Liver Pathology PDF

Liver Pathology Diffuse Hepatocellular disease Hepatocellular disease causes hepatocyte dysfunction and interferes with normal liver function. Effect of disease process on the whole liver ranges from simple fatty changes to more severe hepatitis or progressive cirrhosis. Par...

Liver Pathology Diffuse Hepatocellular disease Hepatocellular disease causes hepatocyte dysfunction and interferes with normal liver function. Effect of disease process on the whole liver ranges from simple fatty changes to more severe hepatitis or progressive cirrhosis. Parenchymal disease process produces changes that can decrease but more commonly increase normal echo density and often affect liver’s size. As disease progresses, liver is generally more difficult to penetrate due to increased sound attenuation. Most common cause of acute liver failure in the United States is an overdose of acetaminophen, usually as a suicide attempt. Fatty Infiltration AKA Steatosis is accumulation of triglycerides within hepatocytes Most common causes- metabolic syndrome (type 2 diabetes, Obesity) & alcohol abuse drugs, nutritional status, metabolic abnormalities, severe hepatitis Incidence is 30% in US Reversible, range from mild to severe SONOGRAPHIC FINDINGS: Increased echogenicity, decreased acoustic penetration, i increased attenuation makes it hard to see the posterior liver and diaphragm FOCAL FATTY INFILTRATION: Focal regions of increased echogenicity within normal liver. Commonly seen at porta hepatis and the whole liver is infected and hepatics think increase of echogencity FOCAL FATTY SPARING: Focal regions of normal liver within a fatty infiltrated liver. Sparred areas are seen as hypoechoic areas within a hyperechoic liver Sparred areas commonly seen adjacent anterior to GB, in Porta hepatis, caudate lobe, and at liver margins Darker When entire liver is not affected Fat spared areas are seen as decreased echogenicity within normal or echogenic liver Most often seen anterior to the GB or by the GB fossa Anterior to portal vein at the porta hepatis  Around the liver margins Within the left lobe Areas of spared areas is hypoechoic Lack of visuation to the vessels is more severe. Hepatomelgy arrows are pointing to focal fatty sparing anterior to GB and anterior to portal hepatis lack of visualiza?on of internal vessels, marked difference in echogenicity between liver and kidney, and decreased sound penetra?on limi?ng visualiza?on of diaphragm use lower frequency!!!!  arrows poin?ng Focal fa(y infiltra/on (arrows) noted in right lobe. Same patient: Lower frequency sector, liver is identified to diaphragm, and renal parenchyma echoes are seen Focal infiltration increase hypo Two areas of focal fatty sparing (arrows) are seen in classic locations as hypoechoic, irregular shaped areas anterior to gallbladder and portal vein. Glycogen Storage Disease GSD Autosomal recessive disorder Genetically acquired disorder= results in excess deposits of glycogen in the liver Patient usually has absence or deficiency of one of enzymes responsible for making or breaking down glycogen Associated with fatty infiltration and hepatic adenomas There are 11 different GSD’s  *GSD type 1- defect enzyme glucose-6-phosphatase- originally known as “Von Gierke’s Disease” May cause hypoglycemia, abdominal distension, fatigue, and irritability. Sonographic appearance Type 1 Fatty liver increased echogenicity difficult to penetrate hepatic adenomas hepatomegaly Transverse image in a man with known glycogen storage disease demonstrates fatty infiltration of the liver and hypoechoic liver lesions consistent with liver cell adenomas (cursors) Hepatitis Inflammation of the liver from: infectious (viral, bacterial, fungal, parasitic organisms) or noninfectious (medications, toxins and autoimmune disorders) agents Can elevate ALT, AST, conjugated and unconjugated bilirubin Viral hepatitis may be mild or extensive and account for most cases - Route of transmission: Types A, B, C, D, and E account for 95% of all acute hepatitis cases. Hepatitis A: highly contagious liver infection caused by hepatitis A virus – FECAL/ORAL  Hepatitis B: Serious liver infection caused by hepatitis B virus; preventable by vaccine- BLOOD/BODY FLUIDS Hepatitis C: Infection caused by virus that attacks liver and leads to inflammation- BLOOD /BODY FLUIDS- Hepatitis C is often caused by sharing needles, before 1992 was spread through blood transfusions and organ transplant. HEP C is associated with chronic liver disease and is most frequent indication for liver transplantation Alcoholic hepatitis: Liver inflammation caused by excess alcohol consumption. Autoimmune hepatitis: Inflammation in liver occurs when immune system attacks liver. Viral hepatitis pathology: Liver cell injury, swelling, varying cellular degeneration, possible necrosis, an immune system response, and regeneration. Fulminant hepatitis pathology: Massive necrosis of liver parenchyma; decrease in liver size (acute yellow atrophy), sudden and severe onset leading to shock, coma, and possible rapid death from marked liver necrosis. Acute Hepatitis “Starry Night” or Periportal Cuffing- bright dots Hypoechoic liver Liver enlarged Hyperechoic portal vein walls Chronic Hepatitis Hyperechoic liver Small liver Decreased echogenicity of portal vein walls-  Role of sonography 1. Document is acute or chronic Pachamama changes 2. Document hepatomelgy 3. Biliary obstruction is that the source of jaundice Periportal Cuffing thick bands around the walls acute linear bands portal vein very prominate hyperechoic Transverse image in a pa?ent with acute hepa??s demonstra?ng vessels seen as linear bands extending out to the periphery of the liver. liver is hypoechoic decrease in echogenicity starry night Sagittal image through liver and right kidney demonstrating decreased liver echogenicity and increased delineation of portal triad echoes secondary to edematous changes from acute hepatitis. This is “starry night” sign Cirrhosis General term for a diffuse process that destroys normal liver lobule architecture. Initial changes cause liver enlargement but continued insult results in hepatic atrophy > resulting in blood coagulopathy > hepatic enchaphalophathy > and portal hypertension. CAUSES: Hepatitis C – most common cause of cirrhosis 2nd cause is Alcoholism was once the major cause of cirrhosis in US- but Hep C is now nation’s leading cause of both chronic hepatitis and cirrhosis  Alcoholic liver disease Non-alcoholic fatty liver disease (NAFLD)- KNon-alcoholic Steatohepatitis (NASH)- type of NAFLD a buildup fat in the liver Hepatitis B MISC CAUSES: Autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, hemochromatosis (Iron deposition, Wilson disease (copper deposition), drug-induced liver disease, venous outflow disease (Budd-Chiari), right sides heart failure/tricuspid regurgitation Cirrhosis liver function test- Increased liver function tests associated with cirrhosis 1. AST (SGOT) 2. ALT (SGPT) 3. GGT 4. LDH (lactate dehydrogenase) 5. Conjugated bilirubin Cirrhosis sonographic findings Hepatomegaly (ACUTE) Liver Atrophy (CHRONIC) right lobe because of the bloody supply Caudate lobe enlargement- not enough blood flow Surface lobe enlargement – regenerative nodules Fatty infiltration – increased echogenicity- liver Internal textural changes ranging from fine to coarse and from hypoechoic to hyperechoic. Loss of delineation of intrahepatic vasculature- hard to define Changes related to portal hypertension Increased incidence of Hepatocellular Cancer HCC Secondary findings of cirrhosis should be documented and can include: Portal hypertension Splenomegaly Varices Collaterals Ascites Common collaterals or varices include: Recanalization of the paraumbilical vein coming off the left portal vein Esophageal varices Splenic varices Splenorenal shunt See lig of teres recanalization Sagittal: Image of cirrhotic liver demonstrates multiple hypoechoic areas that are compatible with regenerating nodules. 2nd nodules of fillers decrease of the liver lobulated decrease in size 4. Arrows Regenerate nodules to get better healthy liver is hypoechoic fibrosis geniting liver looks lobucated Sagittal: Level of IVC, enlarged caudate lobe (CL) associated with advanced cirrhosis. Caudate lobe enlargement is thought to be from alterations in portal blood flow to liver secondary to venous compression by fibrosis and regenerative nodules. Ascites nodules surfaces exp, pain gli High frequency linear array image of a patient with mild cirrhosis. Notice nodularity of parenchyma and slight irregularity of capsule (arrow).  double arrows hyperechoic mass may BE HCC Patient presents with elevated AFP and cirrhosis. Arrow is pointing to a biopsy-proven HCC. Sonogram on another patient with a biopsy-proven HCC (double arrows) visualizes a regenerating nodule (single arrow). Q. Sagittal image of left upper quadrant showing a recanalized umbilical vein (arrows). Lig of teres demonstrate structure R. Color Doppler image of same image as in Q showing flow toward the skin surface. R. Same image locations as in R now with a spectral Doppler signal showing that flow is venous. R. A color Doppler image following the recanalized umbilical vein under skin to level of umbilicus. Demonstrate down to umbilical Doppler image demonstrates reversed flow (hepatofugal) in main portal vein and hepatopetal flow of the hepatic artery spectral Doppler of main portal vein demonstrates hepatofugal flow. Blood should go to the liver. Portal hypertension  mul?ple cys?c areas superior to aorta compa?ble with esophageal varices. These areas are filled in with color Doppler. Splenomegaly Portal hypertension Most common cause is cirrhosis and destruction of liver cells Normal vein pressure is 5-10mmHg which is higher than normal inferior vena cava pressure. With fibrosis resulting in resistance to liver profusion portal vein pressure increases gets high and go the opposite direction. Hepatic artery and portal vein should go to the same direction move red Normal blood pressure is to high. The resistance and perfusion is hypertension Portal vein diameter > 13mm suggest portal hypertension  Portal hypertension is asymptomatic- patients usually present with upper GI hemorrhage due to rupture of esophageal varices that extend from right and left gastric (coronary) veins that are branches of the portal vein Asympatic Surgical techniques to lower portal pressure: Portacaval shunt’ Splenorenal shunt/Linton shunt Distal splenorenal shunt/Warren shunt TIPS procedure. Go to the jugular bypass to the hepatic veins. Secondary signs portal hypertension: Splenomegaly Ascites Portal systemic venous collaterals- open up the pressure is increase Clinical Signs Portal Hypertension: Hematemesis- vomiting up blood Hepatic encephalopathy- confused Caput medusa (dilated abd wall veins)- Physical signs of collaterals: Dilated veins on anterior Abd wall Caput Medusa- tortuous collateral around umbilicus Hemorrhoids Ascites-fluid wave Collaterals formation Paraumbilical v. /recanalized umbilical vein Gastroesophageal vein Splenorenal varices Intestinal varices  Rectal varices (hemorrhoids) Hepatfugul flow Venous collateral- left portal vein BUDD-chiari Syndrome Hepatic vein obstruction, Possible IVC involvement Patients presents with signs associated portal hypertension- ascites, hepatomegaly, splenomegaly. Non–specific clinical triad sign is ascites, hepatomegaly and abdominal pain Causes: Often idiopathic (approx. 