S – ED / S Normal: 0.5 – 0.8 Buscarini E et al. Ultraschall Med 2004 ; 25 : 348 – 55.
  15. 15. Normal hepatic artery Accleration Time (AT) or Rise Time (RT) Time in seconds from onset of systole to peak systole Normal value: ≤ 0.08 second
  16. 16. Normal spectral Doppler of HA * Buscarini E et al. Ultraschall Med 2004 ; 25 : 348 – 55. Diameter* 5 ± 1 mm PSV 70 ± 10 cm/sec RI 0.50 – 0.80 RT < 0.08 sec
  17. 17. Normal hepatic artery One or two systolic peaks Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. RI Calculated from highest peak, early or late AT Calculated considering first peak
  18. 18. Normal portal vein • Diameter Upper limits of normal: 13 – 16 mm > 20 – 30% increase with food & inspiration • Flow direction Towards liver (hepatopetal) Throughout entire cardiac cycle • Velocity Varies greatly (Max – Mean – Min – TAMV) Mean velocity: 15 – 18 cm/s Varies with cardiac & respiration activity Undulating appearance of waveform Goyal N et al. Clin Radiology 2009 ; 64 : 1056 – 1066.
  19. 19. Normal portal vein Normal monophasic waveform with mild phasicity Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. Duplex US of main PV
  20. 20. Helical portal vein flow Donor PV > recipient PV If not properly recognized, it can produce the mistaken impression of PV flow reversal Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  21. 21. Helical portal vein flow Mimic of hepatofugal flow Wachsberg RH et al. RadioGraphics 2002 ; 22 : 123 – 140. Hepatopetal flow within liver confirms that net flow is hepatopetal
  22. 22. Causes of helical portal vein flow Near bifurcation • Normal subjects 2% • Severe liver disease 20% • TIPS • Post-liver transplantationDonor PV > recipient PV • Portal vein stenosis Robinson KA et al. Ultrasound Quarterly 2009 ; 25 : 3 – 13.
  23. 23. Piggy-back anastomosis of the IVC Schematic image Subcostal scan to visualize the anastomosis US & color Doppler US Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. –
  24. 24. Normal hepatic vein Normal triphasic waveform flow Spectral Doppler of hepatic vein Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  25. 25. Normal hepatic vein waveform – 3 components Kruskal JB et al. RadioGraphics 2004 ; 24 : 657 – 675. A Atrial systole S Ventricular systole D Atrial diastole A S D S wave > D wave Commonly described as triphasic
  26. 26.  Reversible Doppler findings in the immediate post-operative period
  27. 27. Reversible Doppler findings in post-op period • Starry sky pattern • Pneumobilia • Pleural effusion • Hepatic artery Elevated PSV Decrease RI Reversed diastolic flow Tardus parvus waveform • Portal vein Increased velocity Pulsatile flow • Hepatic veins Monophasic flow • HV-IVC anastomosis Turbulence Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211.
  28. 28. Starry sky pattern Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. US on 1st post-operative day US 3 days after OLT Normal hepatic echotexture Echogenic portal venules & diminished parenchymal echogenicity (edema)
  29. 29. Pneumobilia Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. US image on first postoperative day after OLT Normal finding after bilio-enteric anastomosis in OLT
  30. 30. Pleural effusion Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. Moderate right pleural effusion, a common finding Usually resolve within few days US image on 1st post-operative day after OLT
  31. 31. Elevated PSV in hepatic artery Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. 1st postoperative day of OLT PSV: 283 cm/sec – normal RI Due to anastomotic edema Perivascular vibration is seen PSV: 192 cm/sec Resolution of anastomotic edema No peri-vascular vibration 3 days after OLT
  32. 32. 1st postoperative day of OLT Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. Decrease resistance index in hepatic artery Elevated PSV: 303 cm/sec Low RI: 0.45 3 days after OLT Decreased PSV: 118 cm/sec Increased RI: 0.56 Resolution of narrowing secondary to anastomotic edema
