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CHAPTER 5 Inferior Vena Cava Scanning Protocol 89
17. The IVC is right lateral to all of the following except the
a) aorta.
b) caudate lobe.
c) left renal vein.
d) portal splenic confluence.
18. The IVC is posterior to all of the following except the
a) uncinate process.
b) spine.
c) hepatic veins.
d) common bile duct.
19. The IVC passes through a deep fossa on the posterior surface of the
liver between the ______________ and ______________.
a) caudate lobe and gallbladder fossa
b) spine and right lateral lobe
c) caudate lobe and bare area
d) bare area and diaphragm
20. Normally, the diameter of the IVC will ______________ during the
Valsalva maneuver or inspiration.
a) decrease
b) increase
c) collapse
d) stay the same
21. The orientation of the IVC within the body is
a) vertical oblique.
b) vertical.
c) oblique.
d) horizontal.
22. Which of the following vessels runs posterior to the IVC?
a) left renal vein
b) right hepatic artery
c) right renal artery
d) left renal artery
23. The IVC lies along the posterior surface of what lobe of the liver?
a) left
b) caudate
c) quadrate
d) anterior segment of the right
90 PART III Abdominal Scanning Protocols
Pancreas
Left
Anterior
Posterior
24. In the following transverse scanning plane image, a(n) _________
section of the IVC is visualized.
Spine
body
Splenic vein
Superior
mesenteric
artery
Aorta
Pancreas
tail
Left
renal vein
Left renal
artery
Liver
Gastroduodenal
confluence
Pancreas
Right
Portal
splenic
head
artery
Inferior
vena cava
Crus of diaphragm
Right renal artery
a) transverse
b) longitudinal
c) sagittal
d) axial
25. In the transverse scanning plane image above, a(n) _________
section of the left renal vein is visualized.
a) transverse
b) longitudinal
c) sagittal
d) axial
CHAPTER 5 Inferior Vena Cava Scanning Protocol 91
Common
rior
26. In the following sagittal scanning plane image, a(n) _________
section of the IVC is visualized.
Liver
Portal
vein
Superior
Inferior
vena cava
Diaphragm
Anterior
Posterior
a) transverse
b) longitudinal
c) sagittal
d) axial
27. In the sagittal scanning plane image above, a(n) _________ section
of the right renal artery is visualized.
a) transverse
b) longitudinal
c) sagittal
d) axial
bile duct
Pancreas
head
Right
renal
artery
Infe
Spine
Hepatic veins
Falciform ligament
Esophagus
Ligamentum teres
ftRigh
Ligamentum teres
Bile
border
*
Portal vein
ry
Proper hepatic artery
Gastroduodenal
t
Le
Diaphragm
Right lobe
Common duct
Gallbladder
Right adrenal gland
Right kidney
Inferior border
ducts
Gallbladder
Right lobe
IVC
Aorta
Anterior View of Liver
Falciform ligament
*
Left lobe
Spleen
Stomach
Left adrenal gland
Left kidney
Pancreas
Duodenum
Quadrate lobe
Hepatic artery
Portal vein
Left hepatic artery
Right portal vein
Right hepatic artery
artery
Common duct
Gallbladder
Bare area
Inferior vena cava
Hepatic veins
Caudate
lobe
View of Liver From Below
Left portal vein
IVC
Aorta
Vessels and Ducts of Liver
Ligamentum venosum
Common hepatic artery
Celiac trunk
Splenic artery
Splenic vein
Inferior mesenteric vein
Superior mesenteric arte
Superior mesenteric vein
Superior
Portal triad
Liver Scanning Protocol
Betty Bates Tempkin
Key Words
Anterior surface
Biliary tract
Caudate lobe
Common hepatic artery
Coronary ligament
Cystic artery
Falciform ligament
Gastroduodenal artery
Gastrohepatic ligament
Glisson’s capsule
Hepatic ducts
Hepatic veins
Hepatoduodenal ligament
Inferior surface
Intraperitoneal
Left functional lobe
Left hepatic artery
Left intersegmental fissure
Left lobe
Left triangular ligament
Ligamentum teres
Ligamentum teres fissure
Ligamentum venosum fissure
Main lobar fissure
Middle hepatic artery
Porta hepatis
Portal triad
Portal vein
Portal venous system
Posterior surface
Proper hepatic artery
Quadrate lobe
Right functional lobe
Right hepatic artery
Right lobe
Right triangular ligament
Superior surface
CHAPTER 6
Objectives
At the end of this chapter, you will be able to:
• Define the key words.
