Lecture : 1

liver –Anatomy and diffuse pathology

Course: FRD3062 Medical Imaging Science and Methods 4

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(Advanced Ultrasound )Lecture : Topic 1
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Learning outcomes–Adv.ultrasound

• Sonographic anatomy of the abdominal organs and related

structures.
• Sonographic representation of common abdominal
pathologies.
• Selection of appropriate ultrasound equipment, and
optimisation of technical factors.
• Scanning techniques for the liver, gallbladder, biliary
system, anterior abdominal wall & hernias, peritoneum &
retroperitoneum and Doppler ultrasound of the upper
abdomen.
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The liver

• Largest organ
• Good acoustic window
• Variable approach needed

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Anatomy

• RUQ, right hypochondrium

• Extends inferiorly into epigastrium, laterally into left
hypochondrium
• Upper border - 5th intercostal space
• Lower border - approx costal margin
• Superior, anterior and part of posterior surface in contact
with diaphragm
• Men 1400 - 1800g
• Women 1200 - 1400g

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Anatomy

• Right lobe > Left lobe

• Size increases with height and body surface area,

decreases with age

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Anatomy – Vascular: Hepatic Veins

• 3 major HV
– Right HV - runs in right intersegmental fissure
– Middle HV - runs in main lobar fissure
– Left HV - cephalad boundary between medial/lateral
segments left lobe

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Anatomy - The Portal Triad

• Branch of PV, HA and bile duct contained within connective

tissue sheath
• MPV divides to left and right portal veins
– Left and right intrahepatic bile ducts
– Left and right HA

http://www.karger.com/Article/Fulltext/323482
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Physiology

• Metabolises fats, carbohydrates and proteins

• Forms bile and urea, glycogenesis
• Secretes cholesterol
• Formation of lymph fluid

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Liver Function Tests

• Raised ALT (Alanine aminotransferase)

or AST (Aspartate aminotransferase)
– Inflammation of the hepatic cells
• Raised ALP (Alkaline Phosphatase)
– Inflammation of the biliary tract cells
• Raised GGT (Gamma Glutamyltranspeptidase)
– Hepatocellular disease, produced by bile ducts

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Liver Function Tests

• BILIRUBIN
– Yellowish pigment in bile formed by RBC breakdown
– Increased amounts cause jaundice
– Measured in urine and serum

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Liver - Ultrasound Appearance

• Homogeneous, moderately echogenic throughout

• Echogenicity Renal sinus ≥ pancreas ≥spleen ≥ liver ≥
renal cortex
• Pitfalls
– Altered kidney, pancreas, spleen texture and brightness
– Inter-observer variability
– System variability

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Ultrasound Appearance
(compare with pancreas)

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Ultrasound Appearance
(compared to R kidney)

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Liver-L Lobe

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Liver- R lobe

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Ultrasound Appearance

• PORTAL VEINS
– Hyperechoic walls - collagenous sheath
– Intra-segmental - run through middle of each liver segment
– Largest at porta hepatis and decrease in size towards diaphragm

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Ultrasound Appearance - PV

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Ultrasound Appearance

• HEPATIC VEINS
– Thin walls - not seen on ultrasound*
– Inter- segmental
– Largest at diaphragm becoming smaller toward porta hepatis

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Ultrasound Appearance - HV

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Ultrasound Appearance

• HEPATIC ARTERIES
– Runs in portal triad - follows same course as portal vein
– Hyperechoic arterial wall

• Identified by:
– Doppler signal only after porta hepatis

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Ultrasound Appearance - HA

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Anatomy - Couinard’s System

• Now universal for lesion localization

• Functional segments

• Each segment contains:

– Portal triad –hepatic artery, portal vein and bile duct

– Surgical relevance

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Anatomy - Couinard’s
1. Caudate Lobe
2. Left lateral superior(posterior)
3. Left lateral inferior(anterior)
4a. Left medial superior
4b. Left medial inferior
5. Right anterior inferior
6. Right posterior inferior
7. Right posterior superior
8. Right anterior superior

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Anatomy - Couinard’s

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Caudate Lobe Long

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Caudate Lobe Trans

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Anatomy - Couinard’s

4a
2
8

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Anatomy - Couinard’s

4 3
5/8

1 2

6/7

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Anatomy - Couinard’s

Ant

8 4
MHV
5/8 RPV
3

7/6
7

Post

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Anatomy - Couinard’s

2/3

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Anatomy - Couinard’s

2/3

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Anatomy - Couinard’s

8 3
4a
7
6
1 2

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Anatomy - Couinard’s

2 3

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 Diseases that affect the functional cells of the liver, the hepatocytes, are referred to as
diffuse liver diseases. These diseases are treated medically rather than surgically. Diffuse
Diffuse Liver Disease disease occurs as the hepatocytes are damaged and liver function decreases.

• Hepatic Steatosis (Fatty Infiltration)

• Cirrhosis
• Hepatitis

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Fatty Infiltration (Hepatic Steatosis)

• Accumulation of fat within hepatic cells

• Acquired, reversible disorder of metabolism
• Most common causes - obesity, alcoholism, diabetes
• Focal or diffuse

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Fatty Infiltration - Ultrasound

Fatty liver is diagnosed based on the following ultrasound

parameters: parenchymal brightness, liver-to-kidney
contrast, deep beam attenuation, bright vessel walls, and
gallbladder wall definition.

