Abdominal Ultrasound: Liver Flashcards

Connects the liver to the anterior diaphragm and the anterior abdominal wall.

homogeneous

Renal sinus > Pancreas > spleen > renal cortex

lies anterior

The bare area comes in direct contact with the diaphragm

congenital variant extension of the right lobe of the liver beyond the lower pole of the right kidney.

It can be mistaken for hepatomegaly

20 cm / 15 cm

division of the liver longitudinally

transverse division of the liver

Left Medial superior

Left lateral superior

Left lateral inferior

Left medial inferior

Right anterior inferior

Right posterior inferior

Right posterior superior

Right anterior superior

right hypochondriac

epigastrium

Left hypochondriac to the left mammary line

Glisson's capsule

Fibrous peritoneum - covers all but bare area

medial / lateral

posterior / anterior

portal veins - 80%

Hepatic arteries - 20%

sits on the mesentery

anterior to the portal hepatis

ligament terres and the gallbladder fossa.

left portal vein

hepatic artery

branches of the left portal vein

branches of the right portal vein

small veins to the IVC

Celiac axis

umbilical vein

ductus venosum

IVC

heart

ligament teres

ligament venosum

recanalization of the ligament teres

they lie in fibrofatty tracks

runs long outside of falciform ligament?

round ligament

ligament teres

MPV kisses the IVC

courses superiorly toward the right then posteriorly at the liver hylum

Main lobar fissure

Rt intersegmental fissure

Right hepatic vein

Left hepatic vein

Left Portal Vein

Ligamentum Teres

Lt Intersegmental fissure

ligament venosum

less than 13 mm

cirrhosis

portal hypertension

separates the right liver lobe into anterior and posterior sections

caudate from the medial left lobe

separates the medial left lobe from the lateral left lobe.

metabolism

detoxification

storage

gluconeogenesis

glucolysis

hepatocytes are affected

treated medically

surgically

liver metabolism

chemical process that occur in the body that are necessary for matenance of life

catabolic - meow

anabolism - build

catobolized to glucose to use as energy

sent to the liver

converted to glycogen

stored

liver converts glycogen back to glucose

liver disease

converted by hepatocytes to lipoproteins

fats broken down to monoglycerides and diglycerides

they are soluble in plasma and may be transported by the blood.

liver converts them to glucose and cholesterol

they are unable to convert to lipoproteins

instead are converted to triglycerides

they are not soluble so they get stuck in the liver

FATTY LIVER disease

Prothrombin time - the amount of time it takes for blood to clot

partial thromboplastin is the time it takes for plasma to clot

disease condition of cogulation

No

not enough albumin

edema & ascites

portal hypertension

they are converted to amino acids then sent to the liver

makes proteins

important protein produced in large quantities in the liver.

vascular fluid pressure

ADEK

The liver

fibrinogen

prothrombin

factors V, VII, IX, X

check labs for

PT

PTT

INR

international normalized ratio

only used when the patient is taking blood thinner

precursor to the production of factors V, VII, IX, X

No K no factors V, VII, IX, X, No clotting

True

inadequate coagulation which results in uncontrolable hemorrhage.

Bile emulsifies fat

No bile = no fat will be broken down

if fat is not broken down, fat soluble vitamins are not absorbed (K)

No K = No clotting factor.

True

detection of liver disease

when hepatocytes are damaged hepatic enzymes leak into the blood and can be detected with lab tests.

toxic byproduct of nitrogen metabolism

toxic levels will rise

Ex. Ammonia NH4

it is converted to urea then sent to then excreted by the kidneys

Fetor Hepaticus

fruity breath

confusion

coordination loss

coma

tremor

BUN

creatin

Blood Urea Nitrogen

drug dosages may need to be lowered because they are not removed by the liver

hormones rise

liver can't break down estrogen

gynecomastia

testicular atrophy

water

bile salts

bile pigments

cholesterol

lecithin

protein

AST

ALT

LDH

Alkaline Phosphatase

Bilirubin (direct, indirect, total)

Prothrombin time

Albumin & Globlins

AST

present in tissue but only released in blood when tissue is damaged

SGOT

Acute hepatitis

Cirrhosis

Infectious Mononucleosis

Infectious Mononucleosis

True

AST is non specific

it can be produced by any organ with a high metabolism rate.

