Sonography 102 Liver & Gallbladder

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The size of the CD

1-2mm

The lab values that will increase due to bile obstruction are:

1. ALP 2. Direct (conjugated bilirubin)

The lab values that may be increased due to liver cell disease are:

1. ALT 2. AST 3. Indirect (unconjugated bilirubin) 4. LDH

Sonographic appearance of GB is:

1. Anechoic lumen 2. Echogenic wall

RPV bifurcates into:

1. Anterior branch 2. Posterior branch

The right lobe is divided into:

1. Anterior segment 2. Posterior segment

The three segments of GB are:

1. Fundus 2. Body 3. Neck

The biliary system consists of

1. Gallbladder 2. Right and left hepatic ducts 3. Common hepatic duct 4. Cystic duct 5. Common bile duct

Liver is made up of:

1. Hepatocytes - synthesize, metabolize and excrete a variety of compounds 2. Kupffer- phagocytizes (destroy) bacteria and foreign materials 3. Fibrous tissue

The function of Spiral valves of Heister is

1. It prevents collapsing or distending of the cystic duct 2. It control inward & outward flow of bile

The 5 land marks that divide the left lobe into medial and lateral segment are:

1. LHV 2. LPV 3. Left intersegmental fissure 4. Ligamentum teres 5. Falciform ligament

The left lobe is divided into:

1. Lateral segment 2. Medial segment (quadrate lobe)

The 2 ligaments that are identified on a routine sac are:

1. Ligamentum teres: 2. Ligamentum venosum

The 5 land marks that divide the liver into right and left lobe are

1. MHV 2. MPV 3. MLF 4. GB 5. IVC

The 3 fissures of the liver are:

1. Main lobar fissure 2. Right intersegmental fissure-not seen by u/s 3. Left intersegmental fissure-not seen by u/s

LPV bifurcates into:

1. Medial branch 2. Lateral branch

The main functions of the liver are:

1. Metabolism of carbohydrate, lipid and protein 2. Storing certain vitamins, minerals, and sugars 3. Filtration/detoxification 4. Digestion: secretion & storage of bile 5. Producing immune (phagocytosis) factors and removing bacteria, helping the body fight infection (Kupffer cells) 6. The liver is responsible for hemopoiesis during the embryonic life

The caudate lobe is bordered by:

1. Posteriorly by IVC 2. Anteriorly by ligamentum venosum (remnant of ductus venosus) 3. Anteroinferiorly by proximal LT portal vein

The 3 land marks that divide the right lobe into anterior and posterior segment are:

1. RHV 2. RPV 3. Right intersegmental fissure

The 3 lobes of the liver are:

1. Right Lobe-the largest 2. Left lobe 3. Caudate lobe (tail)-Spiegel's lobe-the smallest

The 2 most patient positioning for scanning the biliray systems are:

1. Supine 2. Left lateral decubitus (LLD)

The 3 t layers GB wall are:

1. The mucosal layer/mucous membrane-innermost layer, consists of multiple folds 2. The fibromuscular layer/muscularis- the middle layer. The epithelium and muscular layers of the gallbladder wall have tiny pockets called Rokitansky-Aschoff sinuses (RAS sinus) 3. The serosal layer/adventitia -The outer layer

What is the diameter of an adult liver?

13-15 cm

The size of the CHD

3-4mm

The transducer choice for scanning the biliary system is:

3.0 MHz or 3.5 MHz curvilinear. 5.0 MHz curvilinear for thin patients and anterior lying gallbladders

The normal width of the gallbladder is

4-5 cm

Normal pressure in the portal vein is:

5-10mmHg

The size of the CBD

6-7mm, Up to 10 mm is normal for size if the patient does not have a GB(cholecystectomy) . Add 1 mm/decade past 60 yrs. (60 yr. = 6 mm)

The couinaud classification of liver anatomy divides the liver into ___ functionally segments

9

The size of the MPV should be

<13mm

Liver function tests (LFT's) refers to:

A group of various laboratory (blood) tests established to provide the clinician with an analysis of how the liver is performing under normal and diseased conditions

Between ALT & AST which one is more sensitive for liver cell disease?

