The Digestive System Organ

Scanning 8
Mei Zhang

Abstract
The objective of this chapter is how to learn to operate scanning of the
digestive system organs and read the image figures, which contains the
contents of the scanning method, section structures, measuring method as
well as normal and clinical application value of the liver, gallbladder, bile
ducts, pancreas, spleen, stomach, duodenum, jejunum, colon and rectum
accompanied by 67 pictures of sonograms and 63 pictures of schematic
diagrams. The patient’s position, preparation, the location and direction of
the transducer are described in the scanning methods. Transverse, longitu-
dinal, and oblique scanning methods are introduced. The section struc-
tures show every organ plane in the image figures. The measuring methods
and normal describe the specification requirement of measurements in
standard section and the normal range. One of the most characteristic in
this atlas is the clinical application value which introduces the details of
what diseases can be diagnosed by this section. The liver scanning includes
the scans on the subxiphoid, right intercostal space, and right subcostal.
The image figures, color Doppler flow images, and pulsed Doppler wave-
form of the portal vein, hepatic arteries, hepatic vein, and inferior vena
cava are also provided.

M. Zhang
Ultrasonic Diagnosis Department,
Beijing Royal Integrative Medicine Hospital,
Beijing, China
e-mail: doctorzhangmei@126.com

© Springer Nature Singapore Pte Ltd. and People’s Military Medical Press 2018 203
M. Zhang (ed.), Atlas of Human Body Ultrasound Scanning,
https://doi.org/10.1007/978-981-10-5834-9_8
204 M. Zhang

Abbreviations

AA abdominal aorta P pancreas

AG adrenal gland (SAG`suprarenal gland) PB pancreatic body
Ao aorta PH pancreatic head
Au antrum PHA proper hepatic artery
BL bladder. Ps psoas major
Bo bowel PST prostate
CBD common bile duct PT pancreatic tail
CA celiac artery PV portal vein
CHD common hepatic duct QL quadrate lobe
CHA common hepatic artery RA renal artery
CL caudate lobe. RAG right adrenal gland
Co colon RSG right suprarenal gland
DAo descending aorta RHA right hepatic artery
Dia diaphragm RHD right hepatic duct
DU duodenum RHV right hepatic vein
E esophagus RK renal kidney
GB gallbladder RL right liver
HA hepatic artery RPV right portal vein
IVC inferior vena cava RRA right renal artery
LA left atrium RRV right renal vein
LAD left adrenal gland RV renal vein
LAG left suprarenal gland S Sinus
LHA left hepatic artery SB body of stomach
LHD left hepatic duct SF fundus of stomach
LHV left hepatic vein SMA superior mesenteric artery
LLV left lateral ventricle SMV superior mesenteric vein
LK left kidney SpA splenic artery
LL left liver SpV splenic vein
LPV left portal vein S spine
LRA left renal artery Sp spleen
LRV left renal vein SVC superior vena cave
LTH ligament teres hepatis St stomach
M Medulla VL venose lig
MHV middle hepatic vein
8 The Digestive System Organ Scanning 205

1 Liver Scanning

1.1 Longitudinal Scanning

of the Liver Through
the Abdominal Aorta

Fig. 8.1 Longitudinal

section of the liver and
the abdominal aorta

PB
LL SpV
SpA
CA
SMA
LA

E
Ao
206
1.1.1 Scanning Method
The patient should be on fast for 8–12 hours with
a supine position. Probe is placed vertically in the
middle line of the subxiphoid.
1.1.2 Section Structure
Longitudinal sections of the left hepatic lobe, the
abdominal aorta and oblique section of the
esophagus.
M. Zhang
1.1.3 Measuring Method and Normal
Measuring anteroposterior diameter of the left
hepatic lobe from the top of anterior capsule to
the posterior capsule. Anteroposterior diameter
should be less than 7 cm in the normal liver.
1.1.4 The Clinical Application Value
This plane is the standard section for measuring
anteroposterior diameter of the left liver lobe.
The size, shape, and parenchyma echogenicity of
the liver are observed.
8 The Digestive System Organ Scanning 207

1.2  ongitudinal Scanning of the

L
Liver through the Inferior
Vena Cava on Subxiphoid

Fig. 8.2 Longitudinal

scanning of the liver
through the inferior vena
cava on subxiphoid

QL

MHV CBD
PV

IVC
CL
208
1.2.1 Scanning Method
The patient should be on fast for 8–12 hours with
a supine position. Probe is placed vertically in the
subxiphoid, slightly inclined to the right.
1.2.2 Section Structure
Longitudinal section of the quadrate lobe, caudate
lobe, and inferior vena cava (posterior liver seg-
ment) and oblique scan of the portal vein, middle
hepatic vein, and common bile duct are shown.
1.2.3 Measuring Method and Normal
Measuring the diameter of the inferior vena cava
(segment of the posterior liver and segment of
entering the right atrium).
M. Zhang
1.2.4 Clinical Application Value
The placeholder lesions, expansion, narrowness,
blood clots, etc, in the inferior vena cava such as
Budd-Chiari’s syndrome are diagnosed by this
plane.
1.2.5 Notice
Diameter of the inferior vena cava changes with
breathing, narrows when exhaling, and widens
when inhaling.
8 The Digestive System Organ Scanning 209

1.3  ransverse Scan of the Left

T
and Right Liver Through the
Porta Hepatis on Subxiphoid

Fig. 8.3 Transverse

scan of the left and right
liver through the porta
hepatis on subxiphoid.
Note: 1 umbilical and
sagittal, 2 the external
inferior branch of left
portal vein, 3 the
external superior branch
of the left portal vein, 4
right hepatic bile duct,
and 5 left hepatic bile
duct

