What is The

LIVER

An organ in the upper

abdomen that aids
in digestion and
remove waste
products and wornout cells from the
blood. It is the
largest solid&
glandular organ in
the body.

What is the blood supply of the

?liver

Liver has a dual blood supply; portal

vein(75%) & hepatic artery (25%),The
hepatic veins are responsible for drainage
of filtered blood from the liver into the IVC.

What about Liver anatomy??

Liver anatomy can be described using two different
aspects

Morphological

anatomy

is based on the external

appearance of the liver and
does not show the internal
features of vessels and
biliary ducts branching,
which are important in
hepatic surgery.

Functional

anatomy

divides the liver into eight

functionally independent
segments.
Each segment has its own
vascular inflow, outflow and
biliary drainage

Whats the significance of

!?functional anatomy
In order to perform segmental or
subsegmental resection of the liver, the
surgeon must know exactly which parts
of the liver are diseased so that vascular
supply and venous and biliary drainage
can be preserved& also Because of this
division into self-contained units, each
segment can be resected without
damaging those remaining.

There

are many anatomical and

functional descriptions of the liver
anatomy such as Classical
Anatomy &Bismuth's
classification however
(Couinaud classification) is the
most commonly used
classification.

Couinaud classification

The Couinaud classification of liver

anatomy divides the liver into eight

functionally independent segments.
Each segment has its own vascular
inflow (hepatic artery & portal vein),
outflow (hepatic vein) and biliary
drainage

How are the segments spatially

?separated
Right

hepatic vein divides the right lobe into

anterior and posterior segments (segment 6& 7

usually not visulaized at the frontal view).
Middle hepatic vein divides the liver into right
and left lobes (or right and left hemiliver). This
plane runs from the inferior vena cava to the
gallbladder fossa (Cantlie's line)
Left hepatic vein divides the left lobe into a
medial and lateral part.
Portal vein divides the liver
into upper & lower segments.

??What are liver segments

Couinaud's numbering
system:

1-Caudate Lobe (posteriorly)

2-Left Superior Lateral segment
3-Left Inferior Lateral segment
4a-Left Superior Medial segment
4b-Left Inferior Medial segment
5-Right Inferior Anterior segment
6-Right Inferior Postrior segment
7-Right Superior Postrior
segment
8-Right Superior Anterior
segment

How can you interpret this

classification at the transverse
?images
Imagine

the liver is sliced at 4 levels &

then analyze the previously mentioned
liver segments at each level:

This figure is a
transverse image
through the superior
liver segments, that
are divided by the
hepatic veins.

This figure shows

transverse image at the
level of the left portal
vein.
At this level the left
portal vein divides the
left lobe of liver into
superior segments (2 and
4A) and inferior
segments (3 and 4B).

The image on the left is

at the level of right
portal vein. At this level
right portal vein divides
the right lobe of the
liver into superior
segments (7 and 8) and
the inferior segments
(5 and 6).
The level of right portal
vein is inferior to the
level of left portal vein

below the level of the

main portal vein:
The gallbladder separates
segment(V) from
segment (IVB).
The ligamentum teres
divides segment(IVB)
and (III) segments.

TO REMEMBER

Above

Level of splenic v&main

portl v

the level of this image

segments from left to right
are7,8,4,2
Below & at this level segments from
left to right are 6,5,4,3

Modalities of Liver
Imaging
Ultrasound
CT
MRI
Nuclear

Medicine

Ultrasound

Is the first and the most commonly obtained

method of examination in patients with RUQ
pains, abnormal LFTs, or suspected liver masses.

Is a noninvasive and excellent screening tool.

Used to evaluate the presence of bile duct

obstruction and gallstones as well as to
distinguish a solid lesion from a cystic one.

Has low sensitivity and high false negative

rate for detection of liver metastases.

 Ultrasound

Doppler imaging can be very

helpful in identifying vascular
abnormalities, i.e. patency of hepatic
vessels, portal vein, and IVC as well as flow
direction in these vessels. Flow in the
portal vein and hepatic arteries are
hepatopedal (toward the liver) while flow in
hepatic veins and hepatic ducts are
hepatofugal (away from the liver).

CT

Uses X-ray to acquire data that can be displayed in

axial, coronal, and sagittal planes.

I.V. iodinated contrast is commonly used in liver

imaging to demonstrate any abnormal
enhancement of a hepatic lesion and to show
vascular structures.

