Hepatobilier Ultrasound

Dr.Yanto Budiman, Sp.Rad, M.Kes Bagian Radiologi FKUAJ / RSAJ

Liver Gall Bladder and Biliar Tract Pancreas Spleen

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 ultrasound unless outlined by fluid Size : longitudinal length 16 cm.

The renal cortex is slightly less echogenic than the liver parenchyma.

Liver Capsule

left lobe of liver

Ligamentum teres Left lobe of liver LPV stomach

Shadowing from ligament

Tranverse section at the inferior edge of the left lobe

Inferior aspect left lobe of liver

Ligamentum teres
stomach

The segment of the liver

The surgical Portal vein segments of the liver
Right hepatic vein
VIII Middle hepatic vein Left hepatic vein II

VII
I

IV
III

V
VI Portal vein

Falciform ligament

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, fibrous walls 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. These latter vessels are too small to detect by ultrasound in the peripheral parts of the liver, but can readily be demonstrated in the larger, proximal branches

The right and left branches of the portal vein.

The portal vein radical is branch of the hepatic artery and within the hyperechoic fibrous sheath.

associated with a a biliary duct (arrows)

 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.

CD

HA

The porta hepatis. A variant with the hepatic artery anterior to the duct. CD = common duct.

HA PV CD

 Unlike the portal tracts, the hepatic veins do not have a fibrous sheath and their walls are therefore less reflective. The anatomy of the hepatic venous confluence varies. In most cases the single, main right hepatic vein (RHV) flows directly into the IVC, and the middle and left have a common trunk. In 1535% of patients the left hepatic vein (LHV) and middle hepatic vein (MHV) are separate.

The left hepatic vein. Vessel walls are not as reflective as portal veins; however, maximum reflectivity is produced when the beam is perpendicular to the walls, as at the periphery of this vessel.

The portal venous system

The normal portal vein (PV) waveform is monophasic 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 fibrotic diseases. 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 portal hypertension. High velocities are unusual, but can be due to anastomotic stenoses in transplant patients).

Normal portal vein waveform. Respiratory modulations are evident.

(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.

The hepatic artery

The main hepatic artery arises from the coeliac axis and carries oxygenated blood to the liver from the aorta. Its origin makes it a pulsatile vessel and the relatively low resistance of the hepatic vascular bed means 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 and tortuous course. Use the MPV as a marker, scanning from the right intercostal space to maintain a low angle with the vessel. The hepatic artery is just anterior to this and of a higher velocity .

(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).

 Liver Pathologies

Multiple cysts in the liver. In this case the kidneys are normal.usually associated with polycystic kidney disease.

Three small Hemangiomas (arrows)

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

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 or posterior segment of right hepatic lobe

Focal fatty sparing

(A) Fatty infiltration increases the hepato-renal contrast. The portal tracts are reduced in prominence, giving a more homogeneous appearance. (B) Attenuation of the beam by fat prevents demonstration of far-field structures.

Hepatitis The liver frequently appears normal on ultrasound. 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 dark liver appearance is non-specific, and may also occur in leukaemia, cardiac failure, AIDS and other conditions.-starry sky pattern

 The inflammation may start at the portal tracts working outwards into the surrounding parenchyma, the so-called periportal hepatitis. In such cases, the portal tracts become less well-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

(A) Subtle changes of oedema in acute hepatitis: the liver is hypoechoic compared with the right kidney, mildly enlarged and has prominent portal tracts. (B) Chronic hepatitis and cirrhosis, demonstrating a coarse-textured, nodular liver.

 Hepatitis

Cirrhosis
Diffuse process characterized by fibrosis and the conversion normal liver tissue into abnormal nodule Causes : alcoholism ( 70%), viral hepatitis, metabolic disorder, cardiovascular disorder

Cirrhosis
Normal parenchyma Changes in texture Changes in reflectivity May appear normal, particulary in early stages Coarse texture (micronodular) Irregular nodular appearance (macronodular) 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 liver Small, shrunken liver Nodular, irregular surface outline Possible disproportionate hypertrophy of left or caudate lobes

Changes in size and outline

Focal lesions Vascular

Increased incidence of HCC Regenerative nodules 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 nonspesific finding) Ascites, splenomegaly, and lymphadenopathy

Other signs

Cirrhosis

A.

B Cirrhosis: coarse echo pattern. (A) Longitudinal view shows coarse echo pattern. (B, C) Coarse slightly inhomogeneous 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).

Portal Hypertention
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

(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 has macronodular cirrhosis with ascites.

(C) Balanced PV flow. Alternate forward and reverse low-velocity flow on the Doppler spectrum. The PV colour Doppler alternates red and blue.

(C) Colour Doppler demonstrates the tortuous vascular channel of a spleno-renal shunt. (D) Large patent para-umbilical channel running along the ligamentum teres to the anterior abdominal wall in a patient with end-stage chronic liver disease and portal hypertension.

(E) The para-umbilical vein culminates in a caput medusae just beneath the umbilicus. (F) Varices can be seen around the gallbladder wall in a case of hepatic fibrosis with portal hypertension.

(G) Collaterals in portal hypertension

HEPATOCELLULAR CARCINOMA (HCC)

Hepato Cellular Carcinoma Symptom :

RUQ pain, abdominal mass Elevation AFP Sign of cirrhosis, associated with chronic liver disease. Weight loss hepatomegaly

Ultrasound appearances
Vary from hypo- to hyperechogenic or mixed echogenicity focal lesions Enlarged liver Wave-form surface Usually shows hyperechoic with central necrotic that given hypo- to anechoic appearances with irregular edge It is difficult to differ the normal liver to early stage of hepatoma 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. CT and MRI may be useful.

 Colour and spectral Doppler can demonstrate vigorous flow, which help to distinguish HCCs from 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

(A) Exophytic hepatocellular carcinoma (HCC) in a patient with cirrhosis (B) Multifocal HCCs (arrows) in a cirrhotic patient

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

Hepatocellular carcinoma: color Doppler sonography. (A) Increased color flow (arrows) is seen surrounding the tumor nodule (the basket pattern). (B) Abnormal vessels with increased color flow are seen within the tumor (arrows) (vessels within the tumor pattern)

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 : <3mm

Normal gall bladder

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

Cholelithiasis

GB Pathologies contd Polyps Adenomyomatosis

Hyperplastic changes in gall blader wall overgrowth mucosa, thickening muscular wall and formation of intramural diverticular : Rokitansky-Aschoff sinuses.

Polyp gallblader- no acoustic shadow & non-gravity dependent

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 Choledocholithiasis

85 % found in distal duct near the head of pancreas Dilated CBD (normal 5mm)

Cholangitis

CBD Stone

Pancreas Indication :
Identify tumors or masses Suspected pancreatitis

Normal size
Head : 2-3 cm anteroposterior Body : 2 cm anteroposterior Tail : 3 cm Duct : < 2mm

Pancreas Pathologies
Pancreatitis acute and chronic Pancreatitis Carcinoma Pancreas metastase Pancreatic cyst

 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 (1520 %), or tail (5%) Obstructed pancreatic duct, adjacent lymphadenopathy, encasement of adjacent vasculature

Acute Pancreatitis

Chronic pancreatitis - calcification

Tiny cyst in the body of pancreas

Spleen Indication : LUQ pain, Enlarged spleen at Physical examination, susp.infection Normal size : length <13 cm, AP : 7 cm, transverse : 5 cm

Spleen Pathology Splenomegaly Lymphoma

Enlargement Miliary nodule < 5mm Multifocal masses , sixe 1-10 cm

Lymphoma

THANK YOU