Technique and US in hepatobiliary disease US hepatobiliary system Technique and US in hepatobiliary disease พญ.เสาวลักษณ์ ชนม์ยืน รังสีแพทย์ โรงพยาบาลน่าน

Outline Anatomy US technique Hepatobiliary tract disease( Liver, gallbladder and biliary tract )

Anatomy

ส่วนยอด บน ของ ตับ อยู่ที่ซี่โครงที่ 5 หรือ ต่ำกว่าราวนม ครึ่งนิ้ว

ท่อที่ผ่าน เข้า-ออก Liver มี 4 ท่อ ดังนี้ 1. Hepatic Vein 2. Portal Vein 3. Bile Duct 4. Hepatic Artery

Hepatic segmental landmarks

Normal liver anAtomy -the ligamentum venosum (FL) separating the caudate lobe (C) and the left lateral segment (LL) -the ligamentum teres (LT)The left lateral segment (LL) and the left medial segment (LM) are separated by the ligamentum teres. -The interlobar fissure (IF) -The interlobar fissure and the gallbladder fossa separate the left medial segment (LM) from the right anterior segment (RA). -umbilical segment of the left portal vein (U)

Biliary system

Technique

Upper Abdominal Ultrasonography supine position นอนหงาย left lateral decubitus position นอนตะแคง เอาด้านซ้ายลง right lateral decubitus position นอนตะแคง เอาด้านขวาลง

วาง probe เอียงไปทาง ด้านซ้าย STOMACH ศีรษะ เท้า

เอียง probe จากด้านซ้าย มาเกือบกึ่งกลาง stomach Aorta

เห็น aorta and branches

เห็น pancreas ในการตรวจ Sagittal view in epigastrium

เลื่อน probe ผ่านกึ่งกลาง มาทางขวา

Caudate lobe IVC

Ligamentum teres

เอียง probe ขึ้น ไปทางศีรษะ จะเห็นหัวใจ

เลื่อน probe ลงมาจะเห็น pancreas

Hepatic veins เทเข้า IVC

IVa II VIII VII

RHV LHV MHV

Portal vein Periportal fibrofatty tissue produces brighter echoes around the portal veins Normal size ไม่ควรเกิน 13 mm ถ้ามากกว่านี้ให้สงสัยว่ามีภาวะ portal hypertension

Main portal vein แยกเป็น right และ left portal veins

IVC H

Gallbladder GB PV

Dilated CBD

Branches of Right Portal vein VIII VI VII

Right subcostal section in left lateral decubitus position ท่าตะแคงจะทำให้ ตับเลื่อนลงมา เราจะเห็น lesion บางอย่างที่ ท่านอนหงาย มองไม่เห็น

The liver

Liver Size - Right MCL  วัด craniocaudal direction ขนาดน้อยกว่า 15 cm Indirect signs of hepatomegaly extension of the right lobe below the lower pole of the kidney rounding of the inferior tip of the liver extension of the left lobe into the LUQ above the spleen

Liver mass /Focal lesion Liver abnormality Parenchymal disease -Fatty liver -Liver cirrhosis -Periductal fibrosis Liver mass /Focal lesion

Liver parenchyma Homogeneous echogenicity โดยที่ echogenicity of the liver ≥ renal cortex, < renal capsule < spleen, < pancreas Smooth surface Visible tubular structuresare hepatic veins and portal veins Hepatic veins ; thin wall  IVC Portal vein ; thick wall  hepatic hilum Bile duct parallel with portal vein seen at porta hepatis

Diffuse hepatic inhomogeneity COMMON -cirrhosis -metastasis -fatty infiltration UNCOMMON -hepatocellular cancer -hepatic fibrosis -lymphoma

Fatty infiltration เทียบกับ kidney and pancreas Intracellular deposition of triglycerides within hepatocytes Causes – Alcoholic ,Steroid ,DM,Drug NASH ( Nonalcoholic Steatohepatitis ) = Severe fatty liver with hepatomegaly with inflammation and fibrosis Findings - Increased echogenicity of the liver, finer echotexture than normal liver เทียบกับ kidney and pancreas ปกติ liver ขาวกว่า kidney เล็กน้อย ถ้า fatty infiltrate จะเห็นเนื้อตับกับไตแยกจากกันชัดเจน ปกตื liver จะดำกว่า pancreas ถ้า fatty infiltrate เนื้อตับจะขาวกว่า

