1. The Liver SONO 131 Lecture #5

2. Anatomy

3. Sonographic Presentation

4. Anterior & Posterior Views

5. Superior & Inferior Views

6. Couinaud’s Hepatic Segments

7. Hepatic Vascular System

8. Portal SystemHepatic VeinsHepatic Arteries Function Deoxygenated blood from spleen, pancreas, GB, and bowel to liver 70 – 80% hepatic blood flow Deoxygenated blood from liver into IVC Oxygenated blood from aorta to liver 20 – 30% oxygenated supply Sonographic Features Intra segmental Origin @ porta hepatis Echogenic reflective walls Branch horizontally Inter lobar Inter segmental Drain toward RA No reflective walls Branch longitudinally Respiratory variation Very small – especially away from porta hepatis Scan Technique Main & LPV – anterior RPV – right intercostal Transverse plane High in epigastrium Anterior Doppler Flow Pattern Low velocity, continuous Toward liver, undulations Velocity ↑w/ inspiration Flow toward IVC Triphasic curve Antegrade diastolic flow Low resistance flow

9. Portal Vein Doppler Normal Portal Flow Portal Flow in Tricuspid Regurg

10. Hepatic Vein Doppler Hepatic Vein - Normal Hepatic Vein – Abnormal

11. Hepatic Artery Doppler

12. Liver Function(s)

13. Liver Cells

15. Primary Functions of the Liver Metabolism Carbohydrate Protein Digestion Bile Storage Iron Vitamins Detoxification Drugs and poisons

16. Hepatic Metabolic Functions

17. Hepatic Detoxification Waste products of energy production Waste produce of metabolic activities Hormone & drug break down

18. Commercial Product Liver DETOX's Unique Formula: Milk Thistle - a natural herb, traditionally used to support detoxification functions of the liver. L-Methionine - an amino acid that the liver uses to create glutathione. N-Acetyl-Cystine - the liver also uses NAC to create glutathione. Alpha Lipoic Acid - is an antioxidant that helps revitalize glutathione and supports the antitoxin activities of the liver. Selenium - helps zinc and vitamins (both antioxidants) to function better in their detoxification properties. Ayurvedic Herbs - these herbs have long been used to promote the detoxification capabilities of the liver.

19. Liver Function Tests AST ALT LDH Alkaline Phosphatase Bilirubin Prothrombin Time Albumin and globulins

20. Bilirubin – a bile pigment resulting from the breakdown of old blood cells Formed by Kupffer cells and excreted by hepatocyes Increases with any chronic inflammatory disease Reported types Total = mixture of conjugated + unconjugated  Increases in in chronic liver cell disease (Cirrhosis) Unconjugated or indirect  Increases in isolated acute hepatocellular disease Conjugated or direct bilirubin  Increases in biliary duct obstruction Liver Function Tests

21. Serum Albumin – protein that is a component of blood Synthesized by liver Responsible for maintenance of osmotic pressure in blood Decreased levels Liver dysfunction Malnutrition Renal disease Liver Function Tests

22. AST – Aspartate aminotransferase, formerly know as SGOT Enzyme found in liver, muscles and tissues with high metabolic rates Liver causes for abnormal AST Acute hepatitis Cirrhosis Hepatic necrosis Injury to the liver Metastases to the liver Fatty changes Non-Liver causes for abnormal AST Mononucleosis Myocardial Infarction Liver Function Tests

23. ALT – Alanine aminotransferase (formerly SGPT) Enzyme produced in the hepatocytes Elevated ALT Hepatitis Obstructive jaundice Hepatocellular disease Shock & drug toxicity causing liver cell death Liver Function Tests

24. Alkaline Phosphatase – enzyme produced in liver, kidneys, bones, intestines and placenta Increase with normal ALT & AST Bile duct obstruction Primary biliary cirrhosis Sclerosing cholangitis Nonbiliary causes for increase Abscesses Liver carcinoma Cirrhosis Liver Function Tests

25. Condition BilirubinSerum Albumin ASTALTAlkaline Phosphatase Hepato- cellular Disease Obstruction Normal

26. Sonographic Evaluation Patient Preparation NPO for at least 6 hours Transducer 2.5 to 5 MHz curvilinear or sector Patient Position Supine and decubitus as necessary Patient Breathing Full inspiration

27. Liver attenuation Liver texture Vascular structures Ligaments, fissures Sonographic Evaluation

28. Liver Images – Transverse & Longitudinal

29. Liver Images - Transverse

30. Measurements Anteroposterior 10 – 12.5cm Transverse 20 – 22.5 cm

31. Normal or Not? Transverse Liver