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Liver ultrasound


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Liver ultrasound

  1. 1. Liver ultrasoundLiver ultrasound ByBy Dr. Tarek MansourDr. Tarek Mansour Faculty of medicineFaculty of medicine Al-Azhar universityAl-Azhar university
  2. 2.  Normal liver.Normal liver.  Doppler of hepatic vessels.Doppler of hepatic vessels.  Diffuse liver diseases pattern.Diffuse liver diseases pattern.  Portal hypertension.Portal hypertension.  Focal liver masses.Focal liver masses.
  3. 3. Liver techniqueLiver technique  Always clear 2-3 cmAlways clear 2-3 cm beyond the margin ofbeyond the margin of any organ to avoidany organ to avoid exophytic or adjacentexophytic or adjacent masses.masses.
  4. 4. Normal liverNormal liver  SizeSize  ShapeShape  EchogenicityEchogenicity  EchotextureEchotexture  TechniqueTechnique - smooth TGC- smooth TGC - diaphragm- diaphragm - vessel lumen- vessel lumen - clear all margins- clear all margins
  5. 5. Parenchymal organ echogenicityParenchymal organ echogenicity  Renal medulla < renal cortex < liverRenal medulla < renal cortex < liver  Liver < spleenLiver < spleen  Liver < pancreas.Liver < pancreas.  Pancreas < renal sinus & retro. fatPancreas < renal sinus & retro. fat
  6. 6.  Sonographically theSonographically the vessels seen visiblevessels seen visible within the liverwithin the liver parenchyma are hepaticparenchyma are hepatic and portal veins.and portal veins.  Hepatic arteries and bileHepatic arteries and bile ducts not seen unlessducts not seen unless abnormally dilated butabnormally dilated but seen in porta hepatis.seen in porta hepatis.
  7. 7. Portal veinsPortal veins  Echogenic (bright) wallsEchogenic (bright) walls - used for evaluation- used for evaluation of evaluation of liverof evaluation of liver parenchyma.parenchyma.  Enter the liver through portaEnter the liver through porta hepatis.hepatis.  Largest portal vein divide inLargest portal vein divide in the middle of liver.the middle of liver.  More horizontally oriented.More horizontally oriented.  Pass within lobes andPass within lobes and segments.segments.  Flow into liver.Flow into liver.
  8. 8. Portal veinPortal vein Reasons for bright wallsReasons for bright walls  Portal triadPortal triad -Portal vein-Portal vein -Hepatic artery-Hepatic artery -Bile duct-Bile duct  Glisson's capsuleGlisson's capsule  Lymphatic nerves.Lymphatic nerves.  Connective tissueConnective tissue
  9. 9. Hepatic veinsHepatic veins  Imperceptible margins.Imperceptible margins.  Enlarge toward the IVC.Enlarge toward the IVC.  More vertically oriented.More vertically oriented.  Umbrella configuration.Umbrella configuration.  Runs between lobes andRuns between lobes and segments.segments.  Used as anatomic divider ofUsed as anatomic divider of the liver.the liver.  Flow out the liverFlow out the liver
  10. 10. Transverse liver scanTransverse liver scan Anatomic landmarkAnatomic landmark  Upper: large hepatic veinsUpper: large hepatic veins joint IVCjoint IVC  Mid: large central portal veinsMid: large central portal veins (left higher than right).(left higher than right).  Lower:Lower: -No large veins.-No large veins. -Falciform ligament-Falciform ligament -Ligamentum teres.-Ligamentum teres.
  11. 11. Ligamentum teresLigamentum teres  Obliterated fetal reminant ofObliterated fetal reminant of the umbilical vein in thethe umbilical vein in the fissure for ligamentum teres.fissure for ligamentum teres.  Joins the umbilical segmentJoins the umbilical segment of the left portal vein.of the left portal vein.  May recanalize in portalMay recanalize in portal hypertension.hypertension.  Not to be mistaken for aNot to be mistaken for a mass or calcium.mass or calcium.  Divides left lobe.Divides left lobe.
