Sonography 102 Liver & Gallbladder
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