Fatty Infiltration Sensitivity 60-94 % Specificity 66-95 % Diffuse - Grading -mild = mildly increasing echogenicity -moderate = blurring of veins margins -severe = significant of posterior shadowing Focal fatty infiltration

Diffuse Fatty liver grading 1.Normal 2.Mild - increasing echogenicity 3.Moderate - increasing echogenicity ,impaired visualised hepatic vessels and diaphragm 4.Severe - markedly increasing liver echogenicity with poor penetration, poor visualised hepatic vessels and diaphragm

Focal fatty sparing Focal Fatty infiltration Focal fat infiltration Focal fatty sparing Diffuse fatty infiltration with FFS Geographic hypoechoic area Usually located in front of the RPV or PV bifurcation or around the gallbladder Lack of mass effect on hepatic vessels Focal or nodular Anterior aspect of LL (esp. medial segment), adjacent to the falciform ligament, anterior to the PV bifurcation Atypical locations metastases or hemangioma

Focal fatty sparing Focal fat sparing at preportal and gallbladder fossa regions

Focal fatty infiltration 2 ภาพแรกเทียบเนื้อ liver VS kidney, liver VS spleen/// บรรยายภาพที่ 3 attenuation of the sound beam with progressive decreased echogenicity of the deeper aspects of the liver, indicating more advanced fatty infiltration Multiple focal nodular areas of increased echogenicity Focal fat infiltration No mass effect Focal nodular fatty infiltration

Cirrhosis US appearance Surface nodularity reliable sign Coarsening and nodularity of the liver parenchyma(RN/DN) Segmental hypertrophy/atrophy Hypertrophy of the caudate lobe and lateral segments of left lobe (S2&3) Atrophy of the posterior segments (S6&7) of the right lobe RL:LL(longitudinal ratio) < 1.3 (normal =1.44) Signs of portal hypertension

Sonographic signs of portal hypertension Ascitis Splenomegaly Portal vein enlargement >13 mm Portosystemic collateral Enlarged hepatic arteries Hepatofugal(reversed)portal flow

Liver CIRRHOSIS diffuse heterogeneity and nodularity to the liver parenchyma surface nodularity Liver CIRRHOSIS multiple nodular impressions on the hepatic vein lumen Scattered multifocal hypoechoic nodules

Liver abnormality Liver mass /Focal lesion Parenchymal disease -Fatty liver -Liver cirrhosis -Periductal fibrosis Liver mass /Focal lesion

Echogenicity of liver mass /Focal liver lesion Echogenic pattern - calcifications - anechogenic - hypoechogenic - isoechogenic - hyperechogenic - mixed echogenic Outline - well defined / poor Others - acoustic shadow - posterior enhancement - dilated bile duct

Calcifications

Calcification in the liver

Cysts Simple cyst Complex cyst Most common focal liver lesion Anechoic lumen Increased through transmission A well-defined back wall Partial septation/ puckering of the wall Complex cyst Internal echoes Thick wall Septations that are numerous or thick Solid elements Calcification 2 รูปแรกเป็น simple cyst, รูปที่สามเป็น complex cyst

Causes of cystic lesions in the liver

Liver abscess Complex fluid collections with a mixed echogenicity May mimic solid hepatic masses Thick-walled cystic lesions or cysts with fluid-fluid levels Gas forming abscess DDx: hematoma, hemorrhagic cyst, necrotic or hemorrhagic tumor

Liver abscess Large hypoechoic lesion with increased through transmission Complex cystic lesion Multiple small hypoechoic solid-appearing lesions Large heterogeneous, predominantly hyperechoic, lesion

Hemangioma Approximately 7% of adult, F>M, 10% are multiple Typical appearance (60-70%) homogeneous round/lobulated hyperechoic mass usually less than 3 cm sharp&smooth margins calcification มีได้ แต่ rare Atypical hemangiomas Hyperechoic periphery and a hypoechoic center “reverse target” appearance Hemangioma ไม่ค่อยมี flow แต่ถ้าก้อนนั้นมี flow ให้สงสัย HCC or metastasis

