Falciform ligament

LIVER
•LARGEST SOLID ORGAN IN THE
BODY
•IT WEIGHS 1600 GRAMS IN
MALES AND 1400 GRAMS IN
FEMALES
•COVERED BY GLISSON
CAPSULE
 LIVER DIVISIONS
•LEFT LOBE
-DIVIDED INTO MEDIAL
AND LATERAL SEGMENTS BY THE
LEFT HEPATIC VEIN AND
LIGAMENTUM OF TERES
 LIVER
• RIGHT LOBE
DIVISIONS
-ANTERIOR AND POSTERIOR SEGMENTS
-SIX TIMES LARGER THAN THE LEFT
LOBE
-THREE POSTERIOR FOSSAE:
GALLBLADDER
PORTA HEPATIS
INFERIOR VENA CAVA
 LIVER DIVISIONS
•CAUDATE LOBE
-SMALLEST LOBE OF LIVER
-SEPARATED FROM THE
LEFT LOBE BY THE
LIGAMENTUM OF VENOSUM
 VASCULAR ANATOMY
• HEPATIC ARTERIES
ENTERS THE LIVER AT THE PORTA
HEPATIS AND DIVIDES INTO RIGHT
MIDDLE AND LEFT
30% OF THE LIVER’S BLOOD
SUPPLY IS THROUGH THIS ARTERY
LIES MEDIAL TO CHD AND
ANTERIOR TO MAIN PORTAL VEIN
2-4 mm
VASCULAR ANATOMY
• HEPATIC VEINS
RIGHT, MIDDLE, LEFT
CONVERGE TO EMPTY IN IVC
TRANSPORT DEOXYGENATED
BLOOD FROM LIVER CELLS TO IVC
FOLLOW A STRAIGHT
LONGITUDINAL COURSE
INCREASING IN CALIBER CLOSER
TO DIAPHRAGM
 VASCULAR ANATOMY
• PORTAL VEINS
-MAIN PORTAL VEIN ENTERS PORTA HEPATIS
AND DIVIDE INTO LEFT AND RIGHT PORTAL
VEINS
-PROVIDE 70% OF LIVER’S BLOOD SUPPLY
-TRANSPORT NUTRIENT RICH FROM
DIGESTIVE TRACT TO THE LIVER CELLS FOR
METABOLIC PROCESSING AND STORAGE
-WALLS CONTAIN FIBRIN
-DIAMETER NOT EXCEED 13mm
 LIVER SPACES
• MORISON POUCH
-LATERAL TO THE RIGHT LOBE OF THE
LIVER ANTERIOR TO THE KIDNEY
• SUBHEPATIC SPACE
-SPACE LOCATED BETWEEN INFERIOR
EGDE OF THE RIGHT LOBE AND ANTERIOR TO
THE RIGHT KIDNEY
• SUBPHRENIC SPACE
-SPACE BETWEEN DIAPHRAGM AND
SUPERIOR BORDER OF LIVER
 FUNCTIONS
• BREAKS DOWN RED BLOOD CELLS,
PRODUCING BILE PIGMENTS
• SECRETES BILE INTO THE DUODENUM
THROUGH THE BILE PRODUCTS
• CONVERTS EXCESS AMINO ACIDS INTO
UREA AND GLUCOSE
• RELEASES GLYCOGEN AS GLUCOSE
• MANUFACTURES HEPARIN
 FUNCTIONS
• STORES IRON AND CERTAIN
VITAMINS
• PERFORMS METABOLISM OF
PROTEINS, FATS AND
CARBOHYDRATES
• DETOXIFIES MANY DRUGS AND
POISONS THAT ENTER THE BODY
• PHAGOCYTIZES BACTERIA AND
WEAKENED RED BLOOD CELLS
SONOGRAPHIC APPEARANCE

LIVER
• HOMOGENOUS, MODERATELY
ECHOGENIC
• ANECHOIC TUBULAR
STRUCTURES WITHIN THE
PARENCHYMA REPRESENTING
BLOOD VESSELS AND BILIARY
DUCTS
 SONOGRAPHIC APPEARANCE
• BILE DUCTS
 SONOGRAPHIC APPEARANCE
• HEPATIC VEIN
SONOGRAPHIC APPEARANCE

