Ultrasound examination of the liver. Ultrasound measurement of the liver Segmental structure of the liver on ultrasound
PROBLEMS OF ULTRASONIC ASSESSMENT OF LIVER SIZE
V. A. Izranov, N. V. Kazantseva, M. A. Beletskaya
PROBLEMS OF METHODOLOGICAL APPROACHES TO MEASUREMENT AND ASSESSMENT OF LIVER SIZE BY US
The size of the liver varies depending on the age and body type of the person. Palpation and percussion are standards of clinical examination, but they do not accurately assess mild liver enlargements. Accurate measurement of liver size is especially important when liver disease is suspected. But according to a number of studies, the measurement of the longitudinal size of the liver varies greatly depending on the examination method and the techniques used by the operator. Measurement of liver size using ultrasound has not yet become routine practice due to the lack of reliable and reproducible techniques. This paper discusses the results of various methods for studying the size of the liver and options for normal sizes depending on the age and constitution of a person.
Liver size varies widely according to age and different body types. Palpation and percussion are standard techniques to measure liver size, but are not accurate enough to detect a small increase. Accurate measurement of the liver by sonography is particularly relevant when a patient is suspected to have hepatitis. According to a number of validated sources, liver length varies greatly depending on the modalities and techniques used by the ultrasound specialist. Ultrasound liver size measurement has not become a routine procedure since a reliable and reproducible ultrasound method has not been established so far. The article describes the results of different methods of liver size measurement and as well as variations in the normal size depending on the age of the patient and his / her body type.
Key words: liver size, ultrasonography, liver measurement, normal variants, body type, age.
Key words: liver length; liver anatomy; sonography, ultrasonography, organo-metry, liver measurement normal range.
Introduction
The size of the liver is one of the sensitive clinical markers of the state of the body. Size standards are the basis for excluding or confirming hepatomegaly. In the modern "imaging era" in medicine, many authors point out that determining the size of the liver by percussion and palpation is unreliable. Of particular importance is the determination of the size of the liver in the last ten
© Izranov V.A., Kazantseva N.V., Beletskaya M.A., 2017
Bulletin of the Baltic Federal University. I. Kant. Ser .: Natural and medical sciences. 2017. No. 1. S. 73-91.
tiletiya gets in connection with her transplantation. In view of this, the judgment about the enlargement of the liver is currently most often based on the results of ultrasound. At the same time, in tutorials on ultrasound diagnostics and in the scientific literature there is conflicting information on the measurement technique and there are no clear data on the peculiarities of the dimensional characteristics of the liver in representatives of various constitutional types.
The goal is to conduct a scientific literature search on normal liver size according to ultrasound data in representatives of various constitutional types and to provide a comparative analysis of liver measurement data.
Research objectives: 1) to provide an overview of methods for determining the size of the liver; 2) provide options for liver sizes with different measurement techniques.
Material and methods. Scientific and medical literature was searched for the keywords “liver size”, “ultrasonography”, “liver measurement”, “normal variants” in the databases Medline, Science Direct, E-Library. The depth of the search is from 1977 to 2016. A comparative analysis of the scientific literature concerning approaches to measuring and assessing the size of the liver by ultrasound has been carried out.
Methods for determining the size of the liver
Determining the size of the liver is a diagnostic task that doctors of various medical specialties have to perform every day, primarily to exclude or ascertain the fact of hepatomegaly.
Determination of liver size began in the "pre-imaging era". Initially, the boundaries and sizes of the liver were determined by percussion and palpation methods. DO Castell and B.B. Frank, D. C. Wolf give the normative sizes of the liver (hepatic dullness) in men and women, depending on body length (height).
Table 1
Average liver sizes in normal individuals as measured by percussion
Body length, cm Longitudinal liver size, cm
along the midclavicular line along the midline of the body
husband. wives husband. wives
160 8,25 6,00 6,00 4,00
165 9,00 6,75 6,50 4,50
166 9,75 7,50 7,00 5,00
169 10,25 8,00 7,50 5,50
172 11,00 8,75 8,00 5,75
175 11,75 9,50 8,50 6,25
Source: .
The same authors describe the location of the liver behind the thoracoabdominal wall in representatives of various body types (see Fig. 1, 2). In the domestic literature, these data were first studied in detail and published by V.N. Shevkunenko and A.M. Geselevich in 1935.
Figure: 1. Front view of the liver with different body types Source:.
Figure: 2. Lateral view of the liver with different body types
Source: .
One of the most common methods of physically determining the size of the liver is according to M.G. Kurlov. Below is a drawing from a textbook on the conduct of internal diseases with a demonstration of the size of the liver according to M.G. Kurlov.
With percussion of the liver according to Kurlov, the following three sizes are determined. The first size is along the right midclavicular line from the upper to the lower border of the absolute dullness of the liver, which is normally 9 - 11 cm.The second size is along the anterior midline from the conditional upper border of the liver, marked at the same level as the upper border of the liver along the right midclavicular line, up to the lower one, is normally 7-9 cm. The third dimension is from the conditional upper border of the liver along the anterior midline to the border of the left lobe of the liver along the edge of the costal arch, which is normally 6 - 8 cm.
Figure: 3. Methods of measurement and standards for liver size according to MG Kurlov: 1 - the size along the right midclavicular line from the upper to the lower limit of the absolute dullness of the liver (9-11 cm); 2 - the size along the midline of the body from the conditional upper border of the liver, marked at the same level as the upper border of the liver along the right midclavicular line, to the lower (7-9 cm); 3 - from the conditional upper border of the liver along the anterior midline to the border of the left lobe of the liver along the edge of the costal arch (6 - 8 cm)
Source: .
Traditionally, the size of the liver is determined by ultrasound in longitudinal scanning along the midclavicular line in the subcostal approach (craniocaudal and anteroposterior sizes right lobe) and along the midline (craniocaudal and anteroposterior dimensions of the left
(A) Mid-clavicular length
In hypersthenics< 12 см, у астеников < 14 см (А + В) Вертикальный + передне-задний размеры = 24-26 см (С) Косой размер (от купола диафрагмы до наиболее удаленной каудальной точки) < 13 см, гепатомегалия > 15.5 cm [Ooetk e! ah! .. 1979]
share) (Fig. 4).
thickness 1.5-2.0 cm Right lobe I caudate lobe< 0.55
Square lobe (IV) 4.3 ± 0.8 cm Caudate lobe, length 6-7 cm,
Angle of the lower edge of the right lobe< 75° Угол нижнего края левой доли < 30°
Figure: 4. Methods of measurement and standards of liver size during ultrasound scanning
Source: .
As can be seen from the accompanying illustration of the manual, the C dimension is designated as "oblique dimension". The obtaining of the maximum cranio-caudal size along the midclavicular line is similarly described in the article by W. Kratzer and co-authors (Fig. 5).
Figure: 5. Measurement of the size of the liver along the largest cranio-caudal diameter in the MCL during inhalation, position on the back: a - sonographic measurement; c - representation of a dimension in a diagram
Source: .
At the same time, alternative methods have been proposed for measuring the craniocaudal size of the right lobe along the midaxillary line and the anterior axillary line in the intercostal approach, which is due to technical difficulties in measurements from the subcostal approach. The recommended reference CRC value from the intercostal approach along the mid-axillary line is 14.0 ± 1.9 cm.
The Clinical Guide to Ultrasound Diagnostics provides the following description of the technique for measuring oblique vertical dimension: “Oblique vertical dimension (CWR) reflects the size of the right lobe of the liver in the direction from the lower edge to the largest bulge of the dome of the diaphragm, obtained by deriving the maximum area of \u200b\u200bthe image of the right lobe. The corresponding image for measuring the CWR of the right lobe of the liver is obtained in the oblique scanning position with the location of the sensor along the midclavicular line along the costal arch with a certain, often individually selected angle of inclination - in the range from 75 to 30 degrees. In the absence of pathology, the CWR of the right lobe of the liver does not exceed 150 mm. As you can see, the methodological approaches for determining the CWR of the right lobe differ significantly. The first sentence from the above quote fully coincides with the description and schematic representation of the size in the works of W. Kratzer and co-authors and S. V. Kapustin and co-authors. At the same time, the methodical approach of oblique scanning along the costal arch along the mean
the clavicular line is fundamentally different from the longitudinal scanning described in the works. With oblique scanning along the costal arch, it is rather difficult (almost impossible) to clearly identify the lower edge of the liver. In this regard, there is a danger of large measurement errors. So, in Figure 6 below, the cursors connect the posterior part of the diaphragmatic surface of the liver and the starting point, which can be either the lower edge or a fragment of the anterior part of the liver, the diaphragmatic surface of the liver, and even a fragment of the visceral surface of the liver.
Figure: 6. Image of the right lobe of the liver when measuring the oblique vertical dimension in the position of oblique scanning along the right costal arch with a moderate tilt of the sensor by 50 - 75 °. Arrows and markers mark the measurement axis
Source: .
The thickness of the right lobe, as indicated in the "Clinical guidelines for ultrasound diagnostics" (1996, 2003), reflects its value from the anterior surface to the transition of the diaphragmatic surface to the visceral surface. Measurement of the thickness of the right lobe is carried out by longitudinal scanning along the midclavicular line or closer to the anteroaxillary line with partial removal of the right kidney along its length into the section. The authors point out that in the absence of liver pathology, the thickness does not exceed 120 - 125 mm. Below is a figure from the "Clinical guidelines for ultrasound diagnosis", commenting on the method of obtaining the thickness of the right lobe of the liver (Fig. 7).
Figure: 7. Image of the right lobe of the liver when measuring its thickness in the position of longitudinal scanning in the area between the right midclavicular and anteroaxillary lines with the vertical position of the sensor. Arrows mark the measurement axis
Source: .
According to the 1980 International Anatomical Nomenclature, only two surfaces are distinguished in the liver - the diaphragmatic and the visceral - and the lower edge of the liver separating them. On the diaphragm surface, in turn, the front, back, upper and right parts are distinguished. Behind, the visceral and diaphragmatic surfaces of the liver do not have a clearly defined border. In this regard, the orientation to the place of transition of the visceral surface to the diaphragm is a very "blurred" criterion for setting the cursor for measurements. In order to more accurately verify the transition area, the authors of the "Clinical guidelines for ultrasound diagnostics" propose to shift the transducer laterally towards the anterior axillary line, thereby deviating from the midclavicular line, along which the craniocaudal size was measured. All this inevitably leads to a high degree of subjectivity in determining the size of the liver according to the measurement methods recommended by the authors.
H. Chelepi (N. Tchelep1) and co-authors point out that hepatomegaly is difficult to objectively diagnose by ultrasound. Normal size the liver of an adult, according to their data, is 15 - 17 cm. In this case, the most reliable results are achieved when measured along the mid-clavicular line from the dome of the diaphragm to the edge of the liver. If the oblique vertical dimension exceeds 15.5 cm, then the liver is "probably enlarged." Reliably diagnose hepatomegaly with ultrasound
it is possible, according to the authors, in cases where the liver extends caudal to the lower pole of the right kidney. However, the use of this approach may be unreliable in patients with Riedel lobes, and therefore requires verification using CT or MRI.
