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Ultrasound > Anatomy > Abdomen
Graphics, Hepatic Visceral Surface
The anterior surface of the liver is
smooth and molds to the diaphragm
and anterior abdominal wall.
Generally, only the anterior/inferior
edge of the liver is palpable on a
physical exam. The liver is covered
with peritoneum, except for the
gallbladder bed, porta hepatis, and
the bare area. Peritoneal re ections
form various ligaments that connect
the liver to the diaphragm and
abdominal wall, including the
falciform ligament, the inferior edge
that contains the ligamentum teres,
and the obliterated remnant of the
umbilical vein.
Graphics, Hepatic Attachments and Relations
The liver is attached to the posterior
abdominal wall and diaphragm by
the left and right triangular and
coronary ligaments. The falciform
ligament attaches the liver to the
anterior abdominal wall. The bare
area is in direct contact with the
right adrenal gland, kidney, and
inferior vena cava (IVC).
Graphics, Hepatic Vessels and Bile Ducts
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Liver
Aya Kamaya, MD, FSRU, FSAR
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Graphic shows the liver inverted,
which is somewhat similar to the
surgeon's view of the upwardly
retracted liver. The structures in the
porta hepatis include the portal vein
(blue), the hepatic artery (red), and
the bile ducts (green). The visceral
surface of the liver is indented by
adjacent viscera. The bare area is
not easily accessible.
Posterior view of the liver shows the
ligamentous attachments. While
these may help to x the liver in
position, abdominal pressure alone
is su cient, as evidenced by
orthotopic liver transplantation,
after which the ligamentous
attachments are lost without the
liver shifting position. The
diaphragmatic peritoneal re ection
is the coronary ligament whose
lateral extensions are the right and
left triangular ligaments. The
falciform ligament separates the
medial and lateral segments of the
left lobe.
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This graphic emphasizes that at

every level of branching and
subdivision, the portal veins, hepatic
arteries, and bile ducts course
together, constituting the portal
triad. Each segment of the liver is
supplied by branches of these
vessels. Conversely, hepatic venous
branches lie between hepatic
segments and interdigitate with the
portal triads, but never run parallel
to them.

Graphics, Hepatic Segments

The 1st of 2 graphics demonstrating Inferior view of the liver shows that
the segmental anatomy of the liver the caudate is entirely posterior,
in a somewhat idealized fashion is abutting the IVC, ligamentum
shown. Segments are numbered in a venosum, and porta hepatis. In this
clockwise direction, starting with the view, a plane through the IVC and
caudate lobe (segment 1), which gallbladder approximately divides
cannot be seen on this frontal view. the left and right lobes.
The falciform ligament divides the
lateral (segments 2 and 3) from the
medial (segments 4A and 4B) left
lobe. The horizontal planes
separating the superior from the
inferior segments follow the course
of the right and left portal veins. An
oblique vertical plane through the
middle hepatic vein, gallbladder
fossa ,and IVC divides the right and
left lobes.

Transverse US, Left Lobe of Liver

Transverse grayscale US of the left Transverse grayscale US of the left Transverse grayscale US of the left
lobe of the liver is shown, centered lobe of the liver is shown. lobe of the liver is shown, centered

