1. Dr/ ABD ALLAH NAZEER. MD.
Ultrasound examination of the liver and gall bladder.

2. 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

3. Scanning Technique
Begin doing a full sweep through the liver.
You will need the patient to take deep inspirations to fully visualize 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
visualization. Also looking intercostally between each rib space can ensure
thorough visualization.
Look For:
Homogeneous v's Attenuative(normal v's fatty)
Smooth v's coarse echotexture
B mode 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
B mode 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.
B mode image an enlarged liver will have rounded borders.
Once you have thoroughly scanned though the liver, then start taking images.

4. An liver series should include the following minimum images;
Longitudinal
Left lobe
Caudate lobe
IVC
Porta hepatis
Comparison to Rt Kidney
Transverse
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 visualize the normal waveform with the atrial contraction.

5. 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

6. Parasagittal Scan Plane.
The Liver and Rt Kidney are
visualized in this view.

7. Intercostal Scan Plane.
The Middle and Rt Hepatic Vein
are visualized in this view.

8. 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.

9. 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.

10. The Portal Vein should have constant forward
flow into the liver (hepatopetal flow) .As seen
in this image, the colour is red ,which is set for
movement towards the probe. If there is flow
reversal,this is hepatofugal (tip: Fugitive= run
away) and represents portal hypertension.
Because the hepatic veins drain
into the IVC immediately prior to
the Right Atrium, they have phasic
flow reflective of cardiac motion.

11. Normal Liver Measurements
—We need to be able to determine such conditions as hepatomegally ,
—It needs to be a consistent measurement to be able to compare sizes
over time.
—The calipers need to be positioned in the same position between
sonographers for accuracy. Ideally the same sonographer should be
used in a follow up assessment.
—The upper border lies in the right mid-clavicular line at the 5th
intercostal space. —Most people have the lower border extending to the
lower costal margin.
—If it is measured in the mid-hepatic line with a large field of view it
should measure <16cm from the posterior diaphragm to the lower
anterior edge. However organ size increases with gender, age ,height,
weight and body surface area.
—If the measurement is made from the anterior diaphragm to the lower
edge of the liver in the mid-clavicular line it should be no >13cm
—Be careful not to get confused with a riedel’s lobe as it can increase the
measurement.

12. MIDCLAVICULAR
Measured in the mid-hepatic line with a large
field of view it should measure <16cm from the
post diaphragm to the lower anterior edge.
MIDHEPATIC
If the measurement is made from the
ant diaphragm to the lower edge of
the liver in the mid-clavicular line it
should be no >13cm.

13. Common Pathology
Fatty liver
Cirrhosis
Liver cysts
Haemangioma
Portal hypertension
Portal vein thrombosis
Hepatic vein thrombosis
Liver abscess/collection
Trauma
Metastases
HCC
Abscess

14. Fatty liver.

15. Fatty liver.

16. Cirrhotic liver.

17. Cirrhotic liver.

18. Bilharzial liver with peri-portal fibrosis.

19. Bilharzial liver with peri-portal fibrosis.

20. A) Sonography of hepatic cysts
Ultrasound images reveal an anechoic lesion in the right lobe of the liver,
with thin walls and clear fluid content. A small projection is seen from the
wall. This may be thickening of the wall or a fine nodule. These findings
suggest a liver cyst. Differential diagnosis: biliary cystadenoma.

22. Ultrasound Typical liver cyst.

23. Color and Power Doppler images of the hepatic cyst showed no
flow in the liver cyst. However, the spectral Doppler trace
showed faint pulsations within this lesion. These pulsations
appear to be transmitted from the abdominal aorta and
appear insignificant. Thus we arrived at a diagnosis of a simple
cyst of the left lobe of the liver, based on these ultrasound and
Color Doppler images. Absence of flow in this cyst ruled out
possibilities like a vascular lesion like aneurysm of the portal
vein or AVM. The liver also shows moderate fatty changes.