Liver size names vary among authors and in the tradition of different clinical imaging techniques. Thus, the vertical (craniocaudal) size is often referred to as liver length or liver height. In other works, the term "length" of the liver is used as a lateral (lateral) size, which intuitively should be more logically designated as the "width" of the liver.
B.L. Riestra-Candelaria and co-authors point out in their work that there are different approaches to determining the length of the liver. The aim of the study was to assess the most correct method for determining the length (craniocaudal size) of the right lobe of the liver. The authors showed that the most accurate measurements of the craniocaudal size of the right lobe can be obtained by measuring along the mid-axillary line from the right dome of the diaphragm to a horizontal line drawn through the lowest point of the edge of the right lobe of the liver. Liver sizes vary with body mass index and waist circumference.
B. Gosink and C.E. Leymaster retrospectively evaluated the results of liver ultrasound in 36 patients who were subjected to pathological sectional examination within a month after ultrasound. Evaluating the results of liver measurements along the mid-hepatic line, the authors found that the liver size of 13 cm or less corresponded, according to the sectional study, to the norm in 93% of cases. The liver size of 15.5 cm or more corresponded to hepatomegaly in 75% of cases. The data of these authors have been included as normative in many guidelines and reviews on ultrasound diagnostics. However, it should be pointed out that the midhepatic line can be reliably determined only on cadaveric material or by CT and MRI. With ultrasound, it is difficult to correctly determine the vertical line strictly between the right and left borders of the liver, therefore, the midclavicular line is often used.
The work analyzes the most common causes of errors in the study of the liver, including the reasons for errors in measuring the size of the liver. The authors note that the anteroposterior liver size is usually measured. In order to obtain correct measurement results, the transducer must be positioned in the sagittal plane along the midclavicular line at the moment of inspiration, when the diaphragm is at its lowest. In most patients (about 90%), the anteroposterior dimension does not exceed 120 mm. When evaluating the measurement results, the patient's height, weight, age and physical status (asthenic or athletic) must be taken into account. If doubts arise in favor of the diagnosis of hepatomegaly, an additional measurement of the longitudinal dimension of the right
lobes with the same position of the sensor (sagittally along the midclavicular line). And only on the basis of the results obtained can a conclusion about possible hepatomegaly be formulated. The authors cite the following values \u200b\u200bas the upper normal limit (95%) for liver size:
The vertical dimension of the right lobe is 126 mm;
The anteroposterior size of the right lobe is 113 mm;
The vertical dimension of the left lobe is 109 mm;
The anteroposterior dimension of the left lobe is 82 mm.
As the authors point out, the anteroposterior dimension of the right lobe should not exceed 130 mm. Anteroposterior dimension greater than 150 mm indicates pathology in 75% of cases. Anteroposterior dimension between 130 and 150 mm does not require individualized assessment. As a criticism, it should be noted that H. Tchelepi, who also refers to the cited study, indicates the 15.5 cm boundary as a measurement from the dome of the diaphragm to the edge of the right lobe of the liver, which corresponds in other sources to the oblique vertical dimension , but not anteroposterior, as indicated in the work.
W. Kratzer (W. Kratzer) and co-authors measured the size of the liver in 2080 persons aged 18 to 88 years in order to identify factors affecting the size of the organ. It was found that body mass index, body length, gender and (in men) the amount of alcohol consumed affect liver size.
A similar study was conducted on 1789 adult subjects by M. Patzak and co-authors. They found that the following factors influenced the vertical size of the liver: gender, age, body mass index, waist / hip index, and fatty liver. Scientists cite 15.0 ± 1.5 cm as the total average value of the vertical size of the liver in the studied group. However, this value cannot be considered as a normative one in connection with averaging over all the studied subgroups.
Given the difficulties in determining hepatomegaly by one or several linear dimensions of the liver, the authors of the work proposed a simple formula for determining the volume of the liver. Using linear regression equations, they developed the formula:
V \u003d 133.2 + 0.422 (C - C A - P L - L),
where V is the volume, calculated in ml (cc); C - C - craniocaudal size (cm); A - P - anteroposterior dimension (cm); L - L - lateral-teral (transverse) size (cm).
K.Z. Lin (1998) proposed a method for calculating the volume of the liver by the height and weight of a patient:
V (ml) \u003d + - 1530.
A significant number of studies are devoted to the determination of the normative boundaries of liver sizes in children.
table 2
Summary table of reference values \u200b\u200bfor liver size in adults, measured using ultrasound
Source Method for determining liver size by ultrasound Liver size, cm
Clinical guidelines on ultrasound diagnostics / ed. V. V. Mitkova, M. V. Medvedeva. M., 1996. T. 1 Oblique vertical dimension: in the position of oblique scanning with the location of the sensor along the midclavicular line along the costal arch<15
Guidance on ultrasound diagnostics / ed. P. E. S. Palmer. Geneva, 2000 Longitudinal size when scanning along the midclavicular line from the diaphragm to the lower edge of the liver<14
Tchelepi H., Ralls P. W., Radin R., Grant E. Sonography of Diffuse Liver Disease / / J. Ultrasound Med. 2002. Vol. 21 Craniocaudal size along the midclavicular line<15,5
Dergachev A.I., Kotlyarov P.M.Abdominal echography: a reference book. M., 2003 Liver height<12
Kratzer W., Fritz V., Mason R. A. et al. Factors affecting liver size: a sonographic survey of 2080 subjects // J. Ultrasound Med. 2003. Vol. 22 (11) Craniocaudal size along the midclavicular line 14.0 ± 1.7
Gotzberger M., Weber C., Kaiser H. C. et al. Alternative sonographic determination of liver size by intercostal scans / / Praxis (Bern 1994). 2006. Vol. 95 (6) Craniocaudal size along the mid-axillary line 14.0 ± 1.9
Textbook of Diagnostic Ultrasonography. 2006. Vol. 2 Maximum vertical size of the right lobe when scanning along the midclavicular line 15-17.5
Clinical sonography: a practical guide / ed. by R.C. Sanders, T.C. Winter. Ill, T. Bieker et al. Lippincott Williams & Wilkins, 2007 Longitudinal scan at a point midway between the spine and the right lateral trunk (midclavicular line)<15
Sidu PS, Chong VK Ultrasound measurements: a practical guide. M., 2009 Longitudinal size along the midclavicular line 10.5 ± 1.5
Sienz M., Ignee A., Dietrich C. F. Reference values \u200b\u200bin abdominal ultrasound - liver and liver vessels // Z. Gastroenterol. 2010. Vol. 48 (9) Craniocaudal size along the midclavicular line<16,0
Walas M. K, Skoczylas K, Gierblinski I. Errors and mistakes in the ultrasound diagnostics of the liver, gallbladder and bile ducts / / Journal of Ultrasonography. 2012. No. 12 Craniocaudal size along the midclavicular line<12,6
Dietrich C. F., Tuma)., Badea R. Ultrasound of the liver. EFSUMB: European Course Book, 2013 Longitudinal dimension when scanning along the midclavicular line from the dome of the diaphragm to the lower edge of the liver<18
Dietrich C. F., Tuma)., Badea R. Ultrasound of the liver. EFSUMB: European Course Book, 2013 Longitudinal craniocaudal dimension when scanning along the midclavicular line from the diaphragm to the inferior border of the liver<15
Kitaev V.M., Belova I.V., Kitaev S.V. Computed tomography in liver diseases. M., 2006; Kitaev V. M., Kitaev S. V. Computed tomography in gastroenterology: a guide for doctors. M., 2016 Craniocaudal size of the right lobe: measured in a plane passing through the midclavicular line<15
Table 3
Summary table of reference values \u200b\u200bof the anteroposterior size of the right lobe of the liver in adults, measured by ultrasound
Clinical guidelines for ultrasound diagnostics / ed. V. V. Mitkova, M. V. Medvedeva. M., 1996.Vol. 1 Longitudinal scanning along the midclavicular line or closer to the anteroaxillary line with partial removal of the right kidney along its longitudinal section into the section of the right kidney Does not exceed 12.0 - 12.5
Dergachev A.I., Kotlyarov P.M.Abdominal echography: a reference book. M., 2003 Liver thickness<10
The end of the table. 3
Source Measurement method Anteroposterior size of the right lobe of the liver, cm
Penu A. Yu. Treatise on clinical echography. Chisinau, 2004 Longitudinal scanning along the midclavicular line 11 ± 1.8
Sidu PS, Chong VK Ultrasound measurements: a practical guide. M., 2009 Anteroposterior size along the midclavicular line 8.1 ± 1.9
Walas M.K., Skoczylas K., Gierblinski I. Errors and mistakes in the ultrasound diagnostics of the liver, gallbladder and bile ducts / / Journal of Ultrasonography. 2012. No12 Longitudinal scanning along the midclavicular line<11,3
Dietrich C. F., Tuma)., Badea R. Ultrasound of the liver. EFSUMB: European Course Book, 2013 Longitudinal scan along the midclavicular line<13
Dietrich C. F., Tuma)., Badea R. Ultrasound of the liver. EFSUMB: European Course Book, 2013 Longitudinal midclavicular line scan: summation of craniocaudal and anteroposterior dimensions<28
MI Pykov, KV Vatolin indicate that during ultrasound examination, measurements of the vertical dimensions of the liver are usually not carried out, since it is rather difficult to do this. The maximum anteroposterior dimension, or thickness, of the right lobe of the liver is measured. In full-term newborns with an average body weight, this size fluctuates about 45 mm, in older children it can reach 130-150 mm, depending on the physical development of the child. Essentially, it measures the inner diameter of the chest, which rigidly limits the liver. In some clinics, measurements of the liver edge protruding from under the costal arch are performed, which, according to the authors, is of limited clinical significance.
It is interesting to correlate the indicated values \u200b\u200bof the anteroposterior size of the right lobe of the liver in older children according to MI Pykov and KV Vatolin with the data of the work, which indicates that in adults in 95% the anteroposterior size does not exceed 113 mm.
A. A. Safak and co-authors, having examined 712 healthy children, determined the normative boundaries of the longitudinal (vertical) liver size in children 7-15 years old. The authors found a weak correlation between liver longitudinal size and age and height in school-aged children. The strongest correlation between the longitudinal size of the liver was found with the body weight of the subject. The authors proposed a formula for calculating the estimated longitudinal size (length) of the liver for use in clinical practice:
Longitudinal liver size (mm) \u003d 96.063 + body weight (kg) 0.509.
Interestingly, in contrast to the above study, a strong positive relationship was obtained between body length and the length (vertical size) of the liver in children. Perhaps this is due to the inclusion of newborns and young children in the group studied. Unfortunately, the authors do not provide specific data on the number of children of different age groups included in the study; they indicate only the total number - 307 children aged from 5 days to 16 years. In this case, it can be assumed that in schoolchildren (7-16 years old), the effect of the body length factor on the liver length factor becomes less pronounced compared to newborns and young children and is inferior in strength to the body weight factor.
