Sonographer in the Making

Liver Flashcards

Informational, double sided. The most important facts on the card, an anatomy illustration and an ultrasound image on each, and a QR to the digital practice questions. No questions printed on the card. The deck opens with the normal liver, anatomy, function, labs, sonographic appearance, and scanning, then moves into the pathology.

Cards 1 and 2 are the normal liver, reformatted from Jenny's own two source cards. Cards 3 and 4 begin the pathology, drawn from the reference texts since the source deck stopped at normal; their images are shown as slots until the pathology figures are pulled. Card size, front and back split, and QR targets are still to be set.

Card 1  ·  Liver: Anatomy
Front
SITM
LIVER
Anatomy
Liver illustration
Liver, anterior view

Key terms

  • Hepatocyte: liver cell performing all liver functions.
  • Falciform ligament: connects liver to diaphragm and abdominal wall; contains the ligamentum teres.
  • Ligamentum teres: remnant of the umbilical vein; bright echogenic focus; separates the medial and lateral segments of the left lobe.
  • Ligamentum venosum: separates the left lobe from the caudate lobe.
  • Main lobar fissure: boundary between right and left lobes; runs portal vein to gallbladder neck; landmark to the gallbladder.
  • Bare area: portion of liver with no peritoneal covering; against the diaphragm.

Position & lobes

  • Largest organ in the abdominal cavity; right hypochondrium, epigastrium, and left hypochondrium to the mammillary line.
  • Inferior to the diaphragm; right lobe covered by the ribs.
  • Lobes: right, left, and caudate (posterior lobe, independent vascular supply).
  • Variant: Riedel's lobe, a tongue like projection of the right lobe.
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Back
SITM
LIVER
Vasculature
Transverse portal triad ultrasound
Portal triad, transverse: "Mickey Mouse sign"

Portal triad & blood supply

  • Portal triad: portal vein + hepatic artery + bile duct.
  • Mickey Mouse sign (transverse): portal vein is the face; hepatic artery and common bile duct are the two ears.
  • Vascular supply: portal vein 70 to 80% of blood; hepatic artery 20 to 30%, oxygenated.
  • Right lobe receives blood from the intestine; left and caudate lobes from the stomach and spleen.
  • Three hepatic veins (right, middle, left) drain into the IVC; portal vein enters at the porta hepatis.

Flow direction

  • Hepatopetal: flow toward the liver (normal portal flow).
  • Hepatofugal: flow away from the liver (normal hepatic vein flow; abnormal if portal).
Tricks: "petal" pulls toward  •  "fugitive" flees away

Embryology

  • Develops from the foregut endoderm; ligamentum teres is a remnant of the fetal umbilical vein.
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Card 2  ·  Liver: Sonographic & Clinical
Front
SITM
LIVER
Sonographic
Right lobe echo texture ultrasound
Right lobe echo texture & measurement

Normal appearance

  • Homogeneous texture with fine, low level echoes.
  • Echogenicity: minimally hyperechoic to isoechoic vs renal cortex; hypoechoic vs spleen; pancreas equal to or slightly more echogenic than liver.
  • Portal veins have brighter (more echogenic) borders than hepatic veins (thicker collagen sheath). Ligaments and fissures appear echogenic to hyperechoic.

Measurements

  • TRV 21 to 22.5 cm; height 13 to 17.5 cm; AP depth 10 to 12.5 cm; SAG about 15.5 cm; portal vein 1.0 to 1.2 cm.
  • Longitudinal length over 20 cm indicates hepatomegaly.

Doppler

  • Hepatic veins show a normal triphasic waveform, reflecting right atrial hemodynamics.
  • Portal flow hepatopetal (toward liver); hepatic vein flow hepatofugal (away).
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Back
SITM
LIVER
Function & Technique

Function

  • Metabolism: converts glucose to and from glycogen, processes fats and proteins.
  • Digestion: secretes bile, excretes bilirubin. Storage: iron and vitamins. Detoxification: breaks down drugs, ammonia, and toxins.