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at the level of the falciform ligament
and pancreas.
Left Lobe of Liver: Left Portal Vein
Transverse grayscale US of the left
lobe of the liver is shown, centered
at the left portal vein.
Left Lobe of Liver: Left Hepatic Vein
Transverse grayscale US of the liver,
centered at the left hepatic lobe,
shows the right, middle, and left
hepatic veins as they join into the
intrahepatic IVC.
Longitudinal US, Left Lobe of Liver
Longitudinal grayscale US of the left
lobe of the liver shows a triangular-
shaped cross section. The heart is
partially visualized above the
diaphragm.
Transverse US, Right Lobe of Liver
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Transverse color Doppler US of the
left lobe of the liver is shown,
centered at the level of the left
portal vein. Flow in the left portal
vein is directed toward the
transducer, indicating that the ow
is hepatopetal and therefore
normal.
Transverse color Doppler US of the
liver, centered at the con uence of
the hepatic veins, shows that the
ow direction is away from the
transducer, directed toward the IVC.
Longitudinal grayscale US of the left
lobe of the liver, at the level of the
aorta, shows the aorta posterior to
the liver, the celiac artery, and
superior mesenteric artery arising
from the aorta.
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at the level of the left hepatic vein.
On this transverse pulsed Doppler
US, spectral tracing of the left portal
vein shows that the ow is
monophasic, directed toward the
transducer, with a mildly undulating
waveform related to slight
transmission of the cardiac cycle,
which is a normal appearance for
the portal vein.
Spectral tracing of the left hepatic
vein, near the con uence with the
IVC, shows a characteristic triphasic
waveform pattern, which represents
re ection of cardiac motion.
Longitudinal grayscale US of the left
lobe of the liver shows the left
hepatic vein and left portal vein in
cross section.
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Transverse grayscale US at the level
of the hepatic vein con uence
shows the right, middle, and left
hepatic veins as they join with the
IVC posteriorly.
Right Lobe of Liver: Right Hepatic Vein
Transverse color Doppler US of the
right lobe of the liver shows that the
right and middle hepatic vein are
directed away from the transducer
and owing toward the IVC.
Main Portal Vein
Longitudinal oblique grayscale US is
shown, centered at the level of the
main portal and right portal vein.
Porta Hepatis
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Transverse grayscale US of the liver
just below the con uence of the
hepatic veins shows the IVC and
more peripheral portions of the
right and left hepatic veins.
Spectral tracing of the right hepatic
vein shows a typical triphasic
waveform with A, S, and D waves
representing re ection of cardiac
motion in the hepatic veins.
Longitudinal oblique color Doppler
US, centered at the level of the main
portal and right portal vein, shows
that ow in the portal vein is
directed toward the liver
(hepatopetal).
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Transverse grayscale US of the right
lobe of the liver, centered at the
right portal vein, shows the
posterior branch of the right portal
vein, which is typically directed away
from the transducer.
Spectral tracing of the middle
hepatic vein shows a typical
triphasic waveform with A, S, and D
waves representing re ection of
cardiac motion in the hepatic veins.
Longitudinal oblique spectral
Doppler US of the main portal vein
shows that the ow is hepatopetal
with gentle undulation re ecting the
cardiac and respiratory cycle.
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Longitudinal oblique spectral tracing
of the main hepatic artery shows a
typical low-resistance waveform
with brisk upstroke and forward
diastolic ow. In this case, the
hepatic artery velocity is 44 cm/s,
which is normal. When measuring
velocity, proper angle correction is
the key to obtaining accurate
velocities.
Longitudinal US, Liver
Longitudinal grayscale US of the
right lobe of the liver is shown,
centered at the level of the IVC.
Other Views of Liver
Longitudinal grayscale US of the
right lobe of the liver shows the liver
ends just above the inferior margin
of the right kidney. Normal hepatic
length should be < 15-15.5 cm in the
midclavicular line. Notice that the
normal hepatic parenchyma is
slightly hyperechoic compared to
the normal kidney.
Additional Images
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Oblique grayscale US of the liver,
centered at the porta hepatis, shows
the common bile duct anterior to
the right hepatic artery and portal
vein. The IVC is seen posterior to the
portal vein.
Longitudinal color Doppler US of the
liver is shown at the level of the IVC.
Transverse high-resolution US of the
liver capsule, as seen here, is
typically obtained with higher
frequencies (7-9 MHz). Subtle
nodularity of the capsule and small
subcapsular liver lesions that may
not be as well visualized with
standard (3-5 MHz) frequencies are
best visualized with this view. Note
the hepatic veins have no
discernible wall, whereas the portal
veins have slightly echogenic walls.
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Oblique color Doppler US of the
liver, centered at the porta hepatis,
shows the common bile duct is
anterior to the portal vein and the
right hepatic artery is between these
2 structures. This is the typical
anatomy in this location, although
anatomic variants of the right
hepatic artery may occur in which
the hepatic artery may be located
anterior to the common bile duct.
Spectral tracing of the IVC shows a
typical triphasic waveform with A, S,
and D waves representing re ection
of cardiac motion in the IVC.
Longitudinal oblique US shows a
normal gallbladder with anechoic
uid within the lumen and normal
appearance of the gallbladder wall.
Normal gallbladder wall thickness
should be measured at the interface
with the liver and should be < 3 mm
in thickness. A fold in the gallbladder
neck is incidentally seen in this
patient.
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GROSS ANATOMY