It is also interesting to note the fact that the anteroposterior size of the left lobe, according to the authors of the work, has a weak correlation (up to 0.5) with all the anthropometric parameters studied by them (height, weight, body surface area, body mass index). Below is a diagram for determining the size of the liver (Fig. 8).
Posterior Anterior
Fig. 8. Scheme for determining the longitudinal and anteroposterior dimensions of the liver: a - measurements were performed along the midclavicular and median sagittal planes; b - longitudinal and anteroposterior dimensions of the right and left lobes of the liver
Methodological contradictions, widespread in modern ultrasound diagnostics for determining the size of the liver, are clearly demonstrated in the work. In order to establish the normal size of the liver in children, the authors examined 523 children aged from 5 days to 16 years using the ultrasound method. The liver was measured in craniocaudal, anteroposterior and medial-lateral directions. A sagittal section of the right and left lobes was obtained on a longitudinal section with the sensor positioned on the mid-clavicular and midline lines strictly perpendicular to the frontal surface of the body. The markers were placed on the lower corner of the liver and its dome so that the line connecting them was parallel to the plane of the body surface. Thus, the authors obtained the craniocaudal dimensions of both lobes.
Figure 9 indicates the measurement principle, which is methodologically quite difficult to implement without errors even in children.
Fig. 9. Longitudinal scanning along the right midclavicular line: 1 - craniocaudal size of the right lobe; 2 - anteroposterior size of the right lobe
Thus, the craniocaudal size (1) in the figure does not reach the edge of the liver, and it is not possible to trace it from the dome of the diaphragm, as a result of which, in order to adequately fulfill the requirements formulated by the authors for measuring the craniocaudal size, it is necessary to draw auxiliary lines through the structures absent on the cut. Of course, this significantly increases the measurement error. The crux of the problem lies in the fact that the sweep of the angle of the convex transducer in most cases does not allow "capture" the dome of the diaphragm and the lower edge of the liver, especially in adults.
P. Alipur (R. Anroig) and co-authors examined 180 healthy children of both sexes aged 1 month to 6 years in order to determine the liver size standards. The vertical and anteroposterior dimensions of the right lobe of the liver were determined. The authors of the article are one of the few who point out the methodological difficulty of determining the vertical size of the liver even in children (it is even more pronounced in adults): often the complete image of the liver “does not fit” on the monitor screen, which reduces the measurement accuracy. In this case, the authors propose the measurement of the vertical size of the liver "fold" from two segments drawn along the midclavicular line in a longitudinal scan: a segment from the highest point of the right lobe located under the dome of the diaphragm to the upper edge of the portal vein and a segment from the upper edge of the portal vein to the edge liver. Using this methodological approach, the authors demonstrated a strong positive correlation between the length of the child's body and the length of the liver.
Several works are devoted to the study of the size of the liver by CT and MRI. So, A.M. Buzina carried out the determination of the linear dimensions of the right and left lobes of the liver in normal conditions depending on age according to the data of magnetic resonance imaging. The author performed MRI biometry of the liver in 186 people (92 women and 94 men) aged 28 to 75 years with suspected liver and extrahepatic biliary tract pathology, which was not confirmed. As a result of the study, it was found that in representatives of the first period of adulthood (men from 21 to 35 years old and women from 20 to 35 years old), the heights of the right and left lobes of the liver are 144.4 ± 2.4 mm and 85.1 ± 1 , 8 mm respectively. In the following age groups, there is a decrease in the size of the liver, progressing with age. The minimum values \u200b\u200bof the quantitative parameters of the liver are observed in the elderly age group (men from 61 to 75 years old and women from 56 to 75 years old). The height of the right and left lobes of the liver reaches 131.6 ± 2.8 mm and 77.1 ± 1.6 mm.
it is impossible to judge about hepatomegaly with a linear indicator (or two in one plane). Was proposed "linear coefficient" of the right lobe of the liver, calculated as the product of its height and thickness and correlated with the volume of the liver. The use of the proposed coefficient is an effective, easily feasible, accessible and reproducible technique for diagnosing hepatomegaly, which allows quantitatively assessing the dynamics of the pathological process.
The paper indicates the need for multicenter studies to standardize the measurement technique and improve the quality of the results of medical imaging studies for determining the size of the liver.
In addition, in recent decades, the somatotypic characteristics of the modern population have changed. Many regions of Russia are characterized by "asthenization" of the population. So, A.A.Romanenko, when examining 207 men of adolescence, found that in more than half of the cases they had an asthenic body type, young men of a pycnic body type were extremely rare. The constitutional features of the physique affect the norms for the size of the liver.
Thus, the analysis of these scientific sources testifies to the pronounced contradictions in the methodological approaches to measuring the size of the liver by ultrasound. Most authors suggest longitudinal scanning along the midclavicular line to determine the craniocaudal and anteroposterior dimensions of the right lobe and along the midline to determine the craniocaudal and anteroposterior dimensions of the left lobe of the liver. Individual researchers during ultrasound determine the transverse dimensions of the liver, while this is a generally accepted method of measurement in computed tomography and MRI. In the scientific literature, there are no normative data on the size of the liver, depending on belonging to different constitutional types.
The normative data on the size of the liver are extremely contradictory and do not allow judging the presence or absence of hepatomegaly by one or two liver sizes. The optimal approach to the diagnosis of hepatomegaly is to calculate the volume of the liver by three sizes and compare it with the required volume calculated on the basis of anthropometric factors.
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Vladimir Alexandrovich Izranov - Dr. med. Sciences, prof., Baltic Federal University I. Kant, Kaliningrad.
E-mail: [email protected]
Natalia Vladimirovna Kazantseva - Cand. honey. Sci., Assoc., Baltic Federal University I. Kant, Kaliningrad. E-mail: [email protected]
Maria Andreevna Beletskaya - Ph.D., Baltic Federal University I. Kant, Kaliningrad.
E-mail: [email protected]
Prof. Vladimir Izranov, I. Kant Baltic Federal University, Kaliningrad.
E-mail: [email protected]
Dr. Natalia Kazantsev, Associate Professor, I. Kant Baltic Federal University, Kaliningrad.
E-mail: [email protected]
Maria ABeletskaya, Postgraduate student, I. Kant Baltic Federal University, Kaliningrad.
Video. Lecture liver segments on ultrasound by Oksana Baltarovich
Video. Lecture on ultrasound of the liver by Vladimir Izranov
Traditionally, the liver is divided into right (large) and left (small) lobes at the site of attachment of the falciform ligament, and the square and caudate lobes are usually referred to as the right lobe of the liver. This division is not truly anatomical, since it does not take into account the course of the blood vessels and bile ducts inside the liver.
Photo. The extension of the sickle ligament (CC) on the visceral surface of the liver is the left longitudinal groove. It contains the round ligament of the liver (CJ) in the front and the venous ligament (VL) in the back. The right longitudinal groove passes through the gallbladder bed (GB) in front and the inferior vena cava (IVC) groove in the back. The central place is occupied by the gate of the liver. Here are the branches of the portal vein (BB), hepatic artery and bile duct. Behind the gate of the liver is the caudate (CD), and anteriorly - the square lobe of the liver.
Surgeons dissect half of the liver along the low-vascular plane, which runs from the middle of the fossa of the gallbladder bed in front to the junction of the middle hepatic vein with the inferior vena cava. This corresponds to the right longitudinal groove on the visceral surface of the liver, thus the square and caudate lobes are referred to as the left lobe of the liver.
In 1957, Quino proposed dividing the liver into segments taking into account the branching of the portal vein system. The course of the branches of the portal vein, hepatic artery and bile ducts coincides, therefore, the portal type of division of the liver into a segment is more anatomical than its division taking into account the branching of the hepatic veins.
Photo. Division of the liver according to Quino into 2 lobes, 5 sectors and 8 segments: The right lobe is divided into the lateral sector - VI, VII segments and the paramedial sector - V, VIII segment. The left lobe is divided into the lateral sector - II, III segments, the paramedial sector - IV segment and the dorsal sector - I segment.
The left and right main portal veins divide the liver lobes into superior and inferior, as well as anterior and posterior segments.
Photo. Division of the liver into segments according to Kuino: A - Eight liver segments: I - caudate lobe, II - left posterolateral segment, III - left anterolateral segment, IVa - left upper medial segment, IVb - left lower medial segment, V - right anterior-lower segment, VI - right posterior-lower segment, VII - right posterior-upper segment, VIII - right anterior-upper segment. B - Segmental division of the portal vein.
Important. The segment names are different in different classifications, BUT the numbering is always the same. Learn the numbering of the segments. Front view from left to right - top row 2487, bottom row 3456. In front, the caudate lobe (segment 1) is not visible. Counterclockwise bottom view - 1234567. Bottom 8 segment is not visible.
How to identify a segment of the liver by ultrasound
The hepatic veins run between the lobes and segments of the liver.
Photo. Cross section of the liver at the level of entry of the right, middle and left hepatic veins (arrows) into the inferior vena cava: The middle hepatic vein (MHV) divides the liver into right and left lobes. The right hepatic vein (RHV) divides the right lobe into lateral (segments 6 and 7) and medial (segments 5 and 8) sectors. The left hepatic vein (LHV) divides the left lobe into lateral (segments 2 and 3) and medial (segments 4A and 4B) sectors. Remember the segments of the upper floor of the liver - counterclockwise 2487.
The portal veins are located centrally within the lobes and segments of the liver.
Photo. Cross-section of the liver at the level of the left portal vein: The left portal vein is directed towards the left lobe, then turns sharply forward. The only place in the portal system with a sharp forward turn is the umbilical segment of the portal vein. It divides the left lobe of the liver into the lateral (segments 2 and 3) and medial (segments 4A and 4B) sectors. Attention. The ovals are a cross section of the right and middle hepatic vein.
Photo. Cross section of the liver at the level of the right portal vein. B - The right portal vein is divided into anterior (RAS) and posterior (RPS) segments. RAS and RPS run centrally within the right medial (8/5 segment) and lateral (7/6 segment) sectors of the liver. Note the right and middle hepatic veins (arrow). The right hepatic vein divides the right lobe into medial and lateral sectors. A line drawn through the middle hepatic vein and the inferior vena cava divides the liver into right and left lobes.
Photo. Cross section at the level of the splenic vein: B - Sickle (FL) and round ligaments (large arrow) divide the left lobe of the liver into medial (segment 4) and lateral (segment 3) sectors. B - the caudate lobe of the liver (1) is limited by the gate of the liver, the inferior vena cava and the venous ligament (two arrows).
Considering all of the above, on the basis of ultrasound, it is possible to determine in which segment of the liver the affected area is located.
Riddle 1. Name the segment in which the liver cyst is located.
