Didactic Module

GENERAL ABDOMINAL AND PELVIS ULTRASOUND

Course 2.2. LIVER ULTRASOUND EVALUATION Authors Dr.Cristian Efrem Dr. Viorela Enchescu
E-EDUMED e-Learning Educational Center in Medicine Agreement N. LLP/LdV/TOI/RO/2010/006 This project has been funded with support from the European Commission. This communication reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein.

Table of contents
Hepatic ultrasonography - objectives Examination conditions Liver ultrasound - indications Ultrasound semiology
Shape Liver segmentation Dimensions Anatomical ratios Hepatic structure

Liver pathology
a. Acute/chronic hepatitis b. Liver stasis c. Hepatic steatosis/Focal steatosis

Table of contents
d. Liver cirrhosis
Caudate lobe Ascites Splenomegaly Hepatic cirrhosis - HC PHT evaluation PHT PV SV SMV PHT spleno-renal shunts pulse colour Doppler exam

f. Portal thrombosis g. Secondary tumours

e. Regional focal liver diseases

Hemangioma Adenoma Focal nodular hyperplasia Regeneration nodules Lipoma Hepatocarcinoma

LIVER ultrasound report

HEPATIC ULTRASONOGRAPHY OBJECTIVES

DIAGNOSIS
Morphological appreciation of the liver - normal anatomical variants Liver pathology assessing diffuse localised Doppler and colour Doppler function examination HTP assesing positive predictive without negative predictive value Detection of thrombosis, vascular abnormalities, collateral circulation

THERAPEUTIC INTERVENTION

- Guided HPB fine and thick needles biopsy kit, gun vacuum - Alcoholization of tumors - Chemoembolistions - Administration of chemotherapy - Drainage of cysts parenchymal hydatic - Drainage of collections intrahepatic perihepatic

EXAMINATION CONDITIONS
Patient a jeun, at 5 - 6 hours from the last meal
Non meteoroid can be prepare with: medicinal carbon metoclopramid clyster Without recently Barium X-ray DEEP INSPIR move down the Diaphragm Avoing: very hairy regions keloid scars Positions (at least 2): supine position laterally left side Optional: sitting semisitting prone position standing Sound approache: subcostal intercostal

LIVER ULTRASOUND INDICATIONS

MAJOR Pain in right hypochondrium and/or superior abdominal level Icteric syndrome Fever of unknown etiology

OTHER INDICATIONS Hepatomegaly Hepatic ptosis Changed hepatic tests Gamma glutamyl transpeptidase Cholinesterases Transaminases Oncology Screening Cirrhosis Screening Intervention Drainage of collections Intratumoural chemotherapy Tumoural embolisation

ULTRASOUND SEMIOLOGY - SHAPE

LEFT LOBE
Examined on longitudinal section epigastric triangular shape 2 important angles:450 and 750 Extended angles >> Diffuse hepatic diseases with/without localized processes (ANGLE SIGN) Under angles 2 cockades = digestive tube sections - Eso-tuberositar junction - Gastric antrum - Vascular mark: Aorta - two emerging: celiac trunk CT and superior mesenteric artery SMA RIGHT LOBE Examined on sections: - right paramedian longitudinal - pentagonal shape, angle 750 -vascular mark: inferior vena cava IVC right lateral longitudinal (prerenal) - shape aproximately triangular mark: right kidney oblique - for hilum in order: hepatic artery, principal billiary duct, portal vein (HA, PBD, PV) CAUDATE LOBE same sections oval, fusiform

LIVER SEGMENTATION

DIMENSIONS ANATOMICAL RATIOS

Hepatic left lobe HLL Diameter A-P: 4-6 cm Diameter C-C: 9 cm Hepatic right lobe HRL Diameter AP: 5-6 cm Diameter CC: 10-11 cm Diameter Prerenal: 12-13 cm Caudate lobe CL Diameter A-P: 1-3 cm Diameter C-C: 3-5 cm A-P antero-posterior C-C cranio-caudal
Left lobe LL with: cord pleural cavity peritoneal cavity digestive tube ganglionar groups: celiacs lomboaortics Right lobe RL with: caudate lobe CL inferior vena cava IVC pre-cava ganglions rib-diaphragm right sinus peritoneal cavity (Morrison space) right kidney and right suprarenal gland

