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Lucas Greiner
Wuppertal/Germany

Lucas Greiner, MD
Professor of Internal Medicine
Director, Medical Clinic 2
Helios-Clinics
University Witten/Herdecke
Heusnerstr. 40
D – 42283 Wuppertal
lgreiner@wuppertal.helios-kliniken.de
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The aorta and inferior vena cava are
visible in every patient (the latter
sometimes following a Valsalva‘ s
maneuver only). They are landmarks in
abdominal ultrasound; whenever
orientation is lost, one should return to
these well known and easily
identifiable organs. This is also true for
the vascular structures of the liver
hilum. Therefore, knowledge of
anatomy of the great vessels including
their main branches is indispensible
(for more details, see also Part I; Arab
J G Vol 2, No 2, October 2001, 358-
371).
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The abdominal Aorta is characterized
by its position, pulsations and by the
typical branching of the celiac axis,
superior mesenteric artery and the iliac
arteries (positioned ventral to the
concomitant veins). In longitudinal
sections, the aorta-slices are band
shaped with more or less well seen
main branches of the celiac axis and
the superior mesenteric artery in the
upper abdomen. The angle between
these two branches encompases the
portion of the pancreas which is
scanned transverse to the organ axis.
In transverse sections, where the aorta
is seen as a circular structure, the
celiac axis looks like a double hooked
structure (the right portion representing
the hepatic artery, the left portion the
splenic artery).
The renal arteries are positioned dorsal
to the renal veins with the right renal
artery crossing under the inferior vena
cava.
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The inferior vena cava is at the same
level in the body as the aorta and
parallels its course on the right down to
the iliac bifurcation. The inferior vena
cava may be visible only in deep
inspiration or in right heart failure. It
shows typical double-pulsatory
movements in healthy people. Easily
demonstrated by ultrasound are the big
venous afferent vessels: the iliac, renal
and hepatic veins. The left renal vein is
positioned ventral to the aorta.
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The superior mesenteric vein and the
splenic vein join in the confluens to
form the portal vein. The splenic vein
is the main landmark for detecting the
pancreas. The other mesenteric veins
are not as easily seen in routine
examination.
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The ultrasound properties of blood and
bile are identical - since they do not
present any acoustic interfaces, their
ultrasound appearance is black
(assuming no possible interfering
artefacts). The plane of section
necessary to visualize the liver hilum
best may vary considerably from case
to case. As a rule, slim (and tall)
patients have a more or less
longitudinal course to the hilar
structures running in the hepato-
duodenal ligament, whereas more
obese (and small) patients show a
rather transverse course; again,
adapting to these individual
circumstances by variations in the
scanning plane will give the best
General view of the porta hepatis and
liver:
1 inferior vena cava, 2 liver veins, 3
portal vein, 4 splenic vein, 5 common
bile duct, 6 superior mesenteric vein;
liver segments
information. In the first group of
patients, more longitudinal sections (in
the supine position) will be sufficient,
whilst right lateral (maybe even
intercostal) sections in left oblique
position may be needed in the second
group.
The course of the portal vein is always
dorsal to the course of the common
bile duct, with the hepatic artery (or
one of its main branches) crossing in
between. Lymphatic vessels are not
visible on ultrasound either in the liver
hilum or elsewhere.
Porta hepatis:
1 common bile duct,
2 portal vein, 3 hepatic artery (note its
intercrossing right branch between 1
and 2)
3DWKRORJ\VHOHFWHG - FKDQJHV in the wall structure
(e.g.,sclerosis, partial thrombosis,
The tubular structures of vessels or inflammation,
containing blood and bile can be - RFFOXVLRQ (complete thrombosis,
influenced by tumor, concretions), or by
- FKDQJHV in liquid pressure - FRPSUHVVLRQ (tumor, lymphoma,
(resulting in a more or less inflammation).
pronounced increase in vessel
diameter),

2
1

2 3

1 Infrarenal aneurysma, 1 Thoracoabdominal aneurysma,

2 normal aorta (longitudinal scan) 2 liver, 3 right ventricle (longitudinal
(longitudinal scan) scan)