  12. 12. Ligamentum venosumLigamentum venosum  The obliterated fetalThe obliterated fetal reminant of ductusreminant of ductus venosus.venosus.  Lie within fissure forLie within fissure for ligamentum venosus.ligamentum venosus.  Does not recanalize inDoes not recanalize in adults.adults.  Separates the left lobeSeparates the left lobe from caudate lobe.from caudate lobe.
  13. 13. Caudate lobeCaudate lobe  Caudate means tail.Caudate means tail.  Functionally autonomous segment, spared inFunctionally autonomous segment, spared in liver diseases.liver diseases.  Blood supply from RT and LT portal vein.Blood supply from RT and LT portal vein.  Dian direct to IVC.Dian direct to IVC.  Pseudomass.Pseudomass.
  14. 14. Enlarged caudate lobeEnlarged caudate lobe  Caudate is enlarged whenCaudate is enlarged when the caudate to right lobethe caudate to right lobe ratio is > 0.65ratio is > 0.65
  15. 15. Hepatic and portal veinsHepatic and portal veins  Basis of modern lobar andBasis of modern lobar and segmental anatomy.segmental anatomy.  Hepatic veins drainHepatic veins drain peripherallyperipherally -Interlobar,-Interlobar, intersegmental.intersegmental. -Used as dividers.-Used as dividers.  Portal veins feed centrally.Portal veins feed centrally. -Intralobar,-Intralobar, intrasegmentalintrasegmental -Used to name-Used to name segments.segments.
  16. 16. Hepatic veins (anatomic dividers)Hepatic veins (anatomic dividers)  MHV divide the liverMHV divide the liver into right and left lobes.into right and left lobes.  RHV divide the rightRHV divide the right lobe into anterior andlobe into anterior and posterior segments.posterior segments.  LHV divide the left lobeLHV divide the left lobe into medial and lateralinto medial and lateral segments (cranially).segments (cranially).
  17. 17. Portal vein define segmentsPortal vein define segments  Feed the segments.Feed the segments.  Define the segments.Define the segments.  Name the segments.Name the segments.
  18. 18. Division of main portal veinDivision of main portal vein  On coronal scan dividesOn coronal scan divides the liver into superiorthe liver into superior and inferior.and inferior.  On axial scan divides theOn axial scan divides the liver into anterior andliver into anterior and posterior.posterior.
  19. 19. Anatomic liver segmentsAnatomic liver segments caudate lobecaudate lobe Segment ISegment I Lateral segment left lobeLateral segment left lobe superiorsuperior SegmentSegment IIII Lateral segment left lobeLateral segment left lobe inferiorinferior SegmentSegment IIIIII Medial segment left lobeMedial segment left lobe SegmentSegment IVIV Anterior segment rightAnterior segment right lobe inferiorlobe inferior SegmentSegment VV Posterior segment rightPosterior segment right lobe inferiorlobe inferior SegmentSegment VIVI Posterior segment rightPosterior segment right lobe superiorlobe superior SegmentSegment VIIVII Anterior segment rightAnterior segment right lobe superiorlobe superior SegmentSegment VIIIVIII
  20. 20. Main portal vein: normal dopplerMain portal vein: normal doppler  Continuous, forward flow.Continuous, forward flow.  Low velocity (15-28 cm/sec.)Low velocity (15-28 cm/sec.)  Hepatopetal flow.Hepatopetal flow.  Undulating patternUndulating pattern -Respiratory variation-Respiratory variation -Increase flow on inspiration.-Increase flow on inspiration.  May reflect cardiac variation.May reflect cardiac variation.  Slightly turbulent.Slightly turbulent.  Location between two capillaryLocation between two capillary beds (mesenteric & hepatic).beds (mesenteric & hepatic).
  21. 21.  Normal portal venous flow directionNormal portal venous flow direction and waveform. Drawing at topand waveform. Drawing at top illustrates that the direction of flow inillustrates that the direction of flow in normal portal veins is antegrade, ornormal portal veins is antegrade, or hepatopetal, which corresponds to ahepatopetal, which corresponds to a waveform above the baseline atwaveform above the baseline at spectral Doppler US. Normal phasicityspectral Doppler US. Normal phasicity may range from low (bottom left) tomay range from low (bottom left) to high (bottom right). Abnormally lowhigh (bottom right). Abnormally low phasicity results in a nonphasicphasicity results in a nonphasic waveform, whereas abnormally highwaveform, whereas abnormally high phasicity results in a pulsatilephasicity results in a pulsatile waveform. The PI is used to quantifywaveform. The PI is used to quantify pulsatility. Normal phasicity results in apulsatility. Normal phasicity results in a PI greater than 0.5.PI greater than 0.5.
