Liver

Protocol (Hepatic or RUQ)

• This protocol includes images of several organs and structures. It has been divided into sections to assist in
determining diagnostic images that should be stored for the physician.
o Pancreas
o Liver
o Gallbladder and Common Bile Duct
• You must always evaluate the entire organ first before you store an image
• You should understand completely why you stored the image and identify everything in the image
• Multiple breathing techniques and patient positions will be required

Organ/ Scan Plane Label Key Landmarks Identified

Order
• Pancreas head
PANCREAS • Portal splenic confluence
• CBD
o If CBD is enlarged, measure internal AP diameter
Transverse plane • Pancreas body
Pancreas
on the body PANCREAS • Aorta
• Measurement
o If pancreatic duct is seen measure internal AP diameter
PANCREAS • Pancreas tail
• Splenic vein

Organ/ Scan Plane Label Key Landmarks Identified

Order
Sagittal LIVER SAG • Left lobe with inferior tip
The transducer is
placed sagittal in the LIVER SAG • Left lobe
mid portion of the
• Caudate lobe
patient’s body
• IVC
LIVER SAG • Right lobe
LIVER • Diaphragm
Sagittal LIVER SAG SUP • Right lobe superior
• Right hemidiaphragm

Sagittal • Right pleural space

The transducer is LIVER SAG MID • Right lobe mid

placed sagittal and • Main portal vein
lateral on the LIVER SAG INF • Right lobe inferior

patient’s body o Demonstrating largest superior to inferior area

o Measure liver length from superior to inferior
• Right kidney

Transverse • Left lobe

LIVER TX
• Caudate lobe

The transducer is • IVC
LIVER placed transverse in
• Right lobe
Transverse the mid portion of
the patient’s body LIVER TX HV • Left lobe
• Right hepatic vein
Angulation of the • Left hepatic vein
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 probe is used for • Middle hepatic vein
right lobe images
LIVER TX • Right lobe-most anterior portion
• Diaphragm
• Right lobe superior
LIVER TX SUP
• Right hemidiaphragm

• Right pleural space
LIVER TX MPV • Right lobe mid
Transverse • Main portal vein
LIVER LIVER TX MPV • Right lobe mid
Transverse The transducer is
• Main portal vein with color Doppler
placed transverse
and lateral on the • Right lobe mid
patient’s body LIVER TX MPV • Main portal vein with color & spectral Doppler
o Normal waveform will demonstrate slight phasic flow
toward the liver
LIVER TX INF • Right lobe-inferior
• Right kidney

Organ/ Scan Plane Label Key Landmarks Identified
Order
GB SUPINE • Gallbladder body
Sagittal plane of SAG • Gallbladder fundus
Gallbladder the GB GB SUPINE • Gallbladder body
SAG • Gallbladder neck
Patient in Transverse plane GB SUPINE TX • Gallbladder mid body with clear delineation of anterior wall
Supine position of the GB • Gallbladder mid body with clear delineation of anterior wall
GB SUPINE TX • Measurement
o measure anterior wall thickness
GB LLD SAG • Gallbladder body
Gallbladder
Sagittal plane of • Gallbladder fundus

Patient in Left the GB GB LLD SAG • Gallbladder body
lateral • Gallbladder neck
decubitus Transverse • Gallbladder mid body
position GB LLD TX
plane of the GB
• Gallbladder body
Gallbladder GB RLD SAG
Sagittal plane of • Gallbladder fundus
Patient in Right the GB • Gallbladder body
GB RLD SAG
lateral • Gallbladder neck
decubitus Transverse plane • Gallbladder mid body
position GB RLD TX
of the GB
• Portal vein
Transverse plane
CBD TX • CBD
of the CBD
• Hepatic artery
Common • Portal vein
Bile Duct CBD SAG
• CBD
• Enlarged image
level of the Sagittal
porta hepatis CBD SAG • Portal vein
plane of the CBD
• CBD
• Enlarged image
CBD SAG
• Portal vein

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 • CBD
• Measurement
o Internal AP diameter