QL LL

5 2
CHD 1
4 3
RPV LPV

CL
RL
IVC
210
1.3.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is transversely placed on
the level of the subxiphoid, scanning slightly
oblique to the right posterior. The patient should
be in full and suspended inspiration to make the
liver move down.
1.3.2 Section Structure
Major structures: the porta hepatis, right portal
vein, and left hepatic portal vein. Ancillary
areas—the right and left liver lobe, oblique sec-
tion of the caudate lobe and quadrate lobe, infe-
rior vena cava, umbilical and sagittal section of
the left portal vein, and left intrahepatic bile duct.
M. Zhang
1.3.3 Measuring Method and Normal
Measuring the right and left portal vein inner diam-
eter, its normal value should be less than 0.8 cm.
1.3.4 Clinical Application Value
This section can be used to determine location of
the left lobe diseases. To observe the region of the
porta hepatis, measuring the right portal vein and
left portal vein. The bifurcation of the portal vein
separating the caudate lobe from the quadrate
lobe. Sagittal segment of the left portal vein is the
boundary of the left interior lobe and the left
exterior lobe.
The caudate lobe is located between portal
vein and inferior vena cava.
8 The Digestive System Organ Scanning 211

1.4  ransverse Scanning of the

T
Left Hepatic Lobe Through
the Left Portal Vein Branches
by Subxiphoid

Fig. 8.4 Transverse

section of the left
hepatic lobe through the
left portal vein branches
by subxiphoid. Note: 1
umbilical and sagittal, 2
the external inferior
branch of left portal
vein, and 3 the external
superior branch of the
left portal vein

LTH
2
1 LL
3

CL

IVC
RL
212
1, Sagittal segment of the left portal sagittal vein
2, Left external-internal branch of the portal vein
3, Left external-superior branch of the portal
vein.
1.4.1 Scanning Method
The patients should be on fast for 8–12 h with a
supine position. Probe is put horizontally at the
level of subxiphoid to scan toward the
posterior-superior.
1.4.2 Section Structure
Major areas are the left hepatic lobe and left
portal vein branches. Ancillary areas are the
transverse section of the inferior vena cava, left
lobe oblique section, sagittal section of the sag-
ittal segment of the left portal, longitudinal sec-
tion of the left external-superior branch and left
external-internal branch, and left intrahepatic
bile duct.
1.4.3 Measuring Method and Normal
The inner diameter of the sagittal segment of the
left portal vein is measured; generally the sagittal
diameter should be less than 1.0 cm, but the sagit-
M. Zhang
tal segment can be a congenital variant. It will be
wide in the case of portal vein hypertension
patients. The thickness of the caudate lobe is
measured, and its normal upper limit is 3 cm.
1.4.4 Clinical Application Value
(1) Positioning of the left lobe lesion location.
The sagittal segment of the left portal vein will
separate the left interior lobe from the left exte-
rior lobe. Link line of the left hepatic cross-sec-
tional and midpoint attachment of left portal vein
branches separates the left exterior-superior lobe
and the left inferior lobe. (2) Observing the left
portal branch whether it appears dilated or nar-
row, with the presence of emboli, (3) and whether
there is dilation of the left intrahepatic bile duct.
(4) The inferior vena cava obstruction, severe cir-
rhosis, or morphological change of the liver can
cause caudate lobe enlargement.
8 The Digestive System Organ Scanning 213

1.5  ongitudinal Scanning of the

L
Left Hepatic Lobe Through the
Caudate Lobe and Medial Lobe

Fig. 8.5 Longitudinal

scanning of the left
hepatic lobe through the
caudate lobe and medial
lobe. Note: 1 umbilical
and sagittal of left portal
vein

LL
VL
1 CBD
CL PV
IVC
214 M. Zhang

1.5.1 Scanning Method 1.5.3 Measuring Method and Normal

The patient should be on fast for 8–12 h with a Measuring the anteroposterior diameter of the
supine position. Probe is placed in the middle caudate lobe. It should be less than 3 cm in the
line of the subxiphoid vertically. normal liver.

1.5.2 Section Structure 1.5.4 The Clinical Application Value

Major structures: longitudinal section of the left This is a standard section for measuring the
hepatic lobe, caudate lobe, and venose ligamen- anteroposterior diameter of the caudate lobe. To
tum. Ancillary areas oblique section of the portal observe the size, shape, and echogenicity of the
vein, inferior vena cava, and common bile duct. hepatic parenchyma of the caudate lobe.
8 The Digestive System Organ Scanning 215

1.6  blique Scanning of the Left

O
External Hepatic Lobe

Fig. 8.6 Oblique

scanning of the left
external hepatic lobe.
Note: 1 umbilical and
sagittal section of the
left portal vein

LL
ST

1 P
SpV

VL
CL
Ao
IVC
216
1.6.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is placed on the subxi-
phoid transversely.
1.6.2 Section Structure
Oblique section of the left external hepatic lobe,
caudate lobe, umbilical, inferior vena cava and
sagittal section of the left portal vein.
M. Zhang
1.6.3 The Clinical Application Value
To observe the size, shape, and parenchyma
echogenicity of the left external lobe of the liver,
especially to observe the area near the external
edge of the left external hepatic lobe to distin-
guish the mass in the liver from that outside.
8 The Digestive System Organ Scanning 217