  22. 22. Main portal vein: abnormal dopplerMain portal vein: abnormal doppler  Pulsatile flow is abnormalPulsatile flow is abnormal - May resemble HV pulsatility.- May resemble HV pulsatility. - Increase right heart pressure.- Increase right heart pressure. - Transmitted pressure through- Transmitted pressure through intrahepatic sinusoids.intrahepatic sinusoids. - Tricuspid regurgitation.- Tricuspid regurgitation. - Moderate to sever right heart- Moderate to sever right heart failure, pericarditis.failure, pericarditis.  Exception: child, young persons.Exception: child, young persons.
  23. 23.  Spectral Doppler US imageSpectral Doppler US image shows a pulsatile waveformshows a pulsatile waveform with flow reversal in the rightwith flow reversal in the right portal vein. The waveformportal vein. The waveform may be systematicallymay be systematically characterized ascharacterized as predominantly antegrade,predominantly antegrade, pulsatile, biphasic-pulsatile, biphasic- bidirectional, and di-bidirectional, and di- inflectional.inflectional.
  24. 24.  Slow portal venous flow. SpectralSlow portal venous flow. Spectral Doppler US image shows slowDoppler US image shows slow flow in the main portal vein. Slowflow in the main portal vein. Slow portal venous flow is aportal venous flow is a consequence of portalconsequence of portal hypertension. In this case, the peakhypertension. In this case, the peak velocity is 9.0 cm/sec, which isvelocity is 9.0 cm/sec, which is well below the lower limit ofwell below the lower limit of normal (16–40 cm/sec). Althoughnormal (16–40 cm/sec). Although portal hypertension may cause aportal hypertension may cause a pulsatile-appearing waveform aspulsatile-appearing waveform as seen in this case, the slow flowseen in this case, the slow flow helps differentiate this conditionhelps differentiate this condition from hyperpulsatile high-velocityfrom hyperpulsatile high-velocity states such as CHF and tricuspidstates such as CHF and tricuspid regurgitation.regurgitation.
  25. 25.  Normal and abnormal portalNormal and abnormal portal venous phasicity. Images show avenous phasicity. Images show a spectrum of increasing pulsatilityspectrum of increasing pulsatility (bottom to top). Note that(bottom to top). Note that increasing pulsatility correspondsincreasing pulsatility corresponds to a decrease in the calculated a decrease in the calculated PI. Although normal phasicity rangesAlthough normal phasicity ranges widely in the portal veins, the PIwidely in the portal veins, the PI should be greater than 0.5 (middleshould be greater than 0.5 (middle and bottom). When the PI is lessand bottom). When the PI is less than 0.5 (top), the waveform maythan 0.5 (top), the waveform may be called pulsatile; this is anbe called pulsatile; this is an abnormal finding.abnormal finding.
  26. 26.  Hepatofugal portal venousHepatofugal portal venous flow. Spectral Doppler USflow. Spectral Doppler US image shows retrogradeimage shows retrograde (hepatofugal) flow in the(hepatofugal) flow in the main portal vein, a findingmain portal vein, a finding that appears blue on thethat appears blue on the color Doppler US image andcolor Doppler US image and is displayed below theis displayed below the baseline on the spectralbaseline on the spectral waveform. Hepatofugal flowwaveform. Hepatofugal flow is due to severe portalis due to severe portal hypertension from any cause.hypertension from any cause.