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Fatty Infiltration - Ultrasound
• Qualitative grades are conveniently labeled mild, moderate,
or severe or grade 0 to 3 (with 0 being normal). Grade 1
(mild) is represented by a slight diffuse increase in fine
echoes in the hepatic parenchyma with normal
visualization of the diaphragm and intrahepatic vessel
borders. Grade 2 (moderate) is represented by a moderate
diffuse increase in fine echoes with slightly impaired
visualization of the intrahepatic vessels and diaphragm.
Grade 3 (marked) is represented by a marked increase in
fine echoes with poor or no visualization of the
intrahepatic vessel borders, diaphragm, and posterior
portion of the right lobe of the liver.

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Fatty Infiltration - Ultrasound

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Fatty Infiltration

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Fatty Liver

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Focal Fatty Sparing Focal fatty sparing of the liver is the localized absence of increased intracellular
hepatic fat, in a liver otherwise fatty in appearance i.e. diffuse hepatic steatosis.

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Cirrhosis
• is a condition in which the liver does not function properly
due to long-term damage. This damage is characterized by
the replacement of normal liver tissue by scar tissue.
Typically, the disease develops slowly over months or
years.
• Classic clinical presentation - hepatomegaly, jaundice,
ascites

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Cirrhosis - Causes

• Viral hepatitis (macronodular)

• Alcohol (micronodular)
• Toxins, medications
• Metabolic disorders
• Prolonged cholestasis
• Hepatic venous obstruction
• Immune disorders

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Cirrhosis - Ultrasound

• Volume redistribution
– Early - enlarged
– Advanced stages - shrinks, may be more marked in right lobe
• Coarse echotexture
• Nodular surface
– Irregularity of liver surface

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Cirrhosis
Normal Mild

Macronodular

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Cirrhosis

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Cirrhosis

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Cirrhosis

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Consequences

• FATTY LIVER - fat deposits cause liver enlargement

– Full recovery possible
• LIVER FIBROSIS - scar tissue forms
– Recovery possible, scar tissue remains
• CIRRHOSIS - Destruction of liver cells through
connective tissue growth
– Damage irreversible

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Hepatitis

• A B C D or E
• B C D - may progress to chronic disease or predispose to
HCC (Hepatocellular Carcinoma)
• Transmission:
– A and E - contaminated food and drink, prevalent in third-world
countries
– B C D - transfusion and sexual contact (blood borne - saliva, sweat)

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Hepatitis

• May be asymptomatic
• Lethargy, nausea, vomiting, jaundice
• Liver enlarged and tender in acute phase

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Hepatitis - Ultrasound

• Frequently normal
• Acute
– Hepatomegaly
– Decreased liver echogenicity - increased portal vein
prominence
– Gallbladder wall thickening
• Chronic
– Cirrhosis

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Hepatitis - Ultrasound

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Vascular Abnormalities

• Portal Hypertension
• Budd-Chiari Syndrome

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Portal Hypertension

• Raised portal venous system pressure as a result of

chronic disease, where blood flow into liver is hindered by
fibrosed nodular change.
• Causes can be intra-hepatic or extra-hepatic

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Portal Hypertension splenic vein

• EXTRAHEPATIC Thrombosis of PV or SV
– Trauma
– Sepsis
– HCC
– Pancreatic carcinoma
– Pancreatitis
– Splenectomy
– Hypercoagulable states

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Portal Hypertension (HT)

INTRAHEPATIC
• Cirrhosis (90% of all portal HT)

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Portal HT – Ultrasound Appearances

• PORTAL VEIN - THROMBOSIS

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Portal HT - Ultrasound

• ASCITES
– Free fluid in pelvis, Morrison’s pouch, Abdominal wall, peritoneal
cavity and spaces

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Budd-Chiari Syndrome

• Partial or complete occlusion of hepatic veins

• Relatively rare
• IVC may or may not be thrombosed
• Clinical course determined by degree of occlusion and
presence of collaterals
• B-mode and Doppler assessment

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Budd-Chiari - Ultrasound

• Liver large and bulbous in acute phase

• As progresses, compensatory hypertrophy or spared
portions - caudate lobe
• Hepatic veins difficult or impossible to image
• Ascites

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Budd-Chiari Syndrome

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Summary

• describe the functional Couinaud anatomy of the liver

• explain the equipment parameters which influence liver
imaging
• describe the sonographic appearance of the normal liver
• describe the ultrasound findings of diffuse pathology-fatty
liver, cirrhosis and hepatitis.
• Differentiate portal hypertension from Budd Chiari
Syndrome

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Questions????

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Quiz

True or False

The left and right lobe of the liver are

approximately equal in size
• False

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Quiz

The LHV and the left intersegmental fissure

separate which liver segments?

2/3 from 4a/b

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Quiz

What is contained within the portal triad?

Portal vein, bile duct and hepatic artery

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 1=right hepatic artery, 2=IVC, 3=coeliac axis, 4=SMA
5=Splenic vein, 6= SMV, 7=portal vein 8=CBD 9=cystic duct
10=RHV
sma=superior mesenteric artery

Label this diagram RHV = right hepatic vein

1
10

4
9

7 6

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