Liver Protocol (Hepatic or RUQ


 This protocol includes images of several organs and structures. It has been divided into
sections to assist in determining diagnostic images that should be stored for the physician.
o Pancreas
o Liver
o Gallbladder and Common Bile Duct
 You must always evaluate the entire organ first before you store an image
 You should understand completely why you stored the image and identify everything in
the image
 Multiple breathing techniques and patient positions will be required

Organ/ Scan Plane Label Key Landmarks Identified
Pancreas head
Portal splenic confluence
o If CBD is enlarged, measure internal AP
 Pancreas body
Pancreas plane on the
 Aorta
 Measurement
o If pancreatic duct is seen measure internal
AP diameter
PANCREAS  Pancreas tail
 Splenic vein
Organ/ Scan Plane Label Key Landmarks
Order Identified
Sagittal LIVER SAG  Left lobe with inferior tip
The transducer
is placed sagittal LIVER SAG  Left lobe
in the mid
 Caudate lobe
portion of the
patient’s body  IVC
LIVER SAG  Right lobe
 Diaphragm
LIVER SAG  Right lobe superior
SUP  Right hemidiaphragm
Sagittal  Right pleural space
The transducer LIVER SAG  Right lobe mid
is placed MID  Main portal vein
sagittal and LIVER SAG  Right lobe inferior
lateral on the INF o Demonstrating largest superior to inferior
patient’s body area
o Measure liver length from superior to inferior
 Right kidney
LIVER Transverse LIVER TX  Left lobe
Transver  Caudate lobe
The transducer
se  IVC

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is placed  Right lobe
transverse in the
LIVER TX  Left lobe
mid portion of
the patient’s
HV  Right hepatic vein
body  Left hepatic vein
 Middle hepatic vein
Angulation of the
LIVER TX  Right lobe-most anterior portion
probe is used for
 Diaphragm
right lobe images
LIVER TX  Right lobe superior
SUP  Right hemidiaphragm
 Right pleural space
LIVER TX  Right lobe mid
MPV  Main portal vein
LIVER Transverse
Transver LIVER TX  Right lobe mid
The transducer
se MPV  Main portal vein with color Doppler
is placed
transverse and
lateral on the  Right lobe mid
patient’s body  Main portal vein with color & spectral Doppler
o Normal waveform will demonstrate slight
phasic flow toward the liver
LIVER TX  Right lobe-inferior
INF  Right kidney

Organ/ Scan Plane Label Key Landmarks Identified
GB SUPINE  Gallbladder body
Sagittal plane SAG  Gallbladder fundus
Gallblad of the GB GB SUPINE  Gallbladder body
der SAG  Gallbladder neck
Transverse GB SUPINE  Gallbladder mid body with clear delineation of
Patient in plane of the TX anterior wall
Supine GB  Gallbladder mid body with clear delineation of
position GB SUPINE anterior wall
TX  Measurement
o measure anterior wall thickness
GB LLD  Gallbladder body
Gallblad SAG  Gallbladder fundus
der Sagittal plane
of the GB GB LLD  Gallbladder body
Patient in SAG  Gallbladder neck
Left lateral
decubitus Transverse  Gallbladder mid body
position plane of the GB LLD TX
Gallblad Sagittal plane GB RLD  Gallbladder body
der of the GB SAG  Gallbladder fundus
GB RLD  Gallbladder body

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Patient in SAG  Gallbladder neck
Right lateral
Transverse  Gallbladder mid body
plane of the GB RLD TX
Transverse  Portal vein
plane of the CBD TX  CBD
CBD  Hepatic artery
 Portal vein
Common CBD SAG
Bile Duct  Enlarged image
CBD SAG  Portal vein
level of the Sagittal
porta plane of the
hepatis  Enlarged image
 Portal vein
 Measurement
o Internal AP diameter