ALT

tends to be used to monitor patients after jaundice has occured

liver specific

acute cirrhosis

hepatic metastasis

pancreatis

obstruction

hepatocellular disease

toxic hepatitis

LDH

present in tissue but not released unless there has been cell death or damage

detects heart attacks

elevated in myocardial infarction & pulmonary infarction

obstruction caused by gallstones

fast for at least 6 hours

The sonographer should explain to the patient that the exam is being performed to visualize the liver and interdependent organs.

The patient should remove any restrictive clothing above the waist. A towel should be tucked around clothing to protect them from gel.

3.25 MHz sector or curved linear array.

2.25 MHz sector or curved linear array.

5.0 MHz sector or curved linear array.

7.4 MHz sector or curved linear array.

Begin doing a full sweep through the liver. Starting sagittal, slightly to the left of midline. Change to a transverse view and sweep up and down the left lobe from a subcostal approach. Look in transverse through the right lobe subcostally or intercostally.
Look for:

• Parenchymal echogenicity
• Capsular contour (smooth, coarse, lobulated)
• Size
• Vascularity
• Fluid
• Masses

Start taking images.
Document the normal anatomy and any pathology found, including measurements and vascularity if indicated.

Sex

Age

Weight

Prior Hepatic Conditions

Family History of Hepatic Conditions

Supine
left lateral decubitus, left posterior oblique, semi-erect, or prone may be used as necessary

Sagittal and Transverse

The transducer may be swept under the intercostal margin to image the liver parenchyma from the anterior abdominal wall to the diaphragm.

The transducer should be angled in a steep cephalic direction to be as parallel to the diaphragm as possible. The transverse plan allows images of liver parenchyma, vascularity and ductal structures.

Deep inspiration and held.

Push belly out.

Alternate positions can be used to displace the bowel out of the field of view.

Place right arm above head to open intercostal spaces

The liver is the largest internal organ. It lies in the right upper quadrant, from the right hypochondria, extending through the epigastrum to the mammary line of the left hypochondria. Generally it lies from the diaphragm to the level of the 8th rib. Size and shape is variable. The liver is covered by the Glisson’s capsule (fibrous peritoneum), except for the bare area that is in contact with the diaphragm. The liver is dived into four lobes.

further divided into lateral and medial segments by the left intersegmental fissure.

divided from the left lobe by the main lobar fissure which passes from the gallbladder fossa to the inferior vena cava. The right lobe is further divided into anterior and posterior segments by the right intersegmental fissure.

found on the inferior, posterior side of the liver. The caudate lobe is bordered by the inferior vena cava posteriorly and the ligament venosum anteriorly. The hepatic veins run between the lobes and segments. The portal veins run centrally within the segments. The ascending portion of the left portal runs in the left intersegmental fissure.

also called the Quadrate lobe, is bordered by the porta hepatis posteriorly, laterally by the gallbladder fossa and ligament terres.

Jaundice
Fatigue
Bruises
Nausea
Vomiting
Abdominal pain
Abnormal tenderness
Anorexia
Weight loss

Decreased appetite

Dark urine
Diarrhea
Blood in stool
Edema
Persistent fever
Bronze skin
Encephalopathy
Pruritus

Cholecystectomy

Congestive heart failure
Palpable mass
Tremors
Bloating
Swelling in the abdomen
Respiratory Infections

When was the last time you had something to eat or drink?

Are you in pain?

Where is your pain located?

How long have you been in pain?

How long does the pain last and does it go away?

Have you had a nausea or vomiting?

Are you experiencing any other symptoms?

Do you have a family history of cancer?

Have you had any lab work done?

