What is The

LIVER

?

An organ in the upper
abdomen that aids
in digestion and
remove waste
products and wornout cells from the
blood. It is the
largest solid&
glandular organ in
the body.

What is the blood supply of the
?liver

Liver has a dual blood supply; portal
vein(75%) & hepatic artery (25%),The
hepatic veins are responsible for drainage
of filtered blood from the liver into the IVC.

What about Liver anatomy??
Liver anatomy can be described using two different
aspects

► Morphological

anatomy

is based on the external
appearance of the liver and
does not show the internal
features of vessels and
biliary ducts branching,
which are important in
hepatic surgery.

► Functional

anatomy

divides the liver into eight
functionally independent
segments.
Each segment has its own
vascular inflow, outflow and
biliary drainage

What’s the significance of !?functional anatomy In order to perform segmental or subsegmental resection of the liver. each segment can be resected without damaging those remaining. . the surgeon must know exactly which parts of the liver are diseased so that vascular supply and venous and biliary drainage can be preserved& also Because of this division into self-contained units.

►There are many anatomical and functional descriptions of the liver anatomy such as Classical Anatomy &Bismuth's classification however (Couinaud classification) is the most commonly used classification. .

Couinaud classification ► The Couinaud classification of liver anatomy divides the liver into eight functionally independent segments. ► Each segment has its own vascular inflow (hepatic artery & portal vein). outflow (hepatic vein) and biliary drainage .

This plane runs from the inferior vena cava to the gallbladder fossa (Cantlie's line) ► Left hepatic vein divides the left lobe into a medial and lateral part. . ► Middle hepatic vein divides the liver into right and left lobes (or right and left hemiliver).How are the segments spatially ?separated ► Right hepatic vein divides the right lobe into anterior and posterior segments (segment 6& 7 usually not visulaized at the frontal view). ► Portal vein divides the liver into upper & lower segments.

??What are liver segments ► Couinaud's numbering system: 1-Caudate Lobe (posteriorly) 2-Left Superior Lateral segment 3-Left Inferior Lateral segment 4a-Left Superior Medial segment 4b-Left Inferior Medial segment 5-Right Inferior Anterior segment 6-Right Inferior Postrior segment 7-Right Superior Postrior segment 8-Right Superior Anterior segment .

How can you interpret this classification at the transverse ?images ► Imagine the liver is sliced at 4 levels & then analyze the previously mentioned liver segments at each level: .

This figure is a transverse image through the superior liver segments. . that are divided by the hepatic veins.

At this level the left portal vein divides the left lobe of liver into superior segments (2 and 4A) and inferior segments (3 and 4B).This figure shows transverse image at the level of the left portal vein. .

The level of right portal vein is inferior to the level of left portal vein .The image on the left is at the level of right portal vein. At this level right portal vein divides the right lobe of the liver into superior segments (7 and 8) and the inferior segments (5 and 6).

below the level of the main portal vein: The gallbladder separates segment(V) from segment (IVB). ► . The ligamentum teres divides segment(IVB) and (III) segments.

4.TO REMEMBER ► Above Level of splenic v&main portl v the level of this image segments from left to right are7.4.2 ► Below & at this level segments from left to right are 6.8.5.3 .

Modalities of Liver Imaging ► Ultrasound ► CT ► MRI ► Nuclear Medicine .

  Is a noninvasive and excellent screening tool.   Has low sensitivity and high false negative rate for detection of liver metastases. or suspected liver masses. .Ultrasound ► ► ► ► Is the first and the most commonly obtained method of examination in patients with RUQ pains. abnormal LFTs.   Used to evaluate the presence of bile duct obstruction and gallstones as well as to distinguish a solid lesion from a cystic one.

patency of hepatic vessels. Flow in the portal vein and hepatic arteries are hepatopedal (toward the liver) while flow in hepatic veins and hepatic ducts are hepatofugal (away from the liver). portal vein. i.e.► Ultrasound Doppler imaging can be very helpful in identifying vascular abnormalities. and IVC as well as flow direction in these vessels. .

celiac trunk.   I.V. coronal. iodinated contrast is commonly used in liver imaging to demonstrate any abnormal enhancement of a hepatic lesion and to show vascular structures.V. liver parenchyma and mixes with blood in portal veins drained into venules and then hepatic veins and then out to the IVC. The contrast agent is injected into veins. hepatic arteries. aorta. . and sagittal planes. travels to the heart.CT ► ► ► Uses X-ray to acquire data that can be displayed in axial.   An I. bolus of 100 to 150 ml of iodinated contrast is often used.