ALT

Postprandial means:

After eating

----- elevation may indicate primary or secondary cancerous liver tumors

Alpha fetoprotein (AFP)

The area where the CBD and PD enter the second portion of the duodenum is called:

Ampulla of vater, hepatopancreatic ampulla

All of the following Lab tests are used to evaluate the liver, EXCEPT

Amylase

The u/s appearance of blood vessels is

Anechoic lumen & echogenic walls

The u/s appearance of the bile ducts is:

Anechoic lumen and echogenic walls.

The right lobe of the liver is divided into _____ segments, while the left lobe is divided into ___ segments.

Anterior and posterior, medial and lateral

A liver mass is located between the middle hepatic vein and the right portal vein, in what lobe of the liver is the mass located?

Anterior right lobe

Which of the following is the function of the coronary ligament?

Attaches the liver to the diaphragm

The liver's exocrine function includes producing

Bile

Which portions of the GB and or Biliary tree are involved in the formation of a Phrygian cap?

Body and Fundus

The caudate lobe is supplied by:

Both left & right hepatic arteries and left & right portal veins

The segmental anatomy of the liver is determined by the:

Branching of the portal veins

On transverse scan, the common duct, hepatic artery, and portal vein have been referred to as the Mickey mouse sign.

CBD to patients right, HA patient's left and PV posterior

Cells of the intestinal mucosa of duodenum secrete a hormone called---------------that causes the gallbladder to contract and release bile.

Cholecystokinin

What is the name of the hormone released from the duodenum causing gallbladder contraction?

Cholecystokinin

The portal triad seen as a Mickey Mouse Sign by ultrasound, the right ear represents -

Common Bile Duct

The patient you are scanning has eaten breakfast prior to your study. What is the appearance of the gallbladder in a patient who ate 2 hrs before the exam?

Contraction of the GB with diffuse wall thickening

__ attaches liver to diaphragm

Coronary and Right & left Triangular

--- attach liver to diaphragm.

Coronary and right & left triangular ligaments

Correct location of the right hepatic vein

Courses superiorly through the right intersegmental fissure

Blood supply the gallbladder is:

Cystic artery supply

----------Connects neck of GB to common hepatic duct.

Cystic duct

The bare area of the liver is in direct contact with

Diaphragm

Which lab value is associated with jaundice?

Direct Bilirubin

CBD takes the bile to -------------

Duodenum (ampulla of vater, hepatopancreatic ampulla)

The u/s appearance of fissures and ligaments is:

Echogenic

The u/s appearance of the MLF is:

Echogenic

The vein that drains the caudate lobe directly into the IVC is called:

Emissary vein

What vessels drain the blood from the caudate lobe

Emissary veins

Which of the following hepatic ligament separates the medial and lateral left lobes of the liver?

Falciform Ligament

___ attaches the liver to the anterior abdominal wall.

Falciform Ligament

-------- attaches the liver to the anterior abdominal wall.

Falciform ligament

True or False Cystic duct is routinely visualized by ultrasound

False

T/F Hepatic veins have thicker walls than portal veins.

False, Portal veins have thicker walls than hepatic veins

T/F The GB is a retroperitoneal organ.

False, it is intraperitoneal organ

T/F Portal veins are intersegmental veins.

False, they are intrasegmental (PV, HA & CBD are intrasegmental), hepatic veins are inter segmental & interlobar.

T/F A non-obstructed bile duct should increase in size after a fatty meal.

False, it should decrease

T/F PVs get larger as they move away from the porta hepatis.

False., PVs get smaller as they move away from the porta hepatis

Patient prep for GB scanning is:

Fasting for 8 to 12 hours to guarantee maximum gallbladder and biliary tract dilatation, but may be scanned after 6 to 8 hours

With hepatopetal flow, the blood I the portal vein & hepatic artery

Flows in the same direction

Outpouching of the GB wall is called:

GB diverticulum

Ectopic gallbladder means:

GB outside its normal location like left side

When the gallbladder cannot be visualized in the RUQ, the sonographer should consider

Gallbladder agenesis and an ectopic gallbladder

Liver is Covered by ----------------capsule.

