kuliah blok gi tract_usg abd_september 2010

7/27/2019 Kuliah Blok GI Tract_USG Abd_september 2010

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Hepatobilier Ultrasound

Dr.Yanto Budiman, Sp.Rad, M.Kes

Bagian Radiologi FKUAJ / RSAJ


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Liver

Gall Bladder and Biliar Tract

Pancreas

Spleen


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The Liver

Normal appearance The liver is a homogenous, mid grey organ

on ultrasound

Slightly increased echogenicity when

compared to the cortex of the right kidney

Its outline is smooth

The liver is surrounded by a thin, hyperechoic

capsule, which is difficult to see on ultrasoundunless outlined by fluid

Size : longitudinal length 16 cm.


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Liver CapsuleThe renal cortex is slightlyless echogenic than the liverparenchyma.


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left lobe of liver

Left lobe of liver

LPV

Ligamentum teres

stomach

Shadowing

from

ligament


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Tranverse section at the

inferior edge of the left lobe

Inferior aspect left lobe of liver

Ligamentum teres

stomach


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The segment of the liver

The surgical Portal vein segments of the liver

Right hepatic veinMiddle hepatic vein

Left hepatic vein

Falciform ligament

Portal vein

VII

VIII

IV

II

III

I

V

VI


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Hepatic vasculature

The portal veins radiate from the porta hepatis,where the main portal vein (MPV) enters the liver .They are encased by the hyperechoic, fibrouswalls of the portal tracts, which make them stand

out from the rest of the parenchyma. Also contained in the portal tracts are a branch of

the hepatic artery and a biliary duct radical. Theselatter vessels are too small to detect by ultrasound

in the peripheral parts of the liver, but can readilybe demonstrated in the larger, proximal branches


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The portal vein radical is associated with a

branch of the hepatic artery and a biliary duct (arrows)

within the hyperechoic fibrous sheath.


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The three main hepatic veins, left, middle and

right, can be traced into the inferior vena cava

(IVC) at the superior margin of the liver . Their course runs, therefore, approximately

perpendicular to the portal vessels, so a section of

liver with a longitudinal image of a hepatic vein is

likely to contain a transverse section through a

portal vein, and vice versa.


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CD

HA

HA

CDPV

The porta hepatis.

A variant with the hepatic

artery anterior to the

duct. CD = common duct.


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Unlike the portal tracts, the hepatic veinsdo not have a fibrous sheath and theirwalls are therefore less reflective. Theanatomy of the hepatic venous confluence

varies. In most cases the single, main righthepatic vein (RHV) flows directly into theIVC, and the middle and left have a

common trunk. In 1535% of patients the left hepatic vein(LHV) and middle hepatic vein (MHV) areseparate.


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The left hepatic vein. Vessel walls are not as reflective as portal

veins; however, maximum reflectivity is produced when thebeam is perpendicular to the walls, as at the periphery of this

vessel.


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The portal venous system

The normal portal vein (PV) waveform ismonophasic with gentle undulations which are

due to respiratory modulation and cardiac activity.

This characteristic is a sign of the normal, flexible

nature of the liver and may be lost in some fibroticdiseases.

The mean PV velocity is normally between 12 and

20 cm per second6 but the normal range is wide.

(A low velocity is associated with portalhypertension. High velocities are unusual, but can

be due to anastomotic stenoses in transplant

patients).


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Normal portal vein waveform.

Respiratory modulations are evident.


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(A) The confluence of the right, middle and

left hepatic veins with the IVC.

(B) Normal hepatic venous waveform.

The reverse flow in the vein (arrows) is due

to atrial systole. Note that the image has also

been frozen during atrial systole, as the

hepatic vein appears red.

RM

L


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The hepatic artery

The main hepatic artery arises from the coeliac axisand carries oxygenated blood to the liver from theaorta. Its origin makes it a pulsatile vessel and therelatively low resistance of the hepatic vascular bedmeans that there is continuous forward flow

throughout the cardiac cycle In a normal subject the hepatic artery may be elusive

on colour Doppler due to its small diameter andtortuous course. Use the MPV as a marker, scanningfrom the right intercostal space to maintain a low

angle with the vessel. The hepatic artery is justanterior to this and of a higher velocity .


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(A) The hepatic artery may be difficult to locate with colour Doppler in some

subjects.

(B) The same patient using power Doppler; visualization is improved.

(C) The normal hepatic artery waveform demonstrates a relatively highvelocity

systolic peak (arrowhead) with good forward end-diastolic flow (arrow).


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Liver Pathologies


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Multiple cysts in the liver. In this case the

kidneys are normal.usually associated

with polycystic kidney disease.