Overview
Liver is largest gland and largest internal organ (average weight: 1,500 g)
Functions
Processes all nutrients (except fats) absorbed from gastrointestinal tract; conveyed via portal vein
Stores glycogen, secretes bile
Relations
Anterior and superior surfaces are smooth and convex
Posterior and inferior surfaces are indented by colon, stomach, right kidney, duodenum, inferior vena cava (IVC), and
gallbladder
Covered by peritoneum except along gallbladder fossa, porta hepatis, and bare area
Bare area: Nonperitoneal posterior superior surface where liver abuts diaphragm
Porta hepatis: Portal vein, hepatic artery, and bile duct are located within hepatoduodenal ligament
Falciform ligament: Extends from liver to anterior abdominal wall
Separates right and left subphrenic peritoneal recesses (between liver and diaphragm)
Marks plane separating medial and lateral segments of left hepatic lobe
Carries round ligament (ligamentum teres), brous remnant of umbilical vein
Ligamentum venosum: Remnant of ductus venosus
Separates caudate from left hepatic lobe
Vascular anatomy (unique dual a erent blood supply)
Portal vein
Carries nutrients from gut and hepatotrophic hormones from pancreas to liver along with oxygen (contains 40%
more oxygen than systemic venous blood)
75-80% of blood supply to liver
Hepatic artery
Supplies 20-25% of blood to liver
Liver is less dependent than biliary tree on hepatic arterial blood supply
Usually arises from celiac artery
Variations are common, including arteries arising from superior mesenteric artery or left gastric artery
Hepatic veins
Usually 3 (right, middle, and left)
Many variations and accessory veins
Venous return from liver
Hepatic veins converge into IVC just below diaphragm and enter into right atrium
Portal triad
At all levels of size and subdivision, branches of hepatic artery, portal vein, and bile ducts travel together
Blood ows into hepatic sinusoids from interlobular branches of hepatic artery and portal vein → hepatocytes
(detoxify blood and produce bile) → bile collects into ducts, blood collects into central veins → hepatic veins
Segmental anatomy of liver
8 hepatic segments
Each receives secondary or tertiary branch of hepatic artery and portal vein
Each is drained by its own bile duct (intrahepatic) and hepatic vein branch
Caudate lobe = segment 1
Has independent portal triads and hepatic venous drainage to IVC
Left lobe
Lateral superior = segment 2
Lateral inferior = segment 3
Medial superior = segment 4A
Medial inferior = segment 4B
Right lobe
Anterior inferior = segment 5
Posterior inferior = segment 6
Posterior superior = segment 7
Anterior superior = segment 8

IMAGING ANATOMY

Internal Contents
Capsule
Re ective Glisson capsule making borders of liver well de ned
Left lobe

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Contains segments 2, 3, 4A, and 4B

Longitudinal scan
Triangular in shape
Rounded upper surface
Sharp inferior border
Transverse scan
Wedge-shaped tapering to left
Liver parenchyma echoes are mid gray with uniform, sponge-like pattern interrupted by vessels
Right lobe
Contains segments 5, 6, 7, and 8
Liver parenchymal echoes similar to left lobe
Sections of right lobe show same basic shape, though right lobe is usually larger than left
Caudate lobe
Longitudinal scan
Almond-shaped structure posterior to left lobe
Transverse scan
Seen as extension of right lobe
Portal veins
Have thicker re ective walls than hepatic veins; portal veins have bromuscular walls
Wall re ectivity also depends on angle of interrogation; portal veins cut at more oblique angle may have less apparent
wall
Can be traced back toward porta hepatis
Normal portal ow is hepatopetal on color Doppler; absent or reversal of ow may be seen in portal hypertension
Normal velocity: 13-55 cm/s
Normal diameter < 13 mm
Portal waveform has undulating appearance due to variations with cardiac activity and respiration
Branches run in transverse plane
Hepatic portal vein anatomy is variable
Hepatic veins
Appear as echolucent defects within liver parenchyma with no re ective wall: Large sinusoids with thin or absent wall
Branches enlarge and can be traced toward IVC
Flow pattern has triphasic waveform
Resulting from transmission of right atrial pulsations into veins
A wave: Atrial contraction (transient reversal of ow)
S wave: Systole (tricuspid valve moves toward apex)
D wave: Diastole
Right hepatic vein
Runs in coronal plane between anterior and posterior segments of right hepatic lobe
Middle hepatic vein
Lies in sagittal or parasagittal plane between right and left hepatic lobe
Left hepatic vein
Runs between medial and lateral segments of left hepatic lobe
Frequently duplicated
1 of 3 major branches of hepatic veins may be absent
Absent right hepatic vein in ~ 6%
Less commonly middle and left hepatic vein
Hepatic artery
Flow pattern has low-resistance characteristics with large amount of continuous forward ow throughout diastole
Normal velocity 40-80 cm/s
Resistive index typically 0.5-0.8
Common hepatic artery usually arises from celiac axis
Classic con guration: 72%
Celiac axis → common hepatic artery → gastroduodenal artery and proper hepatic artery → latter gives rise to right
and left hepatic artery
Variations from classic con guration
Common hepatic artery arising from superior mesenteric artery (SMA) (replaced hepatic artery): 4%
Right hepatic artery arising from SMA (replaced right hepatic artery): 11%
Left hepatic artery arising from left gastric artery (replaced left hepatic artery): 10%
Bile ducts
Normal peripheral intrahepatic bile ducts are too small to be demonstrated
Normal right and left hepatic ducts measuring a few millimeters are usually visible
Normal common duct
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Most visible in its proximal portion just caudal to porta hepatis: < 5 mm
Distal common duct should typically measure < 6-7 mm
In elderly, generalized loss of tissue elasticity with advancing age leads to increase in bile duct diameter: < 8 mm
(somewhat controversial)