Typical Typical “reverse target” appearance Atypical

Hemangioma Usually stable over time ~ 10%  decrease in echogenicity ~ 5%  regress partially or completely ~ 2% enlarge

DDx hyperechoic masses Hemangioma Metastasis Hepatocellular cancer Focal fatty infiltration ถ้าผป มีประวัติ extrahepatic malignancy หรือ history of chronic liver disease ก่อนจะ Dx hemangioma ควร confirm ด้วย CT or MRI แต่ถ้าคนไข้ไม่มี risk factors ก็ไม่จำเป็นต้องตรวจอย่างอื่นเพิ่ม

Hepatocellular carcinoma Strongly associated with chronic liver diseasehepatitis B&C and cirrhosis Growth pattern of HCC solitary, multifocal or diffuse and infiltrating Typical a large dominant lesion with scattered smaller satellite lesions Sonographic appearance  non-specific Venous invasion 30-60% for the portal veins and 15% for the hepatic veins

Hepatocellular carcinoma Pic 3-17

Hepatocellular carcinoma Diffusely infiltrating tumor Intense hypervascularity typical of HCC

Metastases 98% multiple Usually involve both lobes of the liver Variety of sonographic appearance ส่วนใหญ่จะเห็นเป็น “target appearance” echogenic/isoechoic center and a hypoechoic halo Others: hypo/hyperechoic nodule, calcified metastases, cystic metastasis, diffuse heterogeneous

target appearance Echogenic/isoechoic center and a hypoechoic halo

Hepatic target lesions Target lesions are much more likely to be malignant than benign

Other focal liver lesion Benign - Focal nodular hyperplasia hypoechogenic mass with central scar F > M - Hepatic adenoma hyperechogenic with central hypoechogenic area heterogenous echogenicity Malignant CHCA,Biliary cystic tumor

Gallbladder

The gallbladder อยู่ใต้ interlobar fissure ใช้เป็น landmark for identifying the junction between the left and right lobes of the liver งดน้ำงดอาหาร ประมาณ 4-6 ชั่วโมงadequate gallbladder distention + reduce upper abdominal bowel gas

Transverse view GB อยู่ใต้ interlobar fissure ligamentum teres

The gallbladder GB PV

Characteristics of the normal gallbladder

Gallbladder Pathology stones biliary sludge/ microlithiasis polyp contracted gallbladder porcelain gallbladder gallbladder wall thickening acute cholecystitis Chronic cholecystitis Hyperplastic cholecystitis carcinoma of gallbladder

Intraluminal abnormalities in the GB

Gallstone Accuracy 96% -echogenic foci -movable -posterior acousticshadow

sludge Sludge and GS Sludge ball polyp

GB polyp Benign 95% m/c cholesterol polyp

Gallbladder polyp Benign size 5 mm-benign 5-10 mm FU pedunculated m/c multiple stable size Malignant size >10 mm(37-88%) sessile single increasing in size

acute cholecystitis GB wall thickening > 3 mm GB enlargement Pericholecystitic fluid +/- Gall stone US Murphy’s sign positive

GB distension GB wall thickening GS&sludge Pericholecystic fluid collection

GB wall thickening Biliary cause Cholecystitis Adenomyomatosis Cancer AID cholangiopathy Sclerosing cholangitis Non biliary cause Hepatitis Pancreatitis Heart failure Cirrhosis Hypoproteinemia Lymphatic obstruction Portal hypertension

Other gallbladder Disease Adenomyomatosis - Intramural diverticular  diffuse or focal thickening GB wall Carcinoma GB - Focal or diffuse thickenedwall Polypoid maa GB mass

Biliary system

The bile duct จะวิ่งขนานไปกับ portal veins & hepatic arteries Intrahepatic bile duct จะวิ่งขนานไปกับ portal veins & hepatic arteries anterior to the adjacent portal veins IHD ส่วนใหญ่จะตรวจไม่พบใน US หรือถ้าพบก็มักจะมีขนาดไม่เกิน 2 mm