  33. 33. Reversed diastolic flow in hepatic artery Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. 1st postoperative day of OLT 3 days after OLT Normal PSV: 55 cm/sec Reversed or absent diastolic flow Normal waveform Improved RI: 0.87
  34. 34. Tardus parvus waveform in hepatic artery Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. 1st postoperative day of OLT 3 days after OLT Normalization of tardus parvus Increased PSV: 53 cm/sec Improved RI: 0.62 Tardus parvus waveform Low PSV: 23 cm/sec Low RI: 0.43
  35. 35. Increased velocity in portal vein Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. 1st postoperative day of OLT Increased PV velocity: 149 cm/sec Decreased portal resistance 3 days after OLT Improved turbulence Normal PV: 54 cm/sec
  36. 36. Pulsatile flow in portal vein Common finding in congestive heart failure Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. 1st postoperative day of OLT Pulsatile PV waveform due to altered hemodynamics 3 days after OLT Normal monophasic flow
  37. 37. Monophasic flow in hepatic veins Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. 1st postoperative day of OLT Monophasic flow in MHV Graft edema 3 days after OLT Normal triphasic waveform
  38. 38. Turbulence at HV-IVC anastomosis Sanyal R et al. RadioGraphics 2012 ; 32 : 199 – 211. 1st postoperative day of OLT Turbulence at HV-IVC anastomosis 3 days after OLT Resolution of turbulence
  39. 39.  Doppler US of LT complications
  40. 40. Vascular complications of LT • Hepatic artery Stenosis – Thrombosis – PSA • Portal vein Stenosis – Kinking – Thrombosis • Hepatic veins & IVC Stenosis – Kinking – Thrombosis • Splenic artery Splenic artery steal syndrome (SASS) Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  41. 41. Presentation of vascular complications after LT Complication Time of presentation after LT HA thrombosis First two weeks Late HAT occurs but less devastating HA stenosis Few weeks to several months PV thrombosis Within one month PV stenosis Usually late (> 6 months) HV stenosis Usually late (> 6 months) Sanyal R et al. Indian J Radiol Imag 2014 ; 24 : 360 -366.
  42. 42. Hepatic artery Thrombosis – Stenosis – Pseudo-aneurysm (PSA)
  43. 43. HA thrombosis – Systematic review Most severe complications especially when abrupt • Incidence 2 – 12% of adult recipients 2 – 6% in experienced centers • Peak occurrence Seventh day following LT • Re-transplantation Up to 60% • Mortality 33% • Doppler US Identify up to 92% Bekker J, Ploem S, de Jong KP. Am J Transplant 2009 ; 9 : 746 - 57.
  44. 44. Complications of HA thrombosis Transplanted liver extremely sensitive to arterial ischemia • Primary liver non-function • Hepatic infection & abscesses • BT ischemia Lumen filled with biliary necrotic casts Irreversible Biliary stenosis with peritoneal spillage Diffuse & involve all IH branches Only biliary surgical anastomosis (often) Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  45. 45. Manifestations of HA thrombosis • General malaise, fullness or fever • Pain not usually present Denervated transpl liver • Elevated liver enzymes Elevated γGT & AP • Liver failure Elevated bilirubin Prolonged PT
  46. 46. Doppler US in HA thrombosis Visualize artery in hilum & both lobes • Fasting examination Arterial buffer vasoconstriction • Adjust color scale • Doppler gate near PV • Wider Doppler gate Normal arterial spikes within PV Arterial thump in thrombosis • CEUS 1.2 – 2.4 ml SonoVue IV Low mechanical index • Further investigations CECT – angiography Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  47. 47. Doppler US in HA thrombosis • HA in hilum Absence of visualization • Intra-hepatic branches RI ˂ 0.50 AT ˃ 0.08 sec Identification of just one parameter is enough to prompt rapid further investigations
  48. 48. Hepatic artery thrombosis Diffuse heterogenous mixed echogenic change Gray scale US CT scan Widespread periportal low attenuation change O’Briena J et al. European J Radiol 2010; 74 : 206 – 213.
