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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5780_Библиотеки_им_академика_М_И_Перельмана.pdf
8.2 Abnormal Findings
Schmidt, Ultrasound © 2007 Thieme
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ef
Fig. 316 e, f Typical findings in the cervical vessels associated with occlusion of
the ICA. e Longitudinal scan of the CCA shows an abrupt cutoff of blood flow in the
ICA with color reversal (blue). f Transverse scan of the ICA and ECA. The ICA
appears occluded with echogenic material in cross section, with no evidence of
color flow signals. By contrast, the color signals in the ECA indicate flow. An oblique
section of the anechoic internal jugular vein (IJV) appears adjacent to the ICA
Thrombosis, Dissection
..............................................................................................................
n
Jugular vein thrombosis following insertion of a central venous catheter:
See Fig. 317).
ab
8
8
8
Cervical Vessels
Cervical Vessels
Cervical Vessels
Fig. 317a, b Thrombosis of the jugular vein. a Echogenic thrombus (T) in the
jugular vein (JV) following insertion of a CVC. b CDS demonstrates flow (encoded in
blue) around the thrombus
229
8.2 Abnormal Findings
Schmidt, Ultrasound © 2007 Thieme
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8
8
8
cd
Cervical Vessels
Cervical Vessels
Cervical Vessels
Fig. 317 c, d Thrombosis of the jugular vein. c Transverse scan of the jugular vein
demonstrates circumferential flow around the thrombus. d Scan at a higher level
shows the thrombus adherent to the vessel wall
230
9.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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9 Liver
9.1 Examination
Scan Planes
..............................................................................................................
n
Upper abdominal transverse scan (to demonstrate the left lobe of the liver, see
p. 22)
n
Right subcostal oblique scan (see p. 22)
n
High and extended right intercostal scans (see pp. 33 and 24)
n
Paramedian upper abdominal longitudinal scans (see p. 24)
Sonographic Anatomy and Normal Findings
..............................................................................................................
n
The liver exhibits a diaphragmatic surface and a visceral surface.
n
Both surfaces meet anteroinferiorly at the sharp inferior hepatic border and
posterosuperiorly at the fixed part of the diaphragm.
n
The liver is divided anatomically into the right and left lobes, the falciform ligament separating the larger right lobe from the smaller left lobe. The quadrate
lobe (segment IV) and the caudate lobe (segment I) belong physiologically to
the left lobe (Figs.
Fig. 318 Segmental anatomy of
the liver, diaphragmatic surface.
A line between the gallbladder and
inferior vena cava divides the liver
into right (Segment V–VIII) and left
physiologic lobes (Segment I–IV)
318 and 319).
9
Liver9Liver9Liver
Fig. 319 Segmental anatomy of
the liver, visceral surface. Boundaries
of the caudate lobe: upper hepatic
border, falciform ligament, portal
vein, and vena cava. Boundaries of the
quadrate lobe : lower hepatic border,
falciform ligament, gallbladder,
and portal vein
231
9.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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9
n
Normal values: craniocaudal liver diameter on the midclavicular line (MCL) in
heavy-set patients I 120 mm, in asthenic patients I 140 mm. Sum of length
Liver9Liver9Liver
plus depth I 24–26 mm. Depth over the aorta at the level of the celiac trunk
I 40 mm.
Scanning Protocol
..............................................................................................................
n
Transducer: 2.5–5.0 MHz (depending on the abdominal circumference)
n
Right subcostal oblique scan: Ask the patient to take a deep breath and hold it.
Define the dome of the liver with the diaphragm, hepatic veins, portal venous
branches (common hepatic duct), the intrahepatic bile ducts, the gallbladder,
and the hepatic parenchyma (see Fig.
320).
ab
cd
Fig. 320a–d Subcostal oblique scans. a, c Scan through the porta hepatis into the
upper part of the liver. PV = right and left branch of the portal vein. V = inferior
vena cava, arrow = ligamentum venosum. b, d Scan directed from the inferior
hepatic border (at top of image) to the fixed part (at bottom of image) demonstrates the quadrate lobe (QL) and caudate lobe (CL) anterior to the vena cava (VC).
L = right lobe of liver, PV = portal vein
n
Scan through all portions of the liver in a fan-shaped pattern.
n
Upper abdominal longitudinal and intercostal scans: Evaluate the porta hepatis,
the bile ducts, the portal vein, and the lateral portions of the liver (see Fig.
n
Scanning tip: When examination conditions are not ideal, these same planes can
be used for scanning the other portions of the liver and the gallbladder.
232
321).