• PORTAL VEIN
ALCOHOL-INDUCED LIVER DISEASE

dehydrogenase, acetaldehyde, acetate

CIRRHOSIS
• chronic destruction of liver cells and structure, with
nodular regeneration of liver parenchyma and
fibrosis;
• it is an end-stage liver disease
• MAJOR CAUSE: chronic alcoholism
• OTHER CAUSE: postnecrotic viral hepatitis,
hepatotoxic drugs and chemicals that destroy liver
cells, disease of the bile ducts (primary and
secondary biliary cirrhosis), and excessive
deposition of iron pigment within the liver
(hemochromatosis).
 CIRRHOSIS
• WEAKNESS AND FATIGUE
• WEIGHT LOSS
• ABDOMINAL PAIN
• ASCITES
• ELEVATED ASPARTATE
AMINOTRANSFERASE
AND BILIRUBIN
• SKIN CHANGES AND HAIR LOSS
• NON OBSTRUCTIVE JAUNDICE
 CIRRHOSIS
• DIFFUSE INCREASE IN PARENCHYMAL
ECHOGENICITY
• IRREGULAR NODULAR CONTOUR
• INABILITY TO DISTINGUISH PORTAL VEIN
WALL MARGINS
• ENLARGEMENT OF CAUDATE LOBE
• SPLENOMEGALY
• ASCITES
 CIRRHOSIS
• IRREGULAR SURFACE, THIS CAUSES INCREASED
SCATTERING OF US AND ONLY FEW SOUND WAVES
REFLECTED FROM THE CAPSULE RETURN TO THE
TRANSDUCER
• RAREFIES THE PERIPHERAL VASCULATURE WITH THE
REMAINING VISUALIZED VESSELS SHOWING VARIABLE
DIAMETERS AND WIDER CONFLUENCE ANGLES
• NORMAL HEPATIC VEINS FOLLOW A STRAIGHT COURSE
AND JOIN AT AN ACUTE ANGLE
 CIRRHOSIS
• US REFLECTS THE MORPHOLOGIC CHANGES
IN THE LIVER ASSOCIATED WITH CIRRHOSIS .
HEPATIC ECHOTEXTURE IS USUALLY
COARSENED AND HETEROGENEOUS, WITH
NUMEROUS VAGUE NODULES COMMONLY
EVIDENT . WHEN EXAMINED WITH HIGH-
FREQUENCY TRANSDUCERS, THE SURFACE OF
THE LIVER SHOWS FINE OR COARSE
NODULARITY
 HEPATIC CYST
• CYSTS ARE COMMON AND EASILY IDENTIFIED AND
CHARACTERIZED BY US . BENIGN HEPATIC CYSTS CONTAIN
ANECHOIC FLUID AND HAVE THIN WALLS. MOST ARE
SEPTATED THEY VARY IN SIZE FROM TINY TO HUGE AND
ARE COMMONLY MULTIPLE, PRODUCING A BUNCH OF
GRAPES APPEARANCE. SMALL CYSTS MAY MIMIC VESSELS
ON QUICK INSPECTION. DOPPLER IS USEFUL TO CONFIRM
THEIR AVASCULAR NATURE.
 HEPATIC CYST
•ANECHOIC ROUND OR OVAL SHAPED
MASS
•WELL DEFINED, SMOOTH WALL
MARGINS
•POSTERIOR ACOUSTIC
ENHANCEMENT
•MAY CONTAIN SEPTATIONS OR LOW
LEVEL INTERNAL ECHOES
ECHINOCOCCAL CYST
•RIGHT UPPER QUADRANT
PAIN
•LEUKOCYTOSIS
•FEVER
•HEPATOMEGALY
 ECHINOCOCCAL CYST
• SEPTATED CYSTIC MASS (HONEYCOMB)
• MOBILE INTERNAL ECHOES
(SNOWFLAKES)
• CYST CONTAINING SMALLER CYSTS
• COLLAPSED CYST WITHIN A CYST (WATER
LILY SIGN)
• ROUND OR OVAL IN SHAPE
• SMOOTH WALL MARGINS
Honeycomb
Water lily sign
BUDD CHIARI SYNDROME
•ABDOMINAL PAIN
•HEPATOMEGALY
•LOWER EXTREMITY EDEMA
•MILD INCREASE IN ALKALINE
PHOSPHATASE
BUDD CHIARI SYNDROME
• HYPOECHOIC INTRALUMINAL ECHOES IN THE
HEPATIC VEINS
• DILATED HEPATIC VEINS
• VEIN WALL THICKENING
• ABSENCE OF OR ALTERED HEPATIC VENOUS
FLOW
• HEPATOMEGALY
• ASCITES