1.7  blique Scanning of the Left

O
Hepatic Lobe and Caudate
Lobe

Fig. 8.7 Oblique scan

of the left hepatic lobe
and caudate lobe.
Note: 1 umbilical and
sagittal section of left
portal vein, 2 the
external superior branch
of the left portal vein,
and 3 the enternal
branch of left portal vein

3 1
QL 2

LPV VL
CL
IVC Ao
218
1.7.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. The subxiphoid transverse scan-
ning is made, and the direction of the acoustic
beam is toward the posterior-superior.
1.7.2 Section Structure
Transverse-oblique section of the left hepatic
lobe and caudate lobe. Sagittal segment and
transverse segment of the left portal vein, inferior
vena cava, and abdominal aorta. The caudate lobe
M. Zhang
anterior to the inferior vena cava is separated
from the left lobe by the fissure for the ligamen-
tum venosum.
1.7.3 The Clinical Application Value
To observe the size, shape, and parenchyma
echogenicity of the left lobe and caudate lobe of
the liver. To determine whether there is diffused
or space-occupying lesions in those area. The
caudate lobe may be enlarged in some patients
with hepatic cirrhosis.
8 The Digestive System Organ Scanning 219

1.8  ongitudinal scanning of the

L
hepatic left lobe and the
ligament teres hepatis by
subxiphoid

Fig. 8.8 Longitudinal

scanning of the hepatic
left lobe and ligament
teres hepatis. Note: 1
umbilical and sagittal
section of the left portal
vein

QL

1 LTH
PV
LHV
VL

CL
220
1.8.1 Scanning Method
The patient should be on fast for 8–12 h and
should be in a supine position. Probe vertically is
placed in middle line of the subxiphoid.
1.8.2 Section Structure
Longitudinal section of ligament teres hepatis
which arises from the left portal vein to the
anteroinferior edge of the left lobe. Longitudinal
section of the caudate lobe, the quadrate lobe,
and the sac segment of the left portal vein.
1.8.3 Measuring Method and Normal
Measuring anteroposterior diameter of the cau-
date lobe. It should be less than 3 cm in the nor-
mal liver.
M. Zhang
1.8.4 The Clinical Application Value
Paraumbilical vein reopens in the patient of por-
tal hypertension as a tubulous anechoic area,
arises from the left portal vein through the liga-
ment teres hepatis to the interior anteroinferior
edge of the left lobe, and then runs down along
the anterior abdominal wall to the navel. Color
Doppler blood signal can be shown by
CDFI. Ligament teres hepatis which locates in
the left longitudinal furrow of the liver is a land-
mark of the bounder of the left internal lobe
(medial lobe) and left external lobe.
8 The Digestive System Organ Scanning 221

1.9 Oblique scanning of the

ligament teres and the left liver by
subxiphoid

Fig. 8.9 Oblique view

of the ligament teres and
the left liver by
subxiphoid scan

LTH

CHA
CA
PV
Ao
IVC

RL
222
1.9.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Transducer is placed transversely
in the middle line of the subxiphoid. The sound
beam should be posterior-superior in direction.
1.9.2 Section Structure
The ligamentum teres hepatis which is located
in the left longitudinal fissure of the liver
appears as a bright echogenic focus on the
sonogram and is seen as a rounded termination
of the falciform ligament. Oblique section of
left internal and external lobe. Oblique section
M. Zhang
of the left hepatic lobe, right lobe, abdominal
aorta, and esophagus.
1.9.3 The Clinical Application Value
The ligament teres hepatis is a bounder mark of
the left internal lobe and left external lobe. As a
hyperechogenic structure, it should be distin-
guished from hemangioma as well as calcifica-
tions. In patients with portal hypertension, the
paraumbilical vein can be shown in the oblique
section of ligament teres hepatis which is a round
anechoic area and can be filled by color Doppler
blood signal in the condition of CDFI.
8 The Digestive System Organ Scanning 223

1.10 Oblique scanning of the liver

through the gallbladder and inferior
vena cava by the right subcostal
margin

Fig. 8.10 Oblique scan

of the liver through the
gallbladder and inferior
vena cava by the right
subcostal margin

GB
LL

LPV
RPV
VL
CL
IVC
RL
224 M. Zhang

1.10.1 Scanning Method 1.10.3 The Clinical Application Value

The patient should be on fast for 8–12 h with a In this section, the straight-through cable of the
supine position. Probe is transversely placed to gallbladder and the inferior vena cava through the
the right subcostal margin and parallel to it. liver is a mark of the middle line of the liver and
so as a boundary of the left lobe and right lobe.
1.10.2 Section Structure
Oblique transverse section of the liver, gallblad-
der, inferior vena cava, and venous ligament.
8 The Digestive System Organ Scanning 225