50% cases) Congenital causes: IVC membranous obstruction, hepatic vein stenosis or hypoplasia, Hypercoagulable states: Polycythemia vera, paroxysmal nocturnal hemoglobinuria, Factor V Leiden deficiency, Protein C & S deficiency, Antithrombin III deficiency, Antiphospholipid antibody syndrome, Sickle cell disease, Oral contraceptives Infections Pregnancy/Postpartum Tumors: Hepatocellular carcinoma, renal cell carcinoma, adrenal carcinoma Clinically significant: Generally, requires occlusion of at least two hepatic veins. Sonographic findings depend on degree of venous obstruction and underlying cause. Hepatic veins: not visible, narrow, or reversed flow. Gray-scale imaging may show hypertrophy of caudate lobe as liver directs its venous blood to caudate lobe due to direct venous drainage into IVC. Color Doppler may demonstrate enlarged caudate veins draining into IVC. Liver cysts Classified as congenital or acquired. Congenital cysts: True hepatic cysts Categorized as simple cysts or related to hereditary disorders such as polycystic liver disease. True epithedial wall Result from developmental anomalies in formation of intrahepatic bile ductules, proper involution of these ductules, or both.  Incidence increases with age in hepatic cyst Acquired cystic lesions: Categorized and result from traumatic (hematoma, biloma), parasitic (echinococcal), or inflammatory (abscess). Sonographic appearance of a liver cyst Anechoic Thin walled Acoustic enhancement Edge shadowing autosomal 80-90 percent both liver and kidney disease. Isolated in the liver- not autosomal Congenital liver cysts (arrows) in an asymptomatic patient. The classic signs of a simple cyst are seen including enhancement.  Sagi(al image of right lobe of liver showing mul/ple cysts compa/ble with polycys/c liver disease. Pa/ent also had cysts in their kidneys Congenital liver cysts. A B. A simple cyst in the left lobe showing enhancement and a reverberation artifact (arrow). Edge shadowing Echinococcal cyst. AKA-hydatid disease (Acquired cyst) Most common caused by Taenia echinococcus or Echinococcus granulosus—parasitic tapeworm. If larvae invaginate and develop, they become encysted, and generations of daughter cysts develop.  Original unilocular-looking cyst is eventually filled in by multiple cysts of varying size. Sonographic appearance depends on course of larval maturation—possibilities include: (1) solitary cyst with possible mural or shell-like calcification. (2) mother cyst containing internal, peripherally placed daughter cysts. (3) fluid collections with septa—honeycomb appearance. (4) solid-looking cysts, with or without calcification. “Cyst within a cyst” or a “water-lily sign” is detachment of endocyst membrane which result in floating membranes within pericyst that mimic appearance of a water lily Do a Casoniskin test – look for anti-echinococcus antibodies Acquired cyst hematoma Echinococcal cyst  Liver abscesses. 3 FORMS of LIVER ABCESSES 1. Pyogenic Abscess- bacterial Pus containing lesion 80% of cases Escherichia coli most common organism E.coli Biliary tract is most common source Pyogenic enter via portal vein or hepatic artery Right lobe is more affected than left lobe. The way the blood flow to the liver SONOGRAPHIC FINDINGS: Complex mass, irregular walls Gas Reverberation artifact SYMPTOMS: RUQ pain Leukocytosis- increased white blood cells Fever Elevated LFT’s *MUST aspirate to confirm- bacterial fungal, Picture left : Sagittal scan of patient with debris-filled pyogenic liver abscess (A). Note acoustic enhancement (arrow) that helped differentiate this from a solid mass. Picture right: A large liver abscess in a patient with cholecystitis. C. Below left Patient presented with pain, fever, and history of diverticulitis. Sonogram shows complex collection in the left liver lobe compatible with an abscess. Power Doppler demonstrated increased flow around the abscess.  D. Below right Multiple gas-forming pyogenic liver abscesses in a patient with a history ofdiabetes. Notice bright white reflectors (arrows) compatible with gas. This type of abscess is associated with a high mortality rate 2. AMEBIC LIVER ABCESS- parasite Occurs when parasite reaches liver usually via the portal vein Often from contaminated food and/water Most common extraintestinal complication of amoebic dysentery Occurs almost exclusively in Immigrants or travelers Most often involves GI tract. Symptoms usually occur 8-12 weeks after travel date SYMPTOMS & FINDINGS: RUQ pain- hepatomegaly Diarrhea Fever Leukocytosis Elevated LFT’s SONOGRAPHIC FINDINGS: Round hypoechoic / complex mass Usually in right lobe liver around dome Continuous with the liver capsule , acoustic enhancement Aspiration may be required to Diagnose  3. Schistosomiasis. FUNGAL ABSCESS One of the most common parasitic infections in humans Contaminated water with immature worms can penetrate skin and travel via lymphatics and bloodstream to the mesenteric veins. Common parasitic infection in Africa, Asia, Indonesia, China, Japan, South America, and Mediterranean. It is major cause of PORTAL HYPERTENSION & can cause PERIPORTAL FIBROSIS SONOGRAPHIC FINDINGS: Occluded intrahepatic portal veins Thickening of portal vein walls TURTLE BACK SIGN- CLAY BACK Secondary signs- splenomegaly, ascites, SAME AS PORTAL HYPERTENSION esophageal variceal bleeding, portosystemic collaterals THICK AND FIBROTIC LITTLE LINES OF THE TURTLE BACK  (A) and transverse (B) sonograms of liver advanced periportal fibrosis—provides the “turtle back” sonographic appearance (arrows). HIV-AIDS – Infectious Processes Pneumocystis jiroveci (formerly Pneumocystis carinii) is the most common opportunistic infection in HIV-infected persons. Majority of AIDS-infected people eventually develop Pneumocystis pneumonia. Highly active antiretroviral therapy (HAART)- has dramatically decreased the complications associated with HIV- increasing the importance of prompt diagnosis Complications of HIV-AIDS Tuberculosis (TB) most common opportunistic infection w HIV Cytomegalovirus (common herpes virus) Candidiasis- common fungal infection Cryptococcal Meningitis- common central nervous system infection Toxoplasmosis- infection caused by parasite- spread primarily by cats Cryptosporidiosis- infection caused by intestinal parasite -often in animals Kaposi’s sarcoma- tumor blood vessels walls, rare in people not infected with HIV, usually appears pinl, purple red lesions on skin, mouth  Lymphomas- most common early sign is painless swelling lymph nodes (neck, armpit, groin) Kidney disease- (HIVAN) HIV-associated nephropathy- inflammation of glomerulus, may show as larger than normal kidneys by ultrasound Sagittal scan of right liver lobe reveals multiple tiny focal calcifications (starry sky). This pattern is highly suggestive of, but not definitive for, disseminated Pneumcystis infection, whichhis patient did have. Longitudinal sonogram through liver in a HIV-positive patient reveals small focal calcifications. Although this pattern can be seen in patients with disseminated P. jiroveci, other infectious processes in HIV patients may also produce this pattern. This patient had hepatic tuberculosis. Fungal Infection / Abscess Candidiasis Mycotic (fungal) infection of the blood that results in small abscesses in the liver Appearance can change over course of disease process “wheel within a wheel”- is a lesion with a peripheral hypoechoic zone, an inner echogenic wheel and a hypoechoic center- this is earliest stage of fungal infection and most recognizable Outer hypoechoic wheel is fibrosis surrounding the inner echogenic wheel of inflammatory cells and a central hypoechoic area of necrosis OUTER HYPOECHOIC- INNER HYPERECHOIC CENTRAL HYPOECHOIC bulls eye”- lesion appears like this when the hypoechoic center calcifies “Uniformly hypoechoic focus”- most common presentation of lesion- LOOKS LIKE METS LOOK AT CLINCAL HISTORY “echogenic focus”- calcification is the scar formation-seen in late process of disease Multiple small, hypoechoic masses, “wheels within wheels” seen in an immunocompromised patient receiving high-dose chemotherapy. Patient presented with fever. Although metastatic disease could have similar appearance, rapid appearance of multiple masses between short- term imaging sessions and patient’s clinical presentation was more indicative of a fungal infection/candidiasis. Cavernous Hemangiomas Most common benign liver tumor and occurs in up to 4% of general population. Usually incidental finding and often asymptomatic Multiple vascular channels lined with endothelium – the multiple interfaces give the mass its hyperechoic appearance SONOGRAPHIC FINDINGS: Hyperechoic Posterior enhancement May enlarge with pregnancy and estrogen intake May appear hypoechoic within background of fatty liver Usually no color flow within Contrasted enhanced imaging demonstrates centripetal flow Focal Nodular Hyperplasia (FNH) 2nd most common benign liver mass Lacks normal hepatic architecture Arterial supply is from hepatic artery and venous drainage is into hepatic veins No portal venous branch More common in women in reproductive years FNH composed hepatocytes, Kupffer’s cells, bile ductules – organized, well defined and without a true capsule Associated with hemangiomas SONOGRAPHIC FINDINGS: Solid mass with varying echogenicity Solitary lesion 80-95% Central fibrous scar Spoke wheel appearance – COLOR DOPPLER Often right lobe or lt lateral segment- SEEN. “Stealth lesion” isoechoic lesions and produce a mass effect displacing intrahepatic blood vessels Hepatic Adenoma or. (LCA) Liver cell adenoma Occur mostly in women of childbearing age Strongly associated with use oral contraceptives & other estrogens Clinical symptoms vary; can be asymptomatic. Patient may present with pain due to tumor Hemorrhage  Rare, benign epithelial neoplasm composed of normal or atypical hepatocytes. Can be associated with glycogen storage disease Surgical resection is recommended due to risk of malignant transformation SONOGRAPHIC FINDINGS: encapsulated, well-circumscribed, hyperechoic mass with hypoechoic halo; may also appear hypoechoic or isoechoic relative to normal liver parenchyma. On color Doppler: increased vasculature with flow in center of the lesion as well as flow around the periphery. HAS A HALO APPEARANCE ON COLOR DOPPLER Arrow points to an adenoma on a patient who presented with vague RUQ discomfort. *Color Doppler image showing the vascularity of the mass. The vessels gave the mass a halo effect on gray scale. Hepatic Lipoma