Anatomical/ Image Correlation

CBD Hepatic artery

Portal vein CBD measurement

Inner wall to inner wall
Anterior GB wall measurement Transverse Portal triad
Where it enters the liver
Outer wall to inner wall Mickey Mouse sign

Normal Measurement Ranges

Structure Area of Interest Plane Measurement Comments
Common Bile Duct Level of Porta Hepatis Long Axis <7-8 mm • Measure inner wall to inner wall
• If duct is enlarged:
o Look for and document any
intrahepatic ductal dilatation
o Follow CBD to pancreatic
head
• If GB removed, CBD may be
enlarged (up to 11 mm)
Gallbladder wall Anterior Wall Transverse <3 mm • Calipers are placed outside to
inside of the anterior wall
Liver RT Lobe Inferior Sagittal 15-17 cm • Measure superior to inferior
Pancreas Head Transverse Head 2-3.5 cm • Only performed if abnormalities
on the are suspected
body
Pancreatic Duct Body of the pancreas Transverse 2 mm or less • Only performed if duct is
on the visualized
body • Measure internal duct diameter
anterior to posterior
Main Portal Vein Porta Hepatis Transverse Normal AP • Internal AP diameter where MPV
on the measurement is crosses the IVC
body/ long <13 mm o Only performed if
axis on the abnormalities are suspected
vessel Normal flow • Flow should be phasic and
velocity is 20-40 toward the liver
cm/s

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 Liver Protocol

Common Laboratory Values to be Reviewed prior to Examination

Lab Value Organ Level Indication or Association
Amylase • Pancreas Increased • Pancreatitis or other pancreatic disease
Lipase • Pancreas Increased • Pancreatitis or other pancreatic disease
AST (SGOT) • Liver Increased • Hepatitis, fatty liver, cirrhosis other liver disease

ALT (SGPT) • Liver Increased • Jaundice or hepatitis

Alkaline phosphatase • Liver Increased • Biliary obstruction or metastases
• Gallbladder
Bilirubin • Liver Increased • Jaundice, liver damage or obstruction
• Gallbladder

Tips
• Patient should be NPO for this study to reduce the amount of gas present and to prevent contraction of the GB
• Have patient poke out their abdomen or take in a deep breath if having trouble seeing the pancreas
• Pancreatic tail may be evaluated using the spleen as a window
• Sit the patient erect for scanning if suspicious for stones stuck in the neck that weren’t confirmed in LLD or RLD
• Watch your gain settings:
o Making the GB lumen too dark with TGC can mask pathology
o Using too much gain can give the appearance of pathology
• If the GB appears to have artifacts, change to a higher frequency, use harmonics, use a different window, or
have the patient poke out their abdomen
• If the GB is enlarged make sure to evaluate the ducts for signs of stones. These can obstruct the ducts
• To find the CBD:
o Scan from the GB in transverse and follow it to the neck and cystic duct, you will see CBD
o Follow the portal vein from the portal confluence. The CBD will be anterior to the vein
• If the GB has been surgically removed (postcholecystectomy), document a “GB FOSSA” image (main lobar fissure
near porta hepatis) instead of the gallbladder images


• Pathology Seen
o Gray scale sagittal and transverse images
o Gray scale sagittal and transverse images with 3 measurements (length, width, and height)
o Color Doppler image to document the presence of blood flow
o Spectral Doppler image to document the type and velocity of blood flow
o If the wall measures greater than 3 mm, color Doppler can be used to confirm increased flow in the wall due
to cholecystitis.
o If the patient has gallstones and/or gallbladder wall thickening, they should be evaluated for a positive
Murphy’s sign (extreme tenderness upon transducer or manual pressure in the RUQ). This needs to be
reported to the interpreting physician as it indicates acute cholecystitis.
o Must attempt to demonstrate movement of any pathology seen in the GB – sludge and stones will move –
masses will not!!
o If the CBD is enlarged at the porta hepatis, it should be followed to the pancreatic head to evaluate for
stones or an obstructive lesion

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