  49. 49. Doppler US in HA thrombosis Sanyal R et al. Indian J Radiol Imag 2014 ; 24 : 360 - 366. Tardus parvus in LHA Flow in LHA does not exclude HAT CT angiogram Thrombosis of main HA Doppler ultrasound
  50. 50. Hepatic artery stenosis Horrow M et al. AJR 2007; 189 : 346 – 351. Flow in portal vein No flow in hepatic artery Power Doppler at porta hepatis Complete occlusion of hepatic artery CT angiogram
  51. 51. Biliary cast syndrome First described in 1975 • Incidence 2.5% after OLT – Less than sludge & stones • Morphology Hard dark material in biliary ducts Similar shape to BD • Symptoms High fever, jaundice, cholestasis • Characterized Multiple intra-hepatic biliary strictures Ductal dilatation Intrahepatic abscesses Biliary anastomotic leakage • Treatment Surgery is treatment of choice Endoscopic techniques successful & safe Yang Ylet al. World J Gastroenterol 2013 ; 19 (43): 7772 – 77.
  52. 52. Biliary cast syndrome Ha SI et al. Korean J Gastroenterol 2012 ; 60 : 382 – 385. Biliary cast removed endoscopically Hyperechoic material in CBD Initially thought as ascariasis Gray scale US Longitudinal tubular filling defect in CBD ERCP
  53. 53. Biliary cast syndrome Biliary duct necrosis Rubens DJ. Ultrasound Clin 2007 ; 2 : 391 – 413. Linear echogenic debris with acoustic shadows Transverse US Low RI (<0.5) HA stenosis/thrombosis Color Doppler US Extensive BT necrosis Resulting liver abscess CT scan Abscess obscured on US because of shadowing from air in the ducts
  54. 54. Hepatic artery stenosis Milder effect than thrombosis • Incidence Up to 10% • Site Most often at anastomostic site Consequence of arterial kinking • Manifestation Bile duct strictures from ischemia Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. High degree stenosis leads to biliary ischemia
  55. 55. Doppler US of HA stenosis • At stenosis Aliasing on color Doppler PSV ˃ 2m/sec • Post-stenosis Tardus-parvus wave RI ˂ 0.5 AT ˃ 0.08 sec Stenosis could be corrected radiologically or surgically Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  56. 56. Hepatic artery stenosis Main hepatic artery Turbulent flow & high PSV (4.7 m/s) Intra-hepatic artery Tardus-parvus, low RI & long AT Angiogram: high degree HA stenosis Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  57. 57. HA pseudo-aneurysm (PSA) Extra-hepatic PSA considered as surgical urgency • Incidence Less than 1% • Symptoms Usually asymptomatic Rupture with life-threatening hemoperitoneum • Causes Extrahepatic Infection (mycotic PSA) Defective reconstruction Intra-hepatic Percutaneous interventions Focal infection of parenchyma • US US diagnosis is difficult Hypoechoic collection near arterial anastomosis should be evaluated with CDUS or CEUS Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  58. 58. HA pseudo-aneurysm Leong L. Biomed Imaging Interv J 2006; 2(2):e17. High PSV at neck of PATurbulent flow in a lesion near HA DSA of celiac axis: pseudoaneurysm
  59. 59. O’Briena J et al. European J Radiol 2010; 74 : 206 – 213. HA pseudo-aneurysm / yin-Yang pattern Selective arteriography Gray-scale US Echopoor lesion in the liver Color Doppler US Swirling or “yin-yang” pattern
  60. 60. Splenic artery steal syndrome (SASS) First described by Manner in 19911 • Clinic Graft ischemia in early postoperative period non-specific2 Less fulminant than HAT Elevated liver enzymes first Then cholestasis, biliary damage, rejection • Exclude Hepatic arterial thrombosis Hepatic arterial thrombosis Acute rejection • Treatment Splenic artery embolization 1Manner M et al. Transpl Int 1991; 4 : 122 – 124. 2Sanyal R, Shah SN. J Ultrasound Med 2009; 28: 471 – 477.