1 1

1 Lumen of a giant infrarenal 1 Single arteriosclerotic plaque,

aneurysma, 2 thrombotic portions infrarenal abdominal aorta
(transverse ! scan) (longitudinal scan)
 1
1 2

1
1

Right heart failure with 1 dilated cava

1 Multiple plaques, abdominal aorta
inferior and 2 dilated hepatic veins
(longitudinal scan)
(right subcostal scan)

2
1a
3
1b
1
2

Membranous dissection of abdominal

1 cava inferior with 2 tumor spread
aorta with 1a, 1b lumen portions and
(thrombus-like) in renal adenocarcinoma
2 dissection membrane (transverse
3 caudate lobe (longitudinal scan)
scan)

1
2

2
1

1 thrombosis of superior mesenteric 1 thrombosis of left iliacal vein (no

vein (no colour flow), 2 aorta colour flow), 2 iliacal artery (left lower
(longitudinal scan) abdominal scan)
/\PSKQRGHVDQGO\PSKRPD
With the advent of more sophisticated
ultrasound devices even normal
paravascular lymphnodes in the
abdomen may be visible in slim
patients. Routinely however only
enlarged lymphnodes (either benign or
2
1
6 5 7 1
1 5
1 4
3
1 multiple lymphnodes, 2 liver, 3 aorta,
4 vertebral body, 5 celiac axis with 6
hepatic and 7 splenic artery
(transverse scan)
1 multiple lymphnodes anterior and
posterior to 2 aorta (longitudinal
scan)
malignant) can be detected, usually
adjacent to the great vessels (aorta,
celiac axis, inferior vena cava). They
are less pronounced in the liver hilum.
The spleen - as a specifically big
lymphnode - deserves special attention
(see 3.7.).
2
1 3
1, 2 lymhnodes adjacent to 3 head of
pancreas, 4 splenic vein, 5 superior
mesenteric artery (transverse scan)
4
2
3
arrow: retroaortal lymphnode
enlargement (metastatic), 1 abdominal
aorta, 2 celiac axis, 3 superior
mesenteric artery, 4 liver, arrowhead:
left kidney vein (longitudinal section)
3DQFUHDV 5 cm, which in turn will deflect
interfering gas-containing intestinal
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The pancreas appears as a more or
less carrot-shaped organ without a
capsule lying transversely across the
aorta and the spinal column. Its main
portion - the head - is generally to the
right of the second lumbar vertebra.
The junction of the head and the body
is curved around the vertebral column
and the abdominal aorta and the tail
lies in the left upper abdomen touching
the splenic hilum.
The uncinate process as a part of the
pancreatic head surrounds the superior
mesenteric vein. The head of the
pancreas itself is surrounded by the
duodenal C-loop, and penetrated by
the intrapancreatic portion of the
common bile duct.
The pancreas is covered by intestinal
structures (stomach, small and large
intestine) and the left lobe of the liver.
The latter serves – in deep inspiration -
as an acoustic window.
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With the scanning probe in a
transverse position high up in the
epigastrium, a deep inspiration will
move the liver downwards for some 3-
structures. The main anatomical
landmarks used for visualising the
pancreas are the mesenteric vascular
structures which adhere to it, the
splenic and mesenteric vein and their
junction ( the confluens), forming the
portal vein. In gross anatomy, there are
no fixed demarcations between the
three portions of the pancreas (head,
body and tail), and the same is true of
course on ultrasound scanning.
The visualisation of the non-distended
main pancreatic duct as it passes
along the body of the pancreas serves
as a marker of ultrasound machines
which have high resolution capabilties.
The normal organ shows soft passive
movements caused by aortic and
venous pulsations.
The head and body of the pancreas
are detectable in nearly all patients.
The tail region (usually less important)
is somewhat more difficult for the
ultrasonographer due to its small size,
angulated course (with a high
variability ) and sometimes hidden
position behind the gas filled gastric
fundus. If necessary, filling the gastric
fundus with non-sparkling water can
create a good acoustic window for
visualisation of the pancreatic tail.
 Ventral view of the extrahepatic bile Dorsal view of the extrahepatic bile
duct: 1 portal vein, 2 common bile duct, duct: 1 portal vein, 2 common bile duct,
3 pancreatic duct, 4 duodenum 3 pancreatic duct, 4 duodenum