9.1 Examination
Schmidt, Ultrasound © 2007 Thieme
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a b
c d
Fig. 321a–d a, b Upper abdominal longitudinal scan of the subdiaphragmatic
vena cava and the termination of the hepatic veins (arrow). QL = quadrate lobe,
PV = portal vein, CL = caudate lobe, VC = inferior vena cava, L = liver. c, d High
intercostal scan on the right side demonstrates the costophrenic angle (CA),
posterior portions of the diaphragm (DIA) and the entry echo of the lung (L)
9
Liver9Liver9Liver
Overview of Findings, Classification
..............................................................................................................
n
Changes in the liver: Sonographic abnormalities of the liver may consist of diffuse
or circumscribed changes in the normal hepatic architecture:
x
Diffuse changes (see Table 41, p. 234): These refer to a general alteration of nor-
mal liver architecture with regard to size, echogenicity, contours, vasculature,
and tubular tracts. Changes in echo texture and contours are particularly significant.
x
Circumscribed changes (see Table 44, p. 241): focal alterations in the normal
echo texture of the liver. Their detectability depends on the difference in acoustic impedance between the change and normal surrounding liver (anechoic
lesions such as cysts are easily recognized). A lesion that is isoechoic to surrounding liver can be distinguished only by the presence of a hypoechoic rim
or vascular displacement
n
Changes in the portal veins (see Table 45, p. 257) : Abnormalities of the portal
vein and its tributaries may produce changes identical to those found in the
systemic veins (see Table
34, p. 208).
233
9.2 Diffuse Changes
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9
9.2 Diffuse Changes
Liver9Liver9Liver
Overview (Table 41):
..............................................................................................................
Table 41.Diffuse changes in hepatic echogenicity or contours
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Subtle Pronounced
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Alimentary or diabetic fatty liver
(p. 234)
Acute hepatitis (p. 235) Micronodular abscesses, metastases (p. 237)
Chronic hepatitis (p. 235) Toxic fatty liver, chronic toxic liver disease (p. 237)
Fibrosis (p. 235) Severe chronic hepatitis, hepatic cirrhosis (p. 238)
Congestive cirrhosis (p. 236) Diffuse metastasis, metastatic liver during
Incipient hepatic cirrhosis (p. 236)
Diffuse metastasis, systemic
hematologic disease (p. 239)
Subtle Changes in Echogenicity or Contours
..............................................................................................................
n
Alimentary or diabetic fatty liver (Fig. 322):
x
Slight coarsening of the parenchymal echo pattern and increased echogenicity
in relation to the kidney
x
Moderate (14–16 cm) to severe (17–20 cm) hepatic enlargement in longitudinal
section on the MCL
x
Minimal acoustic shadowing on the far side of the liver
x
Rounded hepatic contours
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Sarcoidosis (p. 237)
chemotherapy
ab
Fig. 322a, b Fatty liver (L, LE). a Slight coarsening of the parenchymal echo
pattern, increased echogenicity, distal acoustic shadowing, and organ enlargement. b Longitudinal scan shows increased hepatic echogenicity (relative to the
kidney) and a rounded inferior border (arrows). K = kidney
234
9.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
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n
Acute hepatitis:
x
Markedly good sound transmission or slightly increased echogenicity
x
Inflammatory hilar lymphadenopathy
x
Splenomegaly
x
Empty gallbladder with a thickened wall
n
Chronic viral hepatitis (Fig. 323): variable echogenicity and contour changes, ran-
ging from a normal-appearing liver (mild or “persistent” hepatitis with low activity) to changes like those seen in an early form of hepatic cirrhosis (severe or
“aggressive” hepatitis with high activity).
x
Sonographic signs:
– Slight coarsening of the parenchymal echo pattern. Acoustic shadowing is
seen in chronic toxic liver disease.
– Slight lobulation of the contours
– Incipient dilatation of the portal vein
– Frequent splenomegaly
– Caliber irregularities in the hepatic veins
ab
Fig. 323a, b Chronic hepatitis C, mild form. a Very slight coarsening of the parenchymal echo pattern and increased sonodensity with faint acoustic shadowing.
Right subcostal scan. b CDS: inflammatory hilar lymphadenopathy (LN).
Right intercostal scan through the porta hepatis. VC = vena cava
n
Fibrosis (Fig. 324):
x
Slightly coarsened or mottled echo texture (if secondary to inactive chronic
hepatitis or cirrhosis, resembles the appearance of chronic hepatitis or cirrhosis
but with essentially normal liver values).