Extremely rare fatty tumors  Hepatic lipomas and angiomyolipoma associated with - Tuberous sclerosis (congenital familial disease) SONOGRAPHIC FINDINGS: Hyperechoic mass Propagation speed artifact* Decreased speed of sound in fat (1450 m/s) results in prolonged sound return time BELONGS PROLONG Objects posterior to the fatty mass will be placed farther away from transducer Broken diaphragm CT can confirm fatty nature of mass Hyperechoic liver masses: Hepatic lipoma Hemangioma Echogenic metastasis Focal fatty infiltration Hepatocellular Carcinoma (HCC) AKA- Hepatoma  Most common primary malignancy of liver Occurs predominantly in patients with underlying chronic liver disease & cirrhosis 5th most common CA worldwide Occurs in 10-25% patients with Cirrhosis in US Commonly invade venous structures – portal veins, hepatic veins and IVC Unusual before age 40- most common sixth decade life LABS Associated with increase: AFP * most significant AST (SGOT) ALT (SGPT) SONOGRAPHIC FINDINGS: Variable appearance Most hypoechoic Color Doppler shows chaotic internal vasculature Clinical symptoms: 1. Weight loss 2. Nausea & vomiting 3. RUQ pain 4. Pruritus 5. Splenomegaly 6. Palpable mass 7. Hepatomegaly 8. Jaundice 9. Ascites Treatments: hepatic resection transcatheter arterial chemoembolization percutaneous ethanol injection radiofrequency ablation cryoablation  liver transplant. ARROW- COMPRESS ON THE IVC- LIVER DECREASE IN SIZE Hepatoblastoma infant or child- RARE Most often occur prior to age 2 Hepatomegaly Calcifications may be present Elevated AFP Associated with Beckwith-Wiedemann syndrome Familial adenomatous polyposis- IN THE INTESTENSE Associated lung metastases and portal vein invasion mainly in infants. It is the most common liver tumor of young children. It is composed of epithelial cells resembling fetal hepatocytes sometime with immature small blue (embryonal) cells or mesenchymal differentiation (bone, cartilage, muscle)  Metastatic disease After lymph nodes, liver is the most common site for metastases from cancers arising in other areas. Metastatic liver tumors incidence—18 to 20 times more common than HCC. Most common primary cancers contributing to metastatic liver disease are: Gallbladder, colon, stomach, pancreas, kidney, ovaries, breast, and lung. Liver is vulnerable to metastases because of large blood volume and large reserve of lymphatic drainage. ≈40% of patients with cancer have liver metastases. Easily established in liver due to its dual blood supply and factors that promote cell growth LABS LFT values can be normal: AST, ALT may be elevated. ALP and bilirubin elevated with biliary obstruction. HPERCHOIC AFP is typically not elevated in liver metastatic disease. Sonographic Findings: Hyperechoic metastases- Gastrointestinal tract Hypoechoic metastases- Lymphoma Bulls eye or Target metastases- Lung Calcified metastases- mucinous adenocarcinoma of colon Cystic metastases- leiomyosarcoma- UTERUS Due to nonspecific sonographic appearance of Mets- ultrasound-guided biopsy is needed to determine primary tissue diagnosis  a. Multiple hyperechoic metastatic liver lesions seen in patients with a pancreatic primary. 58-year-old man referred for RUQ pain. Diagnosis of pancreatic head cancer with liver metastases was unexpected. b. Bull’s-eye” lesions—echogenic center with a hypoechoic rim. Patient also had unexpected finding of liver metastases with a lung primary. c. Hypoechoic lesions in this patient with lymphoma. d. This patient was jaundiced and was referred for a biliary ultrasound. The sonography examination showed unexpected findings of infiltrative liver mets. This patient was discovered to have a left renal cell carcinoma. Gallbladder Part 1 The function is to store and transport bile from the liver to the GI system. The biliary system comprises the gallbladder and the hepatic ducts. Anatomy: The hepatic ducts are divided into intrahepatic and extrahepatic ducts. The right and left hepatic ducts (intrahepatic) converge at the porta hepatis to form the common hepatic duct The CHD is joined by the cystic duct to form the common bile duct (CBD). The common bile duct and main pancreatic duct (Duct of Wirsung) join to form Ampulla of Vater CBD passes posterior to first part of the duodenum and pancreatic head The ampulla of Vater empties through the duodenal papilla, controlled by the Sphincter of Oddi  Porta Hepatis- the Portal triad consists of Main Portal vein, Common Hepatic Duct, and Proper Hepatic artery… AKA “Mickey Mouse Sign” Measurements of Biliary Ducts The duct is measured inner wall to inner wall Normal intraluminal measurement for intrahepatic duct is 2 mm or no more than 40% of portal vein Measurement controversy exists for CBD and CHD CHD typically does not measure >4 mm CBD typically should measure 3MM Longitudinal image in patient with positive Murphy sign. Note gallstones, sludge, thickened, edematous wall, and pericholecystic fluid (arrow). Transverse image of another patient with acute cholecystitis and thickened wall (calipers). Hydropic gallbladder and increased color Doppler flow in a patient with positive Murphy sign, sludge, and acute cholecystitis. Longitudinal image of acute cholecystitis, stone, sludge, and increased Doppler flow. Acalculous Cholecystitis Acute Cholecystitis without the presence of gallstones Usually secondary event in critically ill hospitalized patients. AFTER SURGERY Causes: Bile Stasis (Viscous Bile) Decreased GB Contraction Infection (Secondary Event) Sonographic Findings: Wall Thickening + Murphy’s Sign Pericholecystic Fluid Symptoms: RUQ PAIN N/V Associated with: Infection from or post surgery Viral infection TPN > 3 months Severe trauma Severe burns Sepsis HIV/AIDS Blood transfusion reaction High dosage opioid analgesics Thickened gallbladder wall, sludge, and pericholecystic fluid (arrow) are seen in longitudinal image. The patient had RUQ pain, nausea, and vomiting. Transverse image showing thickened gallbladder wall in patient with acute acalculous cholecystitis. Complicated Cholecystitis Patients with acute cholecystitis are at risk for developing Empyema Gallbladder Perforation Gangrenous Cholecystitis Emphysematous Cholecystitis Empyema of Gallbladder Pus in the Gallbladder AKA- Suppurative Cholecystitis Often initiated with obstruction of cystic duct Sonographic Findings: Suspect if atypical bile echoes present Symptoms: *Same as Acute Cholecystitis *Fever, chills, RUQ pain Sepsis possible Gallbladder Perforation  Rare but life threatening complication of acute cholecystitis GB Fundus- most distal part with regard to blood supply- is most common perforation site IN THE FUNDUS BECAUSE OF THE BLOOD SUPPLY IT STARTS TO PERFORATE Localized fluid collection in GB fossa is common Since difficulties in diagnosis cause delay in treatment- higher morbidity & mortality rate are often encountered Labs often show increase in WBC and abnormal LFT’s Complications Include: *Peritonitis (from bile leak) *Pericholecystic Abscess (most common) *Abscesses occur in or around GB, liver, or within peritoneal cavity *Biliary fistula Sonographic Findings: Complex fluid collection (abscess) Irregular GB wall Gallstones Inflammatory changes in GB fossa Focal defect in GB wall Symptoms: RUQ pain N/V Fever  Longitudinal (A) and transverse (B) images in a patient with gallbladder perforation. Defect seen on anterior wall (arrows) is better demonstrated in the transverse section Debris is also located within the gallbladder lumen. Gangrenous Cholecystitis Due to absent blood supply or infection GB wall becomes ischemic- eventually necrotic Lab values usually increase WBC Sonographic Findings: *Often non-specific Thickened- irregular wall with both hyperechoic & hypoechoic striations Gas within GB wall or Lumen Absent GB wall and./or abscess may be present Symptoms: Acutely ill patient Positive Murphy’s sign 1/3 of patients *If nerve damage may not have + Murphy’s sign- so patient often has diffuse pain vs acute Transverse (A) and longitudinal (B) images in acutely ill patient with right upper quadrant pain and fever. GB wall is irregularly thickened, and sludge is also noted.  C. Longitudinal image in latter stages of gangrenous cholecystitis. Air (arrow) seen within fundus of contracted GB. Wall is also thickened and edematous. D. Stent (arrow) placed within GB in patient with gangrenous cholecystitis. Patient acutely ill and unable to have cholecystectomy. Note thick GB wall and ascites. Emphysematous Cholecystitis Acute cholecystitis due to gallbladder wall ischemia & infection Gas forming bacteria invade GB wall, lumen or biliary tree More common in men Occurs more commonly in diabetic patients Higher rate of gangrene & perforation Fatal in about 15% cases Sonographic Findings: Comet-tail or ring-down (reverberation) artifacts are seen due to Gas presence Gas bubbles produced by bacteria may rise to nondependent wall of GB Change position with patient position Air appears as echogenic foci within GB wall or lumen Causes of gas in biliary system: ERCP SURGERY Sphincter of Oddi Papillotomy Choledochojejunostomy (anastomosis of CBD to jejunum) GB (Biliary) fistula Emphysematous cholecystitis  A. Transverse image of GB showing a small amount of air (arrow) within GB wall in a diabetic patient B. Longitudinal image in a different patient with a larger amount of air (arrows) in the wall. With emphysematous cholecystitis, air can be seen within both the wall and GB lumen A. With patient supine, air within GB is seen at neck B. When patient rolls into left decubitus position, air moves out of neck and swirls within GB lumen Chronic Cholecystitis Defined clinically as recurring symptoms of biliary colic due to previous episodes of acute cholecystitis Usually Associated with Gallstones Affects women more than men Occurs more often in elderly Tend to have intolerance to fatty or fried foods associated with intermittent N/V  FINDINGS: Thick GB Wall Contracted GB Sludge & obstructed cystic duct may be present Longitudinal and transverse images demonstrate thickened GB wall, stone, and ascites. Longitudinal image in patient with continued RUQ pain. A stone is seen within the neck of a contracted GB. The stone did not shift even though the patient moved into multiple positions. Gallbladder Wall Thickening GB wall thickness when it measures > 3mm Most common cause is Cholecystitis Nonfasting Patients will have thick GB wall Other CAUSES:  Hypoalbuminemia Ascites Hepatitis Congestive Heart Failure Pancreatitis Varying appearances of thick gallbladder wall in a patient with: A. Hepatitis B. Congestive heart failure C. Cholecystitis D. Pancreatitis E. End-stage liver disease and ascites GALLBLADDER WALL THICKENING Porcelain Gallbladder Calcification of the GB wall associated with chronic cholecystitis More common in men Associated with GB carcinoma SONOGRAPHIC FINDINGS: Single echogenic line rep calcified wall All or part of wall may be calcified If wall is strong reflector, a posterior shadow may be seen and