  61. 61. US Doppler of SASS • Hepatic artery High RI in IH & EH arteries RI usually 0.8 & 1 in diastolic reversal Can be transient post-operative finding Can be indicator of acute rejection • Splenic artery Increased flow in splenic artery • Portal vein High portal vein velocity Sanyal R, Shah SN. J Ultrasound Med 2009 ; 28 : 471 – 477. HAT & stenosis are 2 other causes of graft ischemia Doppler US very sensitive for their diagnosis Low-resistance or absent flow distal to obstruction
  62. 62. Doppler US of SASS / Hepatic artery Sanyal R, Shah SN. J Ultrasound Med 2009; 28 : 471 – 477. Right hepatic artery Diastolic reversal Left hepatic artery Diastolic reversal Main hepatic artery Diastolic reversal
  63. 63. Doppler US of SASS / PV & splenic artery Sanyal R, Shah SN. J Ultrasound Med 2009 ; 28: 471 – 477. Hyperdynamic splenic artery PSV: 272 cm/s Hyperdynamic main PV Mean PV velocity 115 cm/s
  64. 64. Portal vein Stenosis – Kinking – Thrombosis
  65. 65. Portal vein Stenosis – Kinking – Thrombosis • Incidence 1 – 2% of patients • Picture Portal hypertension Hepatic failure Ascites or all of these Do not usually lead to liver failure or graft loss
  66. 66. Doppler US of PV thrombosis • Ultrasound Internal echoes within PV • Color Doppler No flow at all – Flow around thrombus • Differential dg Fresh thrombus vs very slow flow Benign vs malignant thrombus • CEUS Fresh flow: absence of flow Very slow flow: presence of flow Benign thrombus: no enhancement Malignant thrombus: arterial enhancement Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  67. 67. Portal vein thrombosis Echogenic thrombus in main PV with lack of color-filling Sanyal R et al. Indian J Radiol Imag 2014 ; 24 : 360 – 366.
  68. 68. Portal vein cavernoma Chronic portal vein thrombosis Multiple collaterals replacing main portal vein Bhargava P AJR 2011; 196 : WS15 – WS25.
  69. 69. Diagnosis of malignant PV thrombosis • “AASLD” guidelines1 PV > 23 mm in diameter Arterial-like flow on Doppler Increased serum α-FP • Piscaglia criteria2 Mass-forming features of thrombus Disruption of veins walls Thrombus vascularization (US-CT-MRI) • FNA CT- or US-guided 1 DeLeve L et al. Vascular disorders of the liver. Hepatology 2009 ; 49 : 1729 – 1764. Piscaglia F et al. Liver transplantation 2010 ; 16 : 658 – 667.
  70. 70. Malignant PV thrombosis / CEUS 38 pts (15 benigns - 23 malignants) – Conclusive (37/38) Dănilă M et al. Medical Ultrasonography 2011 ; 13 : 102 – 107. Gray-scale US Malignant PVT Arterial phase Enhancement Portal phase Wash-out Late phase Wash-out Contrast-Enhanced US
  71. 71. Malignant PV thrombosis Piscaglia criteria Piscaglia F et al. Liver transplantation 2010 ; 16 : 658 – 667. Low-resistance pulsatile arterial flow in thrombus Thrombus occupying part of the left portal vein Mass-forming features of thrombus Disruption of veins walls
  72. 72. Doppler US of significant PV stenosis • Color Doppler Aliasing at stenosis • Pulsed Doppler PSV ˃ 1 m/s at stenosis 3 – 4 increase in velocity at stenosis site compared to 2 cm upstream Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  73. 73. Portal vein stenosis Color aliasing at vascular anastomosis Sixfold velocity in poststenotic segment relative to prestenotic segment Significant stenosis Long axis of main portal vein Crossin JD et al. RadioGraphics 2003; 23:1093 – 1114.
  74. 74. Portal venous gas in LT • Causes Common transient finding in early postop period Serious disease Bowel necrosis Intra-abdominal abscess Small-bowel obstruction Sepsis • Diagnosis CT scan Doppler US Useful for PV gas detection Does not necessarily indicate severe pathology Abboud B et al. World J Gastroenterol 2009 August 7; 15(29): 3585 – 3590.
