1. DR/ Manal Elmahdy

2. Abdominal ultrasound Ultrasound is the dominant first –line of investigation for a variety of abdominal symptoms. Preparation :-

3. Abdominal ultrasound Indication : 1- Localized abdominal pain with indefinite clinical picture 2- Suspected intra-abdominal abscess 3- Abdominal mass 4- Abdominal trauma 5- suspected cholecystitis 6- Jaundice 7- Liver cirrhosis 8- Suspected metastasis 9- Renal pain

4. General points on upper abdominal technique Scan in a systematic way. Scan any organ in at least two planes, at right angle to each other. Scan the patient in an at least two positions. Use the combination of sub- and intercostal scaning.

5. General points on upper abdominal technique Deep inspiration is useful in a proportion of patients but not all. Position old and ill patient in a comfortable position. Increase the confidence level of your scan by utilising available facilities as changing transducers.

6. Liver RT lobe

7. Liver The diaphragm is shown to the left

8. Liver Left lobe of the liver, ligamentum venosum, and caudate lobe of the liver anterior to the inferior vena cava

9. Liver Middle hepatic vein draining into the inferior vena cava. The homogeneous liver texture is well seen

10. Liver The right hepatic vein drains into the inferior vena cava The liver parenchyma shows the portal and hepatic vascular structures within

11. Hepatic veins

12. CBD

13. Gall bladder

16. Common Congenital from abnormal development of a biliary radicle Acquired from trauma or previous infection Asymptomatic, unless large cause mass effect

17. Peripheral small cysts may be missed on U.S Three characteristic signs :- Anechoic Well defined capsule Exhibits posterior enhancement

18. Due to haemorrhage or infection in a simple cyst Ultrasound appearance:- Low level, fine echoes within the cyst Thin septum within the cyst

19. Usually accompanied by polycystic kidney Rarely affect the liver alone Clinical picture :- Usually asymptomatic Easily palpable Very distended abdomen if kidneys affected

20. Multiple Often separated cysts Variable sizes throughout the liver

21. Caustive organism :- Echinococcus granulosus Slow growing, enlarge at a rate of 1 cm / year until they become symptomatic

22. Diagnosis is an important Why ???? Because aspiration may spread the parasite by seeding along the needle track if the operator is unaware of the diagnosis

23. Well defined cyst Multilocular > unilocular Usually large in size Daughter cysts within larger cysts ( multiseptated cyst ), give honey comb appearance Rim like cyst calcification in 30 % Waterlily sign

25. Amebic abscess, caused by Entamoeba histolytica Pyogenic abscess caused by Aerobic streptococci

26. Fever RUQ pain Vomiting Clinical picture is an important as abscess can be similar to another lesions

27. Very early stage :- hypoechoic or isoechoic solid focal lesion which is zone of nfected, oedematous liver tissue As the infection develop :- the abscess appear full of homogenous echoes from pus

28. At late stage :- appearance of fluid content with debris The margin of the abscess is irregular and often ill defined 30 % of amebic abscess may contain gas

30. Affects any age F > M Common Benign lesion Solitary or multiple Highly vascular Small in size is asymptomatic

31. Samall one :- hyperechoic, rounded, well defined Larger one :- hypoechoic or hyperechoic or heterogenous ( mixed echo pattern ) Posterior acoustic enhancement is common Usually appears avascular on color doppler as blood within the haemangioma is very slow flowing

33. Benign focal lesion Consists of a cluster of atypical liver cells, within this may be pools of bile or focal areas of haemorrhage or necrosis Clinical picture:- Associated with oral contraceptive pills In young women pain May be palpable In rare cases malignant changes occur

34. Usually solitary Encapsulated Small one is homogenous with smooth echopattern Large one is heterogenous echotexture due to haemorrhage or necrosis.

35. Deposition of fat to certain focal area of the liver Predisposing factors :- Obesity Alcoholism Pregnancy Diabetes Certain drugs

36. Ultrasound appearance Oval or rectangular hyperechoic focal area of liver dosen’t display any mass effect May simulate a focal mass e. g metastasis Usually takes three parts 1. Anterior to porta hepatis 2. Left lobe 3. Caudate lobe

37. Area spared from fat in diffusely fatty, hyperechogenic liver Ultrasound appearance :- Regular hypoechoic area ( compared to the echogenicty of fatty liver ) with no mass effect. Can mimic a hypoechoic neoplastic lesion Common sites :- as focal fatty infilteration

38. Rare benign tumor Similar to focal fatty infilteration on sonographic appearance, how can you differentiatie ???

39. Result from some pathological conditions It may be 1. Focal, seen with end stage abscess, haematoma or granuloma 2. Linear, following the course of portal tract, seen with old T. B Ultrasound appearance :- Highly echogenic focal or linear structures cast a strong and definite shadow

42. Thank you