obstruct vis of GB A. Transverse image showing a calcified anterior and posterior wall. B At times, the anterior calcified wall is strongly calcified and the posterior wall cannot be seen. Gallbladder Polyps Masses extending from GB mucosa If less than 10mm unlikely to be cancerous and generally do not require treatment Often asymptomatic No Association with age, Gender or Obesity Majority composed of cholesterol and benign SIZE… Most important indicator of malignancy with polyps Lesions greater than 10mm have higher malignancy rate between 37-88% Sonographic Findings: Fixed, non-mobile hyperechoic-echoic mass attached to wall No posterior shadowing Can be single or multiple Over 1cm should be surgically removed Images A–D: Polyps can be small, large, single, or multiple Careful evaluation is needed to ensure polyps are not mistaken for gallbladder folds or sludge balls.. Hyperplastic Cholecystoses Group of benign, non-inflammatory conditions that are both degenerative and proliferative Adenomyomas* Cholesterosis* Neuromatosis Fibromatosis Lipomatosis Adenomyomatosis Hyperplastic changes involving gallbladder wall causing overgrowth of the mucosa, thickening of the wall, and formation of diverticula More common in woman Diverticula within gallbladder wall (Rokitansky-Aschoff sinuses) accumulates stones or sludge within them Patients may present with RUQ pain Sonographic Findings: *Focal or diffuse wall thickening *Small, round, anechoic spaces in GB wall represent Rokitansky-Aschoff sinuses got *Echogenic foci spaced in GB wall show acoustic shadowing or comet-tail reverberation artifact or *Twinkle artifact with Color Doppler *Gallstones common Thickened wall with echogenic foci and comet tail artifact near neck of GB. Adenomyomatosis throughout the majority of anterior GB wall. Sludge was also seen. Cholesterolosis Lipids (triglycerides & cholesterol) are deposited in the GB wall  More frequent in women Can be diffuse and no impairment of GB Appear as polyps, vary in size and can be as large as 1cm AKA “Strawberry Gallbladder” due to golden yellow lipid deposits against the red gallbladder mucosa (diffuse form) Usually, no clinical symptoms but can experience colicky abdominal pain Longitudinal image of GB demonstrating multiple small, no shadowing foci consistent with cholesterolosis. Gallbladder Carcinoma Signs and Symptoms usually nonspecific and mimic cholecystitis Can metastasize to liver, lymph nodes, CHD, and surrounding organs Less than 50% of GB cancers diagnosed preoperatively Many diagnosed incidentally post-cholecystectomy Late stage – patient jaundice, malaise, weight loss 5 year survival rate is less than 5% Sonographic Findings: Typically, advanced stage by us- Heterogenous, irregular-shaped mass Replaces GB Tumefactive sludge or sludge ball can mimic GB mass GB mass> 1cm, wall thickening >1cm, or disruption of GB wall increase suspicion of malignancy Color Doppler can help show internal vascularity is malignancy present  A. Echoes completely fill GB lumen. A stone (arrow) is seen at posterior portion of GB. Note the irregularly thickened, heterogeneous GB wall. B. A heterogeneous mass extending from GB wall represents GB carcinoma. GallBladder Part 2 Biliary atresia Most common type of obstructive biliary disease in infants and young children Absence / Destruction of extrahepatic bile ducts (CHD & CBD) Twice as common in males Suspected when jaundice (hyperbilirubinemia) persists beyond 14 days of age Up to 38% children can survive with their own liver for 30 years after KPE procedure. Associated with “Triangular Cord Sign” = echogenic, triangular structure anterior to portal vein Kasai portoenterostomy (KPE) Most successful treatment if performed before 90 days of life Liver transplantation also considered Associated with: Polysplenia Absent IVC Situs Inversus Situs ambiguous Cardiac Anamalies (ASD, VSd)  Choledochal cysts Congenital bile duct anomaly- cystic dilation of extrahepatic bile ducts Most common(Type I) involves dilatation of CBD More prevalent in Asia More than 33% of reported cases are from Japan Symptoms usually occur before age 10 Sonographic findings type I: Two cystic structures in the RUQ (Gallbladder and dilated CBD) Intrahepatic bile duct dilatation Associated with: Pancreatitis Cholangitis Cirrhosis Portal hypertension cholangiocarcinoma Choledochal Cyst Longitudinal image in post cholecystectomy patient Choledochal cyst is seen at the porta hepatis (arrows). Caroli disease/ caroli syndrome Congenital anomaly of biliary tract Multifocal segmental dilatation of Intrahepatic bile ducts  Generally inherited associated with: *Congenital hepatic fibrosis *Autosomal recessive polycystic kidney disease *Portal hypertension Sonographic Findings: Multiple cystic structures converge toward porta hepatis communicating with bile ducts Sludge and calculi may accumulate in these ectatic ducts resulting in poor acoustic shadowing Courvoisier gallbladder With a distal mass: Dilation begins with GB Followed by common duct Finally intrahepatic tree Post-removal of mass obstructing GB decompresses actively Ducts passively return to normal to reverse order Hydropic gallbladder Overdistended GB- filled with mucoid , thick bile or pus Most common cause is stone obstructing GB neck or cystic duct Usually non-inflammatory Can be asymptomatic Or RUQ pain N/V Palpable mass Can be Associated with Kawasaki disease Sonographic Findings: Grossly distended Thin-walled measures >5cm TRV (width) Measures > 4cm AP May have stones Causes of a no visualized gallbladder 1. Patient is nonfasting 2. Postcholecystectomy 3. Contracted gallbladder with stones (chronic cholecystitis) 4. Congenitally absent gallbladder 5. Porcelain gallbladder 6. Hepatization of gallbladder 7. Mirizzi syndrome or gallstone ileus 8. GB neoplasms completely filling lumen 9. Ectopic GB 10. Emphysematous GB 11. Overlying bowel 12. Residual barium in nearby bowel Post cholecystectomy The diameter of the common duct increases with age 1 millimeter per decade rule is acceptable rate of size increase Age 60 duct 6mm normal Age 80 duct 8mm normal After it has been surgically removed, there is controversy over the size increase of the common duct Most accepted is the common duct acts as a reservoir for bile storage and may measure up to 10mm Fatty meal Biliary dynamics, gallbladder contractility or obstruction can be assessed by administering a fatty meal CHOLECYSTOKININ- hormone that is released into blood by ingestion of fatty foods, causes gallbladder contraction Equivocal bile duct dilation or abnormal lab values (conjugated bilirubin, ALP-alkaline phosphatase) would be reasons to administer a fatty meal NEGATIVE results= unchanged or decreased size POSITIVE results= DUCT increase in size Biliary obstruction Obstruction causing direct interference with file flow From Intrinsic or Extrinsic (stones, tumors, or strictures) Intrahepatic or extrahepatic Majority are due to pathology in the DISTAL CBD GALLSTONES & Carcinoma of the HEAD of the PANCREAS 2 most common lesions Elevated labs: ALP Direct Bilirubin GGT Clinically: Jaundice RUQ pain Fever Palpable RUQ mas Causes of Biliary Obstruction Include: Choledocholithiasis, Mirizzi syndrome, Cholangitis, Biliary atresia, Choledochal cyst, Carol’s disease, Pancreatic adenocarcinoma, Gallbladder carcinoma Dilated intrahepatic ducts Criteria to differentiate intrahepatic bile ducts from portal veins Parallel channel sign” Double Barreled Shot-Gun Sign” Dilated hepatic duct anterior to portal vein Causes of intrahepatic bile duct dilatation ONLY: Cholangiocarcinoma (Klatskin tumor) Intrahepatic choledocholithiasis Recurrent ptogenic cholangitis Caroli disease Intrahepatic ducts >2mm or more than 40% of portal vein = dilated Level of obstruction Part of the biliary tree that dilates as a result of obstruction depends on the level of obstruction OBSTRUCTION AT THE JUNCTION OF THE RIGHT AND LEFT HEPATIC DUCTS Only the common hepatic duct and intrahepatic ducts will dilate. The gallbladder will be contracted DISTAL COMMON BILE DUCT OBSTRUCTION This is the most common location for an obstructing stone. The entire system distends including the gallbladder COMMON HEPATIC OBSTRUCTION Only intrahepatic ducts dilate. The gallbladder will be contracted Defining the Level and Cause of Intrahepatic Biliary Dilatation CAUSES OF INTRAHEPATIC DILATATION WITH A NORMAL CBD Proximal bile duct tumors (benign and malignant) Klatskin tumor Cholangitis (primary sclerosing cholangitis) Tumors at the porta hepatis (adenopathy and metastases) Mirizzi syndrome Liver neoplasms compressing intrahepatic ducts Benign strictures CAUSES OF INTRAHEPATIC DILATATION WITH A DILATED CBD Choledocholithiasis Carcinoma of pancreatic head Pseudocyst obstructing CBD Acute pancreatitis Chronic pancreatitis Choledochal cyst Lymphadenopathy Benign strictures Ampullary tumors Choledocholithiasis Most common pathology in biliary tract Stones within bile duct Most common cause of extrahepatic obstructive jaundice Complications: Biliary cirrhosis Cholangitis Pancreatitis Symptoms: RUQ pain/ biliary colic Jaundice LABS: Increased alkaline phosphatase Increased conjugated bilirubin Increased transaminase Choledocholithiasis. A. Large stone (arrow) in distal portion of dilated common bile duct (CBD). B. Small stone (arrow) in distal common bile duct Choledocholithiasis. A. Stone (calipers) at distal common bile duct at level of the pancreas. All of the stones have a distal shadow and cause dilatation proximal to the blockage. B. Multiple shadowing stones within the common bile duct at the head of the pancreas. DUO-duodenum; IVC-inferior vena cava; PANC-pancreas; PV-portal vein. Mirizzi syndrome Extrahepatic biliary obstruction due to an impacted stone at the cystic duct causing extrinsic mechanical compression of the common hepatic duct Associated findings: Intrahepatic duct dilatation Cystic duct stone Curved segmental stenosis of CHD Cholecystocholedochal fistula Cholangiocarcinoma (bile duct carcinoma Bile duct adenocarcinoma- typically originate within extrahepatic bile ducts (CHD or CBD) KLATSKIN TUMOR- is a cholangiocarcinoma located at the hepatic hilum (junction of right and left hepatic duct) resulting in intrahepatic but not extrahepatic biliary dilation Occurs equally in men & women between age 50-70 Most common predisposing condition is PRIMARY SCLEROSING CHOLANGITIS Most common finding: Intrahepatic duct dilatation Symptoms: Jaundice Weight loss Abdominal pain LABS: Increased serum bilirubin Increased ALP A. A mass (arrows) is replacing common bile duct (CBD), causing common hepatic duct (CHD) to become dilated. Intrahepatic ducts are also dilated (arrowhead). B. In a different patient, cholangiocarcinoma (arrows) is compressing the duct at the porta hepatis. PV-portal vein. Cholangiocarcinoma C. Metastasis to the from cholangiocarcinoma. The liver is heterogeneous, which represents multiple masses. The GB is also prominent. D. In this case, a mass (arrows) is