Answer: Cross section: The junction of the hepatic veins with the inferior vena cava is located in the upper sections of the liver → the middle hepatic vein separates the right lobe from the left - a cyst in the right lobe → the right hepatic vein divides the right lobe into a lateral and medial sector - a cyst in the upper left medial sector → 8 segment. This is confirmed on the sagittal section - the cyst is located high - cross sections of the hepatic veins are visible. Attention. Remember the coveted code - from left to right 2487. then no need to think long → 8 segment.
Take care of yourself, your Diagnostician!
The ephedra plant (Ma Huang, in Chinese) contains the alkaloids ephedrine, norephedrine, and pseudoephedrine. Alkaloids from 0.5 to 3%. Horsetail ephedra and ephedra ephedra contain more ephedrine, while medium ephedra contains more pseudoephedrine. In the autumn and winter months, the content of alkaloids is maximum. In addition to alkaloids, ephedra contains up to 10% tannins and essential oils.
Ephedrine, norephedrine and pseudoephedrine are similar to adrenaline - they stimulate alpha and beta adrenergic receptors.
This book is intended for the novice amateur ginseng growers who grow the plant in their home gardens, and the ginseng growers who are starting to work on industrial plantations for the first time. The cultivation experience and all recommendations are given taking into account the climatic features of the Non-Black Earth Region. Preparing to describe my experience of growing ginseng, I thought for a long time about where to start the presentation of the accumulated information, and came to the conclusion that it makes sense to briefly and consistently tell about all the path of a ginseng grower that I have traveled so that the reader can weigh their strengths and capabilities in this laborious business.
Dr. Popov on folk remedies for Crohn's disease and ulcerative colitis (NUC): Chronic colitis is very easy to cure if you take a teaspoon of plantain seeds on an empty stomach in the morning and a teaspoon of horse sorrel seeds in the evening.
Nettle shoots are among the first to appear every spring. Nettle is the first gift of spring. Nettle tea will heal, restore strength, raise immunity and awaken the body in spring.
It's time to get rid of the bleeding gums and strengthen the gums. In spring, a unique herb called sverbiga grows. If you eat it for at least a week, bleeding gums will disappear forever.
If you want to get rid of bleeding gums and get rid of periodontal disease - chew oak twigs.
The border between the right and left lobes of the liver (in the form of a strip of high echogenicity) is the sickle-shaped and round ligaments of the liver. The round ligament of the liver in transverse sections is depicted as a hyperechoic formation of an oval or round shape, sometimes giving an acoustic shadow.
With ultrasound examination of the liver, in most cases, it is possible to clearly distinguish all four of its lobes. The anatomical landmarks of the boundaries between the lobes are: the bed of the gallbladder (between the right and square lobes), the round ligament of the liver and the sulcus of the round ligament (between the square and left lobes), the gate of the liver (between the square and caudate lobes), the notch of the venous ligament in the form hyperechoic septum (between the left and caudate lobes). The caudate lobe has a process, the severity of which is clearly
individual. The caudal process, having a fairly large size, can significantly protrude from the side of the visceral surface of the liver.
In addition to the four lobes, 8 anatomical segments can be distinguished in the liver during ultrasound examination. With oblique and transverse scanning, the localization of these segments is as follows:
I segmentcorresponds to the caudate lobe; delimited by the venous ligament from IIand IIIsegments, gates of the liver - from IVsegment, from VIIIsegment of the right lobe - the inferior vena cava (partially) and the mouth of the right hepatic vein;
II segment - located in the lower caudal part of the left lobe, in its center there is a segmental branch of the left lobar trunk of the portal vein;
III segment- occupies the upper cranial section of the left lobe with a similar location of the corresponding branch of the portal vein.
Borders IIand IIIsegments with other segments pass along the border of the left lobe.
IV segmentcorresponds to a square fraction; its borders are the round ligament of the liver and the sulcus of the round ligament (with IIIsegment), gate of the liver (with segment I); indirect landmarks of the boundaries of this segment with the segments of the right lobe are the fossa (bed) of the gallbladder in the form of a hyperechoic cord (its thickness depends on the severity of adipose tissue), heading from the gate of the liver to the lower edge of the right lobe (border with the V segment), and the middle hepatic vein, partly behind IVsegment (border with VIIIsegment);
V segment- is located behind the bed of the gallbladder and somewhat lateral.
VI segment- located below and lateral to the V segment, extending approximately to "/", the right lobe.
VII segment- localized below VIsegment and reaches the contour of the diaphragm.
VIII segment- “reed”, occupies the rest of the right lobe, passes to the diaphragmatic surface behind the square lobe, without a clear border with the latter.
It should be noted that during ultrasound examination there are no clear anatomical landmarks allowing to restrict liver segments within its lobes. The branches of the portal vein can provide some assistance in identifying the central parts of the liver segments.
The shape of the liver in a longitudinal section through all of its lobes during oblique scanning (along the costal arch) can be compared with a large horizontal comma. The transverse section of the liver at the level of its right lobe (with longitudinal scanning) often resembles a crescent in its shape, and at the level of the left lobe it is a triangle.
The liver is covered with a capsule, which is clearly located in the form of a hyperechoic structure, with the exception of the areas adjacent to the diaphragm, since it "merges" with the latter.
The contours of the liver appear to be quite smooth and clear. On the visceral (facing into the abdominal cavity) surface of the liver there are several depressions due to the close adherence to it of organs: the right kidney, right adrenal gland, right bend of the colon, duodenum, stomach. The coronal groove is most often represented by an area of \u200b\u200bretraction along the anterior surface of the liver during oblique scanning. Other elements of the ligamentous apparatus of the liver become visible during ultrasound examination only in the presence of fluid around them. With age, especially after 60 years, there is an increase in the echogenicity of the lower edge of the liver due to sclerotic processes in its capsule.
With longitudinal scanning, it becomes possible to visualize and evaluate the lower edge of the liver. The angle of the lower edge of the right lobe of the liver does not exceed 75 °, the left - 45 °. In this case, the lower edge of the liver does not protrude from under the edge of the costal arch. Exceptions are
cases of liver prolapse and features of the constitutional structure (in hypersthenics, the lower edge of the liver is usually located 1-2 cm below the costal arch).
The size of the liver during ultrasound examination can be determined by various methods. The most informative and generally accepted way to assess the size of the liver is to measure the oblique vertical size (CWR)and thickness (anteroposterior size) of the right lobe, craniocaudal size (KKR)and the thickness of the left lobe.
CWRthe right lobe of the liver is the distance from the lower edge to the largest bulge of the dome of the diaphragm when the maximum area is obtained. This image for measuring CWR takes place during oblique scanning in the position of the transducer along the midclavicular line along the costal arch (with the ultrasound beam directed upward at an angle of 75 ° to 30 °). In the absence of an increase in the liver, the CWR of the right lobe of the liver does not exceed 150 mm. Thickness of the right lobe of the liver- the distance from the anterior surface to the transition point of the diaphragmatic surface to the visceral one; for measurement, a longitudinal scan is performed at the level of the midclavicular or slightly to the left of the anterior axillary line. This indicator should not exceed 120-125 mm.
The CRC of the left lobe of the liver is measured from its lower edge to the diaphragmatic surface and normally it does not exceed 100 mm. Left liver lobe thicknessis the distance from its front to back surface. In the absence of pathology, this indicator does not exceed 50-60 mm. Measurement of these indicators of the left lobe is performed with longitudinal scanning in the sagittal plane along the midline of the body (Fig. 11.1).
Additional information can be obtained by measuring (with longitudinal, oblique or transverse scanning) the thickness of the caudate lobe, which normally does not exceed 30-35 mm.
In children, the CWR of the right lobe of the liver at 5 years old is 40 + 10 mm, at 12 years old - 80 ± 10 mm, at 15 years old - 97 + 10 mm.
However, it should be noted that the obtained digital results of liver measurements are not in all cases an objective indicator that makes it possible to distinguish pathology from the norm, since they depend, among other things, on constitutional features.
Fig. 11.1. Ultrasound. The left lobe of the liver.
1 - front surface; 2 - upper surface; 3 - bottom surface; 4 - cranio-causal size; 5 - anteroposterior size.
Fig. 11.2. Portal vein ultrasound image.
I - the lumen of the portal vein; 2 - the wall of the portal vein.
During ultrasound examination, the liver is quite homogeneous, especially in children, conducts sound well, contains tubular structures of small and medium caliber, which is due to the presence of veins, arteries, bile ducts. Well, especially in children, the venous system of the liver is traced. The connective tissue elements that make up the liver parenchyma complement the echographic picture.
Portal vein(Fig. 11.2), formed by the fusion of the superior mesenteric and splenic veins, in the gate of the liver is divided into right and left lobar branches. The segmental branches of the portal vein are located in the central parts of the liver segments and are further divided into subsegmental branches, the distinctive features of which on the scans are horizontal location and echo-positive walls. The inner diameter of the portal vein gradually decreases distally. Normally, its diameter is 10-14 mm.
Hepatic veins(Fig. 11.3) are usually represented by three large main trunks (right, middle and left) and smaller branches. In some cases, you can observe the "loose" type, in which instead of three large trunks, several smaller veins are located. The right hepatic vein is located in the right lobe of the liver, the middle one runs in the main interlobar sulcus, and the left one is in the left lobe of the liver. Behind the caudate lobe, they flow into the inferior vena cava. Distinctive features of hepatic veins are their radial from the periphery to the center (in the form of a fan) and the absence of their walls during ultrasound examination (the exception is cases in which the ultrasound beam is directed to the vein wall at an angle close to
Fig. 11.3. Ultrasound imaging of the hepatic veins.
1 - right hepatic vein; 2 - left hepatic vein; 3 - segmental branching of the right hepatic vein.
to 90 °). The diameter of the unchanged hepatic veins is in the range of 6-10 mm. Small (up to 1 mm in diameter) their branches can be traced to the periphery of the organ.
Inferior vena cava (IVC)located in the groove between the right, left and caudate lobes of the liver, defined as an anechoic ribbon-like formation with clearly visible walls up to 20-5 mm in diameter. A change in its lumen is noted, following synchronously with deep breathing.
Hepatic arterydefined in the area of \u200b\u200bthe gate of the liver in the form of a tubular structure with a diameter of about 4-6 mm, has hyperechoic walls, located along the portal vein. Its branches can be identified in the bifurcation area, as well as at the level of the lobes. At the next stage of division, the branches of the hepatic artery are usually not located.
Intrahepatic bile ductsin the normal state, they can only be detected at the level of the lobar, they have hyperechoic walls and an inner diameter of about 1 mm.
Structurethe parenchyma of the unchanged liver appears to be fine-grained, includes many small linear and point structures, located evenly throughout the organ. Echogenicitynormal liver is comparable to that of the cortex of a healthy kidney or slightly exceeds it. An exception may be the caudate lobe of the liver, the echogenicity of which is sometimes somewhat lower than the echogenicity of the left lobe of the liver.
