King Saud UniversityKing Saud University

College of medicineCollege of medicine

US of liver and gall US of liver and gall stonestone

outlineoutline::

► Introduction to US.Introduction to US.► Indications of liver and gall bladder Indications of liver and gall bladder

US.US.►Normal anatomy and radiological Normal anatomy and radiological

appearance.appearance.►Pathology of liver and gall bladder.Pathology of liver and gall bladder.►Common pathological cases.Common pathological cases.

Introduction to USIntroduction to US

DefinitionDefinition::

►a diagnostic technique in which high-a diagnostic technique in which high-frequency sound waves penetrate the frequency sound waves penetrate the body, bounce around, and produce body, bounce around, and produce multiple echoes; these echo patterns multiple echoes; these echo patterns can be viewed as an image on a can be viewed as an image on a computer screen.computer screen.

►Frequency ranges used in medical Frequency ranges used in medical Ultrasound imaging are 2 - 15 MHzUltrasound imaging are 2 - 15 MHz

US machineUS machine

PROBES

MACHINE

M- MODE.B- MODE.

COLOR DOPPLERDUPLEX

► CardiologyCardiologyEchocardiography Echocardiography is an essential tool in cardiology, vavular heart is an essential tool in cardiology, vavular heart disease. disease.

► Emergency Medicine:Emergency Medicine:for Trauma patient and acute abdomen.for Trauma patient and acute abdomen.

► Gastroenterology:Gastroenterology:In abdominal sonography, the solid organs of the abdomen In abdominal sonography, the solid organs of the abdomen such as the pancreas, aorta, inferior vena cava, liver, gall such as the pancreas, aorta, inferior vena cava, liver, gall bladder, bile ducts, kidneys, spleen and appendix.bladder, bile ducts, kidneys, spleen and appendix.

► Gynecology:Gynecology:to assess female pelvic organs, uterus ovariesto assess female pelvic organs, uterus ovaries

► Neonatology:Neonatology:for basic assessment of intracerebral structural abnormalities, for basic assessment of intracerebral structural abnormalities, bleeds, ventriculomegaly or hydrocephalus.bleeds, ventriculomegaly or hydrocephalus.

US usesUS uses::

ContCont..► NeurologyNeurology ► for assessing blood flow and stenoses in the carotid arteries (Carotid for assessing blood flow and stenoses in the carotid arteries (Carotid

ultrasonography) ultrasonography)

► Obstetrics:Obstetrics:► sonography is commonly used during pregnancy to check on the development sonography is commonly used during pregnancy to check on the development

of the fetus.of the fetus.

► Urology:Urology:► to study a patient's bladder, prostate or testes.to study a patient's bladder, prostate or testes.

► MusculoskeletalMusculoskeletal► For assessing tendons, muscles, nerves, ligaments, soft tissue masses, and For assessing tendons, muscles, nerves, ligaments, soft tissue masses, and

bone surfacesbone surfaces

► vascular systemvascular system::► To assess patency and possible obstruction of arteries Arterial doppler, To assess patency and possible obstruction of arteries Arterial doppler,

diagnose DVT venous doppler and determine extent and severity of venous diagnose DVT venous doppler and determine extent and severity of venous insufficiencyinsufficiency

Advantages of USAdvantages of US

►noninvasive noninvasive ► inexpensive.inexpensive.►Easy and available.Easy and available.►Safe and non ionizing.Safe and non ionizing.

Disadvantages of USDisadvantages of US

► Inability to penetrate gas or bone.Inability to penetrate gas or bone.►Operator dependant.Operator dependant.►Less sensitive in some situations.Less sensitive in some situations.

Indications of liver and gall Indications of liver and gall bladder USbladder US

►Right upper quadrant pain.Right upper quadrant pain.► Jaundice.Jaundice.►High liver function test.High liver function test.►Fever work up.Fever work up.►Screening for metastasis.Screening for metastasis.

Normal anatomy and Normal anatomy and radiological appearanceradiological appearance

ContCont..

Pathology of the liverPathology of the liver::

►Size.Size.►Diffuse liver disease.Diffuse liver disease.►Focal liver disease.Focal liver disease.►Hepatic vascularity.Hepatic vascularity.►Biliary system obstruction/pathology.Biliary system obstruction/pathology.