  27. 27. Hepatic artery: normal dopplerHepatic artery: normal doppler  Rapid systolicRapid systolic accelerationacceleration  Continuous forward flowContinuous forward flow throughout cardiac cyclethroughout cardiac cycle - Low impedance.- Low impedance.  Same direction as MPV.Same direction as MPV.  RI = 0.5-0.7RI = 0.5-0.7
  28. 28.  Schematics show a spectrum ofSchematics show a spectrum of increasing hepatic arterialincreasing hepatic arterial resistance (bottom to top). Theresistance (bottom to top). The hepatic artery normally has lowhepatic artery normally has low resistance (RI = 0.55–0.7) (middle).resistance (RI = 0.55–0.7) (middle). Resistance below this rangeResistance below this range (bottom) is abnormal. Similarly,(bottom) is abnormal. Similarly, any resistance above this rangeany resistance above this range (top) may also be abnormal. High(top) may also be abnormal. High resistance is less specific for diseaseresistance is less specific for disease than is low resistance.than is low resistance.
  29. 29. Hepatic veins: normal dopplerHepatic veins: normal doppler  Toward IVC and heart.Toward IVC and heart.  Away from transducerAway from transducer (blue).(blue).  Characteristic pulsatileCharacteristic pulsatile flow.flow.
  30. 30.  Diagram illustrates normal hepaticDiagram illustrates normal hepatic venous flow direction and waveform.venous flow direction and waveform. The direction of normal flow isThe direction of normal flow is predominantly antegrade, whichpredominantly antegrade, which corresponds to a waveform that iscorresponds to a waveform that is mostly below the baseline at spectralmostly below the baseline at spectral Doppler US. The term triphasic, whichDoppler US. The term triphasic, which refers to therefers to the aa,, SS, and, and DD inflectioninflection points, is commonly used to describepoints, is commonly used to describe the shape of this waveform; accordingthe shape of this waveform; according to D.A.M., however, this term is ato D.A.M., however, this term is a misnomer, and the termmisnomer, and the term tetrainflectionaltetrainflectional is more accurate, since it includes theis more accurate, since it includes the vv wave and avoids inaccurate phasewave and avoids inaccurate phase quantification. Normal hepatic venousquantification. Normal hepatic venous waveforms may be biphasic (bottomwaveforms may be biphasic (bottom left) or tetraphasic (bottom right).left) or tetraphasic (bottom right).
  31. 31. Hepatic veins: normal dopplerHepatic veins: normal doppler  Reflects respiratory phases.Reflects respiratory phases.  Reflects variations in centralReflects variations in central venous pressure transmittedvenous pressure transmitted from RV.from RV.  Reflect compliance of liverReflect compliance of liver parenchyma.parenchyma.  Triphasic pattern.Triphasic pattern.  Deep respiration or valsalvaDeep respiration or valsalva reduce pulsatility of wavereduce pulsatility of wave form in normals.form in normals.
  32. 32. Hepatic veins: abnormal dopplerHepatic veins: abnormal doppler  Non triphasic flowNon triphasic flow - Elevated right heart- Elevated right heart pressure.pressure.  Decrease pulsatility orDecrease pulsatility or amplitude of phasicamplitude of phasic oscillation.oscillation. - Loss or reversed phase.- Loss or reversed phase.  Monophasic abnormal.Monophasic abnormal. - Flattened wave form.- Flattened wave form. - Resemble PV flow.- Resemble PV flow. - Stiff, non compliant liver.- Stiff, non compliant liver.
  33. 33.  Decreased hepatic venous phasicity.Decreased hepatic venous phasicity. Diagrams illustrate varying degrees ofDiagrams illustrate varying degrees of severity of decreased phasicity in theseverity of decreased phasicity in the hepatic vein. Farrant and Meire (5) firsthepatic vein. Farrant and Meire (5) first described a subjective scale fordescribed a subjective scale for quantifying abnormally decreasedquantifying abnormally decreased phasicity in the hepatic veins, a findingphasicity in the hepatic veins, a finding that is most commonly seen inthat is most commonly seen in cirrhosis. The key to understanding thiscirrhosis. The key to understanding this scale lies in observing the position ofscale lies in observing the position of thethe aa wave relative to the baseline andwave relative to the baseline and peak negativepeak negative SS wave excursion. As thewave excursion. As the distance between thedistance between the aa wave and peakwave and peak negative excursion decreases, phasicitynegative excursion decreases, phasicity is more severely more severely decreased.