kidneys also show corticomedullary differentiation 2-Portal venous phase (when the contrast disperses into the liver parenchyma (liver brighten) and mixes with portal blood (portal v brighten) 3-Equilibrium phase (Delayed phase) (when the contrast further scatters in the parenchyma and drains out the hepatic veins and also be seen in the renal collecting system). .►the hepatic enhancement can be divided into 3 phases: 1-Arterial phase (when the contrast just fills up the aorta and the main hepatic arterial structures).

arterial phase. .   The rationale behind this technique is that primary and secondary malignancies of the liver typically have hepatic arterial supply.V. thus will enhance during the arterial phase. such as hepatoma or metastastic disease.   The appropriate delay times for scanning in the arterial phase and portal venous phase for a 2-3 ml/sec injection are 25 seconds and 70 seconds. respectively. will enhance during portal-venous phase of I. a three-phase technique often should be used: non-contrast phase.► ► ► When searching for hypervascular lesions. whereas benign entities and normal liver parenchyma have primarily portal venous supply. therefore. contrast. and portal venous phase.

then peripheral enhancement in arterial phase &further central filling at portal phase then total enhancement at the delayed image) Very characterstic of hemangioma Rapid Wash out Note here also the lesion at the non contrast image then early enhancement at the arterial phase and rapid wash out a the portal phase (yellow arrows) very characterstic of HCC .Progressive fill in (note the lesion at non enhanced image.

.Patients are allergic to iodinated contrast agents. 2-Lesion detection & characterization . 5-Biliary duct system. 4-Hepatic vascular patency .MRI ► Indications for Liver MRI 1. 3-Anatomic location .

► MRI has many advantages over CT: High soft tissue contrast resolution (can see smaller lesions). MRCP. no iodinated contrast·etc. MRA. No radiation. Multiplanar capability. Multiple sequences. MRV. .

  ► MRI can be helpful in the characterization of a small (< 2 cm) benign hemangioma that is equivocal on CT. .► However. MRI is similar to CT in that it has the same dynamic multiphase contrast enhancement capability.

and interdependent sequence parameters which can affect image quality. focal fatty infiltration/sparing.  At UVa. adrenal adenomas. Breath Hold T2: can be used to evaluate hemangiomas and cysts. MRI sequences are often unique to the institution. timing bolus. or smart prep): can be used to characterize hypervascular lesions. . Turbo spin echo with fat sat or STIR HASTE -Half Fourier acquisition single shot turbo spin echo Dynamic Gad T1 (Arterial. pulse sequence. portal venous. delayed.►      A wide range of MRI sequences is available for liver imaging thanks to the numerous manipulations of field strength. fat in HCC. we use the following: Breath hold T1 spoiled gradient echo (In phase and out of phase): can be used to detect fatty liver.  Since there is little agreement on the best technique.

the intensity of normal liver parenchyma is the same as or slightly higher than that of adjacent muscle. the liver should be brighter than (hyperintense to) the spleen on T1-weighted images and darker than (hypointense to) the spleen on T2-weighted images.► For most techniques. . Normally.

pancreas. extrahepatic biliary apparatus.Developmental Anomalies and Anatomic Variants of the liver Embryonic development of the liver. . and duodenum.

CT reveals agenesis of the right lobe of the liver with compensatory hypertrophy of the left lobe .Agenesis of the right hepatic lobe. A.

.Agenesis of the left hepatic lobe. CT shows tongue like projection (arrow) of caudate lobe at the upper image.

Diaphragmatic invagination As a result of invagination of diaphragmatic slips along the superior aspect of the liver. . pseudoaccessory fissures are formed.

Diaphragmatic invagination mimicking hepatic nodule .

The accessory fissure in the right lobe .Accessory fissure in the under surface of the liver.

it can mimic abnormal structure lateral to the spleen. This occasionally is the case in abdominal ultrasound. The T2weighted image of the upper abdomen reveals leftward lateral extension of the left lobe of the liver . If the communication is not seen. .Sliver of liver.which appears as a crescentic lowintensity structure wrapping around the lateral aspect of the spleen.

. The contrastenhanced CT scan shows medial and posterior extension of the papillary process near the head of the pancreas mimicking a mass lesion.Papillary process of the caudate lobe.

Papillary and caudate process pseudomass. The T1-weighted fatsuppression images reveal medial extension of the papillary process near the head of the pancreas. . Notice the signal characteristics of this mass being similar to the remainder of the liver and not of the pancreas.

A. Topogram from the patient's CT scan displays an elongated inferior extension of the right lobe of the liver (arrows) characteristic of a Reidel lobe .Riedel's lobe.