Rewording 3 Papers

Liver

Anatomical Analysis:

· The liver is the largest organ in the body

· Weigh up to 1600 grams in males and 1400 grams in females

· Focal sparing Hypoechoic mass on to RPV and GB

· Left lobe divides into medial and lateral segments by the left hepatic vein and ligamentum of teres.

· Separated from the caudate lobe by the ligamentum of venosum.

· Separated from the right lobe by the middle hepatic vein superiorly and the main lobar fissure inferiorly falciform ligament.

· Right lobe divides into the anterior and posterior segments by the right hepatic vein

· Six times larger than the left lobe

· Three posterior fossa: gallbladder, porta hepatis and inferior vena cava.

Caudate Lobe:

· Smallest lobe of the liver.

· Separates from the left lobe by the ligamentum venosum.

· Arterial supply through the portal veins or hepatic arteries.

Liver Ligaments:

· Liver is attached to the diaphragm, anterior to the abdominal wall, stomach and retroperitoneum by ligaments.

Coronary:

· Consists of an upper and a lower layer.

· The upper layer is formed by the peritoneum from the upper margin of the bare area to the undersurface of the diaphragm.

· The lower layer is reflected from the lower margin of the bare area to the right kidney and is termed the hepatorenal ligament.

· The right and left triangular ligaments are part of the coronary ligament.

· Connects the posterior liver to the diaphragm.

Falciform :

· Attaches the liver to the anterior abdominal wall.

· Extends from the diaphragm to the umbilicus.

· Separates the right and left subphrenic spaces.

· It’s seen in cases of ascites.

Gastrohepatic :

· Connects the lesser curvature of the stomach to the liver.

Hepatodoudenal :

· Connects the liver to the proximal duodenum.

Teres:

· Lies within the falciform ligament.

· Previous delta umbilical vein.

· Divides left lobe into medial and lateral segments.

· Is inferior to the left portal vein.

Triangular:

· The most lateral portion of the coronary ligament.

· Connects the liver to the body wall.

Venosum:

· Separates the left lobe from the caudate lobe of the liver.

· Obliterated Ductus Venosum.

· Lesser omentum attaches to the liver in the fissure of the ligamentum Venosum.

Liver Spaces

Morrison Pouch (Hepatorenal Pouch):

· Located lateral to the right lobe of the liver and anterior to the right kidney.

· Communicates with the right paracolic space.

Subhepatic Space:

· Space located between the inferior edge of the right lobe and anterior to the right kidney.

Subphrenic space:

· Space located between the diaphragm and the superior border of the liver. Vascular Anatomy

Hepatic Arteries:

· Proper hepatic artery enters the liver at the porta hepatis and divides into the right and left hepatic arteries.

· Thirty percent of the liver’s blood supply is through the hepatic artery.

· Lies medial to the common hepatic duct and anterior to the main portal vein.

· Normal diameter of the proper hepatic artery is 2 to 4mm.

Hepatic veins:

· Right, middle and left hepatic veins converge to empty into the inferior vena cava.

· Transport deoxygenated blood from the liver cells to the inferior vena cava.

· Courses between lobes ( Interlobar) and between segments (Intersegmental).

· Have a minimum amount of collagen in the walls.

· Follow a straight longitudinal course increasing in caliber closer to the diaphragm.

Portal Veins:

· Main portal vein enters the portal vein entering the portal hepatis, diving into the right and left portal veins.

· Left portal vein subdivides into the left medial and left lateral portal veins.

· Right portal vein subdivides into the right anterior and right posterior portal veins.

· Provides approximately 70% of the liver’s blood supply.

· Transport nutrient-rich blood from the digestive tract to the liver cells for metabolic processing and storage.

· Are located within the loves ( Intralobar) or within the segments ( intrasegmental) of the liver.

· Walls contain fibrin.

· Normal diameter of the main portal vein should not exceed 13mm.

Location

Liver is an intraperitoneal organ and it is located in the right hypochondriac region.

Left lobe:

· Lies anterior to the porta hepatis and middle hepatic vein.

· Located inferior to the diaphragm.

· May extend to the left midclavicular line.

Right lobe:

· Lies anterior to the right kidney.

· Located posterior to the middle hepatic vein.

Caudate Lobe:

· Lies anterior and medial to the inferior vena cava in the transverse plane.

· Located posterior to the ligamentum of venosum and porta hepatis.

· Located lateral to the lesser sac.