Anatomical/ Image Correlation

CBD Hepatic

Portal CBD measurement
Inner wall to inner
Anterior GB wall measurement Transverse Portal
Outer wall to inner wall triad
Mickey Mouse Where it enters
sign the liver

Normal Measurement Ranges

Structure Area of Interest Plane Measureme Comments
Common Bile Level of Porta Long Axis <7-8 mm  Measure inner wall to
Duct Hepatis inner wall
 If duct is enlarged:
o Look for and document
any intrahepatic ductal
o Follow CBD to
pancreatic head
 If GB removed, CBD may
be enlarged (up to 11
Gallbladder wall Anterior Wall Transvers <3 mm  Calipers are placed

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e outside to inside of the
anterior wall
Liver RT Lobe Inferior Sagittal 15-17 cm  Measure superior to
Pancreas Head Transvers Head 2-3.5  Only performed if
e on the cm abnormalities are
body suspected
Pancreatic Duct Body of the Transvers 2 mm or less  Only performed if duct is
pancreas e on the visualized
body  Measure internal duct
diameter anterior to
Main Portal Vein Porta Hepatis Transvers Normal AP  Internal AP diameter
e on the measurement where MPV crosses the
body/ is <13 mm IVC
long axis o Only performed if
on the Normal flow abnormalities are
vessel velocity is 20- suspected
40 cm/s  Flow should be phasic and
toward the liver

Liver Protocol

Common Laboratory Values to be Reviewed prior to Examination

Lab Value Organ Level Indication or Association
Amylase  Pancreas Increased  Pancreatitis or other pancreatic disease
Lipase  Pancreas Increased  Pancreatitis or other pancreatic disease
AST (SGOT)  Liver Increased  Hepatitis, fatty liver, cirrhosis other liver
ALT (SGPT)  Liver Increased  Jaundice or hepatitis

Alkaline  Liver Increased  Biliary obstruction or metastases
phosphatase  Gallbladder

Bilirubin  Liver Increased  Jaundice, liver damage or obstruction
 Gallbladder

 Patient should be NPO for this study to reduce the amount of gas present and to prevent
contraction of the GB
 Have patient poke out their abdomen or take in a deep breath if having trouble seeing the
 Pancreatic tail may be evaluated using the spleen as a window
 Sit the patient erect for scanning if suspicious for stones stuck in the neck that weren’t
confirmed in LLD or RLD
 Watch your gain settings:
o Making the GB lumen too dark with TGC can mask pathology

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o Using too much gain can give the appearance of pathology
 If the GB appears to have artifacts, change to a higher frequency, use harmonics, use a
different window, or have the patient poke out their abdomen
 If the GB is enlarged make sure to evaluate the ducts for signs of stones. These can
obstruct the ducts
 To find the CBD:
o Scan from the GB in transverse and follow it to the neck and cystic duct, you will
see CBD
o Follow the portal vein from the portal confluence. The CBD will be anterior to the
 If the GB has been surgically removed (postcholecystectomy), document a “GB FOSSA”
image (main lobar fissure near porta hepatis) instead of the gallbladder images

 Pathology Seen
o Gray scale sagittal and transverse images
o Gray scale sagittal and transverse images with 3 measurements (length, width, and
o Color Doppler image to document the presence of blood flow
o Spectral Doppler image to document the type and velocity of blood flow
o If the wall measures greater than 3 mm, color Doppler can be used to confirm
increased flow in the wall due to cholecystitis.
o If the patient has gallstones and/or gallbladder wall thickening, they should be
evaluated for a positive Murphy’s sign (extreme tenderness upon transducer or manual
pressure in the RUQ). This needs to be reported to the interpreting physician as it
indicates acute cholecystitis.
o Must attempt to demonstrate movement of any pathology seen in the GB – sludge and
stones will move – masses will not!!
o If the CBD is enlarged at the porta hepatis, it should be followed to the pancreatic head
to evaluate for stones or an obstructive lesion

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