Liver ultrasound

By
Dr. Tarek Mansour
Faculty of medicine
Al-Azhar university

Normal liver.
Doppler of hepatic vessels.
Diffuse liver diseases pattern.
Portal hypertension.
Focal liver masses.

Liver technique

Always clear 2-3

cm beyond the
margin of any
organ to avoid
exophytic or
adjacent masses.

Normal liver

Size
Shape
Echogenicity
Echotexture
Technique
- smooth TGC
- diaphragm
- vessel lumen
- clear all
margins

Parenchymal organ
echogenicity

Renal medulla < renal cortex < liver

Liver < spleen
Liver < pancreas.
Pancreas < renal sinus & retro. fat

Sonographically the
vessels seen visible
within the liver
parenchyma are
hepatic and portal
veins.
Hepatic arteries and
bile ducts not seen
unless abnormally
dilated but seen in
porta hepatis.

Portal veins

Echogenic (bright) walls

- used for evaluation
of evaluation of liver
parenchyma.
Enter the liver through
porta hepatis.
Largest portal vein divide
in the middle of liver.
More horizontally
oriented.
Pass within lobes and
segments.
Flow into liver.

Portal vein
Reasons for bright
walls
Portal triad
-Portal vein
-Hepatic artery
-Bile duct
Glisson's capsule
Lymphatic nerves.
Connective tissue

Hepatic veins

Imperceptible margins.
Enlarge toward the IVC.
More vertically
oriented.
Umbrella configuration.
Runs between lobes and
segments.
Used as anatomic
divider of the liver.
Flow out the liver

Transverse liver scan

Anatomic landmark
Upper: large hepatic
veins joint IVC
Mid: large central
portal veins (left higher
than right).
Lower:
-No large veins.
-Falciform ligament
-Ligamentum teres.

Ligamentum teres

Obliterated fetal
reminant of the
umbilical vein in the
fissure for ligamentum
teres.
Joins the umbilical
segment of the left
portal vein.
May recanalize in
portal hypertension.
Not to be mistaken for
a mass or calcium.
Divides left lobe.

Ligamentum venosum

The obliterated
fetal reminant of
ductus venosus.
Lie within fissure
for ligamentum
venosus.
Does not recanalize
in adults.
Separates the left
lobe from caudate
lobe.

Caudate lobe

Caudate means tail.

Functionally autonomous segment,
spared in liver diseases.
Blood supply from RT and LT portal
vein.
Dian direct to IVC.
Pseudomass.

Enlarged caudate lobe

Caudate is
enlarged when the
caudate to right
lobe ratio is > 0.65

Hepatic and portal veins

Basis of modern lobar

and segmental
anatomy.
Hepatic veins drain
peripherally
-Interlobar,
intersegmental.
-Used as dividers.
Portal veins feed
centrally.
-Intralobar,
intrasegmental
-Used to name
segments.

Hepatic veins (anatomic

dividers)

MHV divide the

liver into right and
left lobes.
RHV divide the
right lobe into
anterior and
posterior segments.
LHV divide the left
lobe into medial and
lateral segments
(cranially).

Portal vein define

segments

Feed the
segments.
Define the
segments.
Name the
segments.

Division of main portal

vein

On coronal scan
divides the liver
into superior and
inferior.
On axial scan
divides the liver
into anterior and
posterior.

Anatomic liver segments

caudate lobe

Segment I

Lateral segment left Segment

II
lobe superior
Lateral segment left Segment
III
lobe inferior
Medial segment left Segment
IV
lobe
Anterior segment
right lobe inferior

Segment

Posterior segment
right lobe inferior

Segment

Posterior segment
right lobe superior

Segment

Anterior segment
right lobe superior

Segment

VI

VII

VIII

Main portal vein: normal

doppler

Continuous, forward flow.

Low velocity (15-28
cm/sec.)
Hepatopetal flow.
Undulating pattern
-Respiratory variation
-Increase flow on
inspiration.
May reflect cardiac
variation.
Slightly turbulent.
Location between two
capillary beds (mesenteric
& hepatic).

Normal portal venous flow

direction and waveform.
Drawing at top illustrates that
the direction of flow in normal
portal veins is antegrade, or
hepatopetal, which
corresponds to a waveform
above the baseline at spectral
Doppler US. Normal phasicity
may range from low (bottom
left) to high (bottom right).
Abnormally low phasicity
results in a nonphasic
waveform, whereas
abnormally high phasicity
results in a pulsatile
waveform. The PI is used to
quantify pulsatility. Normal
phasicity results in a PI
greater than 0.5.