Lab values & clinical

  • AST / ALT high suggests hepatocellular damage. Alk Phos / direct bilirubin high suggests obstruction.
  • Ordered for abnormal LFTs, RUQ pain, jaundice, suspected hepatomegaly.
  • Before scanning, correlate liver echotexture vs kidney, spleen, and pancreas, and vascular patency.

Scanning & protocol

  • NPO 6 to 8 hrs; 2.5 to 5 MHz curvilinear or sector probe; supine or RAO, deep inspiration.
  • Survey 4 planes: sagittal, transverse, coronal, subcostal oblique. Measure portal vein at end inspiration.
  • Adequacy: about 15 cm (up to 15 to 20); homogeneous; liver brighter than kidney, less bright than pancreas and spleen; vessels, ligaments, and fissures visible; smooth surface; balanced gain (TGC).
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Card 3  ·  Liver: Diffuse Disease  ·  Pathology
Front
SITM
LIVER
Diffuse Disease
Illustration Fatty (bright) liver vs. normal parenchyma
Diffuse fatty change

Fatty liver (steatosis)

  • Fatty deposits within the hepatocytes; the most common diffuse liver disease. Common causes: alcohol, obesity, diabetes.
  • Diffusely echogenic (bright) liver; increased sound beam attenuation, so the deep liver and diaphragm penetrate poorly and hepatic vessel walls are hard to see.
  • Focal fatty sparing, often near the gallbladder or porta hepatis, is a normal island in a bright liver and can mimic a mass.

Acute hepatitis

  • Inflammation of the liver. The parenchyma may look normal, or the portal vein borders become brighter than usual, the "starry sky" sign, with hepatomegaly.
Trick: bright liver that hides the diaphragm points to fat
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Back
SITM
LIVER
Cirrhosis & Portal HTN
Ultrasound Cirrhotic liver: nodular surface, coarse echotexture, ascites
Cirrhosis with surface nodularity

Cirrhosis

  • End stage chronic liver disease; regenerating nodules replace normal parenchyma. Progression: steatosis to steatohepatitis to cirrhosis to portal hypertension.
  • Sonographic: shrunken, echogenic right lobe; enlarged caudate and left lobes; nodular surface irregularity (best seen against ascites or with a high frequency linear probe); coarse echotexture.
  • Clinical: hepatomegaly early, then jaundice, ascites, and splenomegaly.

Portal hypertension

  • Portal vein enlarges; portosystemic collaterals develop and the umbilical (paraumbilical) vein can recanalize; splenomegaly and ascites follow.
  • Flow: normal hepatopetal portal flow slows, becomes biphasic, then reverses to hepatofugal (away from the liver) in severe disease.
Trick: "petal" toward  •  "fugitive" away, so reversed portal flow (hepatofugal) is the red flag
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Card 4  ·  Liver: Focal Lesions  ·  Pathology
Front
SITM
LIVER
Benign Lesions
Illustration Simple cyst and cavernous hemangioma
Common benign liver lesions

Simple hepatic cyst

  • Anechoic, round, smooth thin wall, with posterior acoustic enhancement (STAR criteria). Solitary or multiple.
  • Polycystic liver disease is associated with polycystic kidney disease.

Cavernous hemangioma

  • The most common benign tumor of the liver; a spongelike mass of blood filled spaces.
  • Typically well defined, homogeneous, and hyperechoic.

Other benign

  • Focal nodular hyperplasia and hepatic adenoma; adenoma is closely linked to oral contraceptive use.
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SITM
LIVER
Malignant & Infection
Ultrasound Hepatic metastases: multiple target lesions
Metastatic disease, target pattern

Hepatocellular carcinoma (HCC)

  • The most common primary liver malignancy; strongly linked to cirrhosis and chronic hepatitis.
  • Variable echogenicity; may invade the portal vein. Clinical: elevated AFP, weight loss.

Metastases

  • The liver is a common site for metastatic spread, and metastases are the most common malignant liver masses overall.
  • Multiple, variable echogenicity; may show a "target" or "bull's eye" pattern, an echogenic center with a hypoechoic halo.

Pyogenic abscess

  • A pus forming collection, often spread from appendicitis, diverticulitis, or cholecystitis.
  • Complex mass with internal echoes and debris; gas can cause dirty shadowing or ring down. Clinical: fever, hepatomegaly.
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