• HYPERCHOIC LIVER PARENCHYMA
• THROMBOSIS IN THE PORTAL VEINS
 LIVER CELL ADENOMA
•LONG HISTORY OF USAGE OF
ORAL CONTRACEPTIVES
•NORMAL LABS
•RUQ PAIN
 LIVER CELL ADENOMA
• RANGE FROM
HYPOECHOIC TO
HYPERECHOIC AND MAY
CONTAIN AREAS OF
INTERNAL HEMORRHAGE,
NECROSIS, FIBROSIS, OR
CALCIFICATION.
 HEPATIC HEMANGIOMA
• HOMOGENOUSLY HYPERECHOIC IN
COMPARISON TO ADJACENT STRUCTURE
• SMOOTH OUTLINE,HEPATIC VEIN CAN BE
SEEN IN THE IMMEDIATE VICINITY
• MOST ARE SMALL, BUT CAN BE QUITE LARGE
• LARGER HEMAGIOMAS ARE HETEROGENOUS
 CAVERNOUS HEMANGIOMA
• BENIGN CONGENITAL NEOPLASM
CONSISTING OF LARGE BLOOD FILLED
CYSTIC SPACES
• FEMALE PREVALENCE
• MOST COMMON BENIGN LIVER MASS
• ASYMPTOMATIC
• RUQ PAIN
 CAVERNOUS HEMANGIOMA
• HOMOGENEOUS
HYPERECHOIC
MASS
• WELL DEFINED
WALL MARGIN
• ROUND IN SHAPE
• MAY INCREASE IN
SIZE
FOCAL NODULAR HYPERPLASIA
• ASYMPTOMATIC
• DISCRETE, LOBULATED HYPERCHOIC
MASS LOCATED ADJACENT TO THE LIVER
CAPSULE
• OTHER PATTERNS: HYPOECHOIC AND
ISOECHOIC TO THE NORMAL LIVER
PARENCHYMA
• HYEPRCHOIC STAR SHAPED AREA IN THE
CENTRAL PORTION OF THE TUMOR
 CANDIDIASIS
•IMMUNE SUPRESSED
PATIENTS
•ABDOMINAL PAIN
•FEVER AND CHILLS
•PALPABLE LIVER
 CANDIDIASIS
• UNIFORMLY HYPOECHOIC LESIONS
WITHIN THE LIVER PARENCHYMA
• THICK WALL MARGINS
• HEPATOMEGALY
• MAY DEMONSTRATE A TARGET OR
WHEEL WITHIN A WHEEL APPERANCE
• HYPERCHOIC LESIONS WITH POSTERIOR
ACOUSTIC SHADOWING
 SCHISTOSOMIASIS
• Parasite entering the skin or mucosa
• Symtoms may take 4-6 weeks to appear
• May take several years to develop
• FINDINGS: Rash, fever, diarrhea, lymphadenopathy
• SONOGRAPHY: increase in echogenicity of portal walls,
thick portal wall margins, atrophy of R Lobe, hypertrophy
of the left lobe, thickening of GB wall
 HEPATIC ABCESS
•ABDOMINAL PAIN
•FEVER AND CHILLS
•LEUKOCYTOSIS
•ELEVATED ALKALINE
PHOSPHATASE
•JAUNDICE
•HEPATOMEGALY
 HEPATIC ABCESS
•COMPLEX MASS
•RIGHT LOBE
•OVAL OR ROUND IN SHAPE
•IRREGULAR WALL MARGINS
•USUALLY SOLITARY
•POSTERIOR ACOUSTIC
ENHANCEMENT
 FATTY INFILTRATION
•ASYMPTOMATIC
•ELEVATED LIVER FUNCTION
TESTS
•HEPATOMEGALY
FATTY INFILTRATION
•DIFFUSE INCREASE IN
PARENCHYMAL
ECHOGENICITY
•NORMAL VESSEL WALL
MARGINS
CLASSIFICATION OF FATTY
INFILTRATION
•GRADE 1
- SLIGHT DIFFUSE INCREASE IN
THE HEAPTIC PARENCHYMA WITH
NORMAL VISUALIZATION OF THE
DIAPHRAGM AND INTRAHEPATIC
VESSEL BORDERS
CLASSIFICATION OF FATTY
INFILTRATION
•GRADE 2
-MODERATE DIFFUSE INCREASE
WITH SLIGHTLY IMPAIRED
VISUALIZATION OF THE
INTRAHEPATIC VESSELS AND
DIAPHRAGM
CLASSIFICATION OF FATTY
INFILTRATION
•GRADE 3
-MARKED INCREASE WITH POOR
OR NO VISUALIZATION OF THE
INTRAHEPATIC VESSEL BORDERS,
DIAPHRAGMAND POSTERIOR
PORTION OF THE RIGHT LOBE OF THE
LIVER
CAUSES OF HEPATIC
STEATOSIS
OBESITY
DIABETES
CIRHHOSIS
HEPATITIS
