1. Advanced abdominal ultrasound.
4th IFAD, Antwerp Hilton
Jeoffrey Schouten
AZ Nikolaas

2. Summary Diffuse liver disease Gallbladder and bile duct disorders
Renal disorders
Abdominal aneurysm
Abdominal trauma

3. Diffuse liver disease Cardiac liver Liver steatosis/dark liver
Liver cirrhosis
Budd Chiari syndrome
Portal vein thrombosis

4. Cardiac liver Aspecific hepatomegaly (‘trop belle image du foie’)
Pericardial/pleural effusion
Ascites
Dilatation inferior caval vein, loss respiratory variation
Dilatation hepatic veins (> 1 cm at 2 cm from the confluence)

5. Cardiac liver

6. Cardiac liver
Expiration
Inspiration

7. Diffuse liver disease Cardiac liver Liver steatosis/dark liver
Liver cirrhosis
Budd Chiari syndrome
Portal vein thrombosis

8. Global steatosis Detecting liver fat Sensitivity: 60-94%
Specificity: 66-95%
US CAN NOT DIFFERENTIATE BETWEEN STEATOSIS AND FIBROSIS

9. Echostructure: ‘dark liver’

10. Diffuse liver disease Cardiac liver Liver steatosis/dark liver
Liver cirrhosis
Budd Chiari syndrome
Portal vein thrombosis

11. Liver cirrhosis Hepatic signs of liver cirrhosis
Rounded marginal edges
Irregular surface
Dysmorphism
Regeneration nodules
Increased echogenicity (subjective)
Heterogeneous echostructure (subjective)
Retraction hepatic veins, loss triphasic flow pattern
Extrahepatic signs of liver cirrhosis
Signs of portal hypertension

12. Cirrhosis
CAVE: DD inflammation

13. Cirrhosis: nodularity

14. Cirrhosis US signs: nodularity
Alterations at liver surface
Low frequency probe (5 MHz): lower liver border
ONLY macronodular cirrhosis/ low sensitivity !!!
High frequency probe (7.5MHz):
Observation subcutaneous liver border (micronodular cirrhosis)
Nodularity no exclusive sign of liver cirrhosis
Nodular regenerative hyperplasia
Metastasis
Steatosis

15. Macronodular cirrhosis

17. Cirrhosis: hepatic vein border irregularities

18. HF probe: diagnosis micronodular cirrhosis
Sensitivity: 91,1% PPV: 93,2%
Specificity: 93,5% NPV: 91,5%

19. Acute liver failure: contours abnormalities

20. Cirrhosis: dysmorfism
Liver dysmorfism in patients with cirrhosis
Hypertrophy caudate lobe
Different indices possible
CAVE Budd Chiari Syndrome
Hypotrophy right liver
Hypertrophy left liver
Pathological mechanism:
Anatomy of caudate lobe (changes in blood supply)

22. nodularity
Venosum ligament

23. US signs of PHT Portal vein changes
Collaterals (umbilical vein, splenic collaterals, epigastric collaterals)
Ascites
Small amounts: in more dependent positions
Paracolic pouch
Hepatorenal pouch (Morrison)
Douglas pouch
Gallbladder wall dilatation
Splenomegaly

24. Portal vein dilatation

25. Hepatofugal flow in portal vein branch

26. Umbilical vein Recanalization in presence of PHT
Normally obliterated fibrous remnant in ligament teres
Extends from the umbilicus to the left portal vein
From the umbilicus it extends to inferior epigastric veins communicating with the iliofemoral system
US features:
Hypoechogenic band running in lig teres

27. Umbilical vein

28. Collaterals: umbilical vein

29. Collaterals: umbilical vein: collaterals

30. Splenic collaterals

31. Ascites: ‘crescent sign’
Morrison pouch
250mL fluid

32. Gross ascites

33. Diffuse liver disease Cardiac liver Liver steatosis/dark liver
Liver cirrhosis
Budd Chiari syndrome
Portal vein thrombosis

34. Budd Chiari Syndrome US diagnosis of BCS Specific signs
Hepatic vein obstruction (acute vs chronic)
Suggestive signs
Intrahepatic collaterals
Caudate vein > 3mm
Non-specific signs
Caudate lobe hypertrophy
Inhomogeous parenchyma
Extrahepatic collaterals

35. BCS: chronic

36. Budd Chiari Syndrome (BCS)

37. BCS: IVC thrombus

38. Diffuse liver disease Cardiac liver Liver steatosis/dark liver
Liver cirrhosis
Budd Chiari syndrome
Portal vein thrombosis

39. Acute portal vein thrombosis

41. Chronic portal vein thrombosis

42. Summary Diffuse liver disease Gallbladder and bile duct disorders
Renal disorders
Abdominal aneurysm
Trauma

43. Gallbladder and bile ducts
Cholecystitis
Bile duct dilatation

44. Acute cholecystitis Thickening gallbladder wall
Oedema gallbladder wall (continuous echo-poor rim around gallbladder or focal echopoor zone in the wall)
Ultrasonic Murphy’s sign
Pericholecystic fluid
Round shape
Gallstones

45. Acute cholecystitis

47. Gallbladder empyema

48. Common bile duct: size
Measurement: proximal portion, just caudal to porta hepatis
Average in adults 4 mm, up to 6 mm is normal
Increase with age up to 10 mm ??
Increase after cholecystectomy up to 8-10 mm ??

50. Bile duct stones Difficulties Superposition of duodenum air
Absence of acoustic shadowing
Air in the common bile duct

51. Dilated intrahepatic bile ducts

54. Dilated intrahepatic bile ducts

55. Summary Diffuse liver disease Gallbladder and bile duct disorders
Renal disorders
Abdominal aneurysm
Abdominal trauma

56. Renal stones

57. Hydronephrosis

58. Summary Diffuse liver disease Gallbladder and bile duct disorders
Renal disorders
Abdominal aneurysm
Trauma

59. Abdominal aorta aneurysm

60. Abdominal aorta aneurysm
Longitudinal
Transverse

61. Summary Diffuse liver disease Gallbladder and bile duct disorders
Renal disorders
Abdominal aneurysm
Abdominal trauma

62. Splenic trauma

63. Splenic rupture

64. Renal trauma

65. Liver trauma

66. Subcapsular hematoma

67. TIPS and TRICKS Investigate the whole abdomen
If possible, ask the patient the region of pain
In trauma patients, parenchymal lesions can show subtle abnormalities