Size abnormalitySize abnormality

► Normal liver size:Normal liver size: 15 cm at MCL.15 cm at MCL.► Hepatomegaly:Hepatomegaly: Infective eg viral hepatitis.Infective eg viral hepatitis. Neoplastic eg. Metastasis.Neoplastic eg. Metastasis. Degenerative eg. early Degenerative eg. early

cirrhosis.cirrhosis. Raised venous pressure eg. Raised venous pressure eg.

Congestive cardiac failure.Congestive cardiac failure. Storage disorder eg. Storage disorder eg.

Amyloidosis.Amyloidosis. Myeloproliferative disorder Myeloproliferative disorder

eg. Polycythaemia rubra eg. Polycythaemia rubra vera.vera.

ContCont..

► Small shrunken Small shrunken liver:liver:

► Late cirrhosis:Late cirrhosis:► Shrunken liver with Shrunken liver with

irregular outlineirregular outline► AscitisAscitis► Portal hypertension.Portal hypertension.► +- focal lesion.+- focal lesion.

Diffuse abnormalityDiffuse abnormality

► Diffuse increase Diffuse increase parenchymal parenchymal echogensityechogensity

(whiter than normal)(whiter than normal)► Diffuse fatty Diffuse fatty

infiltration. infiltration. ► Other infiltrative:Other infiltrative:Malignant Malignant InfectiousInfectiousGlycogen storage Glycogen storage

diseasedisease

ContCont..

► Diffuse decrease in Diffuse decrease in parenchymal parenchymal echogensity.echogensity.

(darker than normal)(darker than normal)► Acute hepatitis.Acute hepatitis.► Other:Other:► Malignant Malignant

infiltration.infiltration.

Focal liver lesionsFocal liver lesions

Benign tumorBenign tumor::► Hemangioma.Hemangioma. Malignant tumorMalignant tumor::► Primary eg. Hepatocellular carcinoma.Primary eg. Hepatocellular carcinoma.► Secondary metastasis eg. Colon breast.Secondary metastasis eg. Colon breast. Infective:Infective:► Abscess Abscess ► hydated cyst.hydated cyst. Congenital:Congenital:► Hepatic cyst.Hepatic cyst.

ContCont..hemangiomasLiver

abscess

HCCmetastasis

ContCont..

Hydated cyst

Vascular abnormalityVascular abnormality

Portal venous systemPortal venous system::► thrombosis.thrombosis.►Portal hypertension.Portal hypertension.

Hepatic venous system:Hepatic venous system:►ThrombosisThrombosis►(budd chiari syndrome).(budd chiari syndrome).

ContCont..

PV thrombosis

Hepatic vein thrombosis

Biliary abnormalityBiliary abnormality► Intra-hepatic biliary radicals.Intra-hepatic biliary radicals.Less than 3mmLess than 3mm► Extra-hepatic Extra-hepatic ““CBDCBD””Less than 8mmLess than 8mm► Causes of dilatation & Causes of dilatation &

obstructionobstruction::o Intra-luminal:Intra-luminal: Stone & mass.Stone & mass.o Mural:Mural: stricture (benign & malignant)stricture (benign & malignant)o Extrinsic:Extrinsic: Compression mass & Lymph Compression mass & Lymph

nodenode

Pathology of gall bladderPathology of gall bladder

► Intra-luminal pathology.Intra-luminal pathology.►Mural pathology.Mural pathology.

Intra-luminal pathologyIntra-luminal pathology

► Gall stone:Gall stone:Acoustic shadowingAcoustic shadowing

► PolypsPolypsNo acoustic No acoustic

shadowing.shadowing.

ContCont..

► Intraluminal:Intraluminal:

Mass lesionMass lesion

+- invasion+- invasion

Gall bladder Gall bladder carcinoma.carcinoma.

Mural pathologyMural pathology

Mural thickening:Mural thickening: Primary:Primary:

Cholecystitis.Cholecystitis.

Secondary:Secondary: Cardiac failure.Cardiac failure. Cirrhosis.Cirrhosis. ascitisascitis HypoalbuminaemiaHypoalbuminaemia Renal failure.Renal failure.

