King Saud University College of medicine US OF

King Saud University College of medicine

US OF LIVER AND GALLBLADDER

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.

Introduction to US

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 1950’s Medical applications in use since late

US machine PROBES MACHINE

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

B- MODE. DUPLEX COLOR DOPPLER

B- MODE DUPLEX

US uses: ► Cardiology ► Emergency Medicine: for Trauma patient and acute abdomen. Echocardiography is an essential tool in cardiology, vavular heart disease. 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.

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

Advantages of US ► Inexpensive ► Easy and available ► Safe and no radiation

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

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

Normal liver appearance

Portal Vein

Hepatic veins

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

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

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

Small shrunken liver < 9 cm ► Late cirrhosis: § Shrunken size § Irregular outline § Ascites § Portal hypertension 8 cm

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

More then normal (more white) Diffuse fatty infiltration Normal

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

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

LIVER ABSCESS METASTASIS HEMANGIOMAS HCC

Cont. Hydated cyst

Vascular abnormality q Portal venous system: § Thrombosis. § Portal hypertension. q Hepatic venous system: § Thrombosis § (budd chiari syndrome).

Hepatic vein thrombosis Normal HV PV THROMBOSIS Normal PV

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

Pathology of gall bladder ► Intra-luminal pathology. ► Mural pathology.

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

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

Mural pathology u. Primary: u. Cholecystitis. u. Secondary: Thick wall u. Cardiac failure. u. Cirrhosis. uascitis u. Hypoalbuminaemia u. Renal failure. Normal

Common pathological cases

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.

► Acute calcular cholecystitis: § Gall stone § Thickening of GB wall >3 mm. § Distended GB

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.

Liver US

► Metastatic liver lesions. § Multiple hypoechoic focal hepatic lesions

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.

8 cm

► Liver cirrhosis § Shrunken liver with irregular outline. § Free fluid (ascites)

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.

CBD = 1. 2 cm

CBD = 1. 2 cm stone u CBD stone: • Dilated CBD