1.11  blique Scanning of the Liver

O
through Hepatic Veins and
the Second Porta Hepatis on
Subxiphoid

Fig. 8.11 Oblique scan

of the liver through
hepatic veins and the
second porta hepatis on
subxiphoid

LL

MHV LHV

RHV

IVC
RL

Dia
226
1.11.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is transversely placed on
the level of the subxiphoid, scanning slightly
oblique to right posterior. The patient should be
in full and suspended inspiration to make the
liver move down.
1.11.2 Section Structure
Oblique views of the liver, the hepatic veins, and
inferior vena cava. Diaphragmatic top area of the
liver near the second porta hepatis.
1.11.3 Measuring Methods
and Normal
Measuring diameter of three hepatic veins.
Measurement should be made in the point of dis-
tance 1–2 cm from the inferior vena cava. The nor-
mal value: left hepatic vein diameter 0.5–0.9 cm,
M. Zhang
middle hepatic venous diameter 0.5–0.9 cm, and
right hepatic vein diameter 0.4–0.9 cm.
1.11.4 Clinical Application Value
(1) Observing the area near the second porta
hepatis and the area near the diaphragmatic top of
the liver. (2) Determining if there are dilation, nar-
rowness, or presence of emboli in the inferior
vena cava or hepatic veins. (3) The middle hepatic
vein is a boundary of the right hepatic lobe and
left hepatic lobe; the left hepatic vein is a bound-
ary mark of the left internal lobe from left external
lobe; the right hepatic vein is the boundary mark
of the right anterior lobe and right posterior lobe.
1.11.5 Notes
Hepatic veins can enter the inferior vena cava
directly, or two branches merge into one and then
enter the inferior vena cava.
8 The Digestive System Organ Scanning 227

1.12  ransversely Scanning the

T
Upper Part of the Porta Hepatis

Fig. 8.12 Transversely

scanning the upper part
of the porta hepatis

LL

LHD
RHD
LPV
RPV
228
1.12.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is placed at the level of the
right subcostal transversely, scanning slightly
oblique to posterior-superior. The patient can be
in full and suspended inspiration to make the
liver move down.
1.12.2 Section Structure
Major structures: the porta hepatis, right portal
vein, and left hepatic portal vein as well as the
right hepatic duct and the left hepatic duct accom-
panying. Ancillary areas—the right and left liver
lobe, oblique section of the caudate lobe and
quadrate lobe, inferior vena cava, umbilical and
sagittal segment of left portal vein, and left intra-
hepatic bile duct.
M. Zhang
1.12.3 Measuring Method and Normal
Measuring the left and right portal vein and
hepatic duct. RPV and LPV normal value is 0.8–
1.3 cm; larger than 1.3 cm is abnormal. The right
and left hepatic duct inner diameter should be
less than ≦0.3 cm.
1.12.4 Clinical Application Value
This section can be used to observe porta hepatis
structure and anatomical relation, to judge
whether there are abnormals in right portal vein
and left portal vein as well as right hepatic duct
and left hepatic duct such as expansion, narrow
or space-occupying lesions.
8 The Digestive System Organ Scanning 229

1.13  ransverse-Oblique View

T
of the Left Liver Through
Longitudinal Section of the Left
Hepatic Vein on the Subxiphoid

Fig. 8.13 Transverse-

oblique view of the left
liver through
longitudinal section of
the left hepatic vein on
the subxiphoid

LL

LHV

IVC
230
1.13.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Subxiphoid scanning toward left
posterior-superior should be performed. Probe is
horizontal.
1.13.2 Section Structure
The transverse-oblique section of the medial and
lateral segment of the left lobe. Longitudinal view
of the left hepatic vein. The segment of the left
hepatic vein drains into the inferior vena cava. The
transverse view of the inferior vena cava.
1.13.3 Measuring Method and Normal
Measuring inner diameter of the left hepatic vein
generally should be less than 1.0 cm. The left
M. Zhang
hepatic vein blood flow can be measured by
pulsed Doppler.
1.13.4 Clinical Application Value
(1) The main left hepatic vein traveling in the left
fissure of the liver is a useful landmark for sepa-
rating the left interior lobe from the left exterior
lobe. Its distal segment and larger branches run-
ning in the left interlobe fissure are a useful land-
mark for separating the left exterior-superior
segment from the left exterior-inferior segment
of the left lobe. (2) To observe whether there are
dilation, narrowness, or presence of emboli in the
left hepatic vein.
8 The Digestive System Organ Scanning 231

1.14  blique Scanning of the Right

O
Liver Through the Porta
Hepatis

Fig. 8.14 Oblique scan

of the right liver through
the porta hepatis

RL

Gb

RPV
CHD

PV
IVC
232
1.14.1 Scanning Method
The patient should be on fast for 8–12 h. Subcostal
scanning should be performed with the patient in
a left lateral decubitus or supine position. Deep
inspiration can make the liver move down as an
acoustic window.
1.14.2 Section Structure
Major areas: longitudinal section of the portal
vein and right portal vein, gallbladder, inferior
vena cava.
M. Zhang
1.14.3 Measuring Method and Normal
Measuring inner diameter of the portal vein and
right portal vein. Generally portal vein diameter
should be measured outside the porta hepatis and
should be less than 1.3–1.4 cm; right portal vein
should be less than 1.0 cm.
1.14.4 Clinical Application Value
This is the standard scan of the porta hepatis, being
used to observe the portal vein, right portal vein,
and liver parenchymal near the porta hepatis.
8 The Digestive System Organ Scanning 233

1.15  ongitudinal Scanning of

L
the Liver Through the Middle
Hepatic Vein on Subxiphoid

Fig. 8.15 Longitudinal

scanning of the liver
through the middle
hepatic vein on
subxiphoid

RL
Gb
CHD
PH

RHD
RPV

MHV IVC
234
1.15.1 Scanning Method
The patient should be on fast for 8–12 h and take
a supine position. Probe is sagittally obliquely put
to the subxiphoid toward slightly right posterior-
superior with an oblique angle about 15–20°.
1.15.2 Section Structure
The longitudinal view of the middle hepatic vein
including its segment of draining into the inferior
vena cava. The liver parenchyma near the second
porta hepatis and dome near the diaphragm.
1.15.3 Measuring Method and Normal
Measuring inner diameter of the middle hepatic
vein at point that is 1–2 cm from the inferior vena
M. Zhang
cava. Its diameter should be less than 1.0 cm
generally.
1.15.4 Clinical Application Value
(1) The hepatic vein and gallbladder can be
shown simultaneously in this section which is a
landmark of the middle line of the liver which
can be used as a dividing line of the right lobe
and right lobe. (2) To diagnose hepatic vein
lesions. (3) To determine the location of the
hepatic space-occupying lesion and the relation-
ship between the lesion and the hepatic vein.
8 The Digestive System Organ Scanning 235