HEPATIC STRUCTURE
Macro: homogenous Micro granular, spongy with equal gray tones light tones in steatosis (bright liver) portal arbor billiary arbor CONTOUR: regular, net hilum concavity extern convexity pathologic embattled > micronodulare cirrhosis boselated > inflamatory afections, thesaurismoses, localized processes (BOSEL SIGN)

LIVER PATHOLOGY ULTRSOUND ASPECTS

ACUTE/CHRONIC HEPATITIS
Inconstant: changes of liver diameters, angles increased, splenomegaly There are not direct signs, - portal tree normal/dilated - PHT - WARNING! absence of dilatation does not mean the absence of PHT - in cholestatic forms parenchyma becomes MACROGRANULAR, NODULAR (sacciforme dilation of intrahepatic billiiary duct) Accompanying signs: Billiary vesicle BV has thickened wall (over 3 mm) due to parietal inflammatory edema, HIPOECHOGENIC Spleen normal or moderately increased

LIVER STASIS
Structure nonhomogenous, diffuse Echogeniticy GLOBALLY LOW Round angles Increased hepatic diameters PATHOGNOMONIC: - IVC dilatation > 2 cm - suprahepatic veins SHV branches dilatation > 1 cm Inconstant ACCOMPANYING SIGNS - right/bilateral hydrothorax - ASCITES in : - Morrisson space - Subfrenic space - Douglas space (standing)

HEPATIC STEATOSIS
Altered liver lobular architecture LIVER homogeneous, hiperechogen (BRIGHT LIVER), - contrasting with the transonic content of SHV, PV - posterior liver parenchyma attenuation - rounded hepatic caudal angle - steatosis beaches focals plots - fat bushing " - anterior of PV bifurcation Causes: different thesaurismoses alcoholism diabetes STEATOSIS DEGREES - after the proportion of attenuated liver parenchyma: Grade 1: - 1/4 Grade 2: - 1/3 Grade 3 - 1/2 BEWARE AT TGC AND CONTRAST CONTROLS OF ULTRASOUND!

FOCAL STEATOSIS
Areas focal areas - located pseudoprocesses Hiperreflected Hiporeflected Angular geometric forms Border phenomenas Digited contours

LIVER CIRRHOSIS

Associated signs: Structure: - Vesicular wall changed normal - "in sandwich" halve, thick > 3 heterogenus mm (wall edema by homogenous anormal proteinemy) type steatosis - Ascites (transsonic) Embattled, boselated - less - liquid blades in surface with lower areas micro/macro nodules - More perihepatic, contrasted with perisplenic > INTESTINAL LOOPS ascites fluid FLOAT IN ASCITES - "SEA CORAL CL hypertrophy 5/5 SIGN cm, in ratio with IVC - Old - cloasonates, hemorrhagic, gray echogen Rounded hepatic inclusions angles - Congestive splenomegaly > 13 cm rounded poles, globular aspect, low echogenicity, nonhomogenous structure

CAUDATE LOBE Segment I, autonomous, IVC

fusiform, ovoid - > globular Dimensions > 5/3,5cm ratios transversal diameter CL/HRL > 0,5 > 0,62, 0,65 incidence 80% hepatic cirrhosis sensitivity 43 84% specificity 100%

ASCITES
- measurable in small amounts - Douglas/Morrisson space moon horn(Weill) - subfrenic spaces intestinal loops sea corals - echoguided paracentesis

SPLENOMEGALY
3 diameters ( L > 13cm) accessories spleens globular character congestive hipoechogen spleen varices non corelation dimensions histology activity

LIVER CIRRHOSIS
- multiple aspect multicentric form - diffuse aspect - can not be differentiated liver cirrhosis with macronodules

PHT EVALUATION
MEASURING THE PORTAL CALIBRE SV In hilum > 8 - 9 mm, preaortic > 1 cm Spleen-mesenteric confluent with sacciform dilatated trajectory and in hilum > 1,5 cm
LACK OF CHANGE OF THE PORTAL VEIN CALIBER DURING INSPIR/EXPIRE (BOLONDI SIGN) REPERMEABILISATION OF UMBILICAL VEIN

additional vascular route, in hilum sinuous, irregular

CANTITATIVE EVALUATION OF PHT BY DOPPLER Flow speed Presional gradient RI DOPPLER COLOR Flow direction INVERSION ? Flow in ramnification Permeabilisation of Portal arbor THROMBOSIS ?