The bile duct Extrahepatic bile duct US ไม่สามารถบอกตำแหน่งของ cystic duct มาเทเข้าได้ จึงบอกไม่ได้ว่าท่อน้ำดีที่ขั้วตับนั้นเป็น CBD or CHD ดังนั้นจึงเรียกกลางๆเป็น common duct common duct < 7 mm วัดจากขอบด้านในของด้านหนึ่งไปอีกด้านหนึ่ง

The bile duct The hepatic artery จะอยู่ anterior to the portal vein และ medial to the common duct

Mickey Mouse appearance

Right hepatic artery จะวิ่งระหว่าง portal vein and common duct

RIGHT HEPATIC ARTERY CHD HEPATIC ARTERY PROPER CBD PORTAL VEIN

Biliary dilatation Intrahepatic duct -larger than 2 mm diameter -more than 40% diameter of the adjacent portal vein

Biliary dilatation Intrahepatic duct -larger than 2 mm diameter -more than 40% diameter of the adjacent portal vein Extrahepatic duct -CHD 4-5 mm -CBD 4-6 mm 6-7 mm equivocal >8 mm indicate ductal dilatation may be tortous or irregular wall

tortuous configuration parallel channel sign Irregular appearance tortuous configuration Posterior enhancement

Biliary dilatation อาจจะไม่พบ ductal dilatation 4-6 mm Extrahepatic duct - CHD 4-5 mm - CBD วัดจากขอบด้านในของด้านหนึ่งไปอีกด้านหนึ่ง 4-6 mm 6-7 mm equivocal >8 mm indicate ductal dilatation Elderly patients and in postcholecystectomy patients อาจพบ common duct dilatation ได้ถึง 9-10 mm Acute, intermittent, and partial obstruction อาจจะไม่พบ ductal dilatation

Dilated CBD

Choledocholithiasis/stone Most common causes of biliary obstruction Intrahepatic duct stones  less common than CBD stones Gall stone --- 15% ass.with CBD stone CBD stone ---95% ass. With GS

CBD stone

Intrahepatic duct stones DDx IHD stones Intrabiliary gas/ pneumobilia Hepatic artery calcification

Pneumobilia brighter reflection and dirtier shadow than do stones a ring-down artifact mobile on real time Intrahepatic arterial calcification two bright parallel lines

Bile duct wall thickening Nonspecific finding Duct wall thickening > 5 mm and disproportionately dilated IHD  suspicion of cholangiocarcinoma

Causes of bile duct wall thickening Risk factor of CHCA > 5 mm and disproportionately dilated IHD Risk factor of CHCA

Increased periportal echo ( IPE ) Normal echo IPE

Increased periportal echo ( IPE )

Increased periportal echo (IPE) grading = Periductal fibrosis ( PDF) IPE Grade 1 is diffuse echogenic foci (‘starry sky’) minimal wall thickening of portal and segmental branches IPE Grade 2 is Ring echoes around vessels in cross-section,pipe-stems parallel with portal vein IPE Grade 3 is echogenic ruff around portal bifurcation and main stem ;main portal vein vessels wall thickening

Hypothesis Repeated infection with O. viverrini by consumption of fresh water fish Worms inhabit in biliary tree Chronic inflammation of biliary tree Periductal fibrosis ( PDF) Cholangiocarcinoma

Cholangiocarcinoma

Ultrasonographic pattern of CHCA 1.Parenchymal mass 2.Dilatation of bile duct without mass 3.Parenchymal mass with dilated duct 4. Dilatation of bile duct with intraluminal mass

Dilatation of bile duct with intraluminal mass Parenchymal mass Mass with ductal dilatation Dilatation of bile duct with intraluminal mass

Take home point Review anatomy Middle hepatic vein is landmark for right and left lobe liver CBD and all bile duct runs parallel to portal vein Comparing echo pattern, liver echo > renal cortex Normal tubular structures visible in liver parenchyma are portal vein, hepatic vein

Take home point Cholangiocarcinoma have non-specific sonographic feature Important in surveillance US 1.abnormal echo mass lesion 2.dilatation of IHD or EHD PDF has protential to be sonographic sign to closely follow up in a risk group of CCA surveillance

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