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Hepatobilier Ultrasound
Dr.Yanto Budiman, Sp.Rad, M.Kes
Bagian Radiologi FKUAJ / RSAJ
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Liver
Gall Bladder and Biliar Tract
Pancreas
Spleen
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The Liver
Normal appearance The liver is a homogenous, mid grey organ
on ultrasound
Slightly increased echogenicity when
compared to the cortex of the right kidney
Its outline is smooth
The liver is surrounded by a thin, hyperechoic
capsule, which is difficult to see on ultrasoundunless outlined by fluid
Size : longitudinal length 16 cm.
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Liver CapsuleThe renal cortex is slightlyless echogenic than the liverparenchyma.
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left lobe of liver
Left lobe of liver
LPV
Ligamentum teres
stomach
Shadowing
from
ligament
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Tranverse section at the
inferior edge of the left lobe
Inferior aspect left lobe of liver
Ligamentum teres
stomach
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The segment of the liver
The surgical Portal vein segments of the liver
Right hepatic veinMiddle hepatic vein
Left hepatic vein
Falciform ligament
Portal vein
VII
VIII
IV
II
III
I
V
VI
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Hepatic vasculature
The portal veins radiate from the porta hepatis,where the main portal vein (MPV) enters the liver .They are encased by the hyperechoic, fibrouswalls of the portal tracts, which make them stand
out from the rest of the parenchyma. Also contained in the portal tracts are a branch of
the hepatic artery and a biliary duct radical. Theselatter vessels are too small to detect by ultrasound
in the peripheral parts of the liver, but can readilybe demonstrated in the larger, proximal branches
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The portal vein radical is associated with a
branch of the hepatic artery and a biliary duct (arrows)
within the hyperechoic fibrous sheath.
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The three main hepatic veins, left, middle and
right, can be traced into the inferior vena cava
(IVC) at the superior margin of the liver . Their course runs, therefore, approximately
perpendicular to the portal vessels, so a section of
liver with a longitudinal image of a hepatic vein is
likely to contain a transverse section through a
portal vein, and vice versa.
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CD
HA
HA
CDPV
The porta hepatis.
A variant with the hepatic
artery anterior to the
duct. CD = common duct.
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Unlike the portal tracts, the hepatic veinsdo not have a fibrous sheath and theirwalls are therefore less reflective. Theanatomy of the hepatic venous confluence
varies. In most cases the single, main righthepatic vein (RHV) flows directly into theIVC, and the middle and left have a
common trunk. In 1535% of patients the left hepatic vein(LHV) and middle hepatic vein (MHV) areseparate.
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The left hepatic vein. Vessel walls are not as reflective as portal
veins; however, maximum reflectivity is produced when thebeam is perpendicular to the walls, as at the periphery of this
vessel.
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The portal venous system
The normal portal vein (PV) waveform ismonophasic with gentle undulations which are
due to respiratory modulation and cardiac activity.
This characteristic is a sign of the normal, flexible
nature of the liver and may be lost in some fibroticdiseases.
The mean PV velocity is normally between 12 and
20 cm per second6 but the normal range is wide.
(A low velocity is associated with portalhypertension. High velocities are unusual, but can
be due to anastomotic stenoses in transplant
patients).
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Normal portal vein waveform.
Respiratory modulations are evident.
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(A) The confluence of the right, middle and
left hepatic veins with the IVC.
(B) Normal hepatic venous waveform.
The reverse flow in the vein (arrows) is due
to atrial systole. Note that the image has also
been frozen during atrial systole, as the
hepatic vein appears red.
RM
L
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The hepatic artery
The main hepatic artery arises from the coeliac axisand carries oxygenated blood to the liver from theaorta. Its origin makes it a pulsatile vessel and therelatively low resistance of the hepatic vascular bedmeans that there is continuous forward flow
throughout the cardiac cycle In a normal subject the hepatic artery may be elusive
on colour Doppler due to its small diameter andtortuous course. Use the MPV as a marker, scanningfrom the right intercostal space to maintain a low
angle with the vessel. The hepatic artery is justanterior to this and of a higher velocity .
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(A) The hepatic artery may be difficult to locate with colour Doppler in some
subjects.
(B) The same patient using power Doppler; visualization is improved.
(C) The normal hepatic artery waveform demonstrates a relatively highvelocity
systolic peak (arrowhead) with good forward end-diastolic flow (arrow).
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Liver Pathologies
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Multiple cysts in the liver. In this case the
kidneys are normal.usually associated
with polycystic kidney disease.