Sonographic Appearance

Liver :

· Homogeneous, moderately echogenic smooth parenchyma.

· Anechoic tubular structures within the parenchyma representing blood vessels and biliary ducts.

Bile Duct:

· Anechoic tubular structure coursing through the liver parenchyma.

· Smooth hyperechoic walls margins.

Hepatic Vein:

· Anechoic tubular structures coursing toward the inferior vena cava.

· Caliber increases closer to the inferior vena cava.

· Smooth margins.

· Multiphasic hepatofugal blood flow pattern.

Portal Vein:

· Anechoic tubular structure coursing from the hepatic hilum through the liver parenchyma.

· Caliber increases closer to the hepatic Hilum.

· Prominent smooth hyperechoic wall margins.

· Phasic hepatopetal blood flow pattern.

· Hepatic Artery: Anechoic tubular structure coursing through the liver parenchyma.

· Smooth wall margins.

· Low resistance hepatopetal blood flow pattern, demonstrating continuous flow throughout diastole.

· Not typically visualized within the liver parenchyma.

Laboratory Values

Alkaline Phosphatase:

· Normal adult range 35 to 150 U/L

· An enzyme produced primarily by the liver, bone, and placenta and excreted through the bile ducts.

· Marked elevations are associated with obstructive Jaundice.

Alpha-Fetoprotein:

· A protein normally synthesised by the liver, yolk sac, and GI tract of the fetus.

· A nonspecific marker for malignancy( of fetus).

Alanine Aminotransferase:

· Normal range 1 to 45 U/L.

· An enzyme found in high concentration in the liver and lower concentrations in the heart, muscle, and kidneys.

· Remains elevated longer than aspirate aminotransferase (AST).

· Used to access jaundice.

· Elevation associated with cirrhosis, hepatitis, and biliary obstruction.

· Mild elevation associated with liver metastasis.

· High in case of chronic liver damage.

Bilirubin:

· Normal total bilirubin 0.3 to 1.1mg/dL.

· Normal direct bilirubin 0.1 to 0.4mg /dL.

· A product from the breakdown of hemoglobin in old red blood cells; a disruption in the process may cause abnormal levels; leakage into tissues gives the skin a yellow appearance.

· Reflects the balance between production and excretion of bile.

· Elevation of direct or conjugated bilirubin is associated with obstruction hepatitis, cirrhosis and liver metastasis.

· Elevation of indirect or unconjugated bilirubin is associated with nonobstructive conditions.

· RBC damage or Splenic disease.

Prothrombin Time:

· Normal clotting time is 10 to 15 seconds.

· Enzyme produced by the liver.

· Production depends on the amount of vitamin K.

· Elevation associated with cirrhosis, malignancy, malabsorption of Vitamin K, and clotting failure.

· Decrease with subacute or acute cholecystitis, internal biliary fistula, carcinoma of the gallbladder, injury of biliary ducts, and prolonged extrahepatic biliary obstruction.

· The last long bleeding after the test indicates liver disease.

Serum Albumin:

· Normal 3.3 to 5.2/dL.

· Decrease suggests a decrease in protein synthesis( protein production inside the liver).

Biliary System

Functions of the Biliary System:

· Transport bile to the gallbladder through the bile duct.

· Store and concentrate bile in the gallbladder.

· Transport bile through the bile ducts to the duodenum.

Biliary Anatomy

Bile Duct:

· The biliary system originates in the liver as a series of ductules coursing between the liver cells.

· Biliary ducts are subdivided into intrahepatic and extrahepatic ducts.

· Intrahepatic ducts follow the course of the portal veins and hepatic arterial branches.

· Extrahepatic ducts include the cystic and common dcuts.

· Bile flows intraductal pressure is lower than the hepatic secretory pressure. Pressure differences are affected by the activity of the sphincter of Oddi, filling and resorption of the bile in the gallbladder and the bile flow from the liver.

Common Hepatic Duct:

· The right and left hepatic duct join near the level of the porta hepatitis, forming the common hepatic duct.

Cystic Duct:

· Drains the gallbladder.

· 2 to 6 cm in length.

· Contains the spiral valves of Heister.

· Courses posterior and inferiorly merging with the CHD to form the common bile duct( CBD).

· Not routinely visualized on ultrasound.

Kidney

· The kidneys are dark reddish brown bean shaped organs located on each side of the vertebral column retroperitoneally.

