Abdominal Ultrasound Anatomy.

Dr/ ABD ALLAH NAZEER. MD.

LIVER
The liver is the largest one organ in the abdomen. It varies considerably in
size and configuration from individual to individual. Ultrasound provides
an excellent means of assessing internal structures of the liver and
evaluating both diffuse and focal parenchymal abnormalities. Familiarity
with the internal hepatic anatomy is important in order to diagnose
disease.
COUINAUD'S ANATOMY
Couinaud Anatomy is becoming the universal nomenclature for hepatic
lesion localization. This description is based on portal segments and is of
both functional and pathologic importance. Each segment has its own
blood supply including arterial, portal, hepatic venous and biliary
drainage. There are eight segments. Segment I is the caudate lobe, II and
III are the left superior and inferior lateral segments respectively. Segment
IV is the medial segment of the left lobe and further divided into IVa and
IVb. The right lobe consists of four segments. Segment V and VI are the
inferior anterior and posterior segments respectively. Segment VII is the
superior posterior segment and segment VIII is the superior anterior one.
Things to look:
1. Position: It is usually 15 to 17cm in length with its upper border
usually at the level of the nipples and its lower border at the level of
the costal cartilage of the 8-9th rib.
2.SIZE Normally, the adult liver weighs from 1400 to 1600gm with the
right lobe six times larger than the left.
3. SHAPE + OUTLINE Wedged shape with smooth outline
4. BRIGHTNESS Pancreas > Liver > Spleen > Kidneys
5. TESTURE Homogenous and fine echopattern.
Scanning Technique
1. Longitudinal scan from the outer margin of the left lobe to the outer
margin of the right lobe.
2. Transverse scan with the probe angled cephalic to include the superior
margin to the inferior margin of the left and right lobe of the liver.
3. Subcostal scan to examine the whole of the right lobe.
4. Intercostal scan which is a supplementary view for examining the right
lobe of the liver especially when the right lobe is well within the rib cage.
 PROBE POSITIONING TO SCAN THE LIVER.
Rt. Lobe Liver.

Parasagittal Scan Plane The Liver and Rt. Kidney are

visualized in this view.
 The Middle and Rt. Hepatic Vein
Intercostal Scan Plane. are visualized in this view.
Subcostal Scan Plane. The probe is angled Rt. Portal Vein is shown coursing
cephalad under the ribs to avoid any transversely in this view.
bowel or ribs shadowing over the liver.
 Left Lobe Of Liver

Normal Anatomy seen in the

Transverse View of the Left Lobe.
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.
The Portal Vein should have constant
forward flow into the liver (hepatopetal
flow) .As seen in this image, the color is
red ,which is set for movement towards
the probe. Be very careful to make sure
you look at the color box on the side of
the image to know the setting.
Because the hepatic veins drain into the IVC
immediately prior to the Right Atrium, they
have phasic flow reflective of cardiac motion.
 ULTRASOUND OF LIVER SEGMENTS

Sagittal Midline. The Ligamentum venosum

Para-sagittal Left. is highlighted in orange.
lhv: Left hepatic vein IVC: Inferior vena cava
Para-sagittal Mid-clavicular.
RPV: Right Portal Vein RHV:
Para-sagittal Right
Right hepatic vein
Porta hepatis is seen with an oblique Oblique left showing the
angle 45degree rotation from the ligamentum teres.
sagittal view to the transverse view.
Transverse Plane showing the Transverse Superior Left
Ligamentum Venosum. lhv: left hepatic vein
mhv: middle hepatic vein
Transverse Mid Right Transverse Superior Right.
rpv: right portal vein
lpv: left portal vein
MIDCLAVICULAR, If the measurement MIDHEPATIC, Measured in the mid
is made from the ant diaphragm to hepatic line with a large field of view
the lower edge of the liver in the mid- it should measure <16cm from the post
clavicular line it should be no >13cm diaphragm to the lower anterior edge.
Gall ladder & Biliary Tract:
The examination begin with the patient in supine position.
Once supine view is obtained, the patient is positioned in the oblique
(both right and left sides up), decubitus views or sometimes in
upright position so that optimal visualization can be obtained and
to determine that stones roll to the dependent portion of the gall
bladder.
Transverse, longitudinal and oblique views with the transducer
are always performed.
PANCREAS
• All vascular landmarks and adjacent structures must be
identified in two planes
• When bowel gas obscures visualization, we ask the
patient to
drink water and use the stomach as a window.
• All patient position must be utilized, obliques, decubitus and
upright when necessary.
 ULTRASOUND OF THE GALLBLADDER – Normal.

A normal Gallbladder should be thin

Normal Scanning Position to take
advantage of using the liver as a
window and displacing the bowel.
walled (<3mm) and anechoic. It is a pear
shaped saccular structure for bile storage
in the Right Upper Quadrant. Its size
varies depending on the amount of bile.
Fasted it will be approximately 10cm
long.
 Folds are commonly seen and are normal.
Make note if pathology such as calculi are contained
within a compartment created by a fold.
A Phrygian cap is a specific, relatively common, inversion of the distal fundus of the gallbladder
into the body. It may become adherent. It is an anatomic variant or acquired abnormality.
 ULTRASOUND OF THE PANCREAS - Normal

Normal Pancreas and

surrounding anatomy.