Sound conductivitythe unchanged liver is good, which makes it possible to visualize its deep sections and the diaphragm.
- the largest parenchymal organ of the abdominal cavity. As a rule, it is located in the epigastrium, occupying the right hypochondrium and going into the left hypochondrium with the left lobe. It can be located on its own to the left or with retroversion of the abdominal organs; in our practice, it was found in 5 patients.
There are two liver surfaces:top and bottom.
Upper - convex, corresponding in shape to the dome of the diaphragm.
Lower- visceral, has an uneven, slightly concave surface and corresponds to the configuration of the abdominal organs adjacent to it. On the lower visceral surface, there are two depressions and transverse grooves that divide this surface into four lobes: right, left, square and caudal. Visceral surface of the right lobe bears the colon-intestinal, renal, duodenal and adrenal impressions. The lower surface of the left lobe carries a bulge of the omental tubercle, esophageal and ventricular impressions. Square fraction located between the fossa of the gallbladder on the right and the fissure of the round ligament on the left, bounded in front by the lower edge, and behind by the gate of the liver. Tail lobe the liver is located behind the gate of the liver, bounded in front by the transverse groove of the gate of the liver, on the right by the groove of the right vein, on the left by the slit of the venous ligament, and behind by the posterior surface of the liver. The liver is covered with peritoneum on all sides.
The following segments are distinguished in the liver.
Segment I - caudate lobe on the visceral surface of the liver.
The remaining seven segments go one after another along the contour of the liver in the opposite direction to the clockwise direction.
The left lobe contains II - III, the square contains segment IV, the right lobe contains segments V, VI and VII.
Segment VIII is located on the diaphragmatic surface of the right lobe (in the dorsal region).
In the liver, the anterior (lower) edge is also distinguished - sharp and posterior rounded.
The anterior segment of the right lobe is projected onto the anterior and upper part of the diaphragmatic surface of the liver. The posterior segment occupies the posterior part of the diaphragmatic surface and the entire visceral surface of the right lobe.
The medial and lateral segments are separated by a left longitudinal depression. The quadrate and caudal lobes make up the medial segment, and the left lobe coincides with the lateral segment. In the middle of the square lobe, there is a duodenal intestinal depression. According to Quino, eight of the most permanent segments are distinguished in the liver, which are grouped in radii around the gate of the liver and are divided along the portal system. The system of division of the liver into segments according to the portal system is anatomically more justified and therefore is more often used in surgical practice.
Echographic division of the liver into lobes and segments is of great practical and clinical importance for clarifying the location of a volumetric formation during puncture aspiration biopsy for the purpose of diagnosis, treatment, or for surgical intervention. However, it should be noted that echographically it is not always possible to accurately differentiate in which segment the pathology is located.
The liver parenchyma consists of cells of the glandular epithelium, which form the hepatic tracts and plates, of which the liver lobules, which produce bile, are composed. Gathering in the interlobular ducts, they connect to each other, forming segmental and lobar (right and left) ducts, and then pass into the general hepatic duct, which emerges from the gate of the liver. The intrahepatic bile ducts are accompanied by the blood vessels of the portal vein branching, hepatic veins, and the hepatic artery itself.
The weight of the liver in a newborn is 135 g (4.5-5.5% of body weight), by two years it doubles, by three - three times. Sometimes the left lobe may extend into the left hypochondrium and cover the spleen. By the age of seven, the borders of the liver correspond to those of an adult, and by the period of puberty, the weight of the liver reaches an average of 1350 g and is 3% of the body weight. An adult's liver weight is 1500 g.
Ultrasound examination of the liver - technique
Echographic examination of the liver is carried out in the morning on an empty stomach, but it is possible at any time of the day without special preparation of the patient. It should be remembered that the elimination of gas-forming products from food significantly improves the echolocation of the liver. Certain difficulties during the study are encountered if the patient is obese, with a particularly dense structure of the subcutaneous fat layer and flatulence. In these cases, it is advisable to repeat the study after appropriate training. To obtain the most optimal information, the study is carried out in various scans and in the position of the patient on his back - first against the background of calm breathing, and then at the height of inspiration. These two positions are mandatory when examining the liver.
In cases where it is not possible to differentiate the upper edge of the liver, the patient should be examined in a semi-recumbent position and standing. With severe flatulence, a high location of the liver and with its small size, the patient is examined in the position on the left side with the right hand thrown back behind the head along the intercostal spaces using a sector sensor with a frequency of 2.5-3.5 MHz. For ultrasound research, it is best to use real-time instruments equipped with a set of linear, convex and sector probes from 2.5 to 5 MHz. When examining thin patients and children, the best results are obtained using a frequency of 5 MHz. Various approaches have been proposed in the literature for scanning the liver. The most optimal is the one that in a particular case allows you to get the most information, that is, to combine various scanning methods.
First step
The study should begin with a transverse scan of the upper floor of the abdominal cavity, from the xiphoid process, slowly moving the probe to the navel and to the right. This allows you to get general information about the anatomy, location of the liver, its relationship with other organs, about the state of the contours and structure of the parenchyma.
Second phase
The most important is an oblique scan along the edge of the costal arch, starting from the level of the midaxillary line and gradually moving towards the midline. In this case, it is possible to study in detail the surfaces, edges and structure of the parenchyma of the right and left lobes of the liver, make measurements, examine the venous, arterial networks and bile ducts.
As a rule, the echographist manages to locate well the right and left lobes, separated by a crescent ligament, in the form of a narrow echo-positive strip. It is almost rarely possible to differentiate the square and tail lobes.
Shape and contours
The shape and contours of the liver are of diagnostic value. The shape of the liver is determined by the ratio of its anatomical irregularities, that is, bulges and lobes. There is no ideal anatomical shape of the liver.
Normally, the echographic contours of the liver are even, clear. Sometimes the upper contour is poorly differentiated, where the echo reflection of the lung and diaphragm is layered. This contour corresponds to the contour of the diaphragm. In order to avoid possible diagnostic errors, the echographist should remember that on the anterior surface of the liver, at its exit from under the ribs, sometimes a bulge can be differentiated in the transverse scan. On the posterior surface of the liver, near the inferior vena cava, in longitudinal and transverse sections, a bulging of the tail lobe is located, which has an indefinite shape and slightly reduced echogenicity in comparison with other parts of the liver. In front of the abdominal aorta, the bulge of the square lobe of the liver is located. In the area of \u200b\u200bthe gate of the liver, in front of the upper pole of the right kidney and the inferior vena cava, sometimes it is possible to locate the retraction of the liver contours. Other irregularities and indistinct contours in the form of single bulges, which, as a rule, are accompanied by a change in echogenicity, indicate the presence of a pathological process (tumor, cyst, abscess, hematoma, etc.).
Unfortunately, modern ultrasound equipment almost does not allow nosological differentiation of these formations.
A certain diagnostic value is the angle formed at the place of transition of the posterior surface of the liver to the anterior one, which normally does not exceed 750 for the right lobe, for the left - 450 Angles are measured in a transverse scan at the level of the right and left lobes. An increase in the angle is characteristic of hepatomegaly, in which the lower edge of the liver is rounded.
Dimensions
The determination of the size of the liver in the clinic is of great importance. Echography allows dynamic observation of their evolution. Unfortunately, in echographic practice, there is no consensus regarding the normal size of the liver. There are various approaches to determining the size of the liver. Some authors (Hagen-Ansert, 1976; Weill, 1978) suggest measuring the true size of the liver; according to their data, transverse dimension is 20-22.5 cm, the vertical dimension of the right lobe is 15-17.5 cm, the anteroposterior dimension, measured at the level of the upper pole of the right kidney, is 10-12.5 cm.
It should be borne in mind that this measurement can only be made in patients with a normal location of the right kidney, with a lowered kidney it loses its value. As a result of examining more than 1,500 practically healthy people, we obtained the following liver values: along the mid-clavicular line 10.5 ± 1.7 cm, the midline 8.2 ± 1.5 and in the transverse 19.0-21.5 cm.As it turned out, these values \u200b\u200bvary significantly and cannot be considered normative. For practical purposes, the most informative indicator should be considered the determination of the thickness of the right lobe along the midclavicular line; if the liver is displaced, then according to the most distant outer (upper and lower) points, according to our data, it is 11 ± 1.8 cm, the thickness of the left lobe with the same measurement method is 5 ± 1.5 cm. According to the literature, ultrasound liver sizes coincide with autopsy data in 80% of cases, and radioisotope scanning - in 93.4-95.6% of cases.
The echographist should remember that the normal size of the liver does not exclude the presence of pathology, especially at the level of changes in function. It should also be remembered that the size of the liver largely depends on the constitutional characteristics of the patient. So, in persons of asthenic constitution, the liver is flat, but elongated, and the size along the midclavicular line (14 cm) is within normal limits. In picnics, the liver is thick but short, 12 cm in size indicates an increase. When determining the size of the liver, the sensor should be strictly perpendicular to the surface of the lobe, since a change in the angle of inclination of the scan leads to errors.
Some authors propose various programs and methods for manipulating the sensor for liver studies, using the division of the abdomen into sectors using the generally accepted lines: anteroaxillary, midclavicular right and left, sterno-sternal, at the level of the xiphoid process, umbilical, pubic. However, their application in practice is limited, since each ultrasound specialist, in addition to knowledge of generally accepted methods, must develop an individual handwriting of liver scanning in order to obtain the most optimal information with the least amount of time.
Echography allows you to determine the area and volume of the liver.
For practical purposes, the determination of the area can be carried out along the outer contours of the entire liver or each lobe separately.
The volume of the liver is determined by the formula V \u003d d * n, where V is the volume (cm3),
d is the thickness of one slice, n is the number of slices, is the area of \u200b\u200bone slice. These calculations are very laborious and in practice are mainly used in liver transplantation. Almost complete coincidence of the volume of the liver, determined by echographic analysis, and in corpses has been proved.
A volume over 900 cm3 indicates an increase.
Echo structure
Echostructure is important in resolving the issue of norm and pathology.
There are various explanations for the formation of the echostructure of the liver. Some authors believe that reflections of ultrasound waves from the surface of small blood vessels, bile ducts and ligaments play a primary role in the development of echo structure. Perhaps this explains the lower echogenicity of the tail lobe of the liver, which anatomically contains fewer blood vessels and bile ducts. Others believe that the echo structure of the liver is formed due to the reflection of ultrasound waves from the border between the hepatic lobules, which are 1–2 mm in diameter, and terminal blood vessels, especially if we take into account the data (Roca-Martinez F., Linhart P., 1982) that the connective normal tissue almost does not reflect ultrasound, and therefore does not affect the formation of the echostructure of the liver.
