liver ultrasound is very important part of abdominal ultrasound. in this cheptar canten normal liver ultrasound and liver pathology ultrasound.

1. ‫من‬‫ح‬‫الر‬‫هللا‬‫م‬‫س‬‫ب‬
‫م‬‫ح‬‫الر‬
‫ری‬‫اب‬‫ر‬‫وب‬‫ت‬‫ل‬‫عدا‬‫د‬‫داون‬‫خ‬‫ام‬‫ن‬‫ب‬
In the name of Allah

2. Liver Anatomy
& Ultrasound
2
By: Dr. Sayeed Hashim
Hashimi Nezhad
1402/9/11

3. 1
.
‫دارای‬ ‫که‬ ‫عضویست‬ ‫کبد‬
1۴۰۰
–
1۶۰۰
‫باشد‬ ‫می‬ ‫وزن‬ ‫گرام‬
.
2
.
‫ناحیه‬
RUP – Epigastric
‫وقسما‬
LUP
‫کرده‬ ‫اشغال‬ ‫را‬
.
•
‫باشد‬ ‫می‬ ‫وجه‬ ‫سه‬ ‫دارای‬ ‫آناتومی‬ ‫نظر‬ ‫از‬ ‫کبد‬
:
❑
‫علوی‬ ‫قدامی‬ ‫وجه‬
Antero superior Surface
❑
‫سفلی‬ ‫وجه‬
Inferior Surface
❑
‫خلفی‬ ‫وجه‬
Posterior Surface
Liver Anatomy

4. •
‫کبد‬
‫باشد‬ ‫می‬ ‫دولوب‬ ‫دارای‬
.
•
‫توسط‬ ‫علوی‬ ‫قدامی‬ ‫وجه‬
Lig – Falciform
‫است‬ ‫شده‬ ‫تقسسیم‬ ‫وچب‬ ‫راست‬ ‫دولوب‬ ‫به‬
.
•
‫حرف‬ ‫شکل‬ ‫به‬ ‫کبد‬ ‫سفلی‬ ‫وجه‬
H
‫به‬
1۰
‫است‬ ‫شده‬ ‫تقسیم‬ ‫قسمت‬
.
Liver Anatomy

5. ‫حرف‬ ‫شکل‬ ‫به‬ ‫کبد‬ ‫سفلی‬ ‫وجه‬
H
‫به‬
1۰
‫است‬ ‫شده‬ ‫تقسیم‬ ‫قسمت‬
.
1
.
Right Lobe
2
.
Left Lobe
3
.
Quadrate Lobe
4
.
Fossa for GB
5
.
Caudate lobe
6
.
Sulcus for IVC
7
.
Pota Hepatis
8
.
Lig Venosum
9
.
Lig Teris
1۰
.
Process of Cudatus

6. ‫از‬ ‫کبد‬ ‫سفلی‬ ‫دروجه‬
Sub costal space
‫کرد‬ ‫مشاهیده‬ ‫را‬ ‫ذیل‬ ‫های‬ ‫ساختمان‬ ‫متوان‬
1
.
Gall Bladder
2
.
Sulcus for Inferior Vena Cava
3
.
Ligament Venu sum
4
.
Ligament Teres
5
.
Porta Hepatis
6
.
Left Lobe of Liver
7
.
Right Lobe of Liver
8
.
Quadrate Lobe
9
.
Caudate Lobe

7. Segments
•1= caudated lobe
•2,3,4 left lobe
•5,6,7,8 right lobe

9. • Anatomically the liver has 4 lobes , but not physiologically
• The hepatic veins divided the liver into 4 segments
• LLS
• LMS
• RAS
• RPS
• Caudate lobe

10. ‫کبدی‬ ‫های‬ ‫اورده‬ ‫براساس‬ ‫کبدی‬ ‫داخل‬ ‫تقسیمات‬
Three large intrahepatic veins drain the liver parenchyma, into the IVC
❑ right hepatic vein,
❑middle hepatic vein
❑left hepatic vein.
❑The veins are important landmarks
❑There are separate smaller veins draining the Caudate lobe of
the liver

11. Right hepatic vein
The right hepatic vein (RHV) runs in the right hepatic fissure and drains segments 5, 6, 7
and 8. The vertical plane of the right hepatic vein separates the segments 6 and 7
(posterior to the plane) from segments 5 and 8 (anterior to this plane).