  34. 34. Sonographic liver patternSonographic liver pattern  NormalNormal  CentrilobularCentrilobular  Fatty-fibroticFatty-fibrotic
  35. 35. Centri-lobular patternCentri-lobular pattern  Decrease echogenicity ofDecrease echogenicity of liver parenchyma.liver parenchyma.  Starry night appearance.Starry night appearance.  Increase visualization of PVIncrease visualization of PV wallwall - Increased brightness.- Increased brightness. - Increased number.- Increased number.  Causes: acute hepatitis, acuteCauses: acute hepatitis, acute RT side HF,RT side HF, leukemia/lymphoma, toxicleukemia/lymphoma, toxic shock, 2% of normal.shock, 2% of normal.
  36. 36. Fulminant hepatic failureFulminant hepatic failure  Liver necrosisLiver necrosis  Starry night appearanceStarry night appearance (acute, edema, necrosis).(acute, edema, necrosis).  Hyperechoic areasHyperechoic areas (normal or regenerated).(normal or regenerated).
  37. 37. Fatty fibrotic patternFatty fibrotic pattern  Increased echogenicity ofIncreased echogenicity of liver parenchyma.liver parenchyma.  Decreased definitions of PVDecreased definitions of PV walls.walls.  EchotextureEchotexture - Homogeneous (fine)- Homogeneous (fine) - Heterogeneous (coarse).- Heterogeneous (coarse).  Posterior sound attenuation.Posterior sound attenuation.  Causes: fatty infiltration,Causes: fatty infiltration, chronic hepatitis, cirrhosis,chronic hepatitis, cirrhosis, acute alcoholic hepatitis.acute alcoholic hepatitis.
  38. 38. Fatty fibrotic patternFatty fibrotic pattern EchotextureEchotexture  homogeneoushomogeneous  heterogeneousheterogeneous
  39. 39. Fatty liverFatty liver  Posterior soundPosterior sound attenuation.attenuation.  Enlarged liver.Enlarged liver.  Tend to have fineTend to have fine homogeneoushomogeneous echotexture.echotexture.
  40. 40. Focal fatty liver changesFocal fatty liver changes  Focal fatty liverFocal fatty liver infiltration.infiltration.  Focal fatty sparingFocal fatty sparing
  41. 41. Liver cirrhosisLiver cirrhosis  Fatty fibrotic patternFatty fibrotic pattern - Heterogeneous texture- Heterogeneous texture (coarse).(coarse). - Almost no posterior- Almost no posterior attenuation.attenuation.  Shrunken liver.Shrunken liver.  Nodular surface.Nodular surface.  Elevated caudate to rightElevated caudate to right lobe ratio (> 0.73 has 99%lobe ratio (> 0.73 has 99% specificity for cirrhosis).specificity for cirrhosis).
  42. 42. Liver cirrhosisLiver cirrhosis  Accounts for > 90% of allAccounts for > 90% of all portal hypertension.portal hypertension.  Distorted liver architecture.Distorted liver architecture. - Fibrosis.- Fibrosis. - Regenerating nodules.- Regenerating nodules. - Distorted vascular- Distorted vascular channelschannels
  43. 43. Portal hypertensionPortal hypertension  Increase hepaticIncrease hepatic resistance.resistance.  Increase portal venousIncrease portal venous pressure.pressure.  Eventually decreaseEventually decrease portal flow.portal flow.  Reversed portal flowReversed portal flow prognostication for riskprognostication for risk of hemorrhage.of hemorrhage.
  44. 44. Portal hypertensionPortal hypertension Sonographic signsSonographic signs  Ascites.Ascites.  Dilated MPV, SV, SMV.Dilated MPV, SV, SMV.  Collateral.Collateral.  Splenomegaly.Splenomegaly.  Various doppler findings.Various doppler findings.
  45. 45. Collateral veinsCollateral veins  Gastroesophageal.Gastroesophageal.  Coronary.Coronary.  Umbilical.Umbilical.  Gastrosplenic.Gastrosplenic.  Splenorenal /Splenorenal / gastrorenal.gastrorenal.  Perisplenic.Perisplenic.  Intestinal (rectum).Intestinal (rectum).  Retroperitoneal.Retroperitoneal.
