This document provides an overview of ultrasound techniques for examining the liver and biliary system. It describes the anatomy of the liver and surrounding structures. Standard scanning planes like subcostal, transverse midline, and longitudinal midline are covered. Specific techniques like "Sabih's backhand" are explained. Normal liver echotexture and features are outlined. Fatty liver is discussed, including patterns, prevalence, and ultrasound appearance. Diagnosing fatty liver requires liver echotexture appearing brighter than kidneys with loss of portal echoes.

1. Ultrasound of the
Liver and Biliary
System
Part 1of 3
Durr-e-Sabih
MBBS. MS. FRCP. FNMB

2. Where is the lesion

4. The liver midline

5. The liver midline

6. Couinads Segments
http://www.radiologyassistant.nl/en/p4375bb8dc241d/anatomy-of-the-liver-segments.html

7. The Relationships

8. Orienting within the liver

9. The Porta-hepatis
o Porta Hepatis
(Hilum of the Liver).
A transverse fissure found
on the posteroinferior surface and
lies between the caudate and
quadrate lobes.
o Through this passes the right and
left branches of:
o Hepatic ducts
o Hepatic artery
o Portal vein

10. Normal Liver Shapes

11. Areas of liver difficult to see with
ultrasound

12. How I do it
o Subcostal section
o Transverse midline
o Longitudinal midline
o Oblique coronal sections, Sabih’s backhand
o Clear the margins
o Look at the lung bases

13. In order to examine any large volume
structure, different probe movements,
usually in combination, are used,
these are the:
Rocking movement
Sliding movement
Rotating movement
Compression
Pushing internal structures

14. Rocking
Imagine a hinge at the probe:skin
interface.

15. Sliding
The probe translates
along the surface of the
skin

16. Rotation

17. Compression
skin
o Displaces gut gas
o Brings probe nearer to
target
o Elicits ultrasound
tenderness
o Can cause fluid to
stream, enabling
solid/cystic diagnosis
o Elicits tenderness
o Pushes adjacent structures
away

18. Compression
skin
o Displaces gut gas
o Brings probe nearer to
target
o Elicits ultrasound
tenderness
o Can cause fluid to
stream, enabling
solid/cystic diagnosis
o Elicits tenderness
o Pushes adjacent structures
away

19. Compression
skin
Whenever gas obscures field of view
Appendicitis
Pancreas
Pelvis

20. Pushing Internal Structures

21. Pushing Internal Structures
Try to separate contiguous structures
Elicit tenderness
Over gallbladder
Appendix
Adnexa

22. Pushing Internal Structures

23. What am I looking for
o Texture (homogenous)
o Focal disease, heterogeneity.
o Surface, should be smooth
o Edges, should be sharp
o Size

24. Coming back to how I do it

25. How I do it
o Subcostal section
o Transverse midline
o Longitudinal midline
o Oblique coronal sections, Sabih’s backhand
o Clear the margins
o Look at the lung bases

26. Subcostal section
o Place probe parallel and
below the right costal
margin
o Direct the probe face
towards the right shoulder
o Rock the probe
o You may ask the patient to
take a deep breath and hold
it

27. 3D arrangement of structures

28. Subcostal section

29. Subcostal
section

30. Subcostal section

32. Hepatic veins and the portal vein
in the subcostal section
Hepatic Veins Portal vein
All three can be seen The left main branch, pars transversa,
The umbilical portion of the left branch
In the upper part of liver near the
diaphragm
In the middle
Tapering thin walls Parallel thick and echogenic walls
Doppler spectra show wide variation
and undulation and reflection of right
heart contraction
Stable flow with little undulation

33. Midline transverse section

35. Midline transverse section

36. Midline transverse section

37. Midline transverse section, the
superficial structures
https://www.netterimages.com/rectus-sheath-cross-section-labeled-anatomy-atlas-5e-general-anatomy-frank-h-netter-4566.html