When assessing the echo structure of the liver, one should take into account the size of the echo signals, their intensity, frequency, distribution over the liver surface and sound conductivity. Echo signals can be small, medium and large, homogeneous (of approximately the same magnitude), inhomogeneous (of different magnitude), in frequency - low, medium and high. Normally, the liver parenchyma has an almost homogeneous, granular structure with a fairly even distribution of small and medium signals of equal intensity, reflected from the network of vessels, bile ducts and ligaments. The liver parenchyma has good sound transmission. All of the above parameters that characterize the normal echo structure of the liver largely depend on the adjustment of the ultrasound device, namely: on the adjustment of the contrast and brightness of the image and on the frequency of the sensor used.
With a decrease in contrast and brightness, echogenicity decreases and the parenchyma becomes blurred, that is, it loses the specificity of the structure. With increased contrast and brightness, the density and echogenicity of the structure are artificially increased. When examining the liver parenchyma with different sensors (linear, convex and sectorial, even of the same frequency, for example 3.5 MHz), one can notice a slight deviation in the magnitude of the signals and the density of the echo structure, which an inexperienced specialist can attribute to pathology. When scanning at different angles of inclination of the sensor against the background of the image of the parenchyma, zones of low echogenicity may appear, which can also be perceived as pathology.
It should be noted that there is a lot of subjectivity in assessing the normal echostructure of the liver parenchyma. The correct interpretation of the normal echostructure of the liver parenchyma can only be given by a specialist with extensive clinical and echographic experience. It should also be noted that even the classically normal structure of the liver parenchyma does not exclude the presence of pathology at the cell level.
Blood vessels and intrahepatic bile ducts
Constantly to the right of the white line of the abdomen, the inferior vena cava is located in the form of a ribbon-like echo-negative formation with a diameter of up to 15 mm with weakly echogenic walls and a change in the lumen synchronously with the act of breathing. The expansion of the lumen of the inferior vena cava is mainly a consequence of the failure of the right sections. Narrowing of the lumen is observed when the volumetric formations of the liver, gallbladder, pancreatic head, enlarged lymph nodes, tumor of the right kidney are compressed, as well as with diffuse parenchymal conditions. Intrahepatic veins are normally visible only when they flow into the inferior vena cava.
Portal vein
After its formation from the superior mesenteric and splenic veins it flows into the gate of the liver, where it is divided into right and left branches and is located in the transverse and sagittal position of the sensor.
In contrast to the inferior vena cava and intrahepatic veins, the portal vein and its branches have echogenic walls, which makes it possible to trace them to the periphery of the liver and differentiate them from intrahepatic veins.
The diameter of the portal vein is on average 8-12 mm. She does not respond to cardiac cycles and breathing acts. With portal hypertension of any origin, it expands and its diameter exceeds 12-14 mm.
Hepatic arteries (hepatic common and hepatic own) can sometimes be visualized as narrow (1-1.5 mm) pulsating structures in the immediate vicinity of the hepatic hilum, running parallel to the portal system, they are easier to differentiate in the presence of Doppler. The vasculature of the liver is visualized mainly in thin patients. Parallel and ventral to the branches of the portal vein are intrahepatic bile ducts, which are devoid of walls and are not normally visible.
Echographic pathology
The main echographic criteria for liver damage are its increase or decrease, a change in the contours of surfaces, a change in echo structure, a decrease in sound conductivity, a change in the hepatic vessels and intrahepatic bile ducts, etc.
Developmental defects
Location anomaly - the liver is very rarely located in the left hypochondrium with the usual arrangement of the rest of the abdominal organs and with retroversion of all organs.
Resizing
Hypoplasia - one of the lobes or the liver as a whole is reduced, is common.
Isolated hepatomegaly in the absence of other pathological conditions. The final conclusion can be objective only when this anomaly is detected in early childhood. The presence of hypoplasia in adults can be asserted only when the weight (volume) and area of \u200b\u200bthe liver do not exceed 1% of the body weight at a rate of 2-3%. They are rare.
Hundreds of suppliers carry hepatitis C medicines from India to Russia, but only M-PHARMA will help you buy sofosbuvir and daclatasvir and professional consultants will answer any questions you may have throughout the therapy.
Video. Lecture by Vladimir Izranov "The size of the liver on ultrasound"
The size of the right lobe of the liver on ultrasound
The size of the right lobe of the liver on ultrasound is measured along the mid-clavicular line
(A) - length (vertical or cranio-caudal size) of the right lobe of the liver in hypersthenics up to 120 mm, and in asthenics up to 140 mm;
(B) - thickness (anteroposterior size) of the right lobe - the norm is up to 110-125 mm;
(A) + (B) \u003d 240-260 mm;
(C) - oblique vertical dimension (KVR) - from the edge of the liver to the most distant cranial point of the diaphragm - the norm is up to 150 mm, with hepatomegaly, KVR is more than 160 mm;
the angle of the lower edge of the right lobe of the liver should be less than 75 °.
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| Photo. A - Plane through the right lobe of the liver on the mid-clavicular line. B - (A) - length (vertical or cranio-caudal size) of the right lobe of the liver; (B) - thickness (anteroposterior dimension) of the right lobe; (C) - oblique vertical dimension (KVR) - from the edge of the liver to the most distant cranial point of the diaphragm; the angle of the lower edge of the right lobe of the liver should be less than 75 °. B - The length of the liver along the midclavicular line in a child. | ||
The size of the left lobe of the liver on ultrasound
The size of the left lobe of the liver on ultrasound is measured along the midline
(A) - length (vertical or cranio-caudal size) of the left lobe of the liver - the norm is up to 60 mm;
(B) - thickness (anteroposterior size) of the left lobe of the liver - the norm is up to 100 mm;
the angle of the lower edge of the left lobe of the liver should be<30°;
(C) - thickness (anteroposterior dimension) of the caudate lobe of the liver.
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| Photo. A - Plane through the left lobe of the liver along the midline. B - (A) - length (vertical or cranio-caudal size) of the left lobe of the liver; (B) - thickness (anteroposterior dimension) of the left lobe of the liver; the angle of the lower edge of the left lobe of the liver should be<30°; (С) – толщина (передне-задний размер) хвостатой доли печени. В - Левая доля печени по срединной линии. | ||
Liver size on ultrasound in children
For screening, it may be sufficient to measure the length of the right lobe and the width of the left lobe of the liver. Plus, the ratio of the width of the left lobe to the caudate lobe (see above) should not exceed 30%. In children, liver size depends on height and weight.
Table. The size of the liver in children according to M.I. Pykov.
| Growth | Right lobe | Left lobe | Portal vein |
| 49-59 | 48,3-58,9 | 21,9-36,5 | 2,5-3,3 |
| 60-69 | 53-66 | 26,4-40,8 | 2,7-3,7 |
| 70-79 | 62,6-73,8 | 32,7-48,1 | 2,9-4,1 |
| 80-89 | 67,5-78,9 | 40,2-55,6 | 3,3-4,9 |
| 90-99 | 73,9-85,3 | 47,4-63,8 | 4-5,4 |
| 100-109 | 79,6-92,6 | 45,5-65,9 | 4,4-5,6 |
| 110-119 | 75,3-97,5 | 57-73 | 4,9-6,3 |
| 120-129 | 88,4-102,2 | 61,1-79,1 | 5,3-6,5 |
| 130-139 | 87,8-104,8 | 67,2-81,8 | 5,7-7,3 |
| 140-149 | 97,2-112,6 | 61-83,8 | 6,4-7,8 |
| 150-159 | 101,8-125,6 | 66,7-87,1 | 6,3-8,3 |
| 160-169 | 104,3-127,7 | 64,9-93,3 | 7,1-8,1 |
| 170 and above | 107,3-128,7 | 70,1-92,3 | 7,1-9,5 |
The ratio of the caudate lobe to the right lobe of the liver - CD / PD
Important!!! The caudate lobe can increase, especially with cirrhosis of the liver.
The caudate lobe of the liver is a functionally autonomous segment. It is supplied with blood by the right and left portal veins, and there is also a direct venous drainage from the portal veins of the caudate lobe into the inferior vena cava. This protects the caudate. In liver diseases, it is affected less than other areas. The ratio of the caudate to the right lobe of the liver (CD / PD) is a specific marker for liver cirrhosis.
HD / PD less than 0.6 - the norm (does not exclude the presence of cirrhosis);
HD / PD 0.6-0.65 - boundary values;
HD / PD more 0.65 - the likelihood of cirrhosis 96% ;
HD / PD more 0.73 - the likelihood of cirrhosis 99% .
Sizes of liver vessels on ultrasound
Inferior vena cava (IVC) - the norm is up to 20-25 mm, clear walls and close to oval shape;
The diameter of the hepatic veins is measured at a distance of 2 cm from the IVC - the norm is up to 6-10 mm;
The diameter of the trunk of the portal vein ("Mickey Mouse head") - the norm is up to 13-14 mm;
Splenic and superior mesenteric veins - the norm is up to 10 mm.
The size of the gallbladder on ultrasound
The length of the gallbladder is 60-80 mm;
The transverse diameter of the gallbladder is 30-40 mm;
Against the background of bends, the total length is measured approximately;
Gallbladder volume \u003d (length + width + height) x 0.523
The size of the gallbladder in children
Table.The size of the gallbladder (McGahan J. P., Phillips H.E., Cox K.L.)
| Age (years) | Length, middle and range (mm) | Width, middle and range (mm) |
| 2-5 | 42 (29-52) | 17 (14-23) |
| 6-8 | 55 (34-65) | 18 (10-24) |
| 9-11 | 56 (44-74) | 19 (12-32) |
| 12-16 | 61 (38-80) | 20 (13-28) |
Take care of yourself, Your Diagnostician!
See also:
Ultrasound of the liver for beginners (lecture at the Diagnostic)
Liver segments on ultrasound (lecture at the Diagnostic)
Doppler of liver vessels (lecture on the Diagnostician)
Liver pathology on ultrasound (lecture at the Diagnostic)
Tags: lectures liver ultrasound
Video. Lecture on ultrasound of the liver by Oksana Baltarovich
Video. Lecture on ultrasound of the liver by Vladimir Izranov
How to set up an ultrasound machine for examining the liver
Adjust the gain - a “soft” linear TGC adjustment (top to bottom and left to right) is appropriate for the liver. It is important to get a clear image of the vessel walls. If the ultrasound penetrates to a sufficient depth, then the diaphragm is visible - this is a bright curved line. The edges of the liver and 2-3 cm outside of it should be visible.
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| Photo. A - The image is clear, the walls of the portal veins are clearly visible (arrow), the signal passes through the diaphragm (a bright curved line below), the edge of the liver is visible. B - On the left, there is good clarity of the image - the walls of the vessels, the diaphragm, the edge of the liver are visible, and on the right the image is blurry. Align the picture by changing the pressure of the sensor on the abdominal wall. B - Hepatocellular carcinoma 5x5 cm grows from the lower edge of the liver (arrow). If the image is limited to the edge of the liver, the formation will remain unrecognized. | ||
Important!!! With an ultrasound of the liver, we are interested in size, shape, echogenicity and echo structure.