  75. 75. Portal vein gas Acute trans-mural mesenteric infarction Wiesner W et al. Radiology 2003 ; 226 : 635 – 650. Intra-hepatic PV gas in periphery of both lobes CECT scan
  76. 76. Portal vein gaz Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. Bright areas in liver parenchyma Accumulation of gas bubbles Gray-scale US Vertical bidirectional spikes At laparotomy: bowel perforation Spectral Doppler US Doppler US is useful for detection of PV gas
  77. 77. Hepatic veins & IVC Kinking – Stenosis – Thrombosis
  78. 78. Hepatic veins & IVC Stenosis – Kinking – Thrombosis • Causes Narrowing of anastomosis Kinking of vessels Transplant organ torsion (size mismatch) • Manifestation Liver failure Portal hypertension Ascites & pleural effusion • Biology Increase liver enzymes & bilirubin Impairment of hepatic synthetic activities Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  79. 79. Doppler US of significant HV stenosis • Color Doppler Aliasing at site of anastomosis Flow reversal in IVC • Pulsed Doppler Upstream Monophasic wave PSV ˂ 15 – 20 cm/s 3 – 4 fold velocity increase at stenosis site compared to few cm upstream Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. Monophasic wave seen in absence of stenosis Serial exams: new appearance of monophasic waveform
  80. 80. HV stenosis at piggyback site Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011. HV stenosis with aliasing Upstream anastomosis: flattened flow (14 cm/s) Within piggyback: turbulent flow (100 cm/s)
  81. 81. IVC stenosis End-to end IVC anastomosis Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114. Gray-scale US Focal narrowing of IVC lumen Spectral Doppler US Twofold velocity increase between pre-stenotic & post-stenotic segment Turbulence at distal IVC anastomosis Color Doppler US
  82. 82. IVC thrombosis Echogenic thrombus of RHV extending into IVC Subcostal oblique US Right paramedian sagittal US IVC thrombus Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114.
  83. 83. Doppler US in hepatic rejection • Parenchymal texture irregularities not specific Their presence may have several cause • Doppler indices unreliable for diagnosis of rejection Biopsy of transplanted liver required for diagnosis of rejection Piscaglia F, Sidhu P, Brabrand K and Borghi A EFSUMB – European Course Book – Liver Transplantation – 2011.
  84. 84.  US of LT complications
  85. 85. Other complications of LT • Abscess • Collection Hematoma, biloma • Hepatic infarct • Biliary obstruction Stone, stenosis, biliary cast synd • Neoplasms Recurrent HCC, PTLPD* • Recurrent disease PSC • Cirrhosis & itscomplications *PTLPD: Post-transplant lympho-proliferative disease
  86. 86. Hepatic abscess Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114. Focal mass in left hepatic lobe Highly echogenic air & dirty shadowing Could be mistaken for gas in bowel Transverse US image Corresponding CECT
  87. 87. Acute and sub-acute fluid collections Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114. Echogenicity similar to adjacent liver Difficult to detect Acute hematoma Sub-acute hematoma Complex septated fluid collection in hepatorenal space
  88. 88. Biloma after LDLT Diagnosed by US guided aspiration Hypoechoic collection in right hepatic lobe Tip of needle during US guided aspiration
  89. 89. Hepatic infract Echogenic focus with hypoechoic rim in left hepatic lobe Biopsy: hepatic infarct Corresponding CECTMidline transverse US Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114.
  90. 90. CBD stone Dilated CBD Echogenic calculus distal acoustic shadowing Right para-median sagittal US Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114.
  91. 91. Anastomotic stricture of bile duct Corresponding ERCP Normal waveform Spectral Doppler of HA CBD stenosis Sagittal US Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114. CBD stenosis
  92. 92. Recurrent hepato-cellular carcinoma Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114. Median sagittal US Corresponding CECT Large mass of mixed echogenicity in right hepatic lobe
  93. 93. Post-transplant lympho-proliferative disease Crossin JD et al. RadioGraphics 2003; 23:1093 – 1114. Large heterogeneous mass displacing porta hepatis Biopsy: PTLPD Transverse US image Contrast-enhanced CT Mass encases vasculature at porta hepatis
  94. 94. Recurrent sclerosing cholangitis Right para-median sagittal US Mural thickening of CBD Magnified view Crossin JD et al. RadioGraphics 2003; 23:1093 – 1114.
  95. 95. Adrenal hemorrhage Crossin JD et al. RadioGraphics 2003; 23: 1093 – 1114. Corresponding CECT Hypoechoic nodule in hepatorenal space Focal adrenal hemorrhage secondary to intra-operative venous infarction Transverse US image
  96. 96. Reference
  97. 97. Thank You

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