ultrasonography in hepato-biliary diseases by - easgld
Transcript of ultrasonography in hepato-biliary diseases by - easgld
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ULTRASONOGRAPHY
IN HEPATO-BILIARY DISEASES
BY Prof. Dr. Gamal Esmat
Professor of Hepatogastroenterology
Cairo University
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Introduction
US in Hepatobiliary Prof. Gamal Esmat
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1. Ultrasound waves• They are waves of very high frequency
ranging between 3.5 – 10 MHz and up to 20 MHz in endosonography.
• Frequency is the number of waves occurring in one second.
• When the frequency increases the resolution increases and penetration decreases.
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• Frequencies used in diagnosis ranges between
3-10 MHz.
• Frequency used in abdominal sonography is 3-5
MHz.• In adults the frequency used 3.5 MHz.
• In children the frequency used 5 MHz.
• In small parts 7MHz.
• In endosonography 7.5-20 MHz.
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2. Echopattern
It means the reflection of waves, which depends on the material which in penetrated by US.
Echofree :When ultrasound waves pass through fluids ( ascites- simple cyst- blood vessels) no reflection occurs and these areas appears as black areas with posterior enhancement .
Echogenic : When ultrasound waves pass through solids (bones – stone)
all waves are reflected and appears as white color with posterior shadow .
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3. Transducers
a. Shape
• Linear
• Sector
• Linear convex
b. Frequency
• Single
• Dual
• Range US in Hepatobiliary Prof. Gamal Esmat
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Liver
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1. Size .
2. Focal lesion .
3. Diffuse liver disease .
4. Hepatic vasculature . ( portal vein & hepatic veins )
5. Intrahepatic biliary radicles .
Liver
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Size:
Lt. Lobe span (5-10 cm).
Rt. Lobe span (8-15 cm).
Liver
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1. Size .
2. Focal lesion .
3. Diffuse liver disease .
4. Hepatic vasculature . ( portal vein & hepatic veins )
5. Intrahepatic biliary radicles .
Liver
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Focal lesions1. Single or Multiple2. Size3. Site (segmental anatomy)4. Echopattern
a. Echofree e.g. hepatic simple cyst, hydatid cyst.b. Hypoechoic e.g. amoebic liver abscess, lymphoma.c. Hyperechoic (echogenic) e.g. haemangioma . d. Hetergenous e.g. cancer, secondary metastasis.
5. Differential diagnosis
Liver
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1. Size.
2. Focal lesion.
3. Diffuse liver disease.
4. Hepatic vasculature. (portal vein & hepatic veins)
5. Intrahepatic biliary radicles.
Liver
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Diffuse liver disease
• Schistosomal hepatic fibrosis: (Thickened portal tracts):– Portal tracts appear in US as portal vein
radicles only. If the wall of these radicles are thickened, we measure the portal tracts (outer-outer diameter). If the diameter is more than 3 mm in more than 3 tracts “Periportal Thickening”.
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Diffuse liver disease
• Liver cirrhosis: coarse echopattern with: (Miliary =echogenic fine liver dots).– Irregular surface.
– Large caudate lobe
– Attenuated hepatic veins.
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Diffuse liver disease• Bright liver: Increase brightness “less dark”.
– Normally, the echopattern of the liver is slightly brighter than the renal parenchyma.
– D.D of Bright liver .• Fatty liver (D.M.–Hyperlipidemia-obese
patients)• Chronic hepatitis• Liver cirrhosis
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1. Size.
2. Focal lesion.
3. Diffuse liver disease.
4. Hepatic vasculature. (portal vein & hepatic veins)
5. Intrahepatic biliary radicles.
Liver
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Hepatic VasculatureA- Portal Vein:• The diameter is normally up to 12mm, in fasting
adults.• From 13-17mm in suspected cases of portal
hypertension.• >17 it is sure portal hypertension.• In some cases of portal hypertension the P.V
diameter is within normal due to the presence of collaterals.