Three small Hemangiomas(arrows)
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a c
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ABSCESS(A) Early stages of a pyogenic abscess(B) The gas contained within this large
abscess
(C) A percutaneous drain is identified in
a liver abscess
a
b
c
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Fatty Liver
Increased of hepatocyte fat content
Can be focal or diffuse
Diffuse is classified as :
mild, slight increase liver echogenity with loss
intrahepatic vessels border, normal visualisation
diapraghm
moderate, slight loss echogenity of diaphragm
severe. No visualization of diapraghm orposterior segment of right hepatic lobe
Focal fatty sparing
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(A) Fatty infiltration increases the hepato-renal contrast. The portaltracts are reduced in prominence, giving a more homogeneousappearance.
(B) Attenuation of the beam by fat prevents demonstration of far-field
structures.
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Hepatitis
The liver frequently appears normal onultrasound.
In the acute stage, if ultrasound changes
are present, the liver is slightly enlarged
with a diffusely hypoechoic parenchyma.
The normally reflective portal tracts are
accentuated in contrast but this darkliver
appearance is non-specific, and may also
occur in leukaemia, cardiac failure, AIDS
and other conditions.-starry sky pattern
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The inflammation may start at the portal
tracts working outwards into the surroundingparenchyma, the so-called periportal
hepatitis.
In such cases, the portal tracts become lesswell-defined and hyperechoic.
The gallbladder wall may also be thickened, ,
portal lymphadenopathy. If the disease progresses to the chronic
stage, the liver may reduce in size, becoming
nodular and coarse in appearance
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(A) Subtle changes of oedema in acute hepatitis: the liver is hypoechoiccompared with the right kidney, mildly enlarged and has prominentportal tracts.
(B) Chronic hepatitis and cirrhosis, demonstrating a coarse-textured,nodular liver.
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Hepatitis
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Diffuse process characterized by fibrosis
and the conversion normal liver tissue intoabnormal nodule
Causes : alcoholism ( 70%), viral hepatitis,
metabolic disorder, cardiovasculardisorder
Cirrhosis
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Normal
parenchyma
May appear normal, particulary in early stages
Changes in
texture
Coarse texture (micronodular)
Irregular nodular appearance (macronodular)
Changes in
reflectivity
Fibrosis increases the overall echogenicity (but not the attenuation)
May be accompanied by fatty change, which increases both echogenicity and
attenuation giving a hyper-reflective near-field with poor penetration to the
posterior liverChanges in
size and
outline
Small, shrunken liver
Nodular, irregular surface outline
Possible disproportionate hypertrophy of left or caudate lobes
Focal lesions Increased incidence of HCC
Regenerative nodules
Vascular Signs of portal hypertension:
-Changes in portal vein direction and velocity
-Possible thrombosis, varices and collaterals, increased hepatic arterial flow
-Flattened, monophasic hepatic venous flow on spectral Doppler (a non-
spesific finding)
Other signs Ascites, splenomegaly, and lymphadenopathy
Cirrhosis
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Cirrhosis
A.B
C
Cirrhosis: coarse echo pattern. (A)
Longitudinal view shows coarse echo
pattern. (B, C) Coarse slightlyinhomogeneous echo pattern of the liver.
The liver is surrounded by ascites. One
sees slight nodularity of the anterior
surface of the liver in (B) (arrows).
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Occurs when the pressure in the portal
venous system is raised
As a result of chronic liver disease,
particularly in the cirrhotic stage, when the
nodular and fibrosed parenchyma of the
liver impedes the flow of blood into the
liver
It is significant because it causes
numerous deleterious effects on the
patient which many of that can be
recognized on ultrasound
Portal Hypertention
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(A) Portal vein (PV) velocity is greatly reduced.
(B) Reversed PV flow in portal hypertension. Note the increased velocity of hepatic arterial flow
indicated by the light colour of red just anterior to the portal vein. The patient hasmacronodular cirrhosis with ascites.
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(C) Balanced PV flow. Alternate forward and reverse low-velocityflow on the Doppler spectrum. The PV colour Doppleralternates red and blue.
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(C) Colour Doppler demonstrates the tortuous vascularchannel of a spleno-renal shunt.
(D) Large patent para-umbilical channel running along theligamentum teres to the anterior abdominal wall in apatient with end-stage chronic liver disease and portal
hypertension.
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(E) The para-umbilical vein culminates in a caputmedusae just beneath the umbilicus.
(F) Varices can be seen around the gallbladder wall in
a case of hepatic fibrosis with portal hypertension.
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(G) Collaterals in portal hypertension
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HEPATOCELLULAR
CARCINOMA (HCC)
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Hepato Cellular Carcinoma
Symptom :
RUQ pain, abdominal mass
Elevation AFP
Sign of cirrhosis, associated with chronic liver
disease.