38. The abdominal wall

39. The abdominal wall

40. Falciform ligament, ligamentum
teres, the major
intrahepatic fissure
ligamentum venosum

41. Falciform ligament

42. Caudate lobe
o Segment 1
o Can appear hypoechoic
o Can mimic or hide lesion
o Can hypertrophy
o Lingual process

43. Lingual process of caudate lobe

44. Caudate lobe

45. Easy to miss
caudate lobe lesions

46. Longitudinal midline

47. Edges and
surface

48. Intercostal, oblique coronal
scanning
http://sciencenordic.com/how-different-are-we-inside

49. Intercostal, oblique coronal
scanning
http://sciencenordic.com/how-different-are-we-inside

50. Right intercostal sections
o High right section
o Diaphragm
o Dome of the right lobe of the liver
o Low right coronal section
o Tip of the right lobe of the liver
o Gallbladder, specially the neck
o Main portal vein
o Right hepatic vein
o Right kidney
o You may ask the patient to turn half way to the
left

52. The main portal vein

53. Right coronal section
Sabih’s backhand

54. Sabih’s
backhand

55. Sabih’s
backhand

56. The main portal vein

57. CBD and PV

58. Clear the margins

59. Lung base

60. Echotexture and shape
o Brighter than the right renal cortex
o Tip of right lobe is sharp and wedge shaped
o Left lobe tip is sharp and the posteror
contour be concave
o Look out for Riedel’s lobe

61. Normal texture

62. Edges and
surface

63. Liver size
o Difficult to diagnose on ultrasound, reliably and
reproducibly 1
o No validated method is commonly used1
o Multiple linear measurements are used1,2
o Tip of right lobe to diaphragm, anterior surface of tip to
diaphragm, transverse extent, depth of left lobe2
o Multiple approaches are used, mid clavicular line, mid
axillary line3
1.Tchelepi H, Sonography of diffuse liver disease. J Ultrasound Med 21:1023–1032, 2002
2.Childs JT. Ultrasound in the assessment of hepatomegaly: A simple technique to determine
an enlarged liver using reliable and valid measurements. Sonogrphy Vol3,. 2. 47-52
3.Candelaria BILATERAL et al. Ultrasound Accuracy of Liver Length Measurement with
Cadaveric Specimens. J Diagn Med Sonogr. 2016;32(1):12-19.

65. Fatty liver
o Accumulation of triglycerides and other fats
in liver cells
o Spectrum includes steatosis (simple fatty
liver disease) steatohepatitis (fatty liver with
inflammation) and cirrhosis

66. Fatty liver
o Commonest liver abnormality detected on
ultrasound
o Multiple patterns can be seen leading to
diagnostic difficulties:
o Diffuse fat accumulation (easiest to diagnose)
o Diffuse fat accumulation with focal sparing
o Focal fat accumulation in a normal background

67. Conditions associated with fatty
liver
Hamer, O. W., et al. (2006). "Fatty liver: imaging patterns and pitfalls. Radiographics 26(6): 1637- 1653.

68. Prevalence
o General population ~15%
o Higher among those:
o Who consume > 60g of alcohol (45%)
o Hyperlipidemia (50%)
o Obesity with a BMI of >30 (75%)
o Both obesity and high alcohol consumption
(95%)
el Hassan AY, Ibrahim EM, al Mulhim FA, Nabhan AA, Chammas MY. Fatty infiltration of the
liver: analysis of prevalence, radiological and clinical features and influence on patient management.
Br J Radiol 1992;65:774–778

69. Normal Echotexture and shape
o Brighter than the right renal cortex
o Tip of right lobe is sharp and wedge shaped
o Left lobe tip is sharp and the posteror
contour can be concave
o Look out for Riedel’s lobe

70. Fatty liver on ultrasound
o Liver echotexture excessive as compared to
kidney and spleen
o Loss of the normal portal cuff echoes
o Poor delineation of diaphragm
Fatty liver should not be diagnosed if only
one or two of the criteria are present…
Some people will diagnose only with
increased
Tchelepi H, Ralls PW, Radin R, Grant E. Sonography of diffuse liver disease. J Ultrasound Med
2002; 12:1023–1032

71. Fatty Liver

73. Fatty liver

74. Focal sparing

75. Focal fatty infiltration

76. End of part 1