• Distinguish the sonographic appearance of the liver and the
terms used to describe it.
• Describe the transducer options for scanning the liver.
• List the various suggested breathing techniques for patients when
scanning the liver.
• List the suggested patient position (and options) when scanning
the liver.
• Describe the patient prep for a liver study.
• Distinguish normal variants of the liver.
• Name the survey steps and explain how to evaluate the entire
length, width, and depth of the liver.
• Explain the order and exact locations to take representative
images of the liver.
• Answer the review questions at the end of the chapter.
93
94 PART III Abdominal Scanning Protocols
Overview
Location
• The liver occupies the right side of the upper abdomen and often
extends beyond the midline of the body to the left side. Generally,
it lies between the level of the nipples to the level of the eighth or
ninth rib.
• Except for a bare area that encompasses most of the liver’s poste-
rior surface, it is intraperitoneal (enclosed in the sac formed by the
parietal peritoneum). Additional interruptions of the peritoneum
at the liver include the gallbladder fossa, porta hepatis (the area of
the hilus/opening where the portal vein and hepatic artery enter
the liver and the common duct exits), falciform ligament attachment, and portions around the inferior vena cava (IVC).
• The liver is the most anterior visceral organ of the peritoneal cav-
ity. The left lobe and majority of the right lobe are surrounded by
the rib cage. The remaining portion of the right lobe is usually in
contact with the abdominal wall.
• Superior, posterior, and anterior liver surfaces abut the diaphragm.
• The left lobe of the liver lies in the left hypochondriac and epigas-
tric regions. It is bounded in front by the rib cage and abdominal
wall and posteriorly it rests on the stomach.
• The right lobe occupies the right hypochondrium. It is bounded
in front by the rib cage and abdominal wall and posteriorly it rests
on the gallbladder, head of the pancreas, right adrenal gland, and
right kidney (primarily the superior pole).
• The caudate lobe is located on the posterior surface of the liver
and lies posterior to the porta hepatis between the fissure for the
ligamentum venosum and the IVC.
Anatomy
• The liver is considered the largest internal organ of the body. Its
mass displaces the gas-filled components of the digestive system,
providing an acoustic window for viewing upper abdominal and
retroperitoneal structures.
• Size and shape are variable. Anteroposterior size is normal up to
15 cm. Viewed anteriorly, it has a basic wedge shape, tapering
toward the left side. The right lobe is significantly larger than the
left lobe.
• The entire liver is encased by Glisson’s capsule, a thick, fibrous,
connective tissue layer that contains nerves, blood vessels, and
lymphatic vessels. In turn, the encased liver is largely covered by
the peritoneum.
• The liver is divided into lobes according to anatomy and into
segments according to function:
CHAPTER 6 Liver Scanning Protocol 95
Liver Lobes
Using the traditional anatomic system, the liver is divided based on
the sonographic identification of specific anatomic landmarks.
(a) Left lobe: Anatomically separated from the right lobe by the fal-
ciform ligament on its superior surface. Divided from the caudate
lobe by the fissure for the ligamentum venosum and on its inferior (visceral) surface from the quadrate lobe by the fissure for the
ligamentum teres.
(b) Right lobe: Anatomically separated from the left lobe by the falci-
form ligament on its superior (diaphragmatic) surface and by the
left intersegmental fissure on its inferior surface. Riedel’s lobe, a
normal anatomic variant, is a projection of the right lobe that can
extend as far as the iliac crest.
(c) Caudate lobe: Anatomically separated from the left lobe by the
fissure for the ligamentum venosum. Boundaries are the IVC on
the right, its margin on the left, which forms the hepatic boundary of the superior recess of the lesser sac, and the porta hepatis
anteriorly.
