King Saud University

1. King Saud University College of medicine

2. US OF LIVER AND GALLBLADDER

3. outline: • Introduction to US. • Indications of liver and gall bladder US. • Normal anatomy and radiological appearance. • Pathologies of the liver and the gall bladder. • Common pathological cases.

4. Introduction to US

5. Definition: • A diagnostic technique in which high-frequency sound waves penetrate the body and produce multiple echoes; these echo patterns can be viewed as an image on a computer screen. • Frequency ranges used in medical Ultrasound imaging are 2 - 15 MHz • Diagnostic Medical applications in use since late 1950’s

6. US machine PROBES MACHINE

7. Ultrasound Language Hyper-echoic = White Hypo-echoic = Light Grey An-echoic = Black

8. B- MODE. DUPLEX COLOR DOPPLER

9. DUPLEX B- MODE

10. US uses: • Cardiology Echocardiography is an essential tool in cardiology, vavular heart disease. • Emergency Medicine: for Trauma patient and acute abdomen. • Gastroenterology: In abdominal sonography, the solid organs of the abdomen such as the pancreas, aorta, inferior vena cava, liver, gall bladder, bile ducts, kidneys, spleen and appendix. • Gynecology: to assess female pelvic organs, uterus ovaries • Neonatology: for basic assessment of intracerebral structural abnormalities, bleeds, ventriculomegaly or hydrocephalus.

11. Cont. • Neurology • for assessing blood flow and stenoses in the carotid arteries (Carotid ultrasonography) • Obstetrics: • sonography is commonly used during pregnancy to check on the development of the fetus. • Urology: • to study a patient's bladder, prostate or testes. • Musculoskeletal • For assessing tendons, muscles, nerves, ligaments, soft tissue masses, and bone surfaces • vascular system: • To assess patency and possible obstruction of arteries Arterial doppler, diagnose DVT venous doppler and determine extent and severity of venous insufficiency

12. Advantages of US • Inexpensive • Easy and available • Safe and no radiation

13. Disadvantages of US • Inability to penetrate gas or bone. • Operator dependent. • Less sensitive in some situations.

14. Indications of liver and gall bladder US • Right upper quadrant pain. • Jaundice. • High liver function test. • Fever work up. • Screening for metastasis.

15. Normal liver appearance

16. Portal Vein

17. Hepatic veins

18. Pathology of the liver: • Size • Diffuse liver disease • Focal liver disease • Hepatic vascularity • Biliary system obstruction/pathology

19. Size abnormality • Normal: 9 -15 cm at Mid Clavicle Line MCL • Large (Hepatomegaly) > 15 cm • Small < 9 cm 14 cm Normal size

20. Large (Hepatomegaly) > 15 cm: Causes: • Infection: eg viral hepatitis • Neoplasm (tumor): eg. metastasis • Cirrhosis: early phase • Metabolic: Amyloidosis /fat • Drugs/toxins: alcohol • Others: Budd Chiari syndrome 17 cm

21. Small shrunken liver < 9 cm • Late cirrhosis: • Shrunken size • Irregular outline • Ascites • Portal hypertension 8 cm

22. Diffuse abnormality • More then normal(more white) • e.g. Diffuse fatty infiltration • Less then normal (more black) • e.g. infection: Acute hepatitis

23. More then normal (more white) Diffuse fatty infiltration Normal

24. Less then normal (more black) infection/ Acute hepatitis Normal

25. Focal liver lesions • Benign tumor: • Hemangioma. • Malignant tumor: • Primary eg. Hepatocellular carcinoma. • Secondary metastasis eg. Colon breast. • Infective: • Abscess • Hydated cyst • Congenital: • Hepatic cyst.

26. LIVER ABSCESS HEMANGIOMAS METASTASIS HCC

27. Cont. Hydated cyst

28. Vascular abnormality • Portal venous system: • Thrombosis. • Portal hypertension. • Hepatic venous system: • Thrombosis • (buddchiari syndrome).

29. PV THROMBOSIS Hepatic vein thrombosis Normal PV Normal HV

30. Biliary abnormality • Intra-hepatic biliary radicals. Less than 3mm • Extra-hepatic “CBD” Less than 8mm • Causes of dilatation & obstruction: • Intra-luminal: • Stone & mass. • Mural: • stricture (benign & malignant) • Extrinsic: • Compression mass & Lymph node Intra hepatic dilatation mass Dilated CBD

31. Pathology of gall bladder • Intra-luminal pathology. • Mural pathology.

32. Intra-luminal pathology • Gall stone: Acoustic shadowing • Polyps No acoustic shadowing.

33. Cont. • Intraluminal: Mass lesion +- invasion Gall bladder carcinoma.

34. Mural pathology • Primary: • Cholecystitis. • Secondary: • Cardiac failure. • Cirrhosis. • ascitis • Hypoalbuminaemia • Renal failure. Thick wall Normal

35. Common pathological cases

36. Case one • Middle age women presented to ED with fever, RUQ pain • On exam She looks ill, febrile and on pain Abdomen: RUQ tenderness • Lab high LFTs & WBC.

38. Acute calcular cholecystitis: • Gall stone • Thickening of GB wall >3mm. • Distended GB

39. Case two • Old man recently discovered to have colonic cancer presented to primary health care clinic with vague upper abdominal pain • On exam: he was thin, ill not febrile or jaundiced. Mild abdominal tenderness enlarged liver with irregular outline. • Lab mildly elevated LFTs.

40. Liver US

41. Metastatic liver lesions. • Multiple hypoechoic focal hepatic lesions

42. Case three • Middle age man known case of HCV+ for 10 years presented to GI out patient clinic with history of abdominal distension. No fever. • On exam: he was ill, slim ,mildly jaundice not febrile. Abdomen: bulging flanks, dilated tortuous vessels around umbilicus. Mild diffuse abdominal tenderness. • Lab high LFTs.

43. 8 cm

44. Liver cirrhosis • Shrunken liver with irregular outline. • Free fluid (ascites)

45. Case four Middle age woman complaining of right upper quadrant pain, dark urine and pale stool. On examination: her skin and sclera are yellowish, not febrile.

46. CBD = 1.2 cm

47. CBD = 1.2 cm stone • CBD stone: • Dilated CBD

48. thank you