Weight loss
hepatomegaly
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Ultrasound appearances
Vary from hypo- to hyperechogenic or mixedechogenicity focal lesions
Enlarged liver
Wave-form surface
Usually shows hyperechoic with central necrotic thatgiven hypo- to anechoic appearances with irregularedge
It is difficult to differ the normal liver to early stage ofhepatoma because they both show iso-echoic
structure It is often difficult to locate small HCCs in a cirrhotic
liver which is already coarse-textured and nodular. CTand MRI may be useful.
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Colour and spectral Doppler can demonstrate
vigorous flow, which help to distinguish HCCsfrom metastases or haemangiomas, which
demonstrate little or no flow. All carcinoma
demonstrate neovascularization which its
characteristics are different from normal.
New vessels have a paucity of smooth muscle in
the intima and media and exhibit low resistance
to bloow flow with high end diastolic flow (EDF).New vessels able to multiply relatively quickly
causing arteriovenous shunting within the mass
which may result in high velocities
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(A) Exophytic hepatocellular carcinoma (HCC) in a
patient with cirrhosis
(B) Multifocal HCCs (arrows) in a cirrhotic patient
Hepatocellular carcinoma
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Hepatocellular carcinoma
Hepatocellular carcinoma. (A) Transverse view shows a large, hypoechoic solid
mass (arrows) within the right lobe. (B) In another patient, sagittal view shows a large,
predominantly hyperechoic, inhomogeneous mass (arrows) within the liver.
Hepatocellular carcinoma
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Hepatocellular carcinoma
Hepatocellular carcinoma: color Doppler sonography. (A) Increased color flow (arrows) is
seen surrounding the tumor nodule (the basket pattern). (B) Abnorm al vesse ls wi th
increasedcolor flow are seen within the tumor (arrows) (vessels within the tumorpattern)
Gall Bladder
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Gall Bladder
Indication
Jaundice
Suspected Cholecystitis
Suspected Gallstones
Best time to image : after 6 hours of fasting
Size : Long axis 6-12 cm , short axis 3-5 cm
Normal gallbladder wall :
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Normal gall bladder
GB pathologies
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GB pathologies
Cholelithiasis/gallstones : echogenic with
posterior acoustic shadow , mobile/impacted
Acute Cholecystitis
Associated with gallstones (90-95%)
sonographic murphys sign
Gallblader wall > 3mm
Sludge, Gallblader dilataion, pericholecystic fluid
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Cholelithiasis
GB Pathologies contd
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GB Pathologies cont d
Polyps
Adenomyomatosis
Hyperplastic changes in gall blader wall
overgrowth mucosa, thickening muscular wall
and formation of intramural diverticular :Rokitansky-Aschoff sinuses.
Polyp gallblader- no acousticshadow & non-gravity dependent
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Adenomyomatosis: (Left)LS demonstrating a thickened gallbladder wall
with a small Rokitansky-Aschoffsinus (arrow) at the fundus. (Right) TS
demonstrating a stone and comet-tail artifacts from within the wall due to
crystal (cholesterol, bile, calculi) deposits.
Bile Ducts
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Bile Ducts
Choledocholithiasis
85 % found in distal duct near the head ofpancreas
Dilated CBD (normal 5mm)
Cholangitis
CBD Stone
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CBD Stone
Pancreas
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Pancreas
Indication :
Identify tumors or masses
Suspected pancreatitis
Normal size
Head : 2-3 cm anteroposterior
Body : 2 cm anteroposterior
Tail : 3 cm
Duct : < 2mm
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Pancreas Pathologies
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Pancreas Pathologies
Pancreatitis acute and chronic
Pancreatitis Carcinoma
Pancreas metastase
Pancreatic cyst
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Acute pancreatitis
enlarged hypoechoic obstructed / dilated pancreatic duct,fluid collections, pseudocysts
Role US : identify gallstones, biliary obstructuion
Chronic pancreatitis
Atrophic gland, dilated duct, calcifications Pancreatitic Carcinoma
Hypoechoic mass located in head (70%), body (15-20 %), or tail (5%)
Obstructed pancreatic duct, adjacentlymphadenopathy, encasement of adjacentvasculature
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Acute Pancreatitis
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Chronic pancreatitis - calcification Tiny cyst in the body of pancreas
Spleen
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Spleen
Indication : LUQ pain, Enlarged spleen at
Physical examination, susp.infection
Normal size : length
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Spleen Pathology
Splenomegaly
Lymphoma
Enlargement
Miliary nodule < 5mm
Multifocal masses , sixe 1-10 cm
Lymphoma
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Lymphoma
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