Pancreas Scan Plane.

 Head of pancreas.
Sagittal Scan Plane Pancreatic Head
Fatty infiltration of the pancreas with
focal sparing of the uncinate process.
You can see no mass effect or compression of the CBD. A progress u/s to
confirm or, if in doubt, a double contrast CT can help confirm this finding.
 ULTRASOUND OF THE SPLEEN – Normal.
Use the lower left intercostal spaces.
Patient in right lateral decubitus (right side down).
Examined either obliquely or longitudinally in coronal plane.

Intercostal scan plane. Normal Spleen.

The size of the spleen can be extremely Accesory spleens or splenunculi are
variable ranging from 7cm- 14cm. common. (singular = splenunculus).
 ULTRASOUND FOR ABDOMINAL AORTA.

Normal Transverse B Mode Aorta. Abdominal Aortic Aneurysm distance

AP and Transverse Diameter should be < 3cm.
to the renal arteries.
Any atherosclerosis should be noted.
 URINARY TRACT.
• Right kidney is best seen with the patient in the supine position
using the liver as an acoustic window.
• With suspended respiration, scanning can be performed either
subcostally or intercostally.
Sagittal and transverse views of the kidneys should be obtained
• Left kidney is best seen in the right lateral decubitus position
(left side up) using a coronal axis. When possible, the spleen
should be used as an acoustic window. Deep inspiration is
recommended
•Urinary bladder has to well distended in order to give good
visualization. Transverse and longitudinal scan planes are used
to determine any lesion or wall-thickening. Sometimes decubitus
position has to be used for differentiate between bladder wall
lesion or stones.
 ULTRASOUND OF THE ADULT KIDNEY - Normal

Longitudinal: Normal Kidney.

Coronal scan plane for
the Right Kidney.
 Transverse normal image

Scan plane transverse kidney

 ULTRASOUND OF THE BLADDER - Normal

Longitudinal Bladder Image

Longitudinal Bladder View.

 Transverse Bladder Image

Transverse Scan Plane

 ULTRASOUND OF THE PROSTATE - Normal

Prostate is situated behind the bladder.

Angle the probe caudally

and in the midline to get a
sagittal view of the prostate.
 Transverse View Prostate

Turn the probe 90degrees and angle

caudally to get the transverse view.
NORMAL PROSTATE IMAGES TRANSRECTAL (TRUS)

Prostate Volume Axial Image

 ULTRASOUND OF THE UTERUS - Normal

Uterus sagittal US image.

Uterus TA probe positioning

for longitudinal scan.
 Trans abdominal view of the uterus:
transverse. Both ovaries are visible

Uterus TA probe positioning

for transverse scan.
 Normal TV image anteverted sagittal.
Transvaginal Technique
Anteverted uterus.
Retroverted transvaginal technique hl.
Retroverted uterus transvaginal scan.
The probe is turned slowly anticlockwise to
visualise the uterus at 90degrees to the
sagittal view. The Maximum Width is
measured in this transverse (coronal) plane.
 ULTRASOUND OF THE OVARIES - Normal

Axial trans-abdominal image with

Use the full urinary bladder the ovary lateral to the uterus.
as an acoustic window to
angle across to the ovary.
Axial trans-vaginal scan plane. Axial trans-vaginal image.
Normal transvaginal ovary demonstration The uterus may be oblique and squash
normal peripheral follicles. the ovary giving it a flattened ovoid shape.
 ULTRASOUND OF THE APPENDIX - Normal

Refer to this study which concluded that

the location of the appendix has wide The appendix can be found from the groin, to
individual variability, and the limitations the umbilicus or even higher under the liver. It
of McBurney's point as an anatomic
landmark should be recognized. is rarely midline or in the left iliac fossa.
 Normal Appendix
Appendicitis can be diagnosed when
the outer diameter of the appendix
measures greater than 6mm.
This image high lights the position of the
caecum and the appendix (mouseover)
 Ultrasound of the Gastrointestinal Tract.

Normal Gut Signature. The normal bowel usually has a 3-layer appearance with an echogenic inner
layer of mucosa and submucosa, a hypoechoic middle layer of muscle wall, and a thin echogenic
outer layer of serosa. Contents of the gut lumen are variable in appearance. A. The gastric antrum
(arrow) is commonly visualized as it crosses anterior to the pancreas (p). B. The gastric antrum in
another patient is distended with mixed echogenicity fluid and shows echogenic mucosal folds (long
arrow). The distended bowel has a thinner hypoechoic muscle zone (short arrow).
Typical Keyboard Pattern of Jejunal Folds. A fluid distended loop
of jejunum (SB) shows the folds of the valvulae conniventes as a
row of echogenic “piano keys” (arrows) extending from its wall.
Thank You.