THE LIVER
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Transcript of THE LIVER
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THE LIVER
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I. Introduction/General Information
A. Largest of viscera
1. ~ 2.5% body weight
2. Completely covered by Glisson’s Capsule
3. Incomplete covering by peritoneum
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General Information, continued …
4. Measurements are ~
a. 21 – 23 cm transverse
b. 15 – 18 cm superior to inferior
c. 10 – 13 cm anterior to posterior
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General Information, continued …
B. Location:
1. right hypochondrium
2. epigastrium
C. Mostly covered by ribs
D. Contains numerous vascular structures
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II. Detailed Anatomy
A. Four lobes
1. Divisions based on blood supply,
bile drainage
2. Anatomical lobes divided by falciform ligament
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Inferior View of the Liver
A
P
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Detailed Anatomy, con’t…
3. Functional Lobesa. right and left lobes
separated by imaginary line
b. from fossa for GB IVC
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Right and Left Functional Lobes of the Liver
Right Lobe
Left Lobe
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Detailed Anatomy, continued …
B. Functional Divisions
1. Right lobe with caudate process
2. Left lobe:
a. Caudate lobe
b. Quadrate lobe
Caudate Process
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Detailed Anatomy, continued …
C. Fissures: 1. Right sagittal (main)2. Left sagittal (accessory)3. Portal4. Right oblique intersegmental5. Lateral intersegmental
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Fissures of the Liver
Main lobar fissure Boundary
between R and L lobes
L.S. on U/S: seen as hyperechoic line from PV to neck of GB
Used to ID GB when it is packed with stones
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Fissures of the Liver
Portal fissure T.S. on U/S Created by portal
veins (triads) R. main PV is //
to anterior body wall
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Segments of the Liver
Hepatic segments I = caudate lobe II & III = superior and
inferior lateral segments, L. lobe
IV = medial segment, L. lobe
V & VI = caudal to transverse plane
VII & VIII = cephalad to transverse plane
I
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Functional divisions, continued …
4. Fossae (Superficial)
a. IVC – posterior
b. Portal Vein – inferior
c. Gallbladder – inferior
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Fossae, Inferior Surface of the Liver
Fossa for IVC
Fossa for Portal Vein
Fossa for Gall Bladder
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Functional Divisions, continued …
5. Impressions (visceral surface): produced by abdominal viscera
a. Gastric (fundus of stomach)b. Renal (right kidney)c. Adrenal (right adrenal gland)d. Duodenal (bulb of duodenum)e. Esophageal (esophagus)f. Right and left colic (flexures of
the colon)
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Visceral Impressions, continued …
•Esophageal
•Renal
•Gastric
•Adrenal
•Duodenal
•Right colic
•Left colic
L
P
R
A
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Detailed Anatomy, continued …
D. Ligaments
1. Falciform (most superficial anteriorly)a. Divides left lobe in two
sections1. anatomical left lobe 2. caudate & quadrate lobes
b. Two layers of peritoneum c. Extends to umbilicus
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Ligaments, continued …
2. Ligamentum teres hepatis
(fetal source??)
3. Ligamentum venosum
(fetal source??)
4. Right/Left Coronary Ligaments
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Hepatic Ligaments
Falciform ligament L. coronary ligament L. triangular ligament
Ligamentum teres hepatis
Ligamentum venosum
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Ligaments, continued …
5. Hepatophrenic & Hepatorenal ligaments:
a. Subdivisions of right coronary
ligament
b. hepatophrenic (superior) & hepatorenal
(inferior)
c. Surround BARE AREA
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Hepatic Ligaments, con’t…
Hepatophrenic ligament
Hepatorenal ligament
Bare Area
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Detailed Anatomy, continued …
E. Lesser Omentum
1. Sleeve-like structure
2. Connects lesser curvature of stomach & bulb of
duodenum to inferior surface of liver
3. AKA: Gastrohepatic or Hepatoduodenal
ligament
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Lesser Omentum, continued …
3. Attachment surrounds Porta Hepatis
4. Continues on each side of ligamentum venosum
5. Extends to caudate & left lobes on posterior surface of liver
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Lesser Omentum
Lesser Omentum: (R) Anterior view, (L) Inferior view
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Detailed Anatomy, con’t…
E. Subphrenic Spaces
1. clinically important
2. common sites for abscesses
3. Between liver and diaphragm
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Subphrenic Spaces, con’t…
4. Right superior posterior subphrenic space
a. Boundaries:- superior: right coronary ligament- anterior: liver- posterior: parietal peritoneum
covering diaphragm
b. Extends inferiorly to….