compressing the GB. A sludge ball is also present. GB, gallbladder; LIV, liver; PV, portal vein Cholangitis Inflammation of the biliary tree May result in cirrhosis, portal hypertension and sepsis Sonographic: bile duct wall thickening LABS IINCREASED: Conjugated bilirubin ALP GGT Amylase & Lipase Leukocytosis CLASSIC TRIAD “CHARCOT TRIAD” RUQ Pain Fever Jaundice Causes: § Most common- choledocholithiasis § ERCP § Obstructive tumors- § pancreatic cancer § Cholangiocarcinoma § Ampullary cancer Primary Sclerosing Cholangitis A. Common bile duct walls (calipers) are thickened in patient with primary sclerosing cholangitis. B. Thickened walls caused dilatation (stellate pattern) of intrahepatic ducts. C. Dilated common bile and common hepatic ducts are seen in patient with cholangitis. Note echogenic, irregular walls of bile ducts. CBD-common bile duct; LT HD-left intrahepatic duct Pneumobilia Air in the biliary tract  Commonly associated with ERCP (endoscopic retrograde cholangiopancreatogram) Ultrasound Findings: Variable length echogenic foci in the intrahepatic ducts Air produces a dirty shadow Important to determine if in duct or portal vein CAUSES: 1. ERCP 2. Sphincter of Oddi papillotomy 3. Choledochojejunostomy 4. Gallbladder fistula 5. Emphysematous cholecystitis A. Echogenic air (arrows) and posterior dirty shadowing seen in right hepatic lobe. B-C. Diffuse, extensive air within intrahepatic ducts follows branching pattern of ducts and portal venous tree. Air moved under real-time observation D. Air (arrows) seen within the common bile duct after a liver transplant. HA, hepatic artery; PV, portal vein. Biliary ascariasis (Roundworm) Disease caused by parasitic roundworm Ascaris lumbricoides  Intestinal and biliary tract obstruction represent most common complication Worm may block the ampulla of Vater or the main pancreatic duct resulting in acute pancreatitis Ascariasis is commonly encountered in South-East Asian countries SONOGRAPHIC FINDINGS: Worms appear as long, thin, echogenic, linear structures within bile ducts or GB 20 to 30 cm in length and up to 6 mm thick) Movement may also be seen Chapter One: Introduction Directional terms: Superior/cranial- toward the head, closer to the head, the upper portion of the body, the upper part of structure or a structure higher than another structure. Inferior/caudal- Toward the feet, away from the head, the lower portion of the body, toward the lower part of a structure, or a structure lower than another structure. Anterior/ventral- Toward the front or at the front of the body or a structure in front of another structure Posterior/dorsal- Toward the back or the back of the body or a structure behind another structure Medial- Toward the middle or midline of the body or the middle of a structure Lateral- Away from the middle or the midline of the body or pertaining to the side Ipsilateral- Located on the same side of the body or affecting the same side of the body Contralateral- Located on the opposite side of the body or affecting the opposite side of the body Distal- Farther from the attachment of an extremity to the trunk or the origin of a body part Superficial- Toward or on the body surface or external Deep- Away from the body surface or internal Patient positions: Oblique- named for the body side closest to the scanning table Right posterior oblique (RPO)- lying on the right posterior surface, the left posterior surface is elevated Left posterior oblique (LPO)- Lying on the left posterior surface, the right posterior surface is elevated Right anterior oblique (RAO)- Lying on the right anterior surface, the left anterior surface is elevated Left anterior oblique (LAO)- Lying on the left anterior surface, the right anterior surface is elevated What directional terms describes a structure closer to the middle? a) Proximal b) Distal c) Medial d) Contralateral Where are the iliac veins located in relationship to the inferior vena cava? a) Inferior b) Cranial c) Ventral d) Ipsilateral Which position describes the patient lying on the right side? a) Right anterior oblique b) Right lateral decubitus c) Right posterior surface d) Right medial oblique – The iliac veins are inferior or caudal to the inferior vena cava. The confluence of the iliac veins forms the inferior vena cava. E. Endovaginally planes. The image presentation on the left illustrates a sagittal plane and the one on the right is the coronal plane. On either presentation, the apex of the image seen on the monitor corresponds to the anatomy closest to the face of the transducer F. Endorectal planes. The image presentation on the left illustrates a sagittal plane and the one on the right is the transverse or coronal plane. On either presentation, the apex of the image seen on the bottom of the monitor corresponds to the anatomy closest to the face of the transducer. What term is correct to describes an anatomical image obtained by recording returning echoes?  a) Sonogram b) Ultrasound c) Echogram d) 2D Planogram Sonogram – A sonogram is a sonographic image is a representation of returning echoes from an organ insonated using ultrasound. What scanning plane and section was used to obtain the sonogram of the left kidney? a) Longitudinal b) Parasagittal c) Coronal d) Transverse Image Quality Definitions: Echogenic Describes an organ or tissue that is capable of producing echoes by reflecting the acoustic beam. Describes relative tissue texture (e.g., more or less echogenic than another tissue). Aberration from normal echogenicity may signify pathology or poor scanning. A. solid arrow, diaphragm). B. In this patient, the transverse section demonstrates that the liver and pancreas textures have a similar echogenicity (isoechoic). (Ao, aorta; IVC, inferior vena cava; PH, pancreatic head; PT, pancreatic tail; RRA, right renal artery; SMV, superior mesenteric vein). Anechoic- 1. Describes the portion of an image that appears echo-free. a. Examples: Urine-filled bladder, bile-filled gallbladder, blood-filled ventricle. 2. Sonolucent or transonic are misnomers and should not be substituted for anechoic. 3. Anechoic is correct to describe the appearance of the echo. 4. Cyst or cyst-like is correct to describe the histopathologic nature of an anechoic structure. Anechoic Longitudinal section made in the supine position. The bile-filled gallbladder (GB) appears anechoic. Hyperechoic, Hypoechoic, Echopenic, Isoechoic Brightness changes occur if scattering amplitude changes from one tissue. Terminology to describe normal and abnormal appearances include: Hyperechoic Hypoechoic Echogenic Isoechoic Hyperechoic echoes are brighter than surrounding tissues or brighter than normal for a tissue or organ. Results from an increased amount of sound scatter relative to the surrounding tissue. Hypoechoic portions of an image are not as bright as surrounding tissues or less bright than normal. - Results from reduced sound scatter relative to the surrounding tissue. Echopenic—a structure less echogenic than others or has few internal echoes. Isoechoic—a structure of equal echo density. Hyperechoic, Hypoechoic, Echogenic, Isoechoic Longitudinal right kidney: Renal capsule is normally hyperechoic compared with surrounding tissues. Renal cortex is homogeneously echogenic, and the pyramids (P) seen in the medulla become more prominent and change from hypoechoic to anechoic with increased diuresis. Area labeled shadowing is caused by bowel gas and is due to low reflectivity (referred to as soft or dirty shadow). D. On a longitudinal section of the right kidney, the renal capsule is normally a specular reflector and is hyperechoic compared to surrounding tissues. The renal cortex is homogeneously echogenic and the pyramids (P) seen in the medulla become more prominent and can change from hypoechoic to anechoic with increased diuresis. The area labeled shadowing is caused by bowel gas and is due to low reflectivity (referred to as soft or dirty shadow). Homogeneous, Heterogeneous Homogeneous- refers to imaged echoes of equal intensity.  A homogeneous portion of the image may be anechoic, hypoechoic, hyperechoic, or echopenic. Heterogeneous- describes tissue or organ structures that have several different echo characteristics. A normal liver, spleen, or testicle has a homogeneous echo texture, whereas a normal kidney is heterogeneous, with several different echo textures Enhancement, Shadowing Acoustic enhancement and acoustic shadowing are opposite, and both are artifacts. Enhancement—increased acoustic signal amplitude returning from regions lying beyond an object that causes little or no attenuation of the sound beam such as fluid-filled structures. Shadowing—reduced echo amplitude from sound not transmitting due to attenuation or low reflectivity. Echogenic calculi attenuate sound. Sound does not pass through results in sharp, distinctive shadow. Air bubbles (bowel gas) do not allow sound transmission, and sound is reflected. Shadowing caused by air is often referred to as soft or dirty shadowing. Enhancement Enhancement of echoes compared with surrounding tissue Usually occurs distal to fluid-filled structures with decreased attenuation, which allows increased signal amplitude The transverse gallbladder is from a patient with cholecystitis (thickened wall) and a cholelithiasis creating an acoustic shadow due to attenuation. Compare Figure 1-6E with Figure 1-6D with the appearance of a shadow due to low reflectivity.(Images courtesy of Philips Medical System, Bothell, WA.) Shadowing Transverse gallbladder with cholecystitis (thickened wall) and cholelithiasis creating an acoustic shadow due to attenuation Compare with image on right with the appearance of a shadow due to low reflectivity. E. The transverse gallbladder is from a patient with cholecystitis (thickened wall) and a cholelithiasis creating an acoustic shadow due to attenuation. Compare Figure 1-6E with Figure 1-6D with the appearance of a shadow due to low reflectivity  1. What term describes reduced echo amplitude due to attenuation? A. Echopenic B. Homogeneous C. Shadowing D. Anechoic Ex. Acoustic shadowing descried reduced echo amplitude from regions lying beyond an attenuating object 2. What terms describes images of equal intensity? a) Homogeneous b) Echopenic  c) Echogenic d) Hypoechoic 3. What term describes reduced echo amplitude due to attenuation? a) Echopenic b) Homogeneous c) Shadowing d) Anechoic Acoustic shadowing descried reduced echo amplitude from regions lying beyond an attenuating object. Sonographic characteristics: Cyst A cyst diagnosis is based on sonographic characteristic criteria: 1. Cysts retain an anechoic center even at high instrument gain settings. 2. The mass has sharply defined posterior wall indicative of a strong interface between cyst fluid and tissue or parenchyma. 3. There is an increased echo amplitude in the tissue beginning at the far wall proceeding distally compared with surrounding tissue. 4. Reverberation artifacts can be identified at the near wall if the cyst is located close to the transducer. 