Three small Hemangiomas(arrows)


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a c


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ABSCESS(A) Early stages of a pyogenic abscess(B) The gas contained within this large

abscess

(C) A percutaneous drain is identified in

a liver abscess

a

b

c


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Fatty Liver

Increased of hepatocyte fat content

Can be focal or diffuse

Diffuse is classified as :

mild, slight increase liver echogenity with loss

intrahepatic vessels border, normal visualisation

diapraghm

moderate, slight loss echogenity of diaphragm

severe. No visualization of diapraghm orposterior segment of right hepatic lobe

Focal fatty sparing


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(A) Fatty infiltration increases the hepato-renal contrast. The portaltracts are reduced in prominence, giving a more homogeneousappearance.

(B) Attenuation of the beam by fat prevents demonstration of far-field

structures.


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Hepatitis

The liver frequently appears normal onultrasound.

In the acute stage, if ultrasound changes

are present, the liver is slightly enlarged

with a diffusely hypoechoic parenchyma.

The normally reflective portal tracts are

accentuated in contrast but this darkliver

appearance is non-specific, and may also

occur in leukaemia, cardiac failure, AIDS

and other conditions.-starry sky pattern


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The inflammation may start at the portal

tracts working outwards into the surroundingparenchyma, the so-called periportal

hepatitis.

In such cases, the portal tracts become lesswell-defined and hyperechoic.

The gallbladder wall may also be thickened, ,

portal lymphadenopathy. If the disease progresses to the chronic

stage, the liver may reduce in size, becoming

nodular and coarse in appearance


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(A) Subtle changes of oedema in acute hepatitis: the liver is hypoechoiccompared with the right kidney, mildly enlarged and has prominentportal tracts.

(B) Chronic hepatitis and cirrhosis, demonstrating a coarse-textured,nodular liver.


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Hepatitis


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Diffuse process characterized by fibrosis

and the conversion normal liver tissue intoabnormal nodule

Causes : alcoholism ( 70%), viral hepatitis,

metabolic disorder, cardiovasculardisorder

Cirrhosis


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Normal

parenchyma

May appear normal, particulary in early stages

Changes in

texture

Coarse texture (micronodular)

Irregular nodular appearance (macronodular)

Changes in

reflectivity

Fibrosis increases the overall echogenicity (but not the attenuation)

May be accompanied by fatty change, which increases both echogenicity and

attenuation giving a hyper-reflective near-field with poor penetration to the

posterior liverChanges in

size and

outline

Small, shrunken liver

Nodular, irregular surface outline

Possible disproportionate hypertrophy of left or caudate lobes

Focal lesions Increased incidence of HCC

Regenerative nodules

Vascular Signs of portal hypertension:

-Changes in portal vein direction and velocity

-Possible thrombosis, varices and collaterals, increased hepatic arterial flow

-Flattened, monophasic hepatic venous flow on spectral Doppler (a non-

spesific finding)

Other signs Ascites, splenomegaly, and lymphadenopathy

Cirrhosis


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Cirrhosis

A.B

C

Cirrhosis: coarse echo pattern. (A)

Longitudinal view shows coarse echo

pattern. (B, C) Coarse slightlyinhomogeneous echo pattern of the liver.

The liver is surrounded by ascites. One

sees slight nodularity of the anterior

surface of the liver in (B) (arrows).


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Occurs when the pressure in the portal

venous system is raised

As a result of chronic liver disease,

particularly in the cirrhotic stage, when the

nodular and fibrosed parenchyma of the

liver impedes the flow of blood into the

liver

It is significant because it causes

numerous deleterious effects on the

patient which many of that can be

recognized on ultrasound

Portal Hypertention


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(A) Portal vein (PV) velocity is greatly reduced.

(B) Reversed PV flow in portal hypertension. Note the increased velocity of hepatic arterial flow

indicated by the light colour of red just anterior to the portal vein. The patient hasmacronodular cirrhosis with ascites.


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(C) Balanced PV flow. Alternate forward and reverse low-velocityflow on the Doppler spectrum. The PV colour Doppleralternates red and blue.


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(C) Colour Doppler demonstrates the tortuous vascularchannel of a spleno-renal shunt.

(D) Large patent para-umbilical channel running along theligamentum teres to the anterior abdominal wall in apatient with end-stage chronic liver disease and portal

hypertension.


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(E) The para-umbilical vein culminates in a caputmedusae just beneath the umbilicus.

(F) Varices can be seen around the gallbladder wall in

a case of hepatic fibrosis with portal hypertension.


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(G) Collaterals in portal hypertension


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HEPATOCELLULAR

CARCINOMA (HCC)


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Hepato Cellular Carcinoma

Symptom :

RUQ pain, abdominal mass

Elevation AFP

Sign of cirrhosis, associated with chronic liver

disease.