1.16 Longitudinal Scanning

of the Right Liver through
the Porta Hepatis

Fig. 8.16 Longitudinal

section of the right liver
through the porta hepatis

RL

RHV

RHD
RPV

IVC
236
1.16.1 Scanning Method
The patient should be on fast for 8–12 h. Subcostal
scanning should be performed with the patient in
a left lateral decubitus or supine position. Taking
a deep inspiration so that the liver moves down as
an acoustic window, making the liver imaging
more clear.
1.16.2 Section Structure
Major areas: longitudinal section of the right
liver and right portal vein. Oblique scan of the
inferior vena cava, common hepatic artery, and
right hepatic biliary duct. Sagittal section of the
pancreatic head.
M. Zhang
1.16.3 Measuring Method and Normal
Measuring inner diameter of the right portal vein,
its normal value should be less than 1.0 cm.
Pulsed Doppler gets the right portal vein flow
spectrum and blood flow velocity at this section,
and its normal value range is 15–20 cm/s.
1.16.4 Clinical Application Value
This is a standard scan of the porta hepatis. The
right portal vein and liver parenchymal near the
porta hepatis are observed. It is also used to
determine whether the portal vein, common
hepatic artery, and right hepatic biliary duct have
dilation and to determine whether there is abnor-
mal echogenicity in them.
8 The Digestive System Organ Scanning 237

1.17  blique Scanning of the Right

O
Anterior Liver and the Left
Medial Lobe of the Liver by
Right Intercostal Space

Fig. 8.17 Oblique view

of the right anterior liver
and the left medial lobe
of the liver by right
intercostal space.
Note: 1 Branch of RPV,
2 Branch of MHV, and 3
Branch of LPV

RL LL

2
3
1

RPV

IVC
238
1.17.1 Scanning Method
The patient should be on fast for 8–12 h. Supine.
Probe is placed inside the right midclavicular
line, the fifth to sixth intercostal space trans-
versely, scanning toward the right posterior-supe-
rior for the right anterior lobe and toward the left
posterior-superior for the left medial lobe.
1.17.2 Section Structure
Oblique section of the right anterior lobe and left
lobe of the liver, right portal vein, inferior vena
M. Zhang
cava, branch of the right hepatic vein, and left
hepatic venous branch.
1.17.3 The Clinical Application Value
Scanning the right anterior lobe and left lobe on
the upper area of the liver, especially to observe
the lesion of the right anterior lobe and left medial
lobe. This section shows the boundary area of left
lobe and right lobe, and should be observed
carefully.
8 The Digestive System Organ Scanning 239

1.18 Oblique Scanning

of the Dome Area in the Right
Liver from the Right
Intercostal Space Approach

Fig. 8.18 Oblique scan

of the dome area in the
right liver from the right
intercostal space
approach. Note: 1 The
inferior lobe of right
lung

1
RL

Dia
240
1.18.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is placed transversely to
the right fourth or fifth intercostal space between
the anterior axillary line and midclavicular line
and scanning toward the right posterior.
1.18.2 Section Structure
The dome area of the right hepatic lobe near the
diaphragm. The right inferior diaphragm space
and right inferior lobe of the lung can be shown.
M. Zhang
1.18.3 The Clinical Application Value
The abnormality in the dome area near the dia-
phragm of the right liver, the right hepatic sub-
capsular lesion, and the fluid collection under
the right diaphragm as well as in the right pleu-
ral cavity can be diagnosed by this section. The
lesions in this area is near the edge of the right
liver, are not easy to be scanned, or may be
overlooked.
8 The Digestive System Organ Scanning 241

1.19  blique Scanning of the Right

O
Liver Through Right the Portal
Vein by the Right Subcostal
Space Approach

Fig. 8.19 Oblique scan

of the right liver through
right portal vein by right
subcostal spaces
approach. Note: 1
Anterior branch of RPV,
2 Posterior branch of
RPV

GB

2 RPV
RHV
242
1.19.1 Scanning Method
The patient should be on fast for 8–12h and in a
supine position. Probe is placed in the right mid-
clavicular line seventh or eighth intercostal spaces,
scanning toward right posterior-superior.
1.19.2 Section Structure
Longitudinal section of the right portal vein and its
branches, oblique scan of the right anterior lobe and
the right posterior lobe of the liver as well as the
gallbladder. A cross section of the right hepatic vein.
The intrahepatic duct accompanying the right portal
vein can be shown clearly if its branches are dilated.
M. Zhang
1.19.3 Measuring Method and Normal
Measuring inner diameter of the right portal vein
and the right intrahepatic duct. Inner diameter of
the right portal vein should be 0.6–1.2 cm. Inner
diameter of the duct should be less than 0.3 cm.
1.19.4 The Clinical Application Value
The right portal vein, right intrahepatic duct and
its branches, as well as their location relationship
can be shown in this plane. We can also observe
the size, shape, and parenchyma echogenicity of
the right liver.
8 The Digestive System Organ Scanning 243