25. Hydatid cyst with multiple hypoechoic internal daughter cysts.

26. Compound
picture of four
images showing
several typical
hemangiomas

27. Hemangioma of liver (hepatic hemangioma)
Images show a large (8 cms.) rounded, well defined, hyperechoic, non-calcific mass in the
right lobe of liver. There is a moderate amount of acoustic enhancement posterior to the
lesion. These ultrasound images show some of the typical features of hemangioma
(cavernous) of the liver. In this case the patient is an adult female which is typical of
hepatic hemangioma. However, usually hemangioma are smaller in size (less than 4 cms.)

28. Multiple Hemangioma of the Liver
Multiple hemangioma of the liver. the lesions are
small in size. Such lesions are rather atypical of hemangioma.

29. Hemangioma of the caudate lobe of liver
Large echogenic hemangioma in the caudate lobe of liver.

30. Subcostal scan through the right liver showing a large
hemangioma with central hypoechoic area due to thrombosis.

32. Hepatic abscess or abscess of Liver (Amebic liver abscess).
Sonography of the liver was done in this case of pain in the right iliac fossa. Ultrasound
image on left shows thickened, edematous wall of the cecum s/o typhlitis. Image on right
shows 2 hypoechoic lesions in the right lobe of liver. Both lesions are fairly large and show
in homogenous echotexture. In view of the underlying disease in the cecum, a diagnosis of
typhlitis with amebic liver (hepatic) abscess (developing stage) was made.

33. Ruptured liver abscess (rupture or leak of hepatic abscess)
Ultrasound images show a large abscess of the right lobe of liver
with rupture of the lower margin of the abscess. The "leaked" fluid
is contained within localized adhesions in the peritoneal cavity.

34. Abdominal CT with i.v. contrast administration, shows a large well defined
hypodense liver mass. B)Abdominal ultrasound show a heterogeneous
hyperechoic mass with a hypoechoic area inside, consistent with liver abscess.

35. Hyperechoic lesion in the right liver with central
calcification, proven to be an adenoma
Large heterogeneous lesion in the left
liver: adenoma with recent bleeding.

36. Irregularly demarcated cirrhotic liver
with small hypoechoic HCC, A: Ascites Hyperechoic HCC.

40. Diffuse metastatic liver involvementTypical metastases with bull's eye aspect

41. Liver metastasis with bull's eye aspect,
protruding at the liver surface.
Hypoechoic liver metastases.

42. Calcified liver metastases

43. Blood vessels disorder of the liver.
The portal vein provides about two thirds of the blood. This blood contains oxygen
and many nutrients brought to the liver from the intestines for processing. The
hepatic artery provides the remaining one third of blood. This oxygen-rich blood
comes from the heart and provides the liver with about half of its oxygen supply.
Receiving blood from two blood vessels helps protect the liver: If one of these
blood vessels is damaged, the liver can often continue to function because it
receives oxygen and nutrients from the other blood supply. Blood leaves the liver
through the hepatic veins. This blood is a mixture of blood from the hepatic artery
and from the portal vein. The hepatic veins carry blood to the inferior vena
cava—the largest vein in the body—which then carries blood from the abdomen
and lower parts of the body to the right side of the heart.
Blood vessel (vascular) disorders of the liver usually result from inadequate blood
flow—whether into or out of the liver. If the problem is blood flow out of the liver,
blood backs up in the liver, causing congestion. In either case, liver cells do not
receive enough blood (called ischemia) and thus are deprived of oxygen and
nutrients. Inadequate blood flow—into or out of the liver—may result from heart
failure or disorders that make blood more likely to clot (clotting disorders). In
clotting disorders, a clot may block the portal vein or a hepatic vein, slowing or
blocking blood flow.

44. Normal vascular structures of the liver.

47. Portal hypertension.

48. Portal hypertension.

49. Cavernous transformation of the portal vein.

50. Portal vein thrombosis.

51. Acute thrombosis of the portal vein with echogenic thrombus inside.

52. Partial thrombosis of the portal vein.

54. Ultrasound of liver graft in 56-year-old man with hepatic artery thrombosis. Color
Doppler ultrasound shows absence of flow in hepatic artery at hilus (arrow).

55. Ultrasound of liver graft in 56-year-old man with hepatic artery
thrombosis. Contrast-enhanced ultrasound reveals no arterial
perfusion in early phase at hilus level (arrow) nor at intrahepatic level.