An I.V. bolus of 100 to 150 ml of iodinated contrast

is often used. The contrast agent is injected into
veins, travels to the heart, aorta, celiac trunk,
hepatic arteries, liver parenchyma and mixes with
blood in portal veins drained into venules and then
hepatic veins and then out to the IVC.

the

hepatic enhancement can be

divided into 3 phases:

1-Arterial phase (when the contrast just fills up the aorta
and the main hepatic arterial structures),kidneys also
show corticomedullary differentiation
2-Portal venous phase (when the contrast disperses into
the liver parenchyma (liver brighten) and mixes with
portal blood (portal v brighten)
3-Equilibrium phase (Delayed phase) (when the contrast
further scatters in the parenchyma and drains out the
hepatic veins and also be seen in the renal collecting
system).

When searching for hypervascular lesions, such as

hepatoma or metastastic disease, a three-phase
technique often should be used: non-contrast
phase, arterial phase, and portal venous phase.

The appropriate delay times for scanning in the

arterial phase and portal venous phase for a 2-3
ml/sec injection are 25 seconds and 70 seconds,
respectively.

The rationale behind this technique is that primary

and secondary malignancies of the liver typically
have hepatic arterial supply, thus will enhance
during the arterial phase, whereas benign entities
and normal liver parenchyma have primarily portal
venous supply, therefore, will enhance during
portal-venous phase of I.V. contrast.

Progressive fill in
(note the lesion at non enhanced
image,then peripheral
enhancement in arterial phase
&further central filling at portal
phase then total enhancement at
the delayed image)
Very characterstic of
hemangioma

Rapid Wash out

Note here also the lesion at

the non contrast image then
early enhancement at the
arterial phase and rapid wash
out a the portal phase
(yellow arrows)
very characterstic of HCC

MRI
Indications

for Liver MRI

1- Patients are allergic to iodinated
contrast agents.
2-Lesion detection & characterization .
3-Anatomic location .
4-Hepatic vascular patency .
5-Biliary duct system.

 MRI

has many advantages over CT:

High soft tissue contrast resolution
(can see smaller lesions),
Multiple sequences,
Multiplanar capability,
MRA, MRV, MRCP,
No radiation, no iodinated contrastetc.

 However,

MRI is similar to CT in that it

has the same dynamic multiphase
contrast enhancement capability.

MRI can be helpful in the

characterization of a small (< 2 cm)
benign hemangioma that is equivocal
on CT.

A wide range of MRI sequences is available for liver

imaging thanks to the numerous manipulations of field
strength, pulse sequence, and interdependent
sequence parameters which can affect image quality.
Since there is little agreement on the best technique,
MRI sequences are often unique to the institution. At
UVa, we use the following:
Breath hold T1 spoiled gradient echo (In phase and out
of phase): can be used to detect fatty liver, fat in HCC,
focal fatty infiltration/sparing, adrenal adenomas.
Breath Hold T2: can be used to evaluate hemangiomas
and cysts.
Turbo spin echo with fat sat or STIR
HASTE -Half Fourier acquisition single shot turbo spin
echo
Dynamic Gad T1 (Arterial, portal venous, delayed,
timing bolus, or smart prep): can be used to
characterize hypervascular lesions.

 For

most techniques, the intensity of

normal liver parenchyma is the same as
or slightly higher than that of adjacent
muscle. Normally, the liver should be
brighter than (hyperintense to) the
spleen on T1-weighted images and
darker than (hypointense to) the spleen
on T2-weighted images.

Developmental Anomalies and

Anatomic Variants of the liver

Embryonic development of
the liver, pancreas,
extrahepatic biliary
apparatus, and duodenum.

Agenesis of the
right hepatic
lobe. A. CT reveals
agenesis of the right
lobe of the liver with
compensatory
hypertrophy of the
left lobe

Agenesis of the
left hepatic lobe.
CT shows tongue
like projection
(arrow) of caudate
lobe at the upper
image.

Diaphragmatic invagination
As a result of invagination of
diaphragmatic slips along the
superior aspect of the liver,
pseudoaccessory fissures are
formed.

Diaphragmatic
invagination mimicking
hepatic nodule

Accessory fissure in
the under surface of
the liver. The
accessory fissure in the
right lobe

Sliver of liver. The T2weighted image of the upper

abdomen reveals leftward
lateral extension of the left
lobe of the liver ,which
appears as a crescentic lowintensity structure wrapping
around the lateral aspect of
the spleen. If the
communication is not seen, it
can mimic abnormal structure
lateral to the spleen. This
occasionally is the case in
abdominal ultrasound.

Papillary process
of the caudate
lobe. The contrastenhanced CT scan
shows medial and
posterior extension
of the papillary
process near the
head of the pancreas
mimicking a mass
lesion.

Papillary and caudate

process pseudomass.
The T1-weighted fatsuppression images
reveal medial extension
of the papillary process
near the head of the
pancreas. Notice the
signal characteristics of
this mass being similar to
the remainder of the liver
and not of the pancreas