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
Portal splenic confluence
PANCREAS
CBD
o If CBD is enlarged, measure internal AP
diameter
Transverse
Pancreas body
Pancreas plane on the
Aorta
body PANCREAS
Measurement
o If pancreatic duct is seen measure internal
AP diameter
PANCREAS Pancreas tail
Splenic vein
Organ/ Scan Plane Label Key Landmarks
Order Identified
Sagittal LIVER SAG Left lobe with inferior tip
The transducer
is placed sagittal LIVER SAG Left lobe
in the mid
Caudate lobe
portion of the
patients body IVC
LIVER SAG Right lobe
Diaphragm
LIVER
Sagittal
LIVER SAG Right lobe superior
SUP Right hemidiaphragm
Sagittal Right pleural space
The transducer LIVER SAG Right lobe mid
is placed MID Main portal vein
sagittal and LIVER SAG Right lobe inferior
lateral on the INF o Demonstrating largest superior to inferior
patients body area
o Measure liver length from superior to inferior
Right kidney
LIVER Transverse LIVER TX Left lobe
Transver Caudate lobe
The transducer
se IVC

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 is placed Right lobe
transverse in the
LIVER TX Left lobe
mid portion of
the patients
HV Right hepatic vein
body Left hepatic vein
Middle hepatic vein
Angulation of the
LIVER TX Right lobe-most anterior portion
probe is used for
Diaphragm
right lobe images
LIVER TX Right lobe superior
SUP Right hemidiaphragm
Right pleural space
LIVER TX Right lobe mid
MPV Main portal vein
LIVER Transverse
Transver LIVER TX Right lobe mid
The transducer
se MPV Main portal vein with color Doppler
is placed
transverse and
lateral on the Right lobe mid
LIVER TX
patients body Main portal vein with color & spectral Doppler
MPV
o Normal waveform will demonstrate slight
phasic flow toward the liver
LIVER TX Right lobe-inferior
INF Right kidney

Organ/ Scan Plane Label Key Landmarks Identified

Order
GB SUPINE Gallbladder body
Sagittal plane SAG Gallbladder fundus
Gallblad of the GB GB SUPINE Gallbladder body
der SAG Gallbladder neck
Transverse GB SUPINE Gallbladder mid body with clear delineation of
Patient in plane of the TX anterior wall
Supine GB Gallbladder mid body with clear delineation of
position GB SUPINE anterior wall
TX Measurement
o measure anterior wall thickness
GB LLD Gallbladder body
Gallblad SAG Gallbladder fundus
der Sagittal plane
of the GB GB LLD Gallbladder body
Patient in SAG Gallbladder neck
Left lateral
decubitus Transverse Gallbladder mid body
position plane of the GB LLD TX
GB
Gallblad Sagittal plane GB RLD Gallbladder body
der of the GB SAG Gallbladder fundus
GB RLD Gallbladder body

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 Patient in SAG Gallbladder neck
Right lateral
Transverse Gallbladder mid body
decubitus
position
plane of the GB RLD TX
GB
Transverse Portal vein
plane of the CBD TX CBD
CBD Hepatic artery
Portal vein
Common CBD SAG
CBD
Bile Duct Enlarged image
CBD SAG Portal vein
level of the Sagittal
CBD
porta plane of the
hepatis Enlarged image
CBD
Portal vein
CBD SAG CBD
Measurement
o Internal AP diameter

Anatomical/ Image Correlation

CBD Hepatic

Portal CBD measurement

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

Normal Measurement Ranges

Structure Area of Interest Plane Measureme Comments

nt
Common Bile Level of Porta Long Axis <7-8 mm Measure inner wall to
Duct Hepatis 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 Transvers <3 mm Calipers are placed

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 e outside to inside of the
anterior wall
Liver RT Lobe Inferior Sagittal 15-17 cm Measure superior to
inferior
Pancreas Head Transvers Head 2-3.5 Only performed if
e on the cm abnormalities are
body suspected
Pancreatic Duct Body of the Transvers 2 mm or less Only performed if duct is
pancreas e on the visualized
body Measure internal duct
diameter anterior to
posterior
Main Portal Vein Porta Hepatis Transvers Normal AP Internal AP diameter
e on the measurement where MPV crosses the
body/ is <13 mm IVC
long axis o Only performed if
on the Normal flow abnormalities are
vessel velocity is 20- suspected
40 cm/s Flow should be phasic and
toward the liver

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 Liver Increased Biliary obstruction or metastases

phosphatase 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 werent
confirmed in LLD or RLD
Watch your gain settings:
o Making the GB lumen too dark with TGC can mask pathology

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 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 Murphys 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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