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Portal Vein Thrombosis
Occurs in association with:
• H.C.C.
• After sclerotherapy.
• After splenectomy
Liver
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Collaterals The presence of any collaterals is a sure sign of Portal
Hypertension1. Para umbilical vein : seen in the falciform ligament.2. Coronary vein : seen in the inferior surface of the left
lobe.Normally less than 5 mm. It is related to oesophageal varices.
3. Splenic hilum collaterals: around splenic veinDirected to the kidney lienorenal collaterals (benign)
Directed to stomach lienogastric: it is related to fundal varices.
Liver
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Hepatic Veins
Importance of hepatic veins:
• Attenuated in Liver cirrhosis and veno-occlusive disease.
• Dilated in congested hepatomegaly.
• In segmented Anatomy.
Liver
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1. Size.
2. Focal lesion.
3. Diffuse liver disease.
4. Hepatic vasculature. (portal vein & hepatic veins)
5. Intrahepatic biliary radicles .
Liver
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Intrahepatic Biliary Radicles• Normally they are not seen, when dilated as in
Obstructed Jaundice “double barrel sign” (portal vein tributary and intrahepatic bile radicle).
• When the obstruction is intrahepatic (e.g hilar cholangiocarcinoma) there is no dilatation of C.B.D but when the obstruction is extra hepatic there is dilatation of C.B.D. more than 8 mm
Liver
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Causes of bile duct obstruction
• Stones in the CBD, hepatic duct, or ampulla of vater
• Cancer head of pancreas, ampulla of vater, cholangiocarcinoma.
• Lesions in the porta hepatis as porta hepatis lymph node enlargement.
• Fasciola or ascaris.
Liver
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Segmental anatomy of the liver
seg 6,7
Caudate lobeseg 1
seg 2Left H.V and hep. Margin
Left H.V and falciform lig.seg 3
Quadrate lobe seg 4
G.B and right hep. V seg 5,8
Rt hep. V. and margin of the liver
Liver
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Gall Bladder
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• Size • Wall thickness.• Contents
• Stone.• Parasites. • Mud.
• Masses polyp cancer
Gall Bladder
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SizeLong axis 6-12 cm , short axis 3-5 cm
• Contracted < 5 cm
• Distended > 12 cm when the patient is
fasting
Gall Bladder
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• Size • Wall thickness.• Contents
• Stone.• Parasites. • Mud.
• Masses polyp cancer
Gall Bladder
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Wall thickness• Measured in the side in contact with the liver.• Normally it is up to 3 mm.• From 3-5 mm >>> suspect thick wall• More than 5 mm >>> It is a thick wall gall bladder
which is seen in:• Cholecystitis (acute-chronic).• Ascites.• Hepatitis ( viral).• Schistosomiasis.
Gall Bladder
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• Size • Wall thickness.• Contents
• Stone.• Parasites. • Mud.• Masses polyp cancer
Gall Bladder
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Contents• Stones:
– seen inside the gall bladder in all positions, mobile except at the neck they appear white with posterior shadow.
• Mud (infected bile)• Thick bile.
– Change with changing position with or without presence of stones. The picture occurs in the presence of thick bile in patients on IV fluids for 3-4 days and in inflammation.
• Parasite: – Fasciola appears pearl shape.– Move as a whole.– Ascaris rare appears as thrill inside G.B
• Cancer & polyps:– Polypoidal or heterogeneous mass.
Gall Bladder
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Spleen
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SizeMeasure the diagonal axis: Normally it
covers the upper 1/3 of the left kidney.
• Longest axis (diagnostic) < 12 cm.
• Relation to kidney.
• Relation to costal margin.
Spleen
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Focal Lesions• Causes:
– Lymphoma.– Cyst (simple-hydatid).– Infarction of a part (triangular area & base toward the edge).– Sarcoma.
• Diffuse disease• Hemosidrosis:
– White dots in spleen– Means Portal Hypertension
Spleen
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