5. Edge shadowing artifacts may appear, depending on the incident angle (refraction) and the thickness of the cystic wall at the periphery of the structure. Longitudinal right kidney: 1. Anechoic center 2. Sharply defined posterior wall 3. Acoustic enhancement artifact / through transmission far wall proceeding distally compared with surrounding tissue  4. Reverberation artifacts at near wall as the cyst is located close to the transducer 5. Edge shadowing artifacts Solid: A solid structure may have a hyperechoic, hypoechoic, echopenic, or anechoic homogeneous echo texture, or it may be heterogeneous because it contains many different types of interfaces. Usually exhibit the following characteristics: 1. internal echoes that increase with an increase in instrument gain settings; 2. irregular, often poorly defined walls and margins; and 3. low-amplitude echoes or shadowing posterior to the mass due to increased acoustic attenuation by soft tissue or calculi Solid Transverse section right liver lobe with a hemangioma The benign solid mass presents with the following sonographic criteria for a solid mass: 1. internal echoes that increase with increased gain settings and 2. low-amplitude echoes (arrow) or shadowing posterior to the mass Complex: A complex structure usually exhibits both anechoic and echogenic areas on the image, originating from both fluid and soft tissue components within the mass. Relative echogenicity complex soft tissue mass is related to a variety of constituents, including: collagen content interstitial components Vascularity degree and type of tissue degeneration Encapsulated mass is a complex structure exhibiting septa between echogenic and anechoic areas. Cyst, Solid, Complex Use amplitude of echoes distal to mass, structure, or organ to evaluate attenuation properties of the mass. Transonic or sonolucent refers to masses, organs, or tissues attenuating little of the acoustic beam—images result with distal high-intensity echoes. Example: Cystic structure with associated acoustic enhancement artifact Masses attenuating large amounts of sound results in marked decrease in the amplitude of distal echoes. Example: Calculi with the associated shadow artifact Which sonographic characteristic is associated with a cystic mass surface?  a) Poorly defined posterior wall b) Increased attenuation c) Retains anechoic center d) Low reflectivity What criteria should be used to evaluate the amplitude of echoes distal to a cystic, solid, or complex mass? a) Edge shadowing b) Attenuation properties c) Irregular margin d) No change with gain settings Preparation: Sonographer examination preparation includes gathering as much patient information as possible: Indications for the study Clinical information Clinical assessment Level of patient apprehension Preliminary Report includes AKA TECHINICAL IMPRESSION Minimum image documentation: 1. Facility, date, time 2. Instrument and transducer information 3. Intensity, MI, TI 4. Patient identification, age, gender 5. Operator identification 6. Icons: Body position, transducer orientation, image orientation if appropriate Minimum information to include on sonographer’s preliminary report (impressions /worksheet): 1. Patient’s name and other identifying information 2. Date of the examination 3. Relevant clinical information that may include classification of disease code 4. Specific examination requested 5. Name of the patient’s health care provider and contact information Technical impressions worksheet should provide key sonographic findings. Ideal: Sonographer and sonologist together determine documentation is sufficient and examination is complete Report should use image quality definitions and interpretation of sonographic characteristics for clear description of findings: 1. Echogenicity ü Anechoic, hypoechoic, hyperechoic, isoechoic, cystic, solid, complex 2. Texture ü Homogeneous, heterogeneous 3. Distribution ü Focal or diffused 4. Artifacts ü Enhancement, shadowing 5. Measurements (location) ü Vessels, ducts, organs, wall thickness, masses 6. Abnormal amounts of fluid collections Scope of Practice and Clinical Standards for the Diagnostic Medical Sonographer (SDMS) Physicians provide a diagnosis or an interpretive report Sonographers function as a delegated agent of the physician and do not practice independently Sonographic findings: Describing an echogenic mass attached to the gallbladder wall that does not move as the patient changes position discusses the sonographic findings. Diagnosis: The patients have a polyp located in the gallbladder wall. Who can legally provide a diagnosis based on the evaluation of the sonographic findings? a) Physician b) Sonographer c) Sonography students d) Clinical instructor/supervisor Statistical Parameters Four possible results for each examination correlated to independent determination of disease (i.e., biopsy, surgical procedure). 1. True-positive result: The sonography findings were positive, and the patient does have the disease or pathology. 2. True-negative result: The sonography findings were negative, and the patient does not have the disease or pathology. 3. False-positive result: The sonography findings were positive, but the patient does not have the disease or pathology. 4. False-negative result: The sonography findings were negative, but the patient does have the disease or pathology.  Sensitivity describes how well the sonography examination documents whatever disease or pathology is present. 1. [true-positive ÷ (true-positive + false-negative) × 100] 2. If number of false-negative examinations decreases, the sensitivity of the examination increases. 5. Specificity describes how well the sonography examination documents normal findings or excludes patients without disease or pathology. 1. [true-negative ÷ (true-negative + false-positive) × 100] 2. If the number of false-positive examinations decreases, the specificity of the examination increases. Accuracy of the sonography examination is its ability to find disease or pathology if present and to not find disease or pathology if not present. [true-positive + true-negative ÷ (all patients receiving the sonographic examination) × 100 Statistical Parameters Positive predictive value: the probability that subjects with a positive test truly have the disease or pathology [true-positive ÷ (true-positives + false-positives) × 100] Negative predictive value: the probability that patients with a negative test are free of disease or pathology [true-negatives ÷ (true-negatives + false-negatives) × 100] If parameter is expressed in fractions between 0 and 1, the parameter needs to be multiplied by 100 for percentage. What increases if the number of false- positive examinations decreases? a) False-negative b) Sensitivity c) Specificity d) Accura  Abdominal wall Fascia- a thin fibrous tissue covers the muscle anteriorly & posteriorly, located between the skin and the underlying structure. Has a rich supply of blood vessels & nerves No internal strength Superficial Fascia- attached to skin, composed of connective tissue & varying amounts of fat Deep Fascia- underlies superficial layers and loosely joined by fibrous strands. Covers the muscles and partitions them into groups. Thin and densely packed- stronger than the superficial Aponeurosis- Layers of flat tendinous fibrous sheets fused with strong connective tissue serves as tendons and primary function is to attach muscles to fixed points. Minimal blood vessels & nerves Located more in ventral abdominal regions Layers—Multilayered Abdominal Wall Consists of: o Skin o Subcutaneous tissue (superficial fascia) o Muscles and their aponeuroses o Deep fascia o Extraperitoneal fat o Parietal peritoneum Abdominal wall muscles: Rectus Abdominal Muscles Pyramidalis External Oblique Internal Oblique Transverse Abdominal The bilaterally paired, vertically orientated rectus abdominis muscles and the small triangular pyramidalis muscle are located on the anterior wall. The three flat, bilaterally paired muscles comprising the anterolateral group include the external oblique, internal oblique, and the transverse abdominal. The strength of the muscles can be contributed to the collaborative relationship of the orientation of the fiber of each muscle. Rectus Sheath Anatomy- Strong, fibrous compartment for the rectus abdominis and pyramidal muscles, also some arteries, veins, lymphatic vessels and nerves. Anterior & posterior layers- formed from intercrossing and interweaving of aponeurosis of flat abdominal muscles. Arcuate Line- Located halfway from umbilicus to pubic symphysis and refers to the transition terminating the posterior rectus sheath covering the proximal superior ¾ of the rectus abdominis muscles Distal to arcuate line- posterior rectus sheath covering terminates and is only covered by transverse fascia which lies below the rectus abdominis muscles and is all that separates the rectus abdominis muscle from the peritoneum Superior to the umbilicus with the posterior layer of the rectus sheath.. Inferior to the umbilicus. The rectus sheath is separated from the parietal peritoneum only by the transversalis fascia Linea Alba Anatomy- Formed by fibers of the anterior and posterior layers of sheath interlace in the anterior median line. Course vertically entire length of abdomen Separates bilateral rectus sheaths Wider superior / narrows more inferiorly In thin/muscular people a groove in skin may be visualized Umbilicus Anatomy- All layers of anterolateral abdominal wall fuse Umbilical ring is a defect in linea alba located under umbilicus Umbilical ring where fetal umbilical vessels passed to and from the cord and placenta After birth-fat accumulation in subcutaneous tissue raises the umbilical ring and depresses the umbilicus  INQUINAL REGION: Inguinal Ligament formed by the as the inferior border of external oblique extends between the ASIS and the pubic tubercle Inguinal Canal – located superior and medial to the inguinal ligament Formed during fetal development Structures enter and exit the abdominal cavity Exit and entry pathways are potential sites for hernias Adults- oblique passageway meas- approx. 4cm long Males- spermatic cord Females- round uterine ligament *blood vessels, lymphatic vessels and illioinguinal nerves Inguinal Canal Openings- 1. Deep (internal inguinal ring- entrance 2. Superficial (external) inguinal ring- exit for spermatic cord or round ligament POSTERIOR ABDOMINAL WALL: Layers-Fascia Covered with continuous layer endoabdominal fascia which is continuous with transversalis fascia. Figure below demonstrates Posterior abdominal wall fascia. The relationship of the psoas fascia, the three layers of the thoracolumbar fascia, and the quadratus lumborum fascia with the muscles and verterbrae are illustrated on this transverse section of the posterior abdominal wall. Composition Lumbar vertebra Posterior abd wall muscles Diaphragm Fascia Lumbar plexus Fat Nerves Blood vessel Lymphatic vessels  Psoas major Bilaterally paired, long, thick, fusiform muscle Iliacus Bilaterally paired, triangular muscle Quadratus lumborum Bilaterally paired, thick muscular sheet Psoas minor Bilaterally paired, long, slender muscle anterior to psoas major Iliopsoas Formed by the psoas and iliacus muscles Latissimus dorsi Bilaterally paired, broadest back muscle Erector spinae A group of three columns of muscle located on each side of the vertebral column Transversospinal An oblique group of three muscles deep to the erector spinae Muscles categorized as superficial & intermediate extrinsic back muscles and superficial layer and deep layer of intrinsic back muscles. 