Glisson's

The majority of the liver is covered by a thick capsule composed of fibrous and elastic elements called

Glisson's capsule

The portal triad seen as a Mickey Mouse Sign by ultrasound, the left ear represents -

Hepatic Artery

The portal triad is made up of

Hepatic artery, Portal vein, bile duct

The ____ are called intersegmental vessels of the liver

Hepatic veins

____ are the majority of hepatic cells

Hepatocytes

Flow away from the liver is called

Hepatofugal (abnormal)

Flow within the hepatic veins is:

Hepatofugal (normal)-away from the liver

Flow within the PVs is called:

Hepatopetal -toward the liver

Flow within the hepatic arteries is

Hepatopetal -toward the liver

The liver should have a____ sonographic appearance.

Homogeneous

Sonographic appearance of the liver is:

Homogeneous parenchyma, mid gray echo texture

---------- courses through the bare area of the liver.

IVC

__ courses through the bare area of the liver

IVC

The caudate lobe lies between what two structures?

IVC & Lateral left lobe

------- Joins splenic vein posterior to the body of the pancreas, usually not easily seen sonographically.

Inferior mesenteric vein (IMV)

The portal veins are ___ and follow a ___ course

Intralobar / intrasegmental

Is the liver retroperitoneal or intraperitoneal organ?

Intraperitoneal organ

The u/s appearance of ligamentum teres is:

Is an echogenic

Which statement best describes the location of the ligamentum venosum?

It forms the anterior border of the caudate lobe

The u/s appearance of the MLF is:

It seen as hyperechoic line extending from RPV to the neck of the GB

--------------- is a fold between the body and neck of gallbladder.

Junctional fold / Hartman's pouch

_____ Phagocytize (destroy) bacteria and foreign materials.

Kupffer Cells

Which of the following is NOT an indication for Gb scanning?

LUQ pain

Ductus venosus divides caudate lobe from:

Left lobe of liver

Left hepatic vein (LHV) drains ----lobe, divides left lobe into ----------- and l-----------segments.

Left, medial and lateral segments

After birth the right UV branch (ductus Venosus) becomes:

Ligamentum Venosum

The ___ separates the caudate lobe from the left lobe of the liver

Ligamentum Venosum

___ is located within the inferior margin of the falciform ligament

Ligamentum teres

The land mark that separates the caudate from left lobe is:

Ligamentum venosum

___ Is the most anterior organ of the body?

Liver

Describe the flow of bile

Liver cells produce bile---right and left hepatic ducts---the right and the left hepatic ducts merge to form common hepatic duct (CHD) ---Cystic duct(CD)---GB, when bile is needed, the bile flowes from the GB—CD-Common bile duct(CBD)

Fissure that connects the neck of the GB to RPV is called:

MLF

The size of the MPV & IMV is:

MPV<13mm SV & IMV<10mm

Sonographically, ____ appears to connect the GB neck and junction of the R & L portal veins.

Main Lobar Fissure

Which of the following fissure is seen by ultrasound?

Main Lobar Fissure

Which of the following intrahepatic structures aids in locating the neck of the GB?

Main Lobar Fissure

The two primary anatomical landmarks for the gallbladder location are

Main Lobar Fissure, Portal Vein

Spiral valves of Heister

May simulate stone, located in the cystic duct, may stimulate shadow.

The round ligament Separate the left lobe into:

Medial & lateral segments

The left intersegmental fissure divides the left lobe into:

Medial and lateral segments (sagittal division). Contains left hepatic vein, falciform ligament and ligamentum teres

Which liver vessel courses within the main lobar fissure?

Middle hepatic Vein

Before performing an abdominal complete study, the adult patients must be

NPO for 8-12 hrs prior to study

The formation of Hartmann's pouch usually occurs in what portion of the GB?

Neck

Agenesis of the GB means:

No GB

Which of the following is true regarding the portal vein?

Normal portal venous pressure is 5-10 mmhg

NPO means

Nothing by mouth

The best way to demonstrate the 3 hepatic veins by u/s is:

Oblique subcostal approach angled toward patient's right shoulder entering IVC

The caudate lobe is located

On posterosuperior aspect of liver

The bare area is located:

On the posterosuperior surface of the liver

The cystic vein drains directly into the:

PV

-----is an Inferior extension of the caudate lobe.