56. Hepatic artery stenosis in 39-year-old man. Doppler ultrasound of hepatic artery
at intrahepatic level shows prolonged acceleration time of 0.153 second.

57. Reversed flow in the hepatic vein due to obstruction.

58. Reversed flow in the hepatic vein due to obstruction.

59. Right hepatic vein thrombosis

60. Ultrasound of the Gall bladder.

61. Fundus
Body
Normal US of
Gall Bladder.

62. Ultrasound of the Gallbladder – Protocol
Patient Preparation
Fast for 6 hours. No food or drink.
Preferably book the appointment in the morning to reduce bowel
gas.
Scanning Technique
Looking supine, left lateral decubitus and erect
Use the liver as a window especially when rolling the pt
onto their left side
Measure the wall <3mm
Is the gallbladder enlarged?>10cm in length
Check with colour Doppler for increased vascularity of the
wall
Assess the cystic duct, neck , body and fundus (sometimes
there is a phrygian cap)

63. Normal Scanning Position to take
advantage of using the liver as a
window and displacing the bowel.
A normal Gallbladder should be thin 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.

64. 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.

70. Ultrasonography with the typical technique and the probe placed at the right
hypochondrium could not locate the gallbladder at the plane of the liver hilum.
Congenital agenesis of the gall bladder.

71. Congenital agenesis of the gall bladder.

72. Multiple gall bladder
multiple septations
forming a honeycomb
appearance.

73. Duplicated gallbladder at US, MRI and
cholangiography with double cystic ducts.

74. Gall bladder stones and sludge.
US criteria for diagnosis of cholelithiasis.
1- Echogenic focus.
2- Cast acoustic shadow.
3- Seek gravitational dependence.

75. Wall-echo-shadow sign with multiple stones.Multiple stones with confluent shadows.Single stone with clean shadow

76. Acute cholecystitis is swelling (inflammation) of the gallbladder. It is
a potentially serious condition that usually needs to be treated in hospital.
Acute cholecystitis is either calcular(95%) or non calcular (5%).
The main symptom of acute cholecystitis is a sudden sharp pain in the
upper right side of your tummy (abdomen) that spreads towards your
right shoulder.
The affected part of the abdomen is usually extremely tender, and
breathing deeply can make the pain worse.
Unlike some others types of abdominal pain , the pain associated with
acute cholecystitis is usually persistent, and doesn't go away within a few
hours.
Some people may additional symptoms, such as:
a high temperature (fever)
nausea and vomiting
sweating
loss of appetite
yellowing of the skin and the whites of the eyes (jaundice)
a bulge in the abdomen.

77. US- GB wall in acute cholecystitis appears
as a thin hypoechoic line sandwiched
between two echogenic lines.
CT- thick wall with hypodense
outer layer (subserosal edema).

78. Acute calculus cholecystitis.

79. Acute acalculous cholecystitis. LEFT: US at the spot of maximum tenderness shows
mural thickening of the gallbladder (arrow) that is completely filled with sludge
(asterix) without any stones. RIGHT: Power-Doppler sonography shows hypervascularity
of the gallbladder wall (arrowhead), as a supporting sign of inflammation.

80. Acute gangrenous cholecystitis.

81. Xanthogranulomatous cholecystitis:
Intramural hypoechoic/hypoattenuating foci of abscess and inflammation.

82. Emphysematous cholecystitis. (A) and (B) TS and LS with gas and debris in the
gallbladder lumen. (C) Gas in the gallbladder lumen completely obscures the content

83. Emphysematous cholecystitis.

84. CT scan showing markedly enlarged gall
bladder with intraluminal blood and thrombus. Hemorrhagic cholecystitis.

85. Hemorrhagic cholecystitis with blood within the bladder lumen.

86. Chronic cholecystitis:
Chronic cholecystitis is gallbladder inflammation that has lasted a
long time. It almost always results from gallstones and from prior
attacks of acute cholecystitis. Chronic cholecystitis is characterized
by repeated attacks of pain (biliary colic) that occur when gallstones
periodically block the cystic duct.
In chronic cholecystitis, the gallbladder is damaged by repeated
attacks of acute inflammation, usually due to gallstones, and may
become thick-walled, scarred, and small. The gallstones may block
the opening of the gallbladder into the cystic duct or block the cystic
duct itself. The gallbladder usually also contains sludge. If scarring is
extensive, calcium may be deposited in the walls of the gallbladder,
causing them to harden (called porcelain gallbladder).
Symptoms
A gallbladder attack, whether in acute or chronic cholecystitis,
begins as pain.