1.20  ongitudinal Scanning of the

L
Right Liver and Right Kidney
from the Right Subcostal

Fig. 8.20 Longitudinal

plane of the right liver
and right kidney from
the right subcostal

RL

RK

Ps
244
1.20.1 Scanning Method
The patient should be on fast for 8–12 h and in a
supine position. Probe is placed in the right sub-
costal sagittally, about 1 cm from the right mid-
clavicular line and perpendicular to the horizontal
line. That patient keeps breathing in can make the
liver move down to facilitate in obtaining the
largest anteroposterior diameter of the right liver.
1.20.2 Section Structure
Longitudinal section of the right hepatic lobe and
right kidney. The right liver and right kidney fos-
sae between the right posterior lobe of the liver
and the upper pole of the right kidney.
1.20.3 Measuring Method and Normal
Measuring the largest anteroposterior diameter of
the right hepatic lobe from the top of the anterior
capsule to the posterior capsule. Anteroposterior
diameter should be less than 14 cm in the normal
liver.
1.20.4 The Clinical Application Value
(1) This is a standard section for measuring
anteroposterior diameter of the right liver lobe.
To observe the size, shape, and parenchyma
M. Zhang
echogenicity of the right liver.(2) Because the
liver and kidney fossae locates at the lowest area
of the abdominal cavity, if effusion appears, it
would be shown here the earliest in supine posi-
tion. (3) Generally, the right liver visceral sur-
face closes to the upper pole of the right the
kidney. Retroperitoneal space-occupying lesions
can increase the distance between the right liver
and the kidney. (4) To be used to make a differ-
ential diagnosis among the liver, right kidney,
and right retroperitoneal lesions. When the
patient takes a deep breath, the lesion in the liver
or in the kidney could move with the breath, but
the lesions located at the retroperitoneal would
not move.
1.20.5 Notes
We think that the largest anteroposterior diam-
eter measurement of the liver is very important
in estimating the size of the right liver lobe
because it can gave the real right liver size with
a minimum error and can make up for the defi-
ciency of the largest oblique diameter measure-
ment. The normal anteroposterior diameter of
the right liver is about 12–14 cm, > 14 cm for
anomalies.
8 The Digestive System Organ Scanning 245

1.21  blique Scanning of the Right

O
Liver Through Right Hepatic
Veins on Subxiphoid

Fig. 8.21 Oblique

scanning of the right liver
through right hepatic veins
on subxiphoid. Note: 1
Right-posterior-edge
hepatic vein

RL

RPV

RHV

Dia

1
IVC
246 M. Zhang

1.21.1 Scanning Method 1.21.3 Measuring Method and Normal

The patients should be on fast for 8–12 h and in a Measuring the largest oblique diameter of the
supine position. Probe is put horizontally toward right hepatic lobe, it should be less than 14 cm.
the right posterior-superior at the level of Measuring inner diameter of the right hepatic
subxiphoid. vein.

1.21.2 Section Structure 1.21.4 Clinical Application Value

Major areas: right hepatic lobe, right hepatic This is the standard plane for measuring the larg-
veins, and inferior vena cava. est oblique diameter of the right hepatic lobe.
8 The Digestive System Organ Scanning 247

1.22  ongitudinal Scanning 1

L
of the Right Liver Through
the Porta Hepatis on the Right
Subcostal

Fig. 8.22 Longitudinal

scan of the right liver
through the porta hepatis
on the right subcostal

RL

CHA PH
RHD
RPV PV
IVC
248
1.22.1 Scanning Method
The patient should be on fast for 8–12 h. Subcostal
scanning should be performed with patient in a
left lateral decubitus or supine position. Having a
deep inspiration so that liver moves down as an
acoustic window.
1.22.2 Section Structure
Major areas: longitudinal section of the right
liver, portal vein, and right portal vein; oblique
scan of the inferior vena cava, proper hepatic
artery, common hepatic artery, and right hepatic
biliary duct; sagittal section of the pancreatic
head.
M. Zhang
1.22.3 Measuring Method and Normal
The portal vein diameter should be measured out-
side the liver and should be less than 1.4 cm; right
portal vein should be less than 1.0 cm. Pulsed
Doppler achieves portal vein flow at this section.
1.22.4 Clinical Application Value
This is a standard scan of the porta hepatis. It is
used to observe portal vein, right portal vein, and
liver parenchymal near the porta hepatis and to
determine whether the portal vein, common
hepatic artery, and right hepatic biliary duct have
dilation and whether there is abnormal echo-
genicity in them.
8 The Digestive System Organ Scanning 249

1.23  ongitudinal Scanning 2

L
of the Right Liver through
the Porta Hepatis

Fig. 8.23 Longitudinal

section 2 of the right
liver through the porta
hepatis on the subcostal

HA
PV
CBD

IVC

RL
250
1.23.1 Scanning Method
The patient should be on fast for 8–12 h. Subcostal
scanning should be performed with the patient in
a supine or left lateral decubitus position; deep
inspiration makes the liver go down as an acous-
tic window.
1.23.2 Section Structure
Major areas: longitudinal section of the right liver,
right portal vein; oblique scan of the inferior vena
cava, hepatic artery, and common biliary duct;
sagittal section of the pancreatic head.
1.23.3 Measuring Method and Normal
Generally the right portal vein diameter should
be less than 1.0 cm. Pulsed Doppler can achieves
M. Zhang
portal vein flow at this section. The inner diame-
ter of the common bile duct can be measured.
1.23.4 Clinical Application Value
This is the standard scan of the porta hepatis,
which can be used to observe the portal vein,
right portal vein, common bile duct, hepatic
artery and liver parenchymal near the porta hepa-
tis, and to determine whether the portal vein,
common hepatic artery, and right hepatic biliary
duct have dilations and whether there is abnormal
echogenicity in them and to observe the size,
shape, and parenchyma echogenicity of the right
liver and to determine whether there is lymph-
adenhypertrophy in area of the porta hepatis.
8 The Digestive System Organ Scanning 251

