The Liver

The LiverSONO 131 Lecture #5

Anatomy

Sonographic Presentation

Anterior & Posterior Views

Superior & Inferior Views

Couinaud’s Hepatic Segments

Hepatic Vascular System

Hepatic Vascular System

Portal System Hepatic Veins Hepatic Arteries

Function Deoxygenated blood from spleen, pancreas, GB, and bowel to liver70 – 80% hepatic blood flow

Deoxygenated blood from liver into IVC

Oxygenated blood from aorta to liver20 – 30% oxygenated supply

Sonographic Features

Intra segmentalOrigin @ porta hepatisEchogenic reflective wallsBranch horizontally

Inter lobarInter segmentalDrain toward RANo reflective wallsBranch longitudinallyRespiratory variation

Very small – especially away from porta hepatis

Scan Technique

Main & LPV – anteriorRPV – right intercostal

Transverse planeHigh in epigastrium

Anterior

Doppler Flow Pattern

Low velocity, continuous Toward liver, undulationsVelocity ↑w/ inspiration

Flow toward IVCTriphasic curve

Antegrade diastolic flowLow resistance flow

Portal Vein Doppler

Normal Portal Flow Portal Flow in Tricuspid Regurg

Hepatic Vein Doppler

Hepatic Vein - Normal Hepatic Vein – Abnormal

Hepatic Artery Doppler

Liver Function(s)

Liver Cells

Liver Cells

Primary Functions of the Liver

Metabolism Carbohydrate Protein

Digestion Bile

Storage Iron Vitamins

Detoxification Drugs and

poisons

Hepatic Metabolic Functions

Hepatic Detoxification

Waste products of energy production

Waste produce of metabolic activities

Hormone & drug break down

Commercial Product

Liver DETOX's Unique Formula: Milk Thistle - a natural herb, traditionally used

to support detoxification functions of the liver. L-Methionine - an amino acid that the liver uses

to create glutathione. N-Acetyl-Cystine - the liver also uses NAC to

create glutathione. Alpha Lipoic Acid - is an antioxidant that helps

revitalize glutathione and supports the antitoxin activities of the liver.

Selenium - helps zinc and vitamins (both antioxidants) to function better in their detoxification properties.

Ayurvedic Herbs - these herbs have long been used to promote the detoxification capabilities of the liver.

Liver Function Tests

AST ALT LDH Alkaline Phosphatase Bilirubin Prothrombin Time Albumin and globulins

Bilirubin – a bile pigment resulting from the breakdown of old blood cells Formed by Kupffer cells and excreted by hepatocyes Increases with any chronic inflammatory disease Reported types

Total = mixture of conjugated + unconjugated Increases in in chronic liver cell disease (Cirrhosis)

Unconjugated or indirect Increases in isolated acute hepatocellular disease

Conjugated or direct bilirubin Increases in biliary duct obstruction

Liver Function Tests

Serum Albumin – protein that is a component of blood Synthesized by liver Responsible for maintenance of osmotic

pressure in blood Decreased levels

Liver dysfunction Malnutrition Renal disease

Liver Function Tests

AST – Aspartate aminotransferase, formerly know as SGOT Enzyme found in liver, muscles and tissues with high

metabolic rates Liver causes for abnormal AST

Acute hepatitis Cirrhosis Hepatic necrosis Injury to the liver Metastases to the liver Fatty changes

Non-Liver causes for abnormal AST Mononucleosis Myocardial Infarction

Liver Function Tests

ALT – Alanine aminotransferase (formerly SGPT) Enzyme produced in the hepatocytes Elevated ALT

Hepatitis Obstructive jaundice Hepatocellular disease Shock & drug toxicity causing liver cell death

Liver Function Tests

Alkaline Phosphatase – enzyme produced in liver, kidneys, bones, intestines and placenta Increase with normal ALT & AST

Bile duct obstruction Primary biliary cirrhosis Sclerosing cholangitis

Nonbiliary causes for increase Abscesses Liver carcinoma Cirrhosis

Liver Function Tests

Liver Function Tests

Condition Bilirubin Serum Albumin

AST ALT Alkaline Phosphatase

Hepato-

cellular

Disease

Obstruction Normal

Sonographic Evaluation

Patient Preparation NPO for at least 6 hours

Transducer 2.5 to 5 MHz curvilinear or sector

Patient Position Supine and decubitus as necessary

Patient Breathing Full inspiration

Liver attenuation

Liver texture

Vascular structures

Ligaments, fissures

Sonographic Evaluation

Liver Images – Transverse & Longitudinal

Liver Images - Transverse

Measurements

Anteroposterior 10 – 12.5cm Transverse 20 – 22.5 cm

Normal or Not?

Transverse Liver