3DWKRORJ\ - YDVFXODUDUFKLWHFWXUH (with respect

VHOHFWHG to the main pancreatic duct, the
common bile duct, the splenic and
As in all parenchymatous organs, an mesenteric vein and their junction,
ultrasound examination of the the confluens),
pancreas gives information relating to - IRFDOOHVLRQV, and adjacent
changes in its structures (e.g.lymphnodes).
- SRVLWLRQ, VKDSH, and VL]H,
- overall UHIOH[LELOLW\ and

1
5
1
6
2 3 2

8 4

Acute pancreatitis with 1 swollen head

Acute pancreatits with 1 spotted head
of pancreas obstructing, 2 common
of pancreas and 2 too good visibility of
bile duct (note 3 distended cystic duct)
lumen and * of wall layers of duodena C
and 4 fluid filled duodenum, 5 hepatic
(transverse scan)
artery, 6 portal vein, 7 liver, 8 right
renal artery,inferior vena cava
 3
1
1

2
2

1
1
3

1 enlarged head of pancreas (two 1 pathological fluid collection,

weeks after inflammatory episode), 2 right liver lobe, 3 right perirenal fatty
2 splenic vein, 3 liver (transverse tissue (right lateral scan)
scan)

3
1

5
6 4

1 pancreatitis 2 liver, 3 gastric antrum, Acute pancreatitis: diminuished

4 superior mesenteric artery, 5 splenic delineability of pancreas, +...+ swollen
vein /confluens, 6 duodenal C duodenal wall, 1 duodenal lumen
(transverse scan) (transverse scan)
 4 1 2

2 3

1
1p

1 acute pancreatitis with

1 huge pseudocyst with 1p penetration
2 pseudocyst and 3 splenic vein,
into the 2 spleen (left lateral scan)
4 liver, 5 aorta (longitudinal scan)

7 6
3

2 4 2
1
6 1
3

5 4
5

Highly reflexible spots (probably

1 pseudocyst (color-artifact, no
calcifications in chronical pancreatitis)
bleeding), 2 confluens, 3 gastro-
in 1 head and body of pancreas,
duodenal artery, 4 reduced panreas
2 gastroduodenal and 3 superior
parenchyma, 5 inferior cava, 6
mesenteric artery, 4 aorta, 5 cava
duodenal C, 7 liver (2nd scans)
inferior, 6 liver
 1
4 5
3
1
1
6
2
3

4 1

1 chronical calcifying panreatitis 1 multiple pseudocysts, 2 aorta,

(confirmed by ERCP) with slight 3 hepatic artery, 4 cava inferior, 5 liver,
compression of 2 portal vein/superior 6 confluens (transverse scans)
mesenteric vein, 3 gastroduodenal artery,
4 liver (modified longitudinal scan)




 




 

 




1 reduced pancreas parenchyma in
chronic inflammation with 2 marked duct 1 marked dilatation of main pancreatic
dilatation, 3 splenic vein/confluens, duct in chronical inflammation with 2
4 superior mesenteric artery, 5 hepatic, reduced parenchyma, 3 confluens, 4
6 gastroduodenal and 7 renal artery, superior mesenteric artery, 5 aorta,
8 aorta, 9 left renal vein, 10 liver 6 duodenal C, 7 gastric corpus
(transverse scan)
 E

 
 
K 

 


1 pancreas tumour with 2 splenic
vein, 3h head, 3b body of pancreas,
+,* slightly dilated main pancreatic duct
4 superior mesenteric artery,
1 confluens, 2 posterior antrum wall,
5 aorta (transverse scan)
3 gastric lumen (with highly reflexible
ingested material), 4 uncinate process
(transverse scan)

 
 
  

1 stent in the stenotic main

1 tumour of pancreas head with 2 tip pancreatic duct in chronic
of fine needle for aspiration cytology; pancreatitis (note the reduced
3 gastroduodenal artery 4 liver parenchyma) 2 superior mesenteric
(transverse scan) artery 3 confluens (transverse scan)