(d) Quadrate lobe: Distinguished sonographically and physiologi-
cally as the medial portion of the left lobe. The porta hepatis borders posteriorly, the margin of the liver anteriorly, the gallbladder
fossa right laterally, and on the left, the fissure for the ligamentum teres.
Liver Segments
Liver segments are based on hepatic function. Segments are determined according to blood supply and biliary drainage. Segmental
liver anatomy is clinically significant for localizing potentially resectable liver lesions.
(a) Two main functional divisions: right and left. Middle
hepatic veins located in the main lobar fissure delineate the liver
into intrahepatic (functional), right and left lobes:
• The right functional lobe is everything to the right of the
plane through the gallbladder fossa and IVC (analogous to the
anatomic right lobe).
n
Two divisions: anterior segment and posterior segment: The right
hepatic vein, located in the right intersegmental fissure,
delineates the anterior and posterior segments. These segments are also separated by the right portal vein that passes
centrally within them.
• The left functional lobe is everything to the left of the plane
through the gallbladder fossa and IVC (analogous to the anatomic left lobe, caudate lobe, and quadrate lobe).
n
Two divisions: medial segment and lateral segment: The medial
segment is analogous to the traditional quadrate lobe. The
96 PART III Abdominal Scanning Protocols
lateral segment is analogous to the anatomic left lobe. The
ascending portion of the left portal vein (in the left intersegmental fissure) delineates the medial and lateral segments.
These segments are also separated by the left hepatic vein (in
the left intersegmental fissure) superiorly and the ligamentum teres inferiorly.
(b) Caudate lobe: the portion of the liver lying posterior to the
porta hepatis, between the fissure for the ligamentum venosum
and the IVC.
• No divisions: It distinctly receives hepatic arterial and portal
venous blood from both the right and left systems, which otherwise individually supply respective right and left lobes. The
left portal vein separates the caudate lobe from the medial segment of the left lobe. The left portal vein runs anterior to the
caudate and posterior to the medial segment. The fissure for
the ligamentum venosum runs along the left anterior margin
of the caudate separating it from medial and lateral segments
of the functional left lobe.
Liver Surfaces
The different surfaces of the liver include distinctions among the posterior, anterior, superior, and inferior surfaces.
(a) Posterior surface:
• Caudate lobe.
• Bare area.
• Deeply indented area centrally where it lies on the spine.
• Fossae for the IVC and ligamentum venosum.
• Attachment to the diaphragm by loose connective tissue.
• Most of this surface is not covered by peritoneum.
(b) Anterior surface:
• Lies inside the peritoneum immediately posterior to the
xiphoid process of the sternum.
• Is part of the diaphragmatic surface until it loses contact on the
left at the seventh or eighth costal cartilage and on the right
anywhere from the 6th to the 10th costal cartilage.
• Is accentuated by a deep notch. The ligamentum teres ascends
from the umbilicus to the umbilical notch of the anterior surface.
(c) Superior surface:
• Is intraperitoneal.
• Is a convex diaphragmatic, smooth surface, separated from
the pleura, lungs, pericardium, and heart by the dome of the
diaphragm.
(d) Inferior surface:
• Is covered by peritoneum except at the porta hepatis and site of
the gallbladder attachment.
CHAPTER 6 Liver Scanning Protocol 97
• Is a concave visceral surface accentuated by fossae and indentations from organs that rest against its surface.
• Of the left lobe is deeply indented by the anterior surface of the
stomach.
• Of the right lobe is accentuated by the hepatic flexure of the
colon, right kidney and adrenal gland, and the duodenum,
where it lies adjacent to the gallbladder neck.
• Anterior mid portion is the quadrate lobe (medial left lobe)
bound by the falciform ligament on the left.
• Posterior mid portion of the inferior surface is the caudate lobe.
The posterior portion of the caudate forms a part of the anterior boundary of the lesser sac.