Sagittal
Left lobe (wedge)
Left lobe W/ caudate lobe
Left lobe W/ aorta
Right lobe W/ IVC
Right lobe W/ dome
Right lobe W/ Morrison’s pouch
Liver/kidney comparison
Right lobe W/ gallbladder

Transverse
Left lobe (wedge)
Left lobe W/ portal vein
Left lobe W/ ligament teres
Right lobe W/ hepatic veins, IVC
Right lobe W/ dome
Right lobe W/ portal veins
Right lobe W/ kidney and gallbladder

Other Images
Transverse Pancreas
-head to tail
Abnormal findings
-Color Doppler
-Measurements
Measurements
-right lobe if indicate

Riedel’s lobe

Absence of left lobe

Multiple sizes

Multiple shapes

Liver size may be measured sagittal from the inferior tip of the liver to the dome

Length: 20 cm

Anterior Posterior: 15 cm

C/RL: <0.6

Obesity

The patient ate before the study

Metabolic disorders such as fatty infiltration will reduce detail

Shadowing

Gas

Aspartate aminotransferase (AST): 5 – 40 units per liter of serum
Alanine aminotransferase (ALT): 7 – 56 units per liter of serum
Lactic acid dehydrogenase (LDH): 122 – 222 U/L
Alkaline phosphatase (alk phos): 45 – 115 U/L
Bilirubin: 0.1 – 1.0 mg/dL
-Indirect: 0.2-0.7 mg/dL
-Direct: 0 – 0.3 mg/dl
-Total: 0.1 – 1.2 mg/dl
Prothrombin time: 9.5 – 13.8 seconds
Albumin: 3.5 – 5 g/dL
Globulins: 13.5 – 16.5

White blood count (WBC): 4,500 – 10,000

Red blood count (RBC): 4.5 – 5.5

Hemoglobin (hbg): 13.5 – 16.5

Hct: 41 – 50

Creatine: 0.5 – 1.4 mg/dl

Cholesterol: <200 mg/dl

Glucose: 60-110 mg/dl

Urinary bile and bilirubin: 1.2 mg/dl

Urinary urobilinogen: 0 – 8 mg/dl

Fecal urobilinogen: 57 to 200 mg./24 hours

Affects the hepatocytes and interferes with liver function

Increased echogenicity
Enlargement of affected area
Decreased penetration
Difficult to identify liver structures
Presentation: Asymptomatic, jaundice, nausea, vomiting and abnormal tenderness

Asymptomatic

jaundice

nausea

vomiting

abnormal tenderness

Abnormal Liver Function Test

Fatty liver is an acquired but reversible disorder of metabolism. Fatty filtration implies increased lipid accumulation in the hepatocytes.

Increased echogenicity
Increased echogenicity
Enlargement of the lobe.
Decreased penetration
Difficult to image
Increased echo texture

Asymptomatic

jaundice

nausea

vomiting

abnormal tenderness.

↑Hepatic Enzymes

↑Alk Phos

↑Direct Bilirubin

ETOH abuse

Diabetes Mellitis

Obsesity

steroids

Inflammatory and infectious disease of the liver caused by complications of liver damage. May be mild to severe.

Mild: Normal echogenicity
Slightly increased echogenicity
Echogenic portal radicals
Prominent portal walls
Hepatosplenomegaly
Thickened gallbladder wall

Asymptomatic

jaundice

nausea

vomiting

abnormal tenderness.

↑AST

↑ALT

↑Bilirubin

Leukopenia

Hepatitis becomes chronic when the inflammation lasts longer than 6 months.

Increased echogenicity
Hypoechoic portal triads.
Fibrosis
Soft posterior shadowing may be apparent.
Difficult to visualize liver structures

nausea

vomiting

anorexia

weight loss

tremors

jaundice

dark urine

fatigue

varicosities

↑AST

↑ALT

↑Bilirubin

Leukopenia

A chronic degenerative disease in which there is parenchymal necrosis, regeneration and fibrous tissue resulting in disorganization of lobular architecture. Lobules are infiltrated with fat. Commonly caused by alcoholism.