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Subphrenic Spaces, continued …
5. Right posterior inferior subphrenic spacea. Boundaries - above: inferior surface of liver - below: transverse colon &
mesocolonb. Extends over right adrenal &
kidney
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Subphrenic Spaces, continued …
c. AKA: Hepatorenal Pouch/Recess, Morrison’s Pouch
d. Patient lying supine:1. Lowest part of peritoneal
cavity is behind liver2. Fluid, pus, etc. collects here3. Can cause abscess
formation
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Subphrenic spaces, continued …
6. Right superior anterior subphrenic space
a. Boundaries:- right side of falciform ligament- upper layer of right coronary ligament- underside of diaphragm- superior surface of liver
b. Found when patient lying prone
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Subphrenic spaces, continued …
7. Most sources of peritoneal contamination are on the right
8. Right posterior & right inferior spaces are most significant sites
9. Infection may spread via diaphragmatic lymphatics
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Detailed Anatomy, continued …
F. Porta Hepatis: contains the following structures
1. Hepatic arteriesa. Usually two, sometimes oneb. Originate from common/proper
hepatic artery c. Course is variable
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Porta Hepatis, continued …
2. Portal vein (supplies 1100 ml/blood per minute)
a. Largest structure in porta
b. Formed by confluence of mesenteric veins &
splenic vein
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Porta Hepatis
Hepatic Artery
Portal Vein
Common Bile Duct
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Porta Hepatis, continued …
3. Hepatic & cystic ducts
4. Nerves:
a. Vagus X (parasympathetic)
b. Fibers from celiac ganglion
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Porta Hepatis, continued …
4. Lymph nodes:
a. most hepatic lymph vessels end in nodes around porta hepatis
b. From here, drain into celiac nodes
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Porta Hepatis, continued …
c. Some vessels pass through falciform ligament
1. through diaphragm
2. into mediastinal nodes
d. enlarged nodes may compress portal vein or hepatic duct
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Detailed Anatomy, continued …
G. Vascular Structures in Liver
1. Largest vessels are portal vein and IVC
a. Portal Vein:
1. appears on T.S. as tubular, echolucent structure
2. courses horizontally from porta hepatis
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Detailed Anatomy, continued …
3. walls echogenic due to structures in portal triad
b. Left Portal Vein:
1. has more variable course
2. May be difficult to trace on transverse scans
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Hepatic Vessels
IVC
Right Portal Vein
Left Portal Vein
Main Portal Vein
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Vascular Structures, continued …
c. Right Portal Vein:
1. anatomical landmark
2. extends into right lobe
3. branches after porta hepatis
4. L.S. shows “dumbbell” or circular structure with
echogenic “collar”
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Computer-enhanced image of RPV, L.S.
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Computer-enhanced 3-D image of RPV, L.S.
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Vascular Structures, continued …
d. IVC:
1. To right of aorta
2. Appears to pass through liver
3. Diameter enlarges after renal veins join (~L-1)
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Computer-enhanced 3-D image of Hepatic Vessels
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Vascular structures, continued …
2. Hepatic Veins: a. Tubular structures b. Enlarge cephalad c. In superior half of liverd. Angles of hepatic vein
branches oriented toward IVCe. Walls not echogenic
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Hepatic Veins
R. Hepatic Vein
Middle Hepatic Vein
L. Hepatic Vein
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Detailed Anatomy, continued …
A. Bile Ducts
1. No “normal” anatomy 2. If dilated:
a. Echogenic collar b. Lobulated shapec. Highly branched over short
distancesd. Converge toward porta hepatis
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Anatomy of the Biliary System (yeah, right…)
A
P
LR
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III. Hepatic Masses
A. May be cystic, solid, or complex
B. Simple Cysts 1. solitary or multiple 2. sonolucent3. well-defined margins4. exhibit posterior acoustic
enhancement5. Congenital cysts may contain cellular debris
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Simple Cysts, Hepatic Masses, continued …
6. Polycysts: usually accompany cysts of kidney, spleen, and/or pancreas
7. Appearance:
a. Wall is distinct, sharp border, crisp edges
b. Shape: spherical
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Hepatic Masses, continued …
C. Complex Masses
1. With central necrosis: irregular walls a. Associated with metastases from
rapidly-growing neoplasmsb. Blood supply can’t supply tumor
growthc. Central part of mass becomes
necrotic
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Complex Masses,Hepatic Masses, continued …
2. With cellular or inflammatory debris: a. walls are irregular
b. Associated with hepatic abscessc. Internal bacterial infection