PHT PV SV SMV
- subjective assesement portal system H.I. - dilatated PV hilum/precava confluent S P > 13mm - SV preaortic spleen hilum varices bunches of grapes - dilatated SMV is not spleen depended

PHT SPLENORENAL SHUNTS

- endoscopic grade
esophageal varices EV with spleno-portal axis - EV grade I II diameter PV 15mm/VS - 10mm - EV grade III diameter PV 12 18mm!!! - noncorelation

PULSE COLOUR DOPPLER EXAM

- centrifugal/centripetal hepatic flow > speeds - flow inversation (8% HC) protection EV rupture (Bolondi)

PULSE COLOUR DOPPLER EXAM

- spleno-portal axis permeability - segmentation/complete thrombosis - portal cavernoma - small vascular images on a portal thrombosis background

REGIONAL FOCAL LIVER DISEASES

CYSTIC FLUID Hepatic solitar cyst Hepatic policystosis (or hepato-renal) Hydatic cyst SEMISOLID Hepatic abcesse amoebian Hematoma capsular intraparenchimal LOCALIZED PROCESSES (LP) SOLID Benign Tumours HEMANGIOMA Malignant Tumours HEPATOCARCINOMA SECONDARY TUMOURS

LOCALIZED PROCESSES (LP) Solid Benign

HISTOLOGIC: Adenoma Fibroma Hematoma Nodular hipertrophy Regenerative Focal
ULTRASOUND ASPECT: LP unique, with different dimensions, well defined, with net, regular contours, visible unmodified neighboring parenchyma Usually - hiperechogenic Heterogeneous - diferent echogeniticy beaches With/without deviation or deformation of vascular trajectories UNINTERRUPTED

HEMANGIOMA
1. capillary hemangiomas 2. cavernous hemangiomas

HEMANGIOMA
TYPICAL regular oval forms well-defined, homogeneous hiperreflected posterior US enhancement

HEMANGIOMA
ATYPICAL differential diagnosis with CCH voluminous irregular, polycyclic contour izoechogenic, heterogenous transonic inclusions delete of US emphasis

ADENOMA
high incidence, young women oral treatment with contraceptives large dimensions irregular contours homogeneous structure, izo-hipoechogenic contrast substance

FOCAL NODULAR HYPERPLASIA

differentiation, especially, histologic and scintigraphic

contrast substance - pulse

functional Kupffer cells

focuse TC 99 colloid izoechogenic lesions with fine

inversion image
vascularisation star-shaped

hiperechogen, perilesional halo

FOCAL NODULAR HYPERPLASIA

hipoechogenic multicenter lesions contrast substance hiperechogenic lesions

hipovascularisation
without posterior acoustic enhancement

REGENERATION NODULE
present in hepatic cirrhosis echogeniticy similar to the normal hepatic parenchima hipoechogenic, compared to the cirrotic parenchima adipose conjunctive tissue, fibrous tissue - FAB simple or multiple location differential diagnosis with multicentric malignant lesions contrast substance

LIPOMA
well defined lesions intense reflected

homogenous
normal perilesional hepatic parenchima without US attenuation nonvascular

HEPATOCARCINOMA
LP visible from 1 cm diameter, with any echografic aspect frequently hipoechogenic sometimes heterogeneous Irregular contour, but quite clear Unique or multicentric Heterogenous structure, sometimes encapsulated With/without adjacent parenchima change Interrupted vessels, deviated, with malignant thrombosis Billiary tree compressions Secondary lesions - in cockade, cloth, chess board Sizes rapid increase

HEPATOCARCINOMA
- peritumoural halo 41,5% - malignant edema not puncture - net contour 25% - differential diagnosis with angioma, hydatic cyst - wiped contour/diffuse 30% - invasive

PORTAL THROMBOSIS
portal invasion sizes/nodules number t <5cm PV invasion 9,8% diffuse invasion 64,7% PV thrombosis ecodense, granular/PV lumen chronic/neoplasm nature

SECONDARY TUMOURS
Rarely unique, often multiple Morphology varied Often HIPOECHOGENIC Poorly defined, wiped contours, in cockade Various dimensions : 1-10 cm Vacuolated tumours central necrosis

LIVER ultrasound report

Morphology Dimensions Outline, surfaces Venous arbor portal suprahepatic Billiary arbor intrahepatic IHBD extrahepatic Parenchyma - aspect LP description: number segmental location sizes -2 diameters shape outlines structure type in comparison with: hepatic vessels billiary arbor