· Each kidney measures 9-12cm long, 4-5cm width, 2.5-3cm height minimum thickness 1mm.

· Each kidney is composed of 3 regions: the renal cortex, renal medulla and renal pelvis.

· In children 7-8 cm and in infants 5-6cm.

· Each kidney is located anterior posterior to psoas muscle and quadrate lumborum.

· Nephrosis is the functional and structural units of kidneys.

· One million nephrons in humans.

Renal Variants

Hypertrophied column of bertini:

· Prominents invaginations of the cortex located at varying depths within the medullary substance of the kidney continuous with the renal cortex.

· Overall the echogenicity is similar to renal parenchyma.

· Lateral indentation of the renal sinus.

· Clear definition from the renal sinus.

· Maximum dimension that does not exceed 3cm.

· Contiguity with the renal cortex.

· Echogenicity similar to renal parenchyma.

Dromedary Hump:

· It has little hum, cortical bulge that occurs at the lateral border of the kidney.

· Mostly on the left side can be mistaken as a neoplasm.

· Echogenicity is identical to renal cortex.

Junctional Parenchymal Defect:

· Triangular echogenicity area in the anterior aspect of the upper pole of renal parenchyma due to fusion.

· Does not close.

· Normal scanning can be seen.

Fetal Lobulation:

· Development variation by the ultrasound in the kidney is lobulated in the renal contour surface of the kidney.

· Loulation in the renal contour.

Duplex Collecting system:

· Complete duplicated collecting system 2 renal pelvis 2 ureters incomplete

· 2 renal pelvis and 1 ureter.

· The ultrasound can not difference between complete or incomplete

· Ultrasound renal sinus appears by moderated echogenic tissue similar to renal parenchyma.

· Pelvis or lower pole looks most time large.

Sinus Lipomatosis :

· Composed of fibrous tissue, fat, lymphatic vessels, and renal vascular structures.

· There is deposition of a moderate amount of fat in the renal sinus that is enlarged and more echogenic .

· Enlargement of the sinus region and increased echogenicity.

· Extrarenal pelvis: Renal pelvis is a triangular shaped structure.

· Ultrasound central cystic area that is either partially or completed beyond the contour of the kidney, continuous with the renal sinus.

Pancreas

· Pancreas is a gland located posterior to the pyloric portion of the stomach.

· It is wrapped around by a c-shaped duodenum.

· It is composed of head, body and tail.

· The pancreas has endocrine and exocrine .

· The endocrine are ducts secrets into the bloodstream (hormones)

· 1% Islets of langerhans

· Insulin decreases blood sugar.

· Glucagon increases blood sugar.

· Exocrine has ducts that secretes on the body surface or in the body cavity.

· 99% composed of pancreatic cells (Acini)

· Protease (Trypsin) digestion of proteins, Lipase(fats), Amylase digestion of carbs, Bicarbonates neutralize acidic environments coming from the stomach.

· The digestive function of pancreas is secretion of pancreatic juice.

· Pancreatic juice is collected by tiny ducts that enter the pancreatic duct which leaves the pancreas & joins the common bile duct just before the bile duct enters the duodenum.

· The opening of the Duodenum where the ducts drain is called Hepatopancreatic ampulla or ampula vateri.

Abdomen /Arteries

· Abdominal aorta position on the left side of the vertebral.

· Abdominal (descending) Aorta is continuation of the thoracic aorta.

· It originated at the level of the diaphragm & it terminates at the level L4, L5 within the pelvis .

· Branching into the right and left common iliac artery.

· The main branches of the abdominal aorta are celiac trunk , Superior Mesenteric Artery, Renal arteries, Inferior Mesenteric Arteries and iliac arteries.

Veins

IVC:

· Originates from joining two common iliac veins at the level L5, 51.

· It is a major route for drainage of venous blood from the lower extremities pelvis and the abdomen.

· It is positioned at the right side of the vertebral column.

Hepatic Veins:

· Drain filter blood from the liver to the IVC.

Portal vein:

· Drains nutrients rich blood from most of the GI to the liver.

Splenic Vein:

· Drains blood from the spleen and Inferior Mesenteric Artery into the portal vein.

Renal Veins:

· Drains blood from the kidneys to the IVC.

· The right renal vein is shorter than the left renal vein because of the position of the IVC.

Spleen

· The largest Lymphatic organ.

· Anterior to Left kidney

· Posterior to the stomach

· Superior to the splenic flexure of the colon.

· Inferior to Diaphragm .