Echogenicity of the liver
Echogenicity is the ability of tissue to reflect ultrasound or create an echo. All abdominal organs have different echogenicity. It is very convenient to compare them with each other along the gradient - the more echogenic the structure, the lighter it is. Echogenicity is compared on a single slice.
The scale of echogenicity of the abdominal organs:
Liver ≥ renal cortex\u003e renal medulla → → liver lighter than kidney; Liver< селезенки → → печень темнее селезенки; Liver ≤ pancreas → → liver darker than pancreas; Pancreas< почечные синусы и жир.
Important!!!Isoechogenicity of the renal cortex and liver parenchyma is the norm, especially in young people.
Important!!!The renal medulla is the least echogenic (dark), while the renal sinuses and fat are the most echogenic (light).
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| Photo. A - The medulla of the kidney (3) is less echogenic than the cortex (2). The renal cortex (2) is less echogenic than the liver (1). Hyperechoic renal sinuses (4) and fat (5). B - The spleen is divided into dark and light areas. In the upper part there are small vessels (arrow), which are not visible in the lower part. Now it is clear, from above the left lobe of the liver. It is less echogenic than the spleen. The liver can be mistaken for a subcapsular hematoma. B - The liver (LLL) is slightly less echogenic or isoechoic to the pancreas (P). | ||
Echostructure of the liver
Echo structure - these are the elements that we can distinguish on the echogram. There are five tubular systems in the liver: bile ducts, portal veins, hepatic arteries, hepatic veins, and lymphatic vessels.
The vascular pattern of the liver is represented by two types of vessels: the portal and hepatic veins. The hepatic artery and bile duct can be seen at the hepatic hilum. In the parenchyma, ONLY pathologically dilated hepatic arteries and bile ducts are visible.
Portal veins on ultrasound
At the gate of the liver, the main portal vein is divided into right and left branches. They are oriented horizontally. Portal veins are part of the hepatic triad - bile duct, portal vein, hepatic artery. The hepatic triad is surrounded by a glisson capsule, nerves, lymphatic vessels and connective tissue, therefore, the portal veins have bright hyperechoic walls. Portal blood flow is directed TO liver - hepatopetal (with CDC - red, with ID - above the isoline).
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| Photo. The branches of the portal vein on ultrasound: A - the right (RPV) and left portal veins depart from the trunk of the portal vein (PT). The left portal vein turns sharply forward - the only site in the portal system with a sharp forward turn is the umbilical segment of the portal vein (US). B - Bright hyperechoic wall of the portal vein (yellow arrow). B - Hepatopetal blood flow in the portal vein. | ||
Hepatic veins on ultrasound
The hepatic veins are oriented almost vertically and converge towards the inferior vena cava, like the spokes of an umbrella. Hepatic veins run lonely, so their walls are not bright on ultrasound. The hepatic veins divide the liver into segments as they are located between segments. The blood flow in the hepatic veins is directed FROM liver - hepatofugal (with CDC - blue).
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| Photo. Hepatic veins on ultrasound: A - On a cross section through the upper part of the liver, we will see longitudinally oriented liver veins (RHV, MHV, LHV). B - If you make a cut below, you can see a cross section of the hepatic veins - ovals without a bright wall (arrows). B - Hepatofugal blood flow in the hepatic vein. | ||
Exception to the rule
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| Photo. A, B - Why is the portal vein wall not hyperechoic (arrow)? If the wall of the portal vein is parallel to the ultrasound beam, we lose resolution. Q - Why does the hepatic vein have a bright hyperechoic wall (arrow)? The thick wall of the large hepatic veins is capable of reflecting ultrasound if it is perpendicular to the ultrasound - this is the best angle for scanning. | ||
Types of liver echostructure
Types of liver echostructure: centrilobular, normal, fibrous-fatty.
| Centrilobular liver edematous, therefore, the echogenicity of the parenchyma is reduced. It seems that there are a lot of small portal veins, and their walls shine brightly - a symptom of the "starry sky". In fact, their number has not increased, just the image is more contrasting. The diaphragm is clearly visible - a very bright line. | Fibrous-fatty degeneration -normal liver tissue is replaced by fatty and fibrous tissue. The liver becomes hyperechoic. The contrast between the parenchyma and the walls of the small portal veins disappears - they are hard to see or not at all. The liver is dense, so the diaphragm is poorly visible. |
| acute viral hepatitis acute right ventricular failure toxic shock syndrome leukemia / lymphoma in 2% of healthy people (more often thin young people and adolescents) | obesity diabetes mellitus chronic hepatitis cirrhosis acute alcoholic hepatitis |
Anatomical landmarks with ultrasound of the liver
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| Photo. A - In the upper part of the liver, the large hepatic veins (RHV, MHV, LHV) flow into the inferior vena cava (IVC). B - In the central part of the liver, the right and left portal veins (PV) are horizontally located. VC - inferior vena cava. CL - caudate lobe. B - In the lower part of the liver, the round ligament of the liver (large arrow) serves as a reference point, which divides the liver into the left (2) and right lobes (3) familiar to us, or the lateral and medial sector of the left lobe according to Quino (for more details, see Liver segments on ultrasound). Two arrows - the venous ligament of the liver, 1 - caudate lobe. | ||
Round and venous ligaments of the liver
Blood from the placenta enters the umbilical vein (v. Umbilcalis). The umbilical vein enters the fetal body through the umbilicus and lies in the left longitudinal groove of the liver. At the gate of the liver, the umbilical vein divides into two branches. One of them flows into the portal vein, and the other passes along the lower surface of the liver to its posterior edge, where it flows into the inferior vena cava - this is the ductus venosus (ductus venosus). Through the ductus vein, most of the blood from the umbilical vein is discharged into the inferior vena cava and is directed to the heart. A filled umbilical vein can be seen in the baby immediately after birth. Then the unnecessary umbilical vein collapses and turns into a thin fibrous cord - a round ligament of the liver (ligamentum teres). The round ligament is located in the anterior part, and the obliterated ductus venous in the form of a ligamentous venous is located in the posterior part of the left longitudinal groove of the liver. Ligaments are surrounded by fat, therefore hyperechoic on ultrasound.
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| Photo. A, B - In the lower parts of the liver, a round ligament of the liver, surrounded by hyperechoic fat (arrow), is visible in the cross section. It divides the liver from the front into the left (2) and right lobes (3) familiar to us, or the lateral and medial sector of the left lobe according to Quino (for more details, see Liver segments on ultrasound). B - The sagittal section shows that the obliterated umbilical vein (arrow) enters the umbilical segment of the left portal vein. | ||
Important!!! In the cross section behind the round ligament, the shadow is NOT a calcification. The ultrasonic beam falls strictly perpendicularly - at an angle of 90 °, if you slightly change the scanning angle, the shadow disappears. In a true calcification, the shadow does not depend on the scanning angle.
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| Photo. A, B - On a transverse section, the venous ligament (lig.venosum) is a hyperechoic line (arrow) that extends from the umbilical segment of the portal vein and above it connects to the inferior vena cava (IVC). The venous groove separates the caudate lobe from the left lobe of the liver (LS), and the inferior vena cava (IVC) from the right lobe of the liver. B - On a sagittal section in the venous sulcus lies the venous ligament surrounded by hyperechoic fat (GHL). The venous sulcus starts from the hepatic hilum, where two vessels are clearly visible - the common hepatic artery (CHA) and the portal vein trunk (MPV). Above the venous ligament (GHL) is the lateral sector of the left lobe (LS) according to Quino (for more details see Liver segments on ultrasound), and below - the caudate lobe (CL) of the liver. | ||
In portal hypertension, the umbilical vein is recanalized, but the ductus venosus is not. It is extremely rare to see it in newborns who have an umbilical catheter installed.
The caudate lobe of the liver
The caudate lobe of the liver is supplied from the right and left portal veins. The portal veins of the caudate lobe are directly connected to the inferior vena cava. This protects the caudate. In liver diseases, it is affected less than other areas.
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| Photo. A - The branch of the portal vein penetrates into the caudate lobe (arrow). B - The vessel (arrow) directly connects the portal vein of the caudate lobe with the inferior vena cava (IVC). B - The caudate lobe sometimes looks like a mass in the liver. The ultrasonic beam passes through the portal structures and is attenuated. There is a partial loss of the signal and we see a hypoechoic formation. If you move the transducer out of the area of \u200b\u200bthe hepatic hilum and look at a different angle, the pseudo-formation will disappear. | ||
Take care of yourself, Your Diagnostician!
See also:
Liver size on ultrasound (based on a lecture by Vladimir Izranov)
Liver segments on ultrasound (based on lectures by Oksana Baltarovich and Vladimir Izranov)
Doppler of liver vessels (based on the lecture by Oksana Baltarovich)
Liver pathology on ultrasound (based on the lecture by Oksana Baltarovich)
Tags: lecture liver ultrasound
Ultrasound examination is an extremely effective way of examining liver pathologies. Such a study provides a huge amount of information about the processes taking place in the organ. An ultrasound scan of the liver can help doctors diagnose various diseases such as fibrosis, hepatomegaly, cancer, jaundice, etc. In addition, ultrasound of the liver can indirectly judge about diseases of the pancreas and other organs of the gastrointestinal tract.
The interpretation of the examination results should be carried out by a specialist, however, it makes sense for patients to arm themselves with basic knowledge.
Brief Normal Liver Anatomy
Correct decoding of the research protocol is impossible without knowledge of anatomy. The liver is the largest abdominal organ in humans; its weight in an adult reaches 1.5 kg. It is the most important organ necessary for cleansing the blood of toxic substances, it is involved in the most important biochemical reactions in the synthesis of proteins and fats. The production of bile necessary for digestion also depends on this gland.
Liver structure
The liver is located in the upper abdominal cavity, occupying the right hypochondrium and epigastrium. The liver has a diaphragmatic and lower visceral surface, which connects with other organs of the abdominal cavity. The liver parenchyma is covered with a capsule.
The liver consists of 4 lobes, namely:
right left square tailed.
The first 2 are large, while the square and caudate are small.
Blood enters the liver from the following sources:
23 blood flow is provided by the portal vein, 13 blood flow is provided by the own hepatic artery.
Deciphering of an ultrasound examination is carried out taking into account data on blood flow and hepatic segments.
Normal ultrasound picture
A healthy liver has a straight, distinct outline with a thin capsule. Its structure should be homogeneous, fine-grained, echogenicity equal to or slightly higher than the echogenicity of healthy kidney parenchyma. The vascular pattern must be preserved. The intrahepatic bile ducts should not be dilated.
Normal parameters of the left lobe: anterior - posterior (thickness) 6 - 8 cm, cranio - caudal (height) up to 10 cm.
Normal parameters of the right lobe: anterior - posterior (thickness) 10.0 - 12.0 cm, cranio - caudal (height) 8.5-12.5 cm, oblique vertical size - up to 15 cm.
Normal parameters of the caudate lobe: length 6-7 cm, thickness 1.5-2.0 cm.