Main portal vein: abnormal

doppler

Pulsatile flow is abnormal

- May resemble HV
pulsatility.
- Increase right heart
pressure.
- Transmitted pressure
through intrahepatic
sinusoids.
- Tricuspid regurgitation.
- Moderate to sever right
heart failure, pericarditis.
Exception: child, young
persons.

Spectral Doppler US
image shows a
pulsatile waveform
with flow reversal in
the right portal vein.
The waveform may be
systematically
characterized as
predominantly
antegrade, pulsatile,
biphasic-bidirectional,
and di-inflectional.

Slow portal venous flow.

Spectral Doppler US image
shows slow flow in the main
portal vein. Slow portal
venous flow is a consequence
of portal hypertension. In
this case, the peak velocity is
9.0 cm/sec, which is well
below the lower limit of
normal (1640 cm/sec).
Although portal hypertension
may cause a pulsatileappearing waveform as seen
in this case, the slow flow
helps differentiate this
condition from hyperpulsatile
high-velocity states such as
CHF and tricuspid
regurgitation.

Normal and abnormal portal

venous phasicity. Images
show a spectrum of
increasing pulsatility
(bottom to top). Note that
increasing pulsatility
corresponds to a decrease in
the calculated PI. Although
normal phasicity ranges
widely in the portal veins,
the PI should be greater
than 0.5 (middle and
bottom). When the PI is less
than 0.5 (top), the waveform
may be called pulsatile; this
is an abnormal finding.

Hepatofugal portal venous

flow. Spectral Doppler US
image shows retrograde
(hepatofugal) flow in the
main portal vein, a finding
that appears blue on the
color Doppler US image
and is displayed below the
baseline on the spectral
waveform. Hepatofugal
flow is due to severe
portal hypertension from
any cause.

Hepatic artery: normal

doppler

Rapid systolic
acceleration
Continuous forward
flow throughout
cardiac cycle
- Low impedance.
Same direction as
MPV.
RI = 0.5-0.7

Schematics show a
spectrum of increasing
hepatic arterial resistance
(bottom to top). The
hepatic artery normally
has low resistance (RI =
0.550.7) (middle).
Resistance below this
range (bottom) is
abnormal. Similarly, any
resistance above this
range (top) may also be
abnormal. High resistance
is less specific for disease
than is low resistance.

Hepatic veins: normal

doppler

Toward IVC and

heart.
Away from
transducer (blue).
Characteristic
pulsatile flow.

Diagram illustrates normal

hepatic venous flow direction
and waveform. The direction of
normal flow is predominantly
antegrade, which corresponds
to a waveform that is mostly
below the baseline at spectral
Doppler US. The term triphasic,
which refers to the a, S, and D
inflection points, is commonly
used to describe the shape of
this waveform; according to
D.A.M., however, this term is a
misnomer, and the term
tetrainflectional is more
accurate, since it includes the v
wave and avoids inaccurate
phase quantification. Normal
hepatic venous waveforms may
be biphasic (bottom left) or
tetraphasic (bottom right).

Hepatic veins: normal

doppler

Reflects respiratory
phases.
Reflects variations in
central venous pressure
transmitted from RV.
Reflect compliance of
liver parenchyma.
Triphasic pattern.
Deep respiration or
valsalva reduce
pulsatility of wave form
in normals.

Hepatic veins: abnormal

doppler

Non triphasic flow

- Elevated right heart
pressure.
Decrease pulsatility or
amplitude of phasic
oscillation.
- Loss or reversed
phase.
Monophasic abnormal.
- Flattened wave
form.
- Resemble PV flow.
- Stiff, non compliant
liver.

Decreased hepatic venous

phasicity. Diagrams illustrate
varying degrees of severity of
decreased phasicity in the
hepatic vein. Farrant and Meire
(5) first described a subjective
scale for quantifying
abnormally decreased phasicity
in the hepatic veins, a finding
that is most commonly seen in
cirrhosis. The key to
understanding this scale lies in
observing the position of the a
wave relative to the baseline
and peak negative S wave
excursion. As the distance
between the a wave and peak
negative excursion decreases,
phasicity is more severely
decreased.