3. Due to echinococcal disease:a. Show irregular wall thicknessb. Parasitic bacteria in sheep feces
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Complex Masses, continued …
4.Hematoma: ill-defined borders, sonolucent-to-complex masses
a. Early: appears sonolucent
b. After clot forms, echogenic
c. Due to liver trauma
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Hepatic Masses, continued …
D. Solid Masses often represent carcinomas
1. Hepatoma: primary liver cancera. Central necrosis may be
presentb. Tumor thrombus may be
detected impinging on major veins
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Solid Masses, Hepatic Masses, continued …
2. Metastatic Liver Diseasea. “Bull’s Eye” or “Target” pattern
[adenocarcinoma of GI Tract]
b. Adenocarcinomas from other sources more echogenic
c. Sonolucent metastases from lymphomas, sarcomas
more complex
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IV. Parenchymal Disorders
A. Sonographic appearance: non-specific1. Stroma = supportive connective
tissue2. Parenychma = functional tissue3. Most liver tissue is parenchyma
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Parenchymal disorders, continued …
B. Cirrhosis: Most common
1. Due to hepatitis or alcoholism
2. Sonographic appearance:
a. Moderately echogenic
b. Liver denser than normal
c. Due to formation of scar tissue
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Cirrhosis, Sonographic appearance, continued …
c. Peripheral intrahepatic vessels indistinct
1. reduced blood supply
2. peripheral vessels obscured by scar tissue
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Cirrhosis, Sonographic appearance, continued …
d. Lobes may show reduced size:
1. right lobe is more affected
2. left lobe enlargement a. compensation
b. decreased function of right lobe
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Cirrhosis, Sonographic appearance, continued …
e. As scar tissue develops, blood flow is affected
1. Blood backs up
2. Spleen and splenic vein enlarge
e. Portal Hypertension
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Cirrhosis, Sonographic appearance, continued …
f. Liver margin:
1. indentations
2. changes in contour
3. blunted edges
4. may be observed on U/S
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Cirrhosis, Sonographic appearance, continued …
g. Increased incidence of hepatoma in advanced cirrhosis
h. detection of ascites aids in differential diagnosis
1. Ascites: fluid in peritoneal cavity
2. Due to portal HTN
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Parenchymal Disorders, continued …
C. Fatty Replacement (prior to cirrhosis)1. Appearance similar to cirrhosis2. May be initial stage of cirrhosis3. Difference:
a. Intrahepatic vessels remain clearly defined
b. No portal HTN
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V. Other Diseases and Conditions
A. Congestive Hepatomegaly:
1. Enlargement of liver secondary to congestive heart failure
2. Homogeneous: liver rarely shows echo changes
3. Tissue attenuation may decrease as liver fills with blood
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Other Disease Conditions, continued …
4. Marked dilation of IVC without respiratory influence is
proof of right heart failure
5. Hepatic vein branches may show enlargement
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Other disease conditions, continued …
6. Thrombosis of IVC may show similarities
-thrombus can be detected
7. Other signs:
a. Ascites
b. dilation of right atrium
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Other diseases and conditions, continued …
B. Liver Abscesses:
1. Commonly found in hepatorenal pouch
2. Appear cystic with irregular borders and fine
precipitates
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Other Disease Conditions, continued …
C. Obstructive Jaundice:
1. Result of obstruction of bile flow
2. Dilation of intrahepatic bile ducts
3. Ultrasound can differentiate between obstructive and hepatocellular jaundice
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Dilated CBD: seen in Obstructive Jaundice
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Other Disease Conditions, continued …
D. Hepatic Artery Aneurysm:
1. May stimulate hepatic abscess
2. Usually appears as sonolucency with surrounding echogenic area (thrombus)
3. Flow of blood changes as blood swirls and clots
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Other Disease Conditions, continued …
E. Klatskin Tumor:
1. Ducts are blocked or fused a. Tumor at junction of Right
and Left Hepatic Ducts
b. Causes obstructive jaundice
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Other Disease Conditions, continued …
F. Courvasier’s Sign:
1. Refers to gallbladder “rate of fill” with tumor vs. stone
2. Hydrops (edema) of gallbladder due to tumor in head of
pancreas
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Other Disease Conditions, continued …
G. Reidel’s Lobe:
1. Anomalous, tongue-like extension
2. From right lobe of liver to the gallbladder
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Reidel’s Lobe
R. Lobe L. Lobe
GB
Reidel’s LobeReidel’s Lobe
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VI. Miscellaneous Data
A. Portal Vein: Measurements
1. Length = 5.5 – 8.0 cm (average = 6.5)
2. Diameter = ~ 1 cm
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Misc. Data, continued …
B. Ampulla of Vater
1. Length = 1 – 14 mm
2. Width = 1.5 – 4.5 mm