Common pathological Common pathological casescases

Case oneCase one

►Middle age women presented to ED Middle age women presented to ED with fever, RUQ painwith fever, RUQ pain

►On examOn exam

She looks ill, febrile and on painShe looks ill, febrile and on pain

Abdomen: RUQ tenderness Abdomen: RUQ tenderness ► Lab high LFTs & WBC.Lab high LFTs & WBC.

ContCont..

► Thickening of GB wall >3mm.Thickening of GB wall >3mm.► Distended GBDistended GB► Pericholecystic fluid.Pericholecystic fluid.► Hyperemia.Hyperemia.► Gall stoneGall stone► Acute calcular cholecystitis. Acute calcular cholecystitis.

Case twoCase two

►Middle age women presented to Middle age women presented to surgical out patient clinic with 2 years surgical out patient clinic with 2 years history of recurrent RUQ pain mild to history of recurrent RUQ pain mild to moderate in severity radiated to the moderate in severity radiated to the right shoulder aggravated by fatty right shoulder aggravated by fatty meal.meal.

►On exam:On exam: obese lady well not distressed, febrile or obese lady well not distressed, febrile or

jaundiced.jaundiced.►Lab LFTs normal.Lab LFTs normal.

ContCont..

► Multiple oval shaped echogenic structures Multiple oval shaped echogenic structures seen within GB causing acoustic shadowingseen within GB causing acoustic shadowing

► GB stonesGB stones

Case threeCase three

►Middle age man presented to ER with Middle age man presented to ER with severe RUQ pain and yellowish severe RUQ pain and yellowish discoloration of skin and sclera.discoloration of skin and sclera.

►On exam:On exam:

he looks ill, jaundiced and on pain but he looks ill, jaundiced and on pain but not febrilenot febrile

►Lab high LFTs. Lab high LFTs.

ContCont..

► Dilated intra-hepatic and extra-hepatic Dilated intra-hepatic and extra-hepatic biliary systembiliary system

► Echogenic structure seen within CBDEchogenic structure seen within CBD► CBD stone causing biliary obstruction.CBD stone causing biliary obstruction.

Case fourCase four

►Old man recently discovered to have Old man recently discovered to have colonic cancercolonic cancer presented to primary presented to primary health care clinic with vague upper health care clinic with vague upper abdominal painabdominal pain

►On exam:On exam:

he was thin, ill not febrile or jaundiced.he was thin, ill not febrile or jaundiced.

Mild abdominal tenderness enlarged liver Mild abdominal tenderness enlarged liver with irregular outline.with irregular outline.

►Lab mildly elevated LFTs.Lab mildly elevated LFTs.

ContCont..

► Multiple hypoechoic focal hepatic lesionsMultiple hypoechoic focal hepatic lesions

► Metastatic liver lesions. Metastatic liver lesions.

Case fiveCase five

► Middle age man known case of HCV+ for 10 Middle age man known case of HCV+ for 10 years presented to GI out patient clinic with years presented to GI out patient clinic with history of weight loss, indigestion and mild history of weight loss, indigestion and mild abdominal pain. No fever.abdominal pain. No fever.

► On exam:On exam:he was ill, slim ,mildly jaundice not febrile.he was ill, slim ,mildly jaundice not febrile.Abdomen: bulging flanks, dilated tortuous Abdomen: bulging flanks, dilated tortuous

vessels around umbilicus. Mild diffuse vessels around umbilicus. Mild diffuse abdominal tenderness.abdominal tenderness.

► Lab high LFTs.Lab high LFTs.

ContCont..

► Shrunken liver with irregular outline.Shrunken liver with irregular outline.► Heterogeneous appearance.Heterogeneous appearance.► Focal hypoechoic lesion.Focal hypoechoic lesion.

► Cirrhotic liver with HCC.Cirrhotic liver with HCC.

Case sixCase six

►Young man known IV drug addict Young man known IV drug addict presented to ER with high fever, chills, presented to ER with high fever, chills, upper abdominal pain and vomitingupper abdominal pain and vomiting

►On exam:On exam:►He looks very ill, febrile and on pain.He looks very ill, febrile and on pain.►Abdomen: RUQ tenderness.Abdomen: RUQ tenderness.►Lab high LFTs & WBC.Lab high LFTs & WBC.

ContCont..

► Focal hypoechoic liver lesion with ill defined Focal hypoechoic liver lesion with ill defined outline.outline.

► Liver abscess.Liver abscess.