Liver Ligaments
Liver ligaments attach the liver to the diaphragm, stomach, anterior
abdominal wall, and retroperitoneum. Liver ligaments are viewable
with ultrasound because of the fat and collagen within and around
these structures. This makes them quite hyperechoic relative to hepatic
parenchyma. The different types of liver ligaments include the falci-
form ligament, ligamentum teres, coronary ligament, right and left triangular ligaments, gastrohepatic ligament, and hepatoduodenal ligament.
(a) Falciform ligament: Parietal peritoneal, anteroposterior fold
that attaches the bare area of the liver to the right rectus muscle
of the anterior abdominal wall. It extends from the diaphragm to
the umbilicus, running along the liver’s anterior surface. It is continuous with the ligamentum teres, which is contained within
its layers. On the liver’s superior (diaphragmatic) surface, it is
described as the anatomical divider of the right and left lobes
and along with the ligamentum teres, functionally designates the
boundary of the left lobe’s medial and lateral segments.
(b) Ligamentum teres: Fibrous, round ligament formed by the oblit-
erated left umbilical vein. Arises from the umbilicus and courses
within the falciform ligament to the umbilical notch on the anterior surface of the liver. Coursing along the inferior (visceral) surface, it continues as the ligamentum venosum (obliterated ductus
venosus) running posteriorly to the IVC.
(c) Coronary ligament: Parietal peritoneal, bifold layer that attaches
the liver’s posterior surface to the diaphragm. Anterior and posterior layers are continuous anteriorly with the falciform ligament
and laterally with the triangular ligaments.
(d) Right and left triangular ligaments: Formed by continuations
of the coronary ligament. Triangular extensions on the right from
the far right border of the bare area to the diaphragm and on the
left from the superior surface of the left lobe to just anterior of the
esophageal opening in the diaphragm.
98 PART III Abdominal Scanning Protocols
(e) Gastrohepatic ligament: Visceral peritoneal, bifold layer also
known as the lesser omentum. From the undersurface of the
liver, it is continuous with the ligamentum venosum. Ascending,
it attaches the undersurface with the lesser curvature of the stomach and the first portion of the duodenum.
(f) Hepatoduodenal ligament: Portion of the lesser omentum that
is located on the right free edge of the gastrohepatic ligament.
Extends to the duodenum and right hepatic flexure and forms
the ventral portion of the foramen of Winslow or the epiploic
foramen. Surrounds the portal triad immediately adjacent to the
porta hepatis.
Liver Fissures
Liver fissures are the normal grooves or folds throughout the liver that
typically form the spaces that contain various blood vessels or ligaments. Ultrasound can identify the fissures associated with the liver
due to the fat and collagen within and around them, which makes
them highly reflective relative to liver parenchyma. Types of liver fissures include main lobar fissure, left intersegmental fissure, fissure for the
ligamentum venosum, and fissure for the ligamentum teres.
(a) Main lobar fissure: Runs obliquely between the neck of the gall-
bladder and right portal vein. Contains the middle hepatic vein
and separates the right and left hepatic lobes. Its course is short
and variable.
(b) Left intersegmental fissure: Subdivides the right lobe into ante-
rior and posterior portions.
(c) Ligamentum venosum fissure: Contains the gastrohepatic liga-
ment and separates the left lobe and caudate lobe.
(d) Ligamentum teres fissure: Forms the left boundary of the quad-
rate or medial portion of the left lobe.
Liver Vessels and Ducts
The liver receives nutrient rich blood from the hepatic artery and the
portal vein, which is highly saturated with oxygen. The hepatic veins
drain the liver of deoxygenated blood. The hepatic ducts transport
bile, a fluid made in the liver, to the bile ducts. The bile ducts convey
the bile to the gallbladder for storage. When bile is needed to aid digestion of fat, the bile ducts carry it into the duodenum. Structures that
make up the liver vessels and ducts include the hepatic arteries, hepatic
veins, portal vein, portal venous system, hepatic ducts, and portal triad.
(a) Hepatic arteries: Supply the liver with oxygenated blood from
the aorta. The celiac axis branch of the aorta divides into the
splenic, left gastric, and common hepatic arteries.
• The common hepatic artery runs directly toward the right
side of the body, anterior to the portal vein and left of the