Papillary process

What is a common cause for non-visualization of the GB?

Patient not NPO

------- is a fold between fundus and body of gallbladder.

Phrygian cap

The MPV and PHA enter the liver in area called

Porta Hepatis

The portal triad seen as a Mickey Mouse Sign by ultrasound, the face represents -

Portal Vein

Which of the following correctly lists the structures found in a portal triad?

Portal Vein, Proper Hepatic Vein, and Bile Duct.

Liver receives blood supply from

Portal vein & Hepatic Artery

All of the following are intrasegmental vessels of the liver

Portal veins, Hepatic Arties, Bile ducts.

CBD passes anterior or posterior to the head of the pancreas?

Posterior

The gallbladder is located ___ to the liver.

Posterior & Inferior

The caudate lobe occupies much of the ___ surface of the liver.

Posterior superior

Superior mesenteric vein (SMV) and Splenic vein (SV) join:

Posterior to the head of the pancreas

On a transverse sonogram, the CBD enters the ___ aspect of the head of the pancreas and lays __ to the IVC.

Posterior, Anterior

------is used to determine the clotting tendency of blood

Prothrombin time (PT)/INR/PTT

The Medical segment of the left lobe is also called

Quadrate Lobe

Another name for the medial segment of the left lobe is:

Quadrate lobe

Some indications for GB U/S are:

RUQ pain, detect gallstones (cholelithiasis), inflammation of the gallbladder (cholecystitis) to check for blocked bile ducts

In utero the umbilical vein brings the oxygenated blood from the mother and enters into the fetal abdomen (liver) and it divides into:

Right UV branch, also referred as the Ductus Venosus and left UV branch

Main lobar fissure divides the liver into:

Right and left lobes, more specifically the right anterior lobe and medial left lobe

Cystic artery is a branch of:

Right hepatic artery

The liver occupies most of the ____ and part of

Right hypochondria & epigastrium

The right intersegmental fissure divides the liver lobe into:

Right lobe into anterior and posterior segments (coronal division). Contains right hepatic vein

Right hepatic vein (RHV) drains----------- lobe, divides right lobe into----------- and -----segments.

Right, anterior and posterior

____ are diverticula of the gallbladder wall

Rokitansky_ Aschoff sinuses

All of the following are true regarding the ligamentum teres, EXCEPT

Round, hyperechoic foci near the porta hepatis

In some patients, the proper hepatic artery bifurcates into the right and left hepatic arteries. In about 10% of patients, the right hepatic artery originates from the ___ and the left hepatic artery originates from the____

SMA, Left gastric artery

MPV is formed by the inion of

SMV + SV + IMV

To eliminate the artifactual shadowing spiral valves of heister, WHAT YOU NEED TO DO:

Scan the area from different angels and planes

The ligamentum teres could recanalizes(reopens) in case of

Severe cirrhosis (liver)

The function of the ductus venosus in utero is:

Shunts blood from umbilical vein to IVC bypassing the liver

------------- Is a muscular valve that controls the flow of digestive juices (bile and pancreatic juice) through the ampulla of Vater into the second part of the duodenum.

Sphincter of Oddi

Another name for Caudate Lobe

Spiegel's lobe

Another name for caudate lobe is:

Spiegel's lobe

A shadowing effect may be seen arising from the cystic duct region. What is the source of he shadow?

Spiral Valves of Heister

-------May cause refractive artifactual shadowing around the neck of the GB.

Spiral valves of Heister

Tiny folds in the cystic duct are called;

Spiral valves of Heister

Portal Vein enters liver carrying blood drained from the

Spleen, Pancreas and Bowel

Portal vein enters liver carrying blood drained from the:

Spleen, stomach, bowel, & pancreas

------ originates at the splenic hilum

Splenic vein

Functions of the GB are:

Store & concentrate bile which aid in digestion

----- Originates at the mesentery (intestine) and Joins splenic vein posterior to the neck of the pancreas to form main portal vein.