12. Middle hepatic vein
MHV runs at the middle hepatic fissure and drains segments 4a, 4b, 5 and 8. The vertical
plane of the middle hepatic vein separates the segments 5 and 8 (posterolateral to this plane)
from segments 4a and 4b (anteromedial to this plane)

13. Left hepatic vein
LHV)runs partially in the fissure for the ligament of tras and the left hepatic fissure. It drains
segments 2, 3, 4a and 4b. It is always located anterior to the left portal vein. The vertical
plane of the left hepatic vein separates the segments 4a and 4b from segments 2 and 3.

23. Portal Veins Ultrasound Appearance
Presentation title 23

27. Biliary Three
Right hepatic & left hepatic ducts
Make common hepatic duct in porta hepatis
3 cm distal to the cystic duct makes CBD
So, CHD +CBD = 1۰ cm
CBD , PV & H.art. Make Mikey’s mouse , when passé through HDL

28. Biliary three

30. How to scan the liver
1. No Preparation need
2. Supine Position
3. Left lateral decubitus
4. Probe 3 .۰- 3.5 MHz
5. Evaluated in both TRN & Sagittal plane
6. Scan Frome subxiphoid area to RUQ
7. Scan in Longitudinal view
8. Transvers view
9. Length should be Measured

32. Video

33. video

34. Biliary Scanning Technique
Rotating the probe then gives transverse and oblique views of the gallbladder.
Using standard views following identification of the gallbladder allows complete
biliary scanning. To achieve complete biliary imaging,

35. Echogenicity
Diaphragm > Renal sinus > Pancreases > Liver> Spleen > Renal cortex
> renal Pyramids

36. Liver normal echogenicity & echotexture
1. Liver echogenicity is mild hyperechoic then renal cortex
2. Echotexture is uniform and homogenous
3. The lower lobe not pass over the lower pole of the right kidney.

37. Pathology of liver
• Hepatomegaly:
• Causes
• Vascular
• Infection
• Tumors
• Cysts
• leukemia/ lymphoma
• Storage disease
• Fatty liver

38. Diagnostic criteria
• Right lobe More than 15.5 cm diameter
• The lower lobe pass over the lower pole of the right kidney
• If lower liver angle > 45 degree
• Reidl’s lobe (‫رسد‬ ‫می‬ ‫کریست‬ ‫ایلیاک‬ ‫تا‬ ‫شده‬ ‫طویل‬ ‫کبد‬ ‫راست‬ ‫)لوب‬

39. Lenth =16cm Width=15,7cm AP=17cm

42. Diffuse liver Disease
Diffuse Parenchymal liver diseases has a number of sonographic features, but most are
non specific. The sonographic appearance of same conditions such as fatty liver and
alcoholic liver may improve rapidly when the primary cause is removed. So the
following are the most typical patterns.

43. Fatty Infiltration
1. The liver become enlarged
2. Echogenicity is increased
3. The right hemidiaphragm and blood vessels can be difficult due to the increased
acoustic attenuation.

44. Sonographic appearance

47. Presentation title 47

48. Focal fatty spring
Presentation title 48

49. Geographic-fatty-infiltration
What is this…?

50. Fatty Alcoholic liver Disease
1. The edge of the right lobe becomes rounded.
2. Left lobe become large
3. Caudate lobe may be seen
4. Increased liver echogenicity
5. Cirrhosis formation
6. Smal size of liver

51. Sonographic appearance

53. Acute Hepatitis
1. Portal triads are seen more prominent
2. Liver echogenicity decrease
3. Diffuse swelling liver (Stary sky) appearance.
4. Liver enlarged
5. GB wall thickened
6. Not: could be the liver appear normal

54. Acute Hepatitis

56. Stary sky

58. Chronic Hepatitis
1. Mostly sonographically normal.
2. Cirrhosis develops.
3. Secondary Fibrosis.

59. Liver Cirrhosis
1. Hyper echoic liver
2. Decreases in size

63. Portal Hypertension
1. Increased Pressure in the portal vein
2. Cause:
1. Liver Fibrosis
2. Obstruction (colat & Tumor)
3. Liver Cirrhosis.
3. Portal vein diameter become large > 1,3cm

67. Biliary Obstruction
1. The CHD is measured intrahepatically at the level of the undivided RPV.
2. The CBD can be Measured at point of largest dimension.
3. Causes of Biliary Dilatation:
1. Stone
2. Tumor

69. Mirizzi Syndrome
1. Uncommon Condition when the stone lies at the cystic duct.
2. Compression to CHD dilated.
3. Stone may penetrate the CHD and make Cholecystenteric fistula

72. Bile Duct Carcinoma
1. Rarely a Tumor may be seen with in a bile duct ( Cholangiocarcinoma)
2. Most CHCM originate within the CBD or CHD
3. 25% of cases cholangiocarcinoma occur at the junction of R&L hepatic duct.
4. Bile duct dilated.