87. Chronic calcular cholecystitis.

88. Chronic calcular cholecystitis.

89. Distended gall bladder containing echogenic, gravity
dependent, mobile, biliary sludge with calculi.

90. Porcelain GB:
Rare, due to chronic inflammation, mural calcification.

91. Biliary sludge is a mixture of particulate solids that
have precipitated from bile. Such sediment consists of
cholesterol crystals, calcium bilirubinate pigment, and
other calcium salts. Sludge is usually detected on
transabdominal ultrasonography. Microscopy of
aspirated bile and endoscopic ultrasonography are far
more sensitive. Biliary sludge is associated with
pregnancy; with rapid weight loss, particularly in the
obese; with critical illness involving low or absent oral
intake and the use of total parenteral nutrition (TPN);
Complications caused by biliary sludge include biliary
colic, acute cholangitis, and acute pancreatitis.
Asymptomatic patients with sludge or microlithiasis
require no therapy.

92. Biliary sludge

93. Biliary sludge

94. Gallbladder polyps are relatively frequent, seen in up to 5% of the
population. Over 90% are benign, and the majority are cholesterol polyps.
Cholesterol polyps are most frequently identified in patients between 40-
50 years of age, and are more common in women (F:M, 2.9:1)

95. Tiny polyp of the gall bladder wall.

96. Multiple gall bladder polyps

97. Large gall bladder polyp.

98. Adenomyomatosis of the gallbladder is a hyperplastic
cholestosis of the gallbladder wall. It is a relatively common
and benign cause of focal gallbladder wall thickening. It is
most easily seen on ultrasound and MRI.
Adenomyomatosis is relatively common, found in ~5% of all
cholecystectomy specimens. It is typically seen in patients in
their 5th decade. The incidence increases with age which may
be the result of protracted inflammation (see below). There is
a female predilection (M:F = 1:3).
It is most often an incidental finding, has no intrinsic malignant
potential, and usually requires no treatment.
Three morphological types of adenomyomatosis are described:
fundal (localized)
segmental (annular)
generalized (diffuse)

99. Segmental adenomyomatosis of gall bladder.

100. Diffuse adenomyomatosis of gall bladder.

101. Adenomyomatosis of the gallbladder with a thickened wall. Color Doppler
shows twinkling artefacts caused by cholesterol crystals in the wall.

102. Adenomyomatosis of the gallbladder with a thickened wall. Color Doppler shows
twinkling artefacts caused by cholesterol crystals in the wall.

103. Gallbladder adenocarcinomas is the most frequent and are
usually asymptomatic until it is no longer curable. As such, early
incidental detection is important, if the occasional patient is to be
successfully treated. Less frequent malignancies is squamous cell
carcinoma, Small cell carcinoma, Carcinosarcoma, Lymphoma and
metastasis.
Epidemiology
Although overall uncommon, gallbladder adenocarcinoma is the
most common primary hepatobiliary carcinoma and the
5th most common malignancy of the gastrointestinal tract
Predominantly affects older persons with long-standing
cholecystolithiasis, and as such is most common in elderly women
(> 60 years of age, F:M ratio = 4:1). Risk factors include
chronic cholecystitis: gallstones are seen in 70-90% of cases
familial adenomatous polyposis syndrome (FAP)
inflammatory bowel disease (IBD)
porcelain gallbladder

104. US of Gall bladder carcinoma.

105. Gallbladder adenocarcinoma.

106. US shows echogenic mass adherent to gallbladder fundus (arrows). CT shows enhancing
mass within the gallbladder (arrows) with involvement of the liver (arrowhead).

107. Gallbladder carcinoma.

108. B-cell lymphoma of the gallbladder.

109. 50-year-old man with renal-cell carcinoma. Intraoperative ultrasound image
of polypoid gallbladder lesion. Postcontrast axial CT image demonstrates
avidly contrast-enhancing polypoid gallbladder lesion (arrow).

110. Thank You.