LIVER IMAGING

Liver Segmental Anatomy

PROBE POSITIONING TO SCAN THE LIVER

Rt Lobe Liver

Parasagittal Scan Plane

The Liver and Rt Kidney are visualised in this

view.

Intercostal Scan Plane

The Middle and Rt Hepatic Vein are visualised in this view.

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

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.

The Portal Vein should have constant forward

Because the hepatic veins drain into the IVC

flow into the liver (hepatopetal flow) .As seen in immediately prior to the Right Atrium, they have 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 phasic flow reflective of cardiac motion. (Hover over the image for a spectral trace)

of the image to know the setting. If there is flow reversal,this is hepatofugal (tip: Fugitive= run away) and represents portal hypertension.

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 o o o o o Left lobe Caudate lobe IVC Porta hepatis Comparison to Rt Kidney

Transverse o o o o Left lobe Left hepatic vein Left portal vein Right portal vein

Middle and Right hepatic vein Demonstrate hepatopetal flow in portal vein Demonstrate hepatic vein flow Document the normal anatomy. Any pathology found in 2 planes, including measurements and any vascularity.

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.