Hepatomegaly
Increased echogenicity and attenuation
Size decrease of right lobe
Size increase of left and caudate lobe
Nodularity
Fibrosis
Hepatospenomegaly
Ascites
Portal hypertension
Hepatoma tumors
caudate lobe may be spared

fatigue

bruises

jaundice

edema

dark urine

blood in stool

fever

Echogenic portal radicals

flatulence.

↑Alk Phos

↑Direct Bilirubin

↑AST

↑ALT

Leukopenia

Characterized by the abnormal storage and collection of glycogen in the tissue of the liver and kidneys. Most common type I – Von Gierke’s

Hepatomegaly
Increased echogenicity and attenuation
Hepatic adenomas
Focal nodular hyperplasia.
Round, homogenous, echogenic tumors

Non-Specific

Disturbances in Acid-Base Balance

This is a rare disease involving excess iron deposits. May lead to cirrhosis and portal hypertension

Hepatomegaly
Cirrhotic changes
Increased echogenicity

Bronze skin

↑Iron levels

This is an increase in portal venous pressure (above 10mmHg) or hepatic venous gradient (above 5mmHg).

Portal vein measures greater than 13mm
Collateral circulation
Flow reversal
Ascites
Hepatosplenomegaly

Gastrointestinal bleeding

blood in the stools

vomiting of blood

Encephalopathy

↑Liver Enzymes

↓Platelet Count

Portal Venous Thrombosis

Portal flow absence
echogenic thrombosis
Worm-like structures near porta hepatis

vague and non-specific

A rare disease which is caused by a thrombosis of the hepatic veins or IVC. Has a high mortality rate.

Ascites
Hepatomegaly
Enlarged caudate lobe
Atrophy of right lobe
Hyperechoic
Inhomogeneous
Fibrosis
Thick Gallbladder wall
Stenosis
Disrupted flow

non-specific

abdominal pain

asia

Albuminuria

↑Alk Phos

↑AFT

Proximal Biliary obstruction proximal to the cystic duct can be caused by gallstones.

Dilated intrahepatic ducts
Carcinoma in the CDB
Gallstones
Gallbladder normal after fatty meal

Jaundice

pruritus

↑Direct Bilirubin

↑Alk Phos

Biliary obstruction distal to the cystic duct

Stone in the common duct
Extrahepatic mass
Dilated intrahepatic ducts
Gallstones
Gallbladder usually small

Jaundice

pruritus

↑Direct Bilirubin

↑Alk Phos

A mass in the area of the porta hepatis

Stone in the common duct
Extrahepatic mass
Dilated intrahepatic ducts
Gallstones
Gallbladder usually small

Jaundice

pruritus

↑Direct Bilirubin

↑Alk Phos

Sonographic Appearance:

Common Duct Stricture

jaundice

past cholecystectomy

increase in direct bilirubin

↑Direct Bilirubin

↑Alk Phos

develops secondary to congestive heart failure.

Dilated IVC, SMV, Portal and Splenic veins

Hepatomegaly

congestive heart failure.

↑ LFT

A hepatic cyst is usually a solitary, non-parasitic cyst of the liver. solitary or multiple. More common in females.

Solitary or multiple
Thin well-defined walls
Anechoic
Posterior enhancement
Rarely fine, linear internal septa, Calcification

Asymptomatic

localized pain

A rare lesion that caused by developmental defects in the formation of bile ducts.

Usually solitary
Varying size
Thin well-defined walls
Anechoic
Posterior enhancement
Generally right lobe lesion

Very small cysts that range from .2 to 2.5 cm. They are most common in patients with severe liver disease.

clusters with a tubular appearance
thin septations that run parallel to the bile ducts and portal veins

This is an autosomal dominant genetic disease in which multiple small cysts cover the liver. 60% of patients with polycystic liver disease will have polycystic kidney disease.

Anechoic
Thin well-defined walls
Posterior enhancement
Multiple
Varying in small size

abdominal pain

bloating or swelling in the abdomen

feeling full

↑WBC

A pus-forming abscess caused by bacteria. The most common bacteria is Escherichia coli and anaerobes.