3 main- bilat paired make up posterior abd wall- psoas major, iliacus, and quadratus lumborum DIAPHRAGM: Right dome is slightly higher than left because of liver presence and central depressed by pericardium. Major muscle inspiration Central part descends during inspiration and ascends during expiration remember ae di Double-domed, musculotendinous partition separates the thoracis cavity and abdominal cavity Superior surface- convex –forms floor of thoracic cavity Inferior surface- concave- forms roof of abdominal cavity Muscular part is located peripherally with fibers converge radially on the trifoliate central aponeurotic part= central tendon Central tendon has no bony attachments and appears incompletely divided into what resembles 3 leaves of wide cloverleaf. Diaphragm. The view of the concave inner surface forming the roof of the abdominopelvic of the abdominopelvic cavity illustrates the fleshy sternal, costal, and lumbar parts of the diaphragm (outlined with broken lines.). Identify the relationship of how each part attaches centrally to the trefoil-shaped central tendon, the aponeurotic insertion of the diaphragmatic muscle fibers.  Area around caval opening is surrounded by muscular part forming a continuous sheet divided into three parts based on areas of attachment 1. Sternal part 2. Costal part 3. Lumbar part Diaphragmatic Crura Musculotendinous bands arising from anterior surfaces of the bodies of the superior three lumbar vertebrae, the anterior longitudinal ligament, and intervertebral discs. Right crus is larger and longer than the left crus appearing as triangular mass anterior to aorta. It arises from the first three lumbar vertebrae and appears posterior to the caudate lobe of the liver.  Left crus arises from the first two lumbar vertebrae. anatomic varients Composed of individual variations in fat and muscle content. Each lateral muscle layer tends to be identifiable in muscular individuals. Muscle groups tend to be indistinct in less well-developed individuals. Fatty layer variation can be significant in obese patients. Scanning the abdominal wall: Sonography of the abdominal wall structures is fast, available, less expensive, and noninvasive. Sonography enables the viewer to see the superficial layers of the abdomen. Clinical questions can be answered in evaluating post trauma or postsurgical patients. Lesions demand excellent near-field imaging Newer- high frequency, short focus transducers 7.56MHz or higher linear array Pathologic processes to image include inflammatory lesions hemorrhage  hernia masses Important to understand the normal sonographic appearance of the abdominal wall, appropriate instrumentation, scanning techniques, and equipment with excellent near-field imaging Evaluating the various layers of the normal abdominal wall and a contiguous diaphragm should be part of every high-quality sonographic abdominal study. Stand-off pads may be required in some cases On transverse sections of the anterior abdominal wall, the subcutaneous tissue linea alba and rectus abdominis muscle can be visualized. A. Superior to the umbilicus, both the anterior and posterior rectus sheath are seen. B. Inferior to the umbilicus, the rectus sheath is separated from the parietal peritoneum only by the transversalis fascia Abdominal wall pathologies Three major categories of disease affect the: Abdominal wall Peritoneum Abdominal spaces  Abdominal wall tissues and membranes lining its spaces are affected by: Inflammatory Trauma Neoplastic changes Abscess Abscess Near surgical site or painful area, subphrenic, subhepatic, paracolic gutters, and left perihepatic, perisplenic, and pelvis Hematoma Near wound or surgical site Ascites Most dependent areas of body, cul-de-sac, Morrison pouch, paracolic gutter, pararenal areas, perihepatic, midabdominal Urinoma Adjacent to kidneys  Lymphocele Adjacent to renal transplant Shape: Lenticular or shape of space Usually good Anechoic, irregular or smooth borders; may have internal echoes, septations, fluid–fluid level; abscesses that contain gas are echogenic and may shadow Shape: Lenticular or shape of space Coincides with stage; good to slow or Change with stage of resolution; fresh blood or decreased; may clotted blood are hypoechoic; clot fragmentation increase due to fluid creates internal echoes and anechoic areas with portion some scattered echoes; may have fluid–fluid level due to cholesterol in red blood cell breakdown; long-standing hematoma may have thick contours Anechoic if benign, ascites if exudative, internal Increased echoes if malignant; bowel and implants in anechoic ascitic fluid Usually anechoic unless infected Increased Usually anechoic but may have septations Increased Abscess: Space-occupying lesions whose fluid content allows them to assume varies shapes. Post-surgical incisional infections Tuberculous paraspinal abscesses Suppurative(pus) inflammation- creates abscess from persistent infection  Periumbilical Abscess Left: A periumbilical abscess presents with a mixed echo appearance with good acoustic transmission. Right: The computed tomography examination demonstrates the size, shape, and periumbilical location (arrows). Intra-abdominal abscess of mixed echogenicity (closed arrow) extending into the pelvic region adjacent to the fluid-filled bladder (open arrow). Good acoustic transmission is demonstrated posterior to the abscess collection. Sonographic appearance of an abscess is quite variable Often an abscess is complex (mixed solid and cystic) debris, septations and gas can be seen within abscess Gas within the abscesses may produce a reverberation (comet-tail) artifact  Abscesses typically demonstrate posterior enhancement depending on the cystic component of it The most reliable finding in a patient with an abscess : Presence of fever Increased white blood cell count Longitudinal image of a left psoas muscle abscess (arrows) located near the left kidney and extending superiorly. The mixed echo appearance demonstrates good acoustic transmission. Rectus Sheath Hematoma Rectus abdominus muscles are 2 longitudinally orientated muscles extending from xiphoid process to the pubic bone. They are encased in a sheath anteriorly and posteriorly. The sheaths join at the midline to form the linea alba which is a complete partition of this compartment Anterior & posterior rectus sheath extend from the costal margin to the arcuate line, which is located midway between the umbilicus and the pubic symphysis, where the posterior wall of the sheath ends. Superior to the arcuate line, hematomas are superficially located confined between the anterior and posterior sheaths and should not move across the midline due to the linea alba Rectus sheath hematoma- results from bleeding from the superior or inferior epigastric vessels (sup & inf umbilicus) or form a tear of the rectus muscle. Inferior to the arcuate line, the posterior rectus sheath is absent with only the weak transversalis fascia and peritoneum separating the abdominal muscle from the abdominal viscera. A rectus muscle hematoma inferior to the arcuate line will extend into the Space of Retzius (retropubic space) within the pelvis causing external compression and irritation of the urinary bladder. The bleeds inferior to the arcuate line are more extensive, without the posterior sheath the bleed does not tamponade as it does above the arcuate line. Although most rectus sheath hematomas are self- limiting, extensive bleeding can result in a decrease in hematocrit and hypovolemic shock.  Rectus Sheath Hematomas Occur due to: External Trauma Trauma from surgery Vigorous muscle contraction Valsalva with severe coughing / vomiting Pregnancy Acoustic transmission coincides with the stage and the age of the hematoma Good to slow acoustic transmission and when fluid portion increases- acoustic transmission increases. As they organize, they are hyperechoic- echogenic Resorb-Hypoechoic phase Liquefy –anechoic phase Sonographically: Variable depending on the age of the bleed  Rectus Sheath Hematoma Is a recognized complication of anticoagulation therapy Hernia: 2 Main Categories: 1. Ventral- anterior / anteriolateral wall (account 75%) Groin- (indirect inguinal, direct inguinal, and femoral 3 Major Factor causing: 1. Abnormal collagen metabolism 2. Pressure overload- (obesity, heavy lifting, coughing, smoking) 3. Natural weak area where vessels penetrate the abdominal wall Direct Hernia- located Medial to the inferior epigastric vessels Indirect Hernia- Located Lateral to the inferior epigastric vessels Epigastric Hernia—occurs due to weakness on the midline of the upper adb wall, on a line between the breast bone and umbilicus Inguinal Hernia- is the most common abd wall hernia occurring more often in men than women Incisional Hernia- result of a post operative weakening of abd wall Indirect Inguinal Hernia- follows the inguinal canal descending from the abdomen into the scrotum. The indirect inguinal hernia is located lateral to the inferior epigastric vessels Umbilical hernia-occurs near umbilicus due to the natural weakness of the abdominal wall from the umbilical cord Direct Inguinal Hernia- occurs slightly to the inside of the site of the indirect hernia, in an area where the abd wall is naturally slightly thinner. The direct inguinal hernia is located medial to the inferior epigastric vessels Femoral Hernia-occurs within the femoral canal adjacent to the femoral vein just below the groin crease and is usually associated with pregnancy Spigelian Hernia- occurs along the edge of the rectus abdominus muscle through the spigleian fascia, which is several inches lateral to the middle of the abdomen Obturator Hernia-protrudes from the pelvic cavity through an opening in the pelvic bone (obturator foramen) because of lack of visible bulging, this hernia is very difficult to diagnose : Longitudinal plane shows an umbilical hernia (UH) containing fat and bowel that passed through a dilated umbilical rings (UR). B: On a different patient, the transverse plane shows a paraumbilical hernia (arrows) containing fat. The contiguous muscle can be seen on the normal abdominal wall on the left. The right sonogram demonstrates a small spigelian hernia (dotted outline) as it herniated through both the torn transverse abdominis (TA) and the internal oblique (IO) muscles. The external oblique (EO) muscle is intact. On this obese patient, there is a large amount of fat seen between internal oblique and external oblique muscle. A mushroom-shaped or anvil-shaped hernia correlates with non-reducibility and the increased risk of strangulation.  