  46. 46. Portal hypertensionPortal hypertension collateral vesselscollateral vessels
  47. 47. Doppler in portal hypertensionDoppler in portal hypertension  Portal vein:Portal vein: - Loss or respiratory- Loss or respiratory variation.variation. - Decrease velocity of MPV.- Decrease velocity of MPV. - Hepatofugal (reversed) flow.- Hepatofugal (reversed) flow.  Hepatic veins:Hepatic veins: - Loss of normal pulsatility.- Loss of normal pulsatility. - Non triphasic flow.- Non triphasic flow. - Flattened wave.- Flattened wave.  Hepatic arteries:Hepatic arteries: - Enlarged hepatic arteries.- Enlarged hepatic arteries.
  48. 48. Focal liver massesFocal liver masses  US is excellent in detecting focal liver lesions.US is excellent in detecting focal liver lesions.  US is specific for liver cysts > 1 cm.US is specific for liver cysts > 1 cm.  Not good in differentiating among pathologic entities.Not good in differentiating among pathologic entities.  No good in distinguishing between benign andNo good in distinguishing between benign and malignant lesions.malignant lesions.  Triphasic study of the lesions by CT and MRI areTriphasic study of the lesions by CT and MRI are excellent.excellent.  US is very helpful in diagnosis, follow up and guidanceUS is very helpful in diagnosis, follow up and guidance biopsy.biopsy.
  49. 49. Simple cystic lesions.Simple cystic lesions.  Cyst.Cyst.  Old hematoma.Old hematoma.  Abscess (hydatid).Abscess (hydatid).  Biloma / seroma.Biloma / seroma.  Vascular:Vascular: - Aneurysm- Aneurysm - Fistula.- Fistula.
  50. 50. Multiple cystic lesionsMultiple cystic lesions  Polycystic liver.Polycystic liver.  EchinococcosesEchinococcoses (hydatid).(hydatid).  Choledochal cysts (typeCholedochal cysts (type 5).5).
  51. 51. Choledochal cystsCholedochal cysts
  52. 52. Complex cystic lesions.Complex cystic lesions.  Hemorrhagic cyst.Hemorrhagic cyst.  Infected cyst.Infected cyst.  HematomaHematoma  Abscess.Abscess.  Biloma/ seroma.Biloma/ seroma.  Biliary cystadenoma.Biliary cystadenoma.  Cystic or necroticCystic or necrotic malignant lesion.malignant lesion.
  53. 53. Liver abscessLiver abscess Difficult in diagnosis.Difficult in diagnosis.
  54. 54. Hypoechoic liver massesHypoechoic liver masses Benign.Benign.  Abscess.Abscess.  Adenoma.Adenoma.  Focal nodularFocal nodular hyperplasia.hyperplasia.  Hemangioma.Hemangioma.  Microabscesses.Microabscesses.  Focal fatty sparing.Focal fatty sparing. Malignant.Malignant.  Metastases.Metastases.  HepatocellularHepatocellular carcinoma.carcinoma.  Lymphoma.Lymphoma.
  55. 55. Hyperechoic liver massesHyperechoic liver masses Benign.Benign.  Hemangioma.Hemangioma.  Abscess.Abscess.  Adenoma.Adenoma.  Focal nodularFocal nodular hyperplasia.hyperplasia.  Hemorrhagic cyst.Hemorrhagic cyst.  Focal fat infiltrate.Focal fat infiltrate. Malignant.Malignant.  Metastases.Metastases.  HepatocellularHepatocellular carcinoma.carcinoma.  Lymphoma.Lymphoma.
  56. 56. Characteristic lesionsCharacteristic lesions  Focal nodularFocal nodular hyperplasiahyperplasia  HemangiomaHemangioma
  57. 57. Characteristic lesionsCharacteristic lesions  Echinococcous cystEchinococcous cyst
  58. 58. Complication of metastases.Complication of metastases.  Biliary obstruction.Biliary obstruction.  Vascular invasion (portalVascular invasion (portal thrombosis).thrombosis).  Necrosis.Necrosis.  Hemorrhage.Hemorrhage.  Infection.Infection.
  59. 59. Thank youThank you