ULTRASOUND OF THE LIVER - Normal

 

For Upper Abdomen Protocol

 

For Liver Scanning Protocol

 

For Liver Function Tests explained

 

LIVER IMAGING

 

 Liver Segments  

Segmental Liver Anatomy

Liver Segmental Anatomy
Click the image to enlarge for a printable version.

 

 

PROBE POSITIONING TO SCAN THE LIVER

Rt Lobe Liver

 Parasagittal Scan Plane

Right Parasagittal Liver
Parasagittal Scan Plane
The Liver and Rt Kidney are visualised in this view.
 
 Intercostal Scan Plane  Intercostal Liver transverse
Intercostal Scan Plane
The Middle and Rt Hepatic Vein are visualised in this view.
  
 Subcostal Scan Plane  Subcostal Liver Transverse
Subcostal Scan Plane. The probe is angled cephalad under the ribs to avoid any bowel or ribs shadowing over the liver.
Rt Portal Vein is shown coursing transversely in this view

Left Lobe Of Liver
 Left Lobe Liver

Midline Abdomen
Scan Plane Left Lobe of Liver. The probe is in the epigastric region just below the sternum. It is angled cephalad to view the left lobe in its entirety. The probe may need to be angled towards the left side to see the most medial edge of the left lobe.

Normal Anatomy seen in the Transverse View of the Left Lobe.

Hover the mouse over the image.


 
 Hepatopetal Flow  hepatic Vein Flow

The Portal Vein should have constant forward flow into the liver (hepatopetal flow) .As seen in this image, the colour is red ,which is set for movement towards the probe. Be very careful to make sure you look at the colour box on the side of the image to know the setting.

If there is flow reversal,this is hepatofugal (tip: Fugitive= run away) and represents portal hypertension.

Because the hepatic veins drain into the IVC immediately prior to the Right Atrium, they have phasic flow reflective of cardiac motion. (Hover over the image for a spectral trace)

 

Ultrasound of the Liver -Protocol

Role of Ultrasound

 To assess the:

  • Size
  • Capsular contour (smooth, coarse, lobulated)
  • Parenchymal echogenicity
  • Vascularity
  • Biliary tree
  • Masses or collections

 

Limitations

  • Obesity and patients with severe cases of metabolic disorders such as haemochromatosis and fatty infiltration will reduce detail and the diagnostic yield of the scan.

Preparation

  • Ideally, fast the patient for 6hours to reduce bowel gas and prevent gall bladder contraction.

 

Equipment Selection

  • Depending on the size of the patient a curved linear array 2-6Mhz.
  • If there is nodularity of the liver border then a linear array with a 7-12MHZ frequency will better appreciate this. Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure.
  • Be prepared to change focal zone position and frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

 

Scanning Technique

Begin doing a full sweep through the liver.

You will need the patient to take deep inspirations to fully visualise the superior borders of the liver.

Look in transverse up and down the left lobe from a subcostal approach. Look in transverse through the right lobe subcostally or intercostally.

Roll the patient in a left lateral decubitus position for assessment of the Rt lobe only after checking for fluid. Bowel gas can overlie the liver in a subcostal approach, so getting the patient to distend their abdomen can help with visualisation. Also looking intercostally between each rib space can ensure thorough visualisation.
Look For:

  • Homogeneous v's Attenuative(normal v's fatty)
  • Smooth v's coarse echotexture
  • bmode image here
  • Size: To measure the size of the liver, use a sagittal approach in the mid clavicular line. Measure from the diaphragm to the inferior border on bmode image. This can be very subjective. Also look at the lower edge of liver in relation to the Rt kidney.It should finish half way down the kidney. Bmode image an enlarged liver will have rounded borders.

Once you have thoroughly scanned though the liver, then start taking images.


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

Common Pathology

  • Fatty liver
  • Liver cysts
  • Haemangioma
  • Portal hypertension
  • Portal vein thrombosis
  • Hepatic vein thrombosis
  • Liver abscess/collection
  • Cirrhosis
  • Trauma
  • Metastases
  • HCC
  • Abscess

 

Basic Hard Copy Imaging

An liver series should include the following minimum images;

  • Longitudinal
    • Left lobe
    • Caudate lobe
    • IVC
    • Porta hepatis
    • Comparison to Rt Kidney
  • Transverse
    • Left lobe
    • Left hepatic vein
    • Left portal vein
    • Right portal vein
  • Middle and Right hepatic vein
Please note that an image must not be taken if it does not have a vessel in it ie. Portal or hepatic vein because you must be able to identify which segment of the liver the image has been taken in. Look at the direction of flow in the portal vein by scanning intercostally to get optimal directional flow with colour Doppler Use spectral Doppler to demonstrate hepatopetal or hepatofugal flow. In a fatty liver the hepatic veins can be assessed and a spectral Doppler used to visualise the normal waveform with the atrial contraction.
  • Remember that the images are only a sample of what you have seen.If you miss the pathology then it does not matter how perfect the images are.

 


 
 

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