ALCOHOL ABUSE
HYPERLIPIDEMIA
METABOLIC
DISORDER
ULCERATIVE
COLITIS
 HEPATIC STEATOSIS
• CLINICAL FINDINGS:
ASYMPTOMATIC
ELEVATED LIVER FUNCTION TEST
HEPATOMEGALY
 HEPATIC STEATOSIS
• DIFFUSE INCREASE IN PARENCHYMAL
ECHOGENECITY
• NORMAL VESSEL WALL MARGINS
• FATTY INFILTRATION ALSO INCREASES THE
ATTENUATION OF THE US BEAM,
DIMINISHING VISUALIZATION OF THE
DIAPHRAGM AND COMMONLY REQUIRING A
LOWER-FREQUENCY TRANSDUCER TO
EXAMINE DEEP PORTIONS OF THE LIVER
HEPATOCELLULAR CARCINOMA
• PALPABLE MASS
• ABDOMINAL PAIN
• WEIGHT LOSS
• UNEXPLAINED FEVER
• ELEVATED ALANINE AMINOTRANSFERASE,
ASPARTATE AMINOTRANSFERASE AND
ALKALINE PHOSPHATASE
• POSITVE ALPHA FETOPROTEIN
• JAUNDICE
HEPATOCELLULAR CARCINOMA
•SOLID MASS WITH VARIABLE
ECHOGENICITY
•MAT DEMONSTRATE HYPOECHOIC
HALO
•MULTIPLE NODULES
•HEPATOMEGALY
•ASCITES
HEPATOCELLULAR CARCINOMA
• Hepatocellular carcinoma may be solitary, multifocal, or
diffuse . Detection in the diseased liver is commonly
difficult with US. Most are hypervascular, with
prominent vascularity shown by color Doppler. Tumor
invasion of the portal and hepatic veins is common.
Tumors may be hyperechoic with internal fat to
hypoechoic and heterogeneous because of
nonliquefactive necrosis. Any solid mass detected by US
in a diseased liver is suspicious for hepatocellular
carcinoma.
HEPATIC METASTASIS
• Metastases are by far the most common malignant
tumors involving the liver. Although some types of
metastases (especially mucinous carcinoma of the
colon or rectum) may produce diffuse, finely
granular calcifications that can be seen on plain
radiographs, the diagnosis of hepatic metastases
usually requires CT, ultrasound, MRI, or
radionuclide studies.
 HEPATIC METASTASES
• HEPATOMEGALY
• RUQ PAIN
• WEIGHT LOSS
• LOSS OF APPETITE
• JAUNDICE
• INCREASE IN AST, ALT AND BLIRUBIN
• MILD INCREASE IN ALKALINE
PHOSPHATASE
 HEPATIC METASTASES
•BULL’S EYE OR TARGET LESION
•HYPERECHOIC MASSES
•CYSTIC MASSES
•COMPLEX MASSES
•DIFFUSE PATTERN
CT scan shows multiple low-
density metastases with high-
density centers (arrows).
 HEPATITIS
• Inflammation of liver
• TYPES:
Deficiency Hepatitis – chronic alcoholism is associated
with malnutrition, deficient diet
Toxic Hepatitis – certain drugs can result in necrosis of the
liver
Viral Hepatitis
A (infectious hepatitis) E
B (serum hepatitis) G
C (non A and non B)
D (delta hepatitis)
Hepatitis B. The liver sonogram illustrates multiple nodules and has
an internal coarse texture with increased echogenicity
 JAUNDICE
• condition in which the skin, whites of the eyes and
mucous membranes turn yellow because of a high
level of bilirubin, a yellow-orange bile pigment

Medical Jaundice (non obstructive)

Hemolytic
Hepatic

Surgical Jaundice (obstructive)