9
Liver9Liver9Liver
ab
Fig. 324a, b Hepatic fibrosis. a Congenital fibrosis in a 23-year-old woman with
portal hypertension following the placement of a portosystemic shunt. A = ascites.
b Inactive chronic sclerosing cholangitis with marked fibrosis: coarse high-level
echoes, wavy course of the hepatic vein (arrows)
235
9.2 Diffuse Changes
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9
x
Coarse, heterogeneous echo pattern
x
Possible distal acoustic shadowing as in a fatty liver
Liver9Liver9Liver
n
Congestive cirrhosis (Fig. 325):
x
Hepatic echogenicity is normal or slightly increased (can be clearly evaluated
owing to increased vascularity); rounded contours
x
Hepatomegaly
x
Hepatic veins and vena cava are dilated, do not show caliber variations with
respiration
x
Enlarged caudate lobe
x
Possible associated findings: ascites, portal vein dilatation, splenomegaly
Fig. 325 Congestive cirrhosis. The liver
still has a normal parenchymal echo
pattern, but note the curved, bulging
inferior border and the tiny breaks in the
capsule (arrows). A = ascites
n
Hepatic cirrhosis (Fig. 326): In early and intermediate stages (Child A and B),
there may be only slight coarsening of the parenchymal echo pattern with very
little disruption or lobulation of the liver contours, resulting in an absence of
characteristic changes (Table
Table 42.Sonographic features of hepatic cirrhosis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Direct signs Indirect signs
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy yyyyyy
Coarsening of the parenchymal echo pattern
(stippled to mottled pattern)
Enlargement and hypoechoic transformation
of the caudate lobe
42).
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Intrahepatic portal vein dilatation i 11 mm,
flow changes (see p. 259)
Portal vein dilatation in the hepatoduodenal
ligament i 13–15mm
Bulging contours Splenomegaly
Vascular irregularities, bowing, abrupt caliber
Ascites
changes
Recanalized umbilical vein Portosystemic collaterals
Breaks in the capsule (“brush” or “shingled
roof” appearance)
Luminal expansion of the hepatic artery
(see Fig. 368, p. 259)
236
9.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
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ab
Fig. 326a, b Hepatic cirrhosis, Child stage A. a Autoimmune cirrhosis: minimal
changes in the echo pattern, slightly wavy contour, increased portal vein diameter
(14.2 mm, cursors). b Hepatic cirrhosis in GAVE syndrome: bulky, slightly wavy
hepatic border with hepatomegaly. The patient presented clinically with recurrent
gastric bleeding, a Quick PT of 60 %, and a history of alcohol abuse.
L = liver, K = kidney
Very Pronounced Changes in Echogenicity or Contours
..............................................................................................................
n
Sarcoidosis (Fig. 327):
x
Pronounced coarsening of the parenchymal echo pattern
x
Hypoechoic micronodular infiltrates
9
Liver9Liver9Liver
Fig. 327 Sarcoidosis of the liver: coarse
parenchymal echo pattern, nonvisualization of the vessels, and multiple small
hypoechoic foci (arrows)
n
Micronodular abscesses or metastases (Fig. 328):
x
Coarse, grainy hypoechoic texture
x
Vessels faint or not visualized (compression by portal vessels, hepatic veins)
ab
Fig. 328a, b Micronodular infiltrates in the liver (L). a Microabscesses in urosepsis:
grainy hypoechoic texture (same appearance as mycotic abscesses). b Micronodular hypoechoic metastases from a neuroendocrine tumor. K = kidney
237
9.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
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9
n
Toxic fatty liver, chronic toxic (drug- or alcohol-induced) liver disease (Fig. 329):
With increasing severity and fibrous transformation, structural changes tend to
Liver9Liver9Liver
occur:
x
Generally increased echogenicity with individual coarse echoes
x
Acoustic shadowing, even with minimal depth of involvement
x
Caliber irregularities and nonvisualization of hepatic veins and small portal
venous branches
x
Incipient lobulation and granularity of hepatic contours
x
Progressive increase in portal vein diameter
Fig. 329 Severe chronic, drug-induced
toxic liver disease with fibrosis: dense,
granular hyperechoic texture with no
detectable vessels and marked acoustic
shadowing (same appearance as chronic
toxic alcoholic liver disease with structural transformation)
n
Severe chronic hepatitis with structural change or cirrhosis (Figs. 330 and 331):
n
Note: The echo pattern and contours of the liver depend on the extent of the
changes, the degree of fibrous transformation that has occurred, and the etiology of the cirrhosis. The appearance of the portal vessels, the presence of
ascites, and the size of the spleen depend on the severity of portal hypertension
and on inflammatory activity.
x
Direct and indirect sonographic signs: see Table 42, p. 236
x
Sonographic signs indicating the etiology of cirrhosis: see Table 43.
ab
Fig. 330a, b Advanced chronic viral hepatitis, hepatic cirrhosis. a Severe chronic
hepatitis B: patchy structural transformation with poor delineation of the hepatic
veins. b Child stage B hepatic cirrhosis in hepatitis C: coarse, echogenic areas of
fibrosis with massive enlargement of the caudate lobe (CL). CL:RL (right liver) =
74:43 mm = 1.7 (cursors; normal ratio J 0.55)
238