The most frequent organism causing the infection is Escherichia coli or anaerobes

Sonographic Appearance:
Varying size
hyperechoic
round or oval margins
Internal debris
Posterior enhancement
Shadowing
Presentation: fever, pain, pleutitis, nausea, vomiting, diarrhea. Elevated liver function tests, leukocytosis, and anemia. The most frequent organism causing the infection is Escherichia coli or anaerobes
Lab Values: ↑WBC, LFT

fever

pain

pleutitis

nausea

vomiting

diarrhea

↑WBC

LFT

This is caused by a type of Candida fungus usually in immunocompromised patients.

Multiple
small
bull’s-eyes or target lesions
Hypoechoic mass
echogenic core

persistent fever and localized pain

↑WBC

a genetic disorder in which phagocytes are unable to kill certain bacteria.

Sonographic Appearance:
Poor borders
hypoechoic mass
Posterior enhancement
Calcifications
shadowing

reoccurring respiratory infections

A collection of pus formed by disintegrated tissue. Primarily a disease of the colon

Hypoechoic
Ill-defined walls
Round or oval
Internal echoes
Posterior enhancement

asymptomatic

abdominal pain

diarrhea leukocytosis

fever.

↑Leukocytes

Infectious cystic disease common in sheep herders, a tapeworm that infects.

Simple
Complex cyst
Posterior enhancement
Round
oval
Calcifications
Septations
Water lily sign (cyst within cyst)

asymptomatic

abdominal pain

abnormal abdominal tenderness

hepatomegaly

abdominal mass

jaundice

fever

anaphylactic reaction

↑WBC

Benign congenital tumor of the liver. Most common and most frequent in females.

Hyperechoic
Posterior enhancement
Round, oval or lobulated
Well-defined walls
Mixed echogenicity from necrosis
Heterogeneous
Calcifications

RUQ pain

tumor of glandular epithelial tissue. More commonly in women taking oral contraceptives.

Sonographic Appearance:
Well defined
Hyperechoic with central hypoechoic area
Solitary
Multiple
Fluid may be present

RUQ pain

rare neoplasm in middle aged women

Multi – loculated lesion
mucinous fluid

palpable mass

...

This is the second most common benign liver mass in women over 40 years of age.

Sonographic Appearance:
Subtle contour abnormalities
Hyperechoic to linear areas
Multiple nodule

Asymptomatic

HCC - This is the most common primary malignant neoplasm.

Sonographic Appearance:
hepatomegaly
Appearance varies
Solitary
Multiple
Hypoechoic
Hyperechoic
Vessel with tumor invasion

palpable mass

appetite disorder

fever

↑alpha-protein test

Liver function test

↑Alk Phos

↑Direct Bilirubin

↑AST, ↑ALT

Leukopenia

This is the most common form of neoplastic involvement of the liver. The primary sites include colon, breast, and lung.

Appearance varies
Multiple nodes
Solitary
Well defined
Echogenic to hypoechoic mass
Homogenous
Calcification
Necrosis

jaundice

hepatomegaly

weight loss

decreased appetite

Abnormal LFT

This is a malignant neoplasm which involves a rapid increase of lymphocytes in the lymph nodes. Hodgkins, and Non-Hodgkins lymphoma.

hepatomegaly
Hypoechoic target lesions
Anechoic
Solid with no enhancement
Hepatosplenomegaly

abnormal LFTs

injury

Hyperechoic hematomas
Hyperechoic to anechoic
Unilateral fluid along laceration
Septations
varies

varies

A liver transplant is performed when other conventional and surgical methods have failed the patient. The most common reason for a transplant is cirrhosis.

Scans should be performed 24, 48, and biweekly post operative

Examine the portal venous system, hepatic arteries, the IVC, and parenchymal patterns
Examine the kidneys and the spleen
Asses the biliary system
Asses the vascular flow

hepatic arteries

...

Swollen lymph nodes

lymphadenopathy in multiple organs

tumor of the adrenal

densely reflective

reflective with central lucency from necrosis

cancer of blood

reflective with central lucency from necrosis