1.24 Transverse Scanning

of the Porta Hepatis
from the Right Subcostal

Fig. 8.24 Transverse

scan of the porta hepatis
from the right subcostal

LL

PHA
Gb
PV
CBD
IVC
Ao

RL
252
1.24.1 Scanning Method
Patient should be on fast for 8–12 h. Subcostal
transversely scanning of porta hepatis should be
performed with patients in a left lateral decubitus
or supine position; deep inspiration makes the
liver go down as an acoustic window.
1.24.2 Section Structure
Major areas: transverse section of the portal vein,
common bile duct, and proper hepatic artery,
which have been referred to as the Mouse Sign by
Bartrum and Crow.
M. Zhang
Ancillary areas: transverse section of the gall-
bladder neck, pancreatic neck, right anterior lobe,
and left internal lobe of the liver.
1.24.3 Clinical Application Value
To observe gallbladder neck diseases which may
not be found by the standard longitudinal scan-
ning and to show the position relationship of the
portal vein, common bile duct, and proper hepatic
artery.
8 The Digestive System Organ Scanning 253

1.25  ransverse Scanning of the

T
Right Liver and the Right
Kidney from the Right
Subcostal

Fig. 8.25 Transverse

scanning of the right
liver and the right
kidney from the right
subcostal

RL
IVC

Dia Ps

RK
254
1.25.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is placed in the right sub-
costal transversely, scanning from above to below.
That the patient keeps breathing in will make the
liver move down and will be shown clearly.
1.25.2 Section Structure
Transverse section of the right posterior hepatic
lobe, pole of the right kidney, and costal-dia-
phragmatic angle.
M. Zhang
1.25.3 The Clinical Application Value
(1) To show the posterior lobe of the liver espe-
cially lower edge angle lesions, (2) to show the
right costal-diaphragmatic angle pleural effusion,
(3) to show the location relationship of the right
posterior lobe of the liver and the right kidney, (4)
and to show the liver and the kidney fossae.
8 The Digestive System Organ Scanning 255

1.26  blique Scanning of the Right

O
Liver Through the Dome
of the Right Diaphragm
from the Right Subcostal

Fig. 8.26 Oblique scan

of the right liver through
the dome of the right
diaphragm from the
right subcostal

LPV
RPV

Dia
IVC
RL
256
1.26.1 Scanning Method
The patient should be on fast for 8–12 h and
should be in a supine position. Probe is trans-
versely placed at the right side of subxiphoid par-
allel to the right costal arch and toward the right
posterior.
1.26.2 Section Structure
The dome area of the right hepatic lobe near the
diaphragm. The right inferior diaphragm space
and the right inferior lobe of the lung.
M. Zhang
1.26.3 The Clinical Application Value
The dome area of the right liver near diaphragm,
the right hepatic subcapsular lesions, subphrenic
abnormal and right pleural effusion can be shown
by this section. The lesions that are located to the
edge of the right liver are so difficult to be
scanned and may be overlooked.
8 The Digestive System Organ Scanning 257

1.27 Longitudinal Scanning

of the Common Hepatic
Artery and Splenic Artery
from the Upper Abdomen

Fig. 8.27 Longitudinal

scanning of the common
hepatic artery and
splenic artery from
upper abdomen

LL

GB

CHA
PV CA

IVC SpA
Ao

RL
258
1.27.1 Scanning Method
The patient should be on an empty stomach for
8–12 h, with a supine position. Probe is put on the
subxiphoid. After showing the standard trans-
verse scan of the pancreas, probe will scan toward
the posterosuperior so that longitudinal section of
the common hepatic artery and splenic artery can
be obtained Major area: longitudinal section of
the common hepatic artery and splenic artery.
1.27.2 Section Structure
Longitudinal section of the common hepatic
artery, proper hepatic artery, splenic artery, and
celiac artery is shown. The upper edge of the pan-
creas and cross section of the inferior vena cave
and abdominal aorta.
1.27.3 Measuring Method
and the Normal
Measuring the inner diameter of the common
hepatic artery, proper hepatic artery, and splenic
artery. The inner diameter of the common hepatic
M. Zhang
artery and proper hepatic artery are 0.39 ± 0.07 cm
and 0.33 ± 0.07 cm, respectively.
1.27.4 Clinical Application Value
(1) To judge whether the hepatic artery is
obstructed or whether there a presence of anasto-
motic stenosis or thrombosis by this section in
liver transplant patients. That color blood flow
interrupts or cannot be shown, and the hepatic
artery blood flow that cannot be measured will
indicate vascular stenosis or occlusion. (2) The
hepatic artery blood flow velocity will be a quick
compensatory in the primary hepatocellular car-
cinoma or portal venous obstructive diseases
such as portal vein thrombosis or tumor emboli.
(3) In patients with splenomegaly, the splenic
artery may be dilated and velocity will be quick.
(4) If the lymph nodes in the abdomen and retro-
peritoneum were enlargement they can be dis-
played around the celiac artery, hepatic artery, or
splenic artery by this section.
8 The Digestive System Organ Scanning
1.28  ommon Hepatic Artery
C
Blood Flow Spectrum
Fig. 8.28 Common
hepatic artery blood flow
spectrum
1.28.1 Scanning Method
The patient should be on fast for 8–12 h and take
a supine position. Probe is put on the subxiphoid,
showing longitudinal section of the common
hepatic artery. The Doppler sample volume is put
in the middle cavity of the common hepatic
artery. Measuring angle is less than 60°.
1.28.2 Measuring Method
and the Normal
Showing pulse Doppler blood flow spectrum and
measuring blood flow velocity and resistance
index. Normal: 91.1 ± 24.9 cm/s. The blood flow
of the hepatic artery appears to have three upward
peaks and a low resistance index.
259
1.28.3 Clinical Application Value
(1) By this section we can judge whether the
hepatic artery is unobstructed and whether there
is a presence of anastomotic stenosis or thrombo-
sis in the patients who received liver transplant.
That color blood flow interrupt or cannot be
shown, and the hepatic artery blood flow that
cannot be measured will indicate a vascular ste-
nosis or occlusion. (2) The hepatic artery blood
flow velocity will be quicken compensatory in
primary hepatocellular carcinoma or portal
venous obstructive diseases such as portal vein
thrombosis or tumor emboli.
260 M. Zhang