74. Biliary Parasites
1. Biliary Parasites are rare.
2. Most common Parasite is Ascaris Lumbricoides.

77. AIDS Cholangitis
1. Intrahepatic bile duct changes often occur in patient with AIDS
2. Irregular wall thickens present

79. Choledochal Cyst
1. Choledochal cysts are commonly categorized into five types.
2. The most common form is a fusiform dilation of the CBD

83. Caroli Disease
1. Caroli disease is a congenital abnormality that result in saccular areas being formed
with in the intrahepatic bile ducts

85. Courvoisier Gallbladder
The Courvoisier sign, sometimes called Courvoisier’s law, refers to
a gallbladder that’s enlarged due to bile buildup. When this happens, you
can usually see or feel your gallbladder through your skin.

88. Biliary atresia
1. This is a rare disease of newborns usually diagnosed be two to three weeks of life
2. Decreased or absent bile flow
3. GB is very small or absent
4. Neonates typically present with jaundice.
5. Intrahepatic duct may be dilated.

90. Triangular Cord Sign

91. Small GB

92. Hydatid cyst
1. Introduction: the hydatic disease, caused by the larvae of Echinococcus granulosus.
2. More infected the right lobe of the liver .
3. Single / multiple
4. Sonographic appearance:
1. Simple Cyst
2. Cyst within cyst (Daughter Cyst)
3. Card wheel appearance
4. Falling snow flacks
5. Calcification
6. The water lily sing

94. The water lily sing

95. Falling snow flacks

96. Card wheel appearance

97. Complication
1. Rupture in peritoneal cavity
2. Portal obstruction and portal hypertension
3. CHD obstruction
4. Rupture to Plural cavity.

98. Hepatic abscess
I. Is a cystic lesion
II. Hypo echoic with internal echo
III. Two types (pyogenic & amoebic )
IV. If thick pus seen to be solid
V. Cant be differentiated from necrotic tumor

100. Amoebic liver abscess
❑Subcapsular
❑Well defined wall
❑Distal enhancement

101. Amoebic liver abscess

102. Amoebic liver abscess

103. What is this …?

104. Pyogenic abscess
• Irregular & less echogenic walls
• Gas's shadow
• Cyst if chronic

105. Pyogenic abscess

106. Pyogenic abscess

107. Sub phrenic abscess
1. On the liver , sub – diaphragmatic
2. Sonolucent
3. Low level Internal echo

108. Sub hepatic abscess
• Hepato-renal angle or Morison’s pouch.
• After Cholecystectomy mostly Abscesses are formed.

110. Hematoma
1. A Liver Hematoma is a pool of blood contained within the liver's capsule. It is usually
caused by trauma (e.g., accidents or injury) but can also happen as a result of certain
surgical or diagnostic procedures or even spontaneously.
2. Differentiate with cyst by color Doppler

111. Sonographic Appearance

112. Subcapsular Hematoma

114. Liver Mass
❑ Liver mass are three type:
1. Benign
2. Malignant
3. Metastatic lesion

115. Benign Liver Lesions
1. Hemangioma:
1. It’s made up of clumped, malformed blood vessel that are fed by the hepatic artery
2. Round
3. Echogenic mass
4. Reach's 3 cm
5. Mostly peripheral
6. Asymptomatic

116. Sonographic appearance
❑ If > 3 Cm , thrombosis may occur within in
❑ May calcified
❑ In 1۰% are multiple
❑ If fatty liver seen hypo echoic
❑ Size remains constant
❑ Slow circulation

117. Sonographic Appearance

123. What is this ….?

124. Hepatocellular Adenoma
I. Rare tumor
II. Related to OCP
III. Multiple if glycogen storage disease
IV. Hemorrhage & changes into malignancy