The diameter of the portal vein is 8-12 mm.
Hepatic segments
The branching of the portal vein and the hepatic artery, as well as the bile ducts, divide synchronously within the liver, which underlies the segmental division of the liver. The generally accepted scheme of the segmental structure of the liver according to Claude Quino. They rely on it when performing operations on the liver.
In ultrasound, using such landmarks as ligaments, veins and liver impressions, it is possible to clarify the localization of the formation in the liver for planning further treatment tactics.
Liver segments
According to this scheme, segment I corresponds to the caudate lobe. The remaining six segments go one after the other along the contour of the liver counterclockwise, if you look at the liver as if from the bottom up, that is, at its visceral surface. Segment II is located in the posterior lateral part of the left lobe, and segment III is located in the front. The square share is the IV segment. V, VI, VII, VIII segments are located in the right hepatic lobe. The V segment is located on the side of the notch of the gallbladder. The VI segment is located in the lateral and lower posterior part of the liver. Segment VII represents the lateral posterior and upper parts of the liver. The VIII segment is located on the diaphragmatic surface of the right lobe of the liver.
Indications and preparation for ultrasound of the liver
Indications for ultrasound examination of the liver may be as follows:
pain in the right upper abdomen; enlarged liver; jaundice; suspicion of the presence of formations in the liver; suspicion of liver cancer; trauma to the abdomen; suspicion of echinococcosis; monitoring the effectiveness of treatment and dynamics of liver diseases.
Usually, the study of the liver is done together with echography of other abdominal organs. Patients need to know how to prepare for an ultrasound of the liver. The correctness of the diagnosis and, as a consequence, the correctness of the appointment of treatment depends on the preparation for an ultrasound examination of the liver.
Before the study, you must:
Observe the diet and rules. This is due to the fact that in the presence of contents in the stomach and intestines, with severe flatulence, the liver can be partially blocked, and thus it becomes impossible to effectively assess its structure.
Not later than 3 days before the procedure, adhere to a diet: food products that cause gas formation should be excluded from the diet. These are legumes, lactic acid foods, black bread, carbonated drinks, sauerkraut, alcohol. You should also exclude raw vegetables and fruits.
You should eat porridge, lean meat and fish, steamed or stewed, breadcrumbs. Drinks include weak tea and water. At the same time, you need to eat fractionally from 4 to 5 times a day.
If, despite the change in the diet, flatulence persists, you should start using enzyme preparations, preparations based on simethicone, as well as activated charcoal or other sorbents 3 days before the examination. For chronic constipation, laxatives should be used during these three days.
If there is a dysfunction or chronic diseases of the stomach or intestines, it is advisable that the attending physician prescribes treatment for several days before the procedure. Some medications cause the liver to enlarge. If the patient is taking any medications, you need to consult a doctor and, if possible, postpone the time of taking it.
If there are no contraindications on the part of any disease and if the patient's condition allows, it is recommended to make a cleansing enema on the day preceding the scan.
Decoding and research results largely depend on whether the patient ate properly before the procedure. The study should be done on an empty stomach, preferably in the morning. Eating and drinking is prohibited 8-12 hours before. If the ultrasound is performed during the day, you should refrain from eating and drinking five to six hours before the procedure.
For diabetics using insulin, two hours before the examination, you can drink a cup of tea without sugar and eat crackers made from white bread.
Before the procedure, it is unacceptable:
conduct a colonoscopy; smoke; eat sweets; take antispasmodics later than 6 hours before the examination.
Simultaneous examination of the liver and other organs
Ultrasound of the gallbladder and liver
To prepare for the study of the gallbladder, you must follow all the rules for preparing for an ultrasound of the liver. The diet isn't much different either. Before sonography of the gallbladder, you should drink weak tea and water. In addition, X-ray examination of the gastrointestinal tract with barium in the previous 24 hours is inappropriate, since the contrast agent in the duodenum creates difficulties in visualizing the bile duct. Ultrasound of the gallbladder and liver is quite informative.
Ultrasound of the liver and pancreas
Recommendations for preparing for a pancreatic examination are the same as for a liver scan. A necessary and most important condition is the absence of contents in the stomach, therefore, the study must be performed on an empty stomach. If the patient underwent an X-ray examination with barium, then an echographic examination of the pancreas can be performed at least 24 hours later. This condition is caused because the barium trapped on the walls of the stomach and intestines will interfere with visualization of the pancreas.
Ultrasound of the kidneys and liver
Preparing for a kidney exam is no different from preparing for an ultrasound exam of the liver. It is desirable that the bladder is filled, since if kidney pathology is detected on ultrasound, it is necessary to examine the ureters and the bladder. Also, you can not eat foods that cause increased flatulence. An ultrasound examination of the kidneys provides enough information to diagnose many diseases, including the pancreas, for example.
Research methodology and detected pathologies
Ultrasound of the liver is usually performed with the patient in the supine position. A special gel is applied to the upper abdomen, after which the doctor applies an ultrasound sensor to the necessary points of the anterior abdominal wall. The doctor asks the patient to take a deep breath and hold his breath, this is necessary for a better examination of the liver, since usually most of it is hidden behind ribs that interfere with visualization.
Sometimes the doctor can install the sensor in the intercostal space, which makes it possible to better examine the organ. During this, the doctor makes the necessary measurements, examines the structure, structure, blood supply of the liver, and then gives the patient a description with an ultrasound conclusion on paper.
With the help of ultrasound examination, the following pathologies in the liver can be suspected or detected:
However, only with the help of an ultrasound method of examination it is not always possible to accurately establish whether an organ is completely healthy. After all, the doctor studies the structure of the organ, but cannot determine how well the liver is coping with its functions. There are other research methods for this.
In addition, with the help of ultrasound of the liver, it is not always possible to clearly establish the nature of focal changes, whether they are malignant or benign, since many of them can have a different ultrasound picture. The most accurate way to establish this is a diagnostic puncture.
What are the features of liver examination in a child?
Echographic examination of the liver for children is done for the same purposes as for adults.
A child needs to prepare for an examination in the same way as adults, with the exception of babies, whose nutrition does not change.
During the study, it is better for the child to be with one of the parents, since any medical procedure causes him anxiety and fear. We need to explain to him that ultrasound is completely painless.
When conducting an ultrasound of the liver, the doctor carefully examines the structure of the child's liver. Normal liver sizes in children differ from adults and change with age. Therefore, when assessing the results of an ultrasound scan, the doctor compares the data obtained with age standards.
The value of ultrasound for detecting liver cancer, foci
Early recognition of cancer is an important challenge facing the doctor. The liver with cancer often degenerates cirrhotic, its uniformity is lost, there are gross changes. Against this background, detecting cancer can be difficult.
Liver cancer is characterized by the presence of a single or multiple lesions. The abnormal structure and contours of the organ are visualized.
Cancer lesions are displayed in different ways. At the onset of the disease, if the tumor is not more than 5 cm, liver cancer is almost impossible to distinguish from other focal formations in the usual gray-scale B-mode. A small neoplasm has a reduced hypoechoicity, rather rarely is isoechoic with a thin hypoechoic rim. With an increase in size, the echogenicity of the tumor increases, the ultrasound picture becomes heterogeneous, the contours become lumpy.
It is especially difficult to diagnose diffuse liver cancer, presented by echogenic multiple foci with indistinct boundaries. At the same time, Doppler sonography shows a significant increase in blood supply in the common hepatic artery and a violation of the structure of the liver vessels.
A malignant tumor (cancer) grows very quickly, increases by about 2 times in 120 days. Cancer inevitably leads to an increase in the size of the liver itself.
The "gold standard" for cancer diagnostics is a fine-needle biopsy of the detected lesion under the control of an ultrasound image. As an alternative, contrast-enhanced ultrasound can be used.
Thus, the diagnosis of liver cancer must be carried out in conjunction with other studies.
Liver puncture under ultrasound control
Hematomas
Such anomalies occur, as a rule, after injuries, as well as surgical interventions. Liver hematomas can be located under the capsule, they can also be located inside its parenchyma.
After trauma to large vessels, hematomas look like formations of an oblong irregular shape with a liquid content that has medium-sized echogenic inclusions. At an early stage, hematoma is defined as an anechoic object without clear boundaries.
Liver ultrasound revealed subcapsular hematoma of the liver
If the bleeding continues, the hematoma also enlarges on the screen of the apparatus. Over time, such a hematoma develops a wall, the internal contents collapse, and with ultrasound it becomes echogenic, heterogeneous. In the future, in this place, the formation of a seroma is possible - a cyst-like structure or calcification.
If the large vessels of the liver are not damaged, the ultrasound picture of the hematoma has a slightly different look. The parenchyma of the liver in this case is saturated with blood, which in turn leads to the appearance of zones of increased echogenicity. With a favorable course, by the end of the second week, the size of the hematoma tends to decrease, the contours become less clear, uneven, the internal contents become heterogeneous. After a month, the hematoma may disappear. With a subcapsular arrangement, the hematoma looks like an elongated anechoic band.
Ultrasound for fibrosis
Fibrosis of the liver can be primary or is a consequence of previous hepatitis or chronic vascular disease. It is manifested by the proliferation of connective tissue that replaces liver tissue. There are several stages of fibrosis. At the last 4 stage, fibrosis turns into cirrhosis of the liver, leading to cancer.
To diagnose fibrosis, a comprehensive examination of the patient is used. Ultrasound can detect the presence of fibrosis, but does not provide data to establish its stage. Typical ultrasound signs of fibrosis are:
homogeneous, sometimes coarse grain structure of the liver; increased echogenicity of the parenchyma; wavy or bumpy surface; accentuated liver vessels; signs of portal hypertension.
The listed signs make it possible to establish the presence of fibrosis when decoding the readings of the devices. To determine its degree, a special ultrasound technique is used to measure the stiffness of the liver tissue - elastography performed on the Fibroscan apparatus. This system differs from a conventional ultrasound scanner by the presence of a sensor with a vibrator. This sensor transmits vibration waves to the liver tissue and simultaneously registers their behavior (propagation velocity), on the basis of which it indicates the rigidity of the organ tissues.
The undoubted advantages of such a study are:
simplicity of use, non-invasiveness (there is no penetration into the patient's body), painlessness.
However, there are also disadvantages: the study is ineffective in patients suffering from ascites. In addition, a large amount of adipose tissue and narrow intercostal spaces make it difficult to obtain accurate data about the organ. Fibroscan has a fairly high specificity in identifying fibrosis.
Thus, ultrasound is a really effective and painless way to diagnose liver abnormalities, helping in the study of diseases such as liver fibrosis, jaundice, benign and malignant tumors (cancer), etc. The results of this study can hardly be overestimated. Ultrasound of the liver is a faithful assistant to the doctor in the diagnosis of many diseases. In this case, the state of the liver can be indirectly judged about the processes of the pancreas, as well as the gallbladder. Deciphering the results of diagnostics of such a vital gland of the body as the liver should be carried out by experienced specialists.