1.29 Longitudinal Scanning

of the Proper Hepatic Artery
from Upper Abdomen

Fig. 8.29 Longitudinal

scanning of the proper
hepatic artery from
upper abdomen

P
SpV
PHA
CHA
RPV CA
Ao
IVC

RL
8 The Digestive System Organ Scanning
1.29.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is put on the subxiphoid.
After showing longitudinal scan of the common
hepatic artery, probe will scan toward the right
posterosuperior so that longitudinal view of the
proper hepatic artery can be obtained.
1.29.2 Section Structure
Longitudinal section of the common hepatic artery
and proper hepatic artery is shown. The common
hepatic artery gives off the gastroduodenal artery
in the right outside the pancreatic head and then
becomes a proper hepatic artery. Oblique section
of the inferior vena cava and right liver, right portal
vein, and celiac artery. The upper area of the pan-
creatic head. Cross section of the abdominal aorta.
1.29.3 Measuring Method
and the Normal
Measuring the inner diameter of the common
hepatic artery and proper hepatic artery. The
inner diameter of the common hepatic artery and
261
proper hepatic artery are 0.39 ± 0.07 cm and
0.33 ± 0.07 cm, respectively.
1.29.4 Clinical Application Value
(1) To judge whether there are obstruction and
whether there is a presence of anastomotic ste-
nosis or thrombosis of the hepatic artery by this
section in liver transplant patients. That color
blood flow interrupts or cannot be shown, and
the hepatic artery blood flow that cannot be
measured will indicate a vascular stenosis or
occlusion. (2) The hepatic artery blood flow
velocity will be a quick compensatory in the
primary hepatocellular carcinoma or portal
venous obstructive diseases such as portal vein
thrombosis or tumor emboli. (3) In the patients
with splenomegaly, splenic artery may be
dilated and velocity will be quick. (4) If the
lymph nodes in the abdomen retroperitoneal
appear enlarged, they can be displayed around
the celiac artery, hepatic artery, or splenic artery
by this section.
262
1.30  he Proper Hepatic Artery
T
Blood Flow Spectrum
Fig. 8.30 The proper
hepatic artery blood flow
spectrum
1.30.1 Scanning Method
The patient should be on fast for 8–12 h with a
supine position. Probe is put on the subxiphoid,
showing longitudinal section of the proper
hepatic artery. The Doppler sample volume is put
in the middle cavity of the proper hepatic artery.
Measuring angle is less than 60°.
1.30.2 Measuring Method
and the Normal
Pulsed Doppler blood flow spectrum is shown.
Blood flow velocity and resistance index are
measured. Normal: 82.2 ± 20.8 cm/s. The hepatic
artery blood flow appears to have three upward
peaks and a low resistance index.
M. Zhang
1.30.3 Clinical Application Value
(1) In liver transplant patients, we observe the
hepatic artery to judge whether there are
obstructed hepatic artery or whether there is a
presence of anastomotic stenosis or thrombosis
by this section. That color blood flow is inter-
rupted or cannot be shown, and the hepatic artery
blood flow that cannot be measured will indicate
vascular stenosis or occlusion. (2) The hepatic
artery blood flow velocity will quicken compen-
satory in the primary hepatocellular carcinoma or
portal venous obstructive diseases such as portal
vein thrombosis or tumor emboli.
8 The Digestive System Organ Scanning 263

1.31  ortal Vein Blood Flow

P
Spectrum from Right
Subcostal Margin

Fig. 8.31 Portal vein

blood flow spectrum
from right subcostal
margin

1.31.1 Scanning Method 1.31.3 Measuring Method

Patient should be on fast for 8–12 h. Subcostal
scanning should be performed with patient in a
left lateral decubitus or supine position. Showing
oblique scan of the right liver through the porta
hepatis. The Doppler sample volume is put in the
middle of the cavity of the portal vein. Measuring
angle is less than 60°.
1.31.2 Section Structure
The blood flow moveform of the portal vein is
gentle and consecutive, appears small pulse with
breathing rhythm.
and the Normal
Showing pulsed Doppler blood flow spectrum
and measuring blood flow velocity of the portal
vein; normal is 15–20 cm/s or 23.8 ± 4.9 cm/s
(zhangmei 1993).
1.31.4 Clinical Application Value
(1) In patients with portal hypertension, portal
vein blood flow slows down and pulse will disap-
pear. (2) To diagnose portal venous obstructive
diseases such as portal vein thrombosis or tumor
emboli.