Weight loss

hepatomegaly


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Ultrasound appearances

Vary from hypo- to hyperechogenic or mixedechogenicity focal lesions

Enlarged liver

Wave-form surface

Usually shows hyperechoic with central necrotic thatgiven hypo- to anechoic appearances with irregularedge

It is difficult to differ the normal liver to early stage ofhepatoma because they both show iso-echoic

structure It is often difficult to locate small HCCs in a cirrhotic

liver which is already coarse-textured and nodular. CTand MRI may be useful.


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Colour and spectral Doppler can demonstrate

vigorous flow, which help to distinguish HCCsfrom metastases or haemangiomas, which

demonstrate little or no flow. All carcinoma

demonstrate neovascularization which its

characteristics are different from normal.

New vessels have a paucity of smooth muscle in

the intima and media and exhibit low resistance

to bloow flow with high end diastolic flow (EDF).New vessels able to multiply relatively quickly

causing arteriovenous shunting within the mass

which may result in high velocities


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(A) Exophytic hepatocellular carcinoma (HCC) in a

patient with cirrhosis

(B) Multifocal HCCs (arrows) in a cirrhotic patient

Hepatocellular carcinoma


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Hepatocellular carcinoma. (A) Transverse view shows a large, hypoechoic solid

mass (arrows) within the right lobe. (B) In another patient, sagittal view shows a large,

predominantly hyperechoic, inhomogeneous mass (arrows) within the liver.



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Hepatocellular carcinoma: color Doppler sonography. (A) Increased color flow (arrows) is

seen surrounding the tumor nodule (the basket pattern). (B) Abnorm al vesse ls wi th

increasedcolor flow are seen within the tumor (arrows) (vessels within the tumorpattern)

Gall Bladder


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Gall Bladder

Indication

Jaundice

Suspected Cholecystitis

Suspected Gallstones

Best time to image : after 6 hours of fasting

Size : Long axis 6-12 cm , short axis 3-5 cm

Normal gallbladder wall :


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Normal gall bladder

GB pathologies


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GB pathologies

Cholelithiasis/gallstones : echogenic with

posterior acoustic shadow , mobile/impacted

Acute Cholecystitis

Associated with gallstones (90-95%)

sonographic murphys sign

Gallblader wall > 3mm

Sludge, Gallblader dilataion, pericholecystic fluid


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Cholelithiasis

GB Pathologies contd


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GB Pathologies cont d

Polyps

Adenomyomatosis

Hyperplastic changes in gall blader wall

overgrowth mucosa, thickening muscular wall

and formation of intramural diverticular :Rokitansky-Aschoff sinuses.

Polyp gallblader- no acousticshadow & non-gravity dependent


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Adenomyomatosis: (Left)LS demonstrating a thickened gallbladder wall

with a small Rokitansky-Aschoffsinus (arrow) at the fundus. (Right) TS

demonstrating a stone and comet-tail artifacts from within the wall due to

crystal (cholesterol, bile, calculi) deposits.

Bile Ducts


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Bile Ducts

Choledocholithiasis

85 % found in distal duct near the head ofpancreas

Dilated CBD (normal 5mm)

Cholangitis

CBD Stone


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CBD Stone

Pancreas


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Pancreas

Indication :

Identify tumors or masses

Suspected pancreatitis

Normal size

Head : 2-3 cm anteroposterior

Body : 2 cm anteroposterior

Tail : 3 cm

Duct : < 2mm


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Pancreas Pathologies


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Pancreas Pathologies

Pancreatitis acute and chronic

Pancreatitis Carcinoma

Pancreas metastase

Pancreatic cyst


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Acute pancreatitis

enlarged hypoechoic obstructed / dilated pancreatic duct,fluid collections, pseudocysts

Role US : identify gallstones, biliary obstructuion

Chronic pancreatitis

Atrophic gland, dilated duct, calcifications Pancreatitic Carcinoma

Hypoechoic mass located in head (70%), body (15-20 %), or tail (5%)

Obstructed pancreatic duct, adjacentlymphadenopathy, encasement of adjacentvasculature


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Acute Pancreatitis


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Chronic pancreatitis - calcification Tiny cyst in the body of pancreas

Spleen


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Spleen

Indication : LUQ pain, Enlarged spleen at

Physical examination, susp.infection

Normal size : length


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Spleen Pathology

Splenomegaly

Lymphoma

Enlargement

Miliary nodule < 5mm

Multifocal masses , sixe 1-10 cm

Lymphoma


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Lymphoma


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THANK YOU

kuliah blok gi tract_usg abd_september 2010

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