Sonographic liver
pattern

Normal
Centrilobular
Fatty-fibrotic

Centri-lobular pattern

Decrease echogenicity of
liver parenchyma.
Starry night appearance.
Increase visualization of
PV wall
- Increased brightness.
- Increased number.
Causes: acute hepatitis,
acute RT side HF,
leukemia/lymphoma, toxic
shock, 2% of normal.

Fulminant hepatic failure

Liver necrosis
Starry night
appearance (acute,
edema, necrosis).
Hyperechoic areas
(normal or
regenerated).

Fatty fibrotic pattern

Increased echogenicity of
liver parenchyma.
Decreased definitions of
PV walls.
Echotexture
- Homogeneous (fine)
- Heterogeneous
(coarse).
Posterior sound
attenuation.
Causes: fatty infiltration,
chronic hepatitis,
cirrhosis, acute alcoholic
hepatitis.

Fatty fibrotic pattern

Echotexture

homogeneous

heterogeneous

Fatty liver

Posterior sound
attenuation.
Enlarged liver.
Tend to have fine
homogeneous
echotexture.

Focal fatty liver changes

Focal fatty liver

infiltration.

Focal fatty sparing

Liver cirrhosis

Fatty fibrotic pattern

- Heterogeneous
texture (coarse).
- Almost no posterior
attenuation.
Shrunken liver.
Nodular surface.
Elevated caudate to
right lobe ratio (> 0.73
has 99% specificity for
cirrhosis).

Liver cirrhosis

Accounts for > 90% of

all portal
hypertension.
Distorted liver
architecture.
- Fibrosis.
- Regenerating
nodules.
- Distorted vascular
channels

Portal hypertension

Increase hepatic
resistance.
Increase portal
venous pressure.
Eventually decrease
portal flow.
Reversed portal flow
prognostication for
risk of hemorrhage.

Portal hypertension
Sonographic signs

Ascites.
Dilated MPV, SV,
SMV.
Collateral.
Splenomegaly.
Various doppler
findings.

Collateral veins

Gastroesophageal.
Coronary.
Umbilical.
Gastrosplenic.
Splenorenal /
gastrorenal.
Perisplenic.
Intestinal (rectum).
Retroperitoneal.

Portal hypertension
collateral vessels

Doppler in portal
hypertension

Portal vein:
- Loss or respiratory
variation.
- Decrease velocity of MPV.
- Hepatofugal (reversed)
flow.
Hepatic veins:
- Loss of normal pulsatility.
- Non triphasic flow.
- Flattened wave.
Hepatic arteries:
- Enlarged hepatic
arteries.

Focal liver masses

US is excellent in detecting focal liver lesions.

US is specific for liver cysts > 1 cm.
Not good in differentiating among pathologic
entities.
No good in distinguishing between benign
and malignant lesions.
Triphasic study of the lesions by CT and MRI
are excellent.
US is very helpful in diagnosis, follow up and
guidance biopsy.

Simple cystic lesions.

Cyst.
Old hematoma.
Abscess (hydatid).
Biloma / seroma.
Vascular:
- Aneurysm
- Fistula.

Multiple cystic lesions

Polycystic liver.

Echinococcoses
(hydatid).

Choledochal cysts
(type 5).

Choledochal cysts

Complex cystic lesions.

Hemorrhagic cyst.
Infected cyst.
Hematoma
Abscess.
Biloma/ seroma.
Biliary
cystadenoma.
Cystic or necrotic
malignant lesion.

Liver abscess
Difficult in diagnosis.

Hypoechoic liver masses

Benign.
Malignant.
Abscess.
Metastases.
Adenoma.
Hepatocellular
carcinoma.
Focal nodular
Lymphoma.
hyperplasia.
Hemangioma.
Microabscesses.
Focal fatty sparing.

Hyperechoic liver masses

Benign.
Hemangioma.
Abscess.
Adenoma.
Focal nodular
hyperplasia.
Hemorrhagic cyst.
Focal fat infiltrate.

Malignant.
Metastases.
Hepatocellular
carcinoma.
Lymphoma.

Characteristic lesions

Focal nodular
hyperplasia

Hemangioma

Characteristic lesions

Echinococcous
cyst

Complication of
metastases.

Biliary obstruction.
Vascular invasion
(portal
thrombosis).
Necrosis.
Hemorrhage.
Infection.

Thank you