Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
I. Introduction/General Information
A. Largest of viscera
1. ~ 2.5% body weight
B. Location:
1. right hypochondrium
2. epigastrium
A. Four lobes
1. Divisions based on blood supply, bile drainage
3. Functional Lobes a. right and left lobes separated by imaginary line b. from fossa for GB IVC
Left Lobe
Right Lobe
B. Functional Divisions
1. Right lobe
with caudate process
C. Fissures: 1. Right sagittal (main) 2. Left sagittal (accessory) 3. Portal 4. Right oblique intersegmental 5. Lateral intersegmental
Portal fissure
T.S. on U/S Created by portal veins (triads) R. main PV is // to anterior body wall
Hepatic segments
I = caudate lobe II & III = superior and inferior lateral segments, L. lobe IV = medial segment, L. lobe V & VI = caudal to transverse plane VII & VIII = cephalad to transverse plane
Fossa for IVC Fossa for Portal Vein Fossa for Gall Bladder
a. b. c. d. e. f.
Gastric (fundus of stomach) Renal (right kidney) Adrenal (right adrenal gland) Duodenal (bulb of duodenum) Esophageal (esophagus) Right and left colic (flexures of the colon)
L A
D. Ligaments 1. Falciform (most superficial anteriorly) a. Divides left lobe in two sections
1. anatomical left lobe 2. caudate & quadrate lobes
Ligaments, continued
3. Ligamentum venosum
(fetal source??)
Hepatic Ligaments
Falciform ligament
Ligaments, continued
5. Hepatophrenic & Hepatorenal ligaments: a. Subdivisions of right coronary ligament b. hepatophrenic (superior) & hepatorenal (inferior) c. Surround BARE AREA
Bare Area
E.
Lesser Omentum 1. Sleeve-like structure 2. Connects lesser curvature of stomach & bulb of duodenum to inferior surface of liver
Lesser Omentum
E. Subphrenic Spaces
1. clinically important
c. AKA: Hepatorenal Pouch/Recess, Morrisons Pouch d. Patient lying supine: 1. Lowest part of peritoneal cavity is behind liver 2. Fluid, pus, etc. collects here 3. Can cause abscess formation
6.
7. Most sources of peritoneal contamination are on the right 8. Right posterior & right inferior spaces are most significant sites
F. Porta Hepatis: contains the following structures 1. Hepatic arteries a. Usually two, sometimes one b. Originate from common/proper hepatic artery c. Course is variable
Porta Hepatis
3. 4.
Hepatic & cystic ducts Nerves: a. Vagus X (parasympathetic) b. Fibers from celiac ganglion
4. Lymph nodes: a. most hepatic lymph vessels end in nodes around porta hepatis
c. Some vessels pass through falciform ligament 1. through diaphragm 2. into mediastinal nodes d. enlarged nodes may compress portal vein or hepatic duct
G. Vascular Structures in Liver 1. Largest vessels are portal vein and IVC a. Portal Vein: 1. appears on T.S. as tubular, echolucent structure
Hepatic Vessels
IVC
1. anatomical landmark
2. extends into right lobe
d. IVC:
1. To right of aorta
2.
Hepatic Veins: a. Tubular structures b. Enlarge cephalad c. In superior half of liver d. Angles of hepatic vein branches oriented toward IVC e. Walls not echogenic
Hepatic Veins
R. Hepatic Vein
Middle Hepatic Vein L. Hepatic Vein
A. Bile Ducts
1. No normal anatomy 2. If dilated: a. Echogenic collar b. Lobulated shape c. Highly branched over short distances d. Converge toward porta hepatis
P R L
6. Polycysts: usually accompany cysts of kidney, spleen, and/or pancreas 7. Appearance: a. Wall is distinct, sharp border, crisp edges
b. Shape: spherical
C.
2. With cellular or inflammatory debris: a. walls are irregular b. Associated with hepatic abscess c. Internal bacterial infection
3. Due to echinococcal disease: a. Show irregular wall thickness b. Parasitic bacteria in sheep feces
D.
A. Sonographic appearance: non-specific 1. Stroma = supportive connective tissue 2. Parenychma = functional tissue 3. Most liver tissue is parenchyma
c. Peripheral intrahepatic vessels indistinct 1. reduced blood supply 2. peripheral vessels obscured by scar tissue
e. Portal Hypertension
f. Liver margin:
1. indentations
2. changes in contour
3. blunted edges
4. may be observed on U/S
C. Fatty Replacement (prior to cirrhosis) 1. Appearance similar to cirrhosis 2. May be initial stage of cirrhosis 3. Difference:
a. Intrahepatic vessels remain clearly defined b. No portal HTN
A. Congestive Hepatomegaly: 1. Enlargement of liver secondary to congestive heart failure 2. Homogeneous: liver rarely shows echo changes 3. Tissue attenuation may decrease as liver fills with blood
4. Marked dilation of IVC without respiratory influence is proof of right heart failure 5. Hepatic vein branches may show enlargement
6. Thrombosis of IVC may show similarities -thrombus can be detected 7. Other signs: a. Ascites b. dilation of right atrium
B.
Liver Abscesses:
1. Commonly found in hepatorenal pouch 2. Appear cystic with irregular borders and fine precipitates
C. Obstructive Jaundice:
D.
2. Usually appears as sonolucency with surrounding echogenic area (thrombus) 3. Flow of blood changes as blood swirls and clots
E. Klatskin Tumor:
1. Ducts are blocked or fused a. Tumor at junction of Right and Left Hepatic Ducts
b. Causes obstructive jaundice
F. Courvasiers Sign: 1. Refers to gallbladder rate of fill with tumor vs. stone 2. Hydrops (edema) of gallbladder due to tumor in head of pancreas
G. Reidels Lobe:
Reidels Lobe
R. Lobe
L. Lobe
GB
B. Ampulla of Vater
1. Length = 1 14 mm
2. Width = 1.5 4.5 mm