Superior mesenteric vein (SMV)

You are trying to evaluate the cystic duct for a possible obstruction, where will you look?

Superior to the neck of the GB

Patient position for scanning the liver is:

Supine or left posterior oblique position, usually with deep inspiration to allow the liver to move inferior to the rib cage

The part of the liver that is not covered by the peritoneum is called:

The bare area

Compare the echogenicity of the liver with:

The liver echo texture is isoechoic to echogenic compared to the spleen

Compare the echogenicity of the liver with the pancreas:

The liver echo texture is less (the liver is darker, hypoechoic) than pancreas

Compare the echogenicity of the liver with the cortex of the kidney:

The liver echo texture is slightly greater than renal cortex

When you measure the size of the ducts measure only--------------- excluding the walls of the ducts.

The lumen, the anechoic area

---------- tapers into cystic duct and it is fixed in its position at MLF

The neck of the GB

80% the blood supply of the liver is through

The portal vein

A patient presents with a history of Reidel's lobe. What are the expected finding on the ultrasound?

The right lobe of the liver will have a tongue like extension that extends inferior to the lower pole of the kidney.

Characteristics of the Hepatic veins

They branch away from the diaphragm, they originate close to the diaphragm and all tree are best seen on transverse scan.

All of the following are characteristics of the hepatic veins, Except:

They have prominent echogenic walls

The reason for scanning the GB in 2 different planes is:

To see if the abnormality seen in the GB is mobile or not, this allows for differentiation between pathologies

A reidel's lobe is a normal liver variant defined as

Tongue like extension of right lobe

T/F As a rule, biliary dilatation will occur proximal to the level of obstruction.

True

T/F GB body and fundus are variable in position.

True

T/F HVs get larger as they move towards the IVC or diaphragm

True

T/F Hepatic veins are the largest tributaries to the IVC

True

T/F Main lobar fissure connects the GB and the PV.

True

T/F Neck of the GB is in a fixed position at main lobar fissure.

True

T/F PVs are smaller as they approach the diaphragm.

True

T/F Portal flow rate and diameter increases with inspiration and after eating.

True

T/F Portal veins branch horizontally (transversely) toward porta hepatis.

True

T/F Portal vessels decrease in size as they course into the liver VS. Hepatic veins increase in size as they near the diaphragm to exit the liver.

True

T/F Postprandial scanning of the GB demonstrates diffuse GB wall thickening.

True

T/F The GB is located posterior & inferior to the liver.

True

T/F The subcostal approach with deep inspiration will provide the best views of the dome of the liver in most patients.

True

T/F Riedel's lobe may increases cranial-caudad liver length

True

True or False The GB is an intraperitoneal organ.

True

The liver is located

Under diaphragm in RUQ, occupies most of the right hypochondria & part of epigastrium

Interruptions in homogeneous appearance of the liver could be because of:

Vascular structures and Ligaments

The normal wall thickness, diameter and length of the GB are:

Wall thickness < 3 mm Cross sectional diameter < 4-5 cm Length is 7-10 cm

In a fasting patient the GB wall measure 2 mm. This measurement is

Within normal limits

The segmental anatomy of the liver is determined by

branching of the portal veins

A non- obstructed bile duct should ____ in size after a fatty meal?

decrease

A normal portal vein will

increase in diameter with deep inspiration

How can you distinguish hepatic veins from the portal veins sonographically. The hepatic veins

increase in size toward the diaphragm; runs longitudinally/ vertically; and affected by Valsalva maneuver

The following statements regarding the dome of the liver is false?

intercostal scanning is the preferred approach to evaluate the dome of the liver.

The superior mesenteric vein

joins the splenic vein posterior to the neck of the pancreas

After birth the left UV branch closed and become

ligamentum teres and round ligament

In a patient with complete situs inversus, the liver will be

located in the left upper quadrant

The main lobar fissure

separates anterior right lobe and medial left lobe

Inferior mesenteric vein (IMV) joins the splenic vein (SV) near the

tail of the pancreas

In order to obtain an optimal image of the liver in thin adult patent, the sonographer should

use a 5.0 MHZ curve linear transducer


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