125. Sonographic appearance
• Typically , single , solid
• Hypoechoic (2۰-4۰%)
• Hyperechoic (3۰%)
• Mixed (5۰%)
• Hemorrhage & may increase in size

130. Focal Nodular Hyperplasia(FNH)
• Second benign tumor
• Common in female
• Typically solid , Homogenous , mostly > 5cm
• Isoechoic / hypoechoic
• May reduced in size
• Calcification occurs in atypical form

131. Sonographic Appearance

133. Nearly isoechoic mass Focal nodular hyperplasia

134. FNH

135. What is this ….?

136. Malignant Hepatic Tumors
A. Hepatocellular carcinoma: It's a very common liver tumor.
A. It is most associated with liver cirrhosis and Chronic hepatitis
B. Increased AFP level in the blood
C. In adult it is Hepatoma.
D. In child Hepato- Blastoma.

137. Sonographic appearances
i. May solitary mass ,
ii. Mass with satellite lesion
iii. Multiple nodules
iv. Diffuse infiltration
v. Small , hypoechoic , solid , homogenous nodule with halo sign
vi. Large heterogenous mass (due to hemorrhage)
vii. Increased vascularity
viii. IVC invasion

139. HCC

141. HCC

144. Halo sign

145. Fibrolamellar carcinoma
Fibrolamellar hepatocellular carcinoma, is a rare primary malignant neoplasm of the liver
that constitutes ۰.8-16% of all hepatocellular malignancies.
It typically affects persons between 5 and 35 years, but there appears to be 2 peak
incidences, at age 10-30 years and at 70-79 years

146. Fibrolamellar carcinoma
a. Sonographic appearance
b. Large , lobulated well defined mass
c. Mix echogenicity
d. NO Hemorrhage , metastasis
e. Differential dx FNH

147. Fibrolamellar carcinoma

148. Fibrolamellar carcinoma in child

149. Cholangiocarcinoma
Cholangiocarcinoma, or bile duct cancer, is a rare form of cancer. It often affects older
adults and has usually spread beyond the bile ducts by the time it’s diagnosed.

150. Sonographic Appearance
1. Echogenic/hypoechoic infiltration

152. Distal cholangiocarcinoma

154. Liver Sarcoma
primary hepatic sarcomas do occur, more commonly in children, and can arise from any type
of connective tissue, including smooth muscle, liver mesenchymal cells, and fatty tissue.

155. Liver Sarcoma

156. Liver Sarcoma

157. Liver Sarcoma

158. ‫نکت‬
‫ه‬
‫تشخیص‬
‫تفریقی‬
‫بین‬
‫تمورهای‬
‫کبدی‬
‫ب‬
‫راساس‬
‫معاینات‬
‫بیوپسی‬
‫و‬
‫هستوپاتولوژی‬
‫صو‬
‫رت‬
‫می‬
‫گرد‬
‫نه‬
‫براساس‬
‫معاینات‬
‫سنوگرافی‬
.
‫نکـــــته‬

159. Liver Metastases
1. The liver is one of the most common sites of metastases, and liver metastases are
more common than primary liver cancers. A large number of malignancies—including
cancers of the:
1. gastrointestinal system (eg, colorectum, stomach, pancreas, biliary)
2. genitourinary system (eg, kidney, prostate)
3. gynecologic system (eg, ovary, endometrium, cervix)
4. neuroendocrine system, and breast; soft-tissue sarcomas;
5. melanomas; and lymphoma to metastasize to the liver

160. L - M

161. L - M

163. bull's eye sign

164. What is this …?

165. What is this …?

166. What is this …?

167. ‫دعا‬ ‫التماس‬
!
‫روح‬ ‫به‬ ‫آنچه‬
‫انسان‬
‫همانا‬ ‫بخشد‬‫می‬ ‫آرامش‬
‫علم‬
‫بس‬ ‫و‬ ‫است‬
.
»
«
‫دانش‬ ‫فقط‬ ،‫کند‬‫می‬ ‫پاک‬ ‫آالیش‬ ‫از‬ ‫را‬ ‫قلب‬ ‫و‬ ‫مغز‬ ‫آنچه‬
‫است‬
.
Presentation title 167

168. Thank you
Dr. Sayeed Hashim
Hashimi Nezhad