ANATOMY IMAGING ISSUES

Questions
Designating and remembering hepatic segments
Portal triads are intrasegmental, hepatic veins are intersegmental
Separating right from left lobe
Plane extending vertically through gallbladder fossa and middle hepatic vein
Separating right anterior from posterior segments
Vertical plane through right hepatic vein
Separating left lateral from medial segments
Plane of falciform ligament
Separating superior from inferior segments
Plane of main right and left portal veins
Segments are numbered in clockwise order, as if looking at anterior surface of liver
Imaging Recommendations
Transducer
2.5- to 6-MHz curvilinear or vector transducer generally most suitable
Higher frequency linear transducer (i.e., 7-9 MHz) useful for evaluation of liver capsule and super cial portions of liver
Left lobe
Subcostal window with full inspiration generally most suitable
Right lobe
Subcostal window
Cranial and rightward angulation useful for visualization of right lobe below dome of hemidiaphragm
Can sometimes be obscured by bowel gas
Intercostal window
Usually gives better resolution for parenchyma without in uence from bowel gas
Right lobe just below hemidiaphragm may not be visible due to obscuration from lung bases
Important to tilt transducer parallel to intercostal space to minimize shadowing from ribs
Imaging Pitfalls
Because of variations of vascular and biliary branching within liver (common), it is frequently impossible to designate precise
boundaries between hepatic segments on imaging studies

CLINICAL IMPLICATIONS

Clinical Importance
Liver US often 1st-line imaging modality in evaluation for elevated liver enzymes
Di use liver disease, such as hepatic steatosis, cirrhosis, hepatomegaly, hepatitis, and biliary ductal dilatation, are well
visualized with US
Documentation of patency of portal vein, hepatic vein waveforms, and hepatic arterial velocities are helpful in evaluation
for etiologies of elevated liver function tests
Liver metastases are common
Primary carcinomas of colon, pancreas, and stomach are common
Portal venous drainage usually results in liver being initial site of metastatic spread from these tumors
Metastases from other non-GI primaries (breast, lung, etc.) commonly spread to liver hematogenously
Primary hepatocellular carcinoma
Common worldwide
Risk factors include chronic viral hepatitis B or C, alcoholic cirrhosis, or nonalcoholic steatohepatitis
US commonly used for screening and surveillance in patients at risk for development of hepatocellular carcinoma,
typically at 6 month intervals

SELECTED REFERENCES

1. Heller MT et al: The role of ultrasonography in the evaluation of di use liver disease. Radiol Clin North Am. 52(6):1163-75, 2014
2. McNaughton DA et al: Doppler US of the liver made simple. Radiographics. 31(1):161-88, 2011
3. Kruskal JB et al: Optimizing Doppler and color ow US: application to hepatic sonography. Radiographics. 24(3):657-75, 2004
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