Inguinal Hernia A. The sonograms on this newborn female with a palpable right lower quadrant mass reveal the uterus (UT) and ovary (OV) herniated through the canal (arrows). B. On another plane, the ovary (OV) is seen in the area of the mass.  Inguinal Hernia Left: Inguinal hernia in a male patient with the left testis in the hernia sac. Right: Color Doppler used to identify blood flow within the herniated testis. Incarceratated Hernia: Incarcerated Hernia: occurs when herniated tissue becomes trapped and cannot easily be moved back into place. An incarcerated hernia can lead to a bowel obstruction or strangulation. An incarcerated hernia can become strangulated, which cuts off blood flow to the tissue that’s trapped.  Incarcerated Abdominal Wall Hernia Left : Incarcerated abdominal wall hernia with dilated non-reducible small bowel loops and effusion in the hernia. This transverse section of the right upper quadrant abdominal wall demonstrates bowel protruding through an abdominal wall defect (arrows). Right: Enlarged non-reducible small bowel loops and effusion within the hernia. Advantages of sonography over other imaging modalities: 1. Ability to scan the patient in both upright and supine positions 2. Ability to include dynamic maneuvers such as Valsalva and compression 3. Ability to document motion in real time Scanning protocol to document hernia information includes: 1. Demonstrating an abdominal wall or groin defect 2. Determining the presence of bowel loops within a lesion 3. Exaggeration of the lesion on straining of the abdominal musculature 4. Reducibility of the lesion with pressure Sonographic Evaluation Can Determine: 1. Location, size, and contents of a hernia 2. At hernia site if there is interruption of the peritoneal line separating the muscles and abdominal contents 3. If the hernia sac is: Fluid-filled Contains peristaltic bowel Motion Gas—shadowing Mesenteric fat Highly reflective, lacks both peristalsis and shadowing Capture dynamic events to store on video loops Neoplasms Primary abdominal wall tumors include: 1. Lipomas 2. Areas of calcification in old surgical scars 3. Desmoid tumors 4. Soft-tissue sarcomas 5. Metastatic carcinoma 6. Melanomas Sonography, CT, MR, and fine-needle biopsy are all valuable tools to distinguish between lipomas, hematomas, abscesses, hernias, and neoplasms Diaphragmatic Pathology Pain Paralysis  Herniation Eventration Peridiaphragmatic abnormalities Pleural effusion/ascites Paralysis: Detected after an abnormal chest x-ray. Cause: Damaged phrenic nerve. Detection: Showing absent or abnormal movement comparing with the opposite unaffected site. Measuring the thickness of the diaphragm during inspiration, comparing with the opposite site (normal diaphragm should get thick in inspiration) Eventration Abnormal elevation of the diaphragm due to failure of the muscle fibers to develop during gestation. This weak area can give way to abdominal organs to protrude into the chest, this is called diaphragmatic hernia. Diaphragmatic eventration can be partial (segmental) or complete. Unilateral or bilateral Congenital eventration appears as abnormal bulge or pouch in the diaphragm that moves with respiration. Hernia: Congenital or acquired Congenital occurs in 1 in 2000-5000 live births, results from maldevelopment or localized weakness. About 56% of affected infants die from respiratory failure. It may allow abdominal contents to enter the thorax (stomach, small bowel, spleen) limiting the development of the lungs and shifting the mediastinum and heart.  Pleural Effusion A,B. Sonographic chest evaluation from the right posterior surface on a pediatric patient with a history of pneumonia. Sonogram reveals a loculated pleural effusion with thick adhesions (arrows) superior to the right lobe of the liver. Right lung (RL) is also seen. Adhesions can make thoracentesis more difficult, but sonography can help guide the procedure. C. Sonographic evaluation from the coronal right chest in a different pediatric patient demonstrates a complex pleural effusion (PE) superior to the right lobe of the liver. Right lung (RL) is also visualized. Diaphragmatic Hernia A. The sonographic evaluation on a prenatal patient reveals a diaphragmatic hernia. The liver is seen on both sides of the diaphragm (arrows). B. The gallbladder (GB) is also seen superior to the diaphrag Peritoneal cavity:  Abdominal cavity — Peritoneum — Parietal layer — Visceral layer Peritoneal Cavity: (abdominal and pelvic) — Greater sac — Lesser sac — Diverticulum from greater sac — Epiploic foramen — Posterior to stomach Greater Omentum: — Apron between small intestine and ant abd. wall — Greater curvature of stomach and transverse colon. Lesser Omentum: Between lesser curvature of stomach and liver Ligiments of the peritoneal cavity: Ligaments divide portions of the peritoneal cavity Understanding ligaments will help understand where to look for fluid and other pathology within peritoneal sac and how to describe its location  Gastrohepatic ligament- AKA lesser omentum, smaller omentum gastrohepatic omentum. Connects lesser curvature of stomach and left sagittal fissure for ligamentum venosum (transverse fissure) of liver. Hepatoduodenal ligament- Thickened free edge of lesser omentum through which courses portal triad. Connects liver to the duodenum. Falciform Ligament- Double-layered fold of peritoneum that ascends from umbilicus to liver. Contained within it is ligamentum teres. Falciform ligament passes on anterior and then superior surface of liver before splitting into two layers. Right layer forms upper layer of coronary ligament; left layer forms upper layer of left triangular ligament. Coronary Ligament- Bifurcation of falciform ligament layers that fuse with parietal peritoneum to form borders of bare area of liver, suspending liver from diaphragm. Right branch becomes coronary ligament, and left branch becomes left triangular ligament. It limits greater sac at its cephalad extent into anterior and posterior compartments in right subphrenic area. Left triangular ligament- Formed by left branch of falciform ligament and parietal peritoneum. Forms left extremity of bare area of liver. Splenorenal Ligament- aka: lienorenal ligament Connects splenic hilum to posterior abdominal wall, through which splenic vein and artery travel. Gastrosplenic Ligament- Connects stomach to spleen and inferior diaphragm. Broad Ligament-  Suspensory ligament extending from lateral uterine sidewalls to pelvic sidewalls dividing pelvis into anterior and posterior compartments in fema Ligamentum Teres- Remnant of the fetal umbilical vein contained within falciform ligament. It passes into a fissure on visceral liver surface to join left branch of portal vein in porta hepatis. Ligamentum Venosum- Exhibits as a fibrous band (remnant of ductus venosus) attached to the left branch of portal vein. It ascends in a fissure on visceral liver surface to attach above IVC. In fetal circulation, oxygenated blood flows to liver via the umbilical vein (ligamentum teres). Most of blood bypasses liver via the ductus venosus (ligamentum venosum) and enters IVC. Spaces of Peritoneum- Potential spaces are created by the peritoneal layer, reflecting between 2 organs or the organ and the peritoneal wall. A potential space is usually an empty fold: when disease is present- fluid or other materials may collect in these spaces. (Ascites, Blood, Pus) Potential Spaces of Peritoneum Left Anterior Subphrenic Space- AKA: Suprahepatic Space An extension of the greater sac between diaphragm and anterior superior liver leftward of falciform ligament Left Posterior Suprahepatic Space. AKA: Superior recess of Lesser Sac An extension of the lesser sac between diaphragm and posterior superior liver. Right Subphrenic Space- AKA Suprahepatic Space An extension of the greater sac between right hemidiaphragm and anterior superior liver rightward of the falciform ligament. Hepatorenal Space. AKA Morrison Pouch Created by peritoneum, reflecting from liver over right kidney and right posterior peritoneal wall. When patient is in supine position, this space is the most gravity-dependent potential space of the abdominal cavity, collecting fluid from the supracolic area and lesser Lesser Sac/Omental Bursa- Sandwiched between posterior stomach and parietal peritoneum covering anterior pancreas (front-to- back) and splenorenal and gastrosplenic ligaments and epiploic foramen [omental foramen, foramen of Winslow] (side-to-side). In cases of posterior gastric wall perforation or inflammation or trauma to the pancreas, fluid or a pseudocyst may be identified in this space. Right Anterior Subphrenic Space and Hepatorenal Space Longitudinal right upper quadrant demonstrates fluid within the right anterior subphrenic space (single arrow); ascites is also seen within the hepatorenal space (double arrows). Lesser Sac (Omental Bursa) Transverse image of the epigastrium demonstrates a hematoma (arrows) within the lesser sac in a patient with acute pancreatitis. The posterior wall of the stomach (ST) borders the hematoma anteriorly. The pancreas forms the posterior border Right & Left Paracolic Gutters- Grooves found along lateral ascending and descending colon that conduct fluids between the supracolic compartment of abdomen and infracolic compartment of inferior abdomen and pelvis. They are important in determining extension of disease. This diagram demonstrates the flow of fluid and other materials between the infracolic and supracolic compartments. Gutters: Transverse image of left paricolic gutter with normal musculature and vasculature. Arrows indicate where free fluid could collect. IP, iliopsoas muscle; CIV, common iliac vein; CIA, common iliac artery. Vesicorectal Space: AKA Cul-de-sac in male Created by peritoneal reflection over the rectum and posterior bladder wall. When the male is in supine position, this space is most gravity-dependent potential space of pelvic cavity draining fluid from infracolic area. Rectouterine Space: AKA- Rectovaginal Pouch, Pouch of Douglas, Posterior Cul-de-sac in female Created by parietal peritoneum draping over anterior rectum, posterior vaginal wall, and posterior uterus. When female is in supine position, this space is the most gravity-dependent potential space of the pelvic cavity draining fluid from the infracolic area. Space of Retzius- AKA- Prevesicle space or Retropubic Space An extraperitoneal potential space located between the anterior wall of the urinary bladder and the pubic symphysis. Uterovesical Space- AKA- Uterovesical Pouch, Anterior Cul-de-sac in female Created by the peritoneal reflection over the uterine fundus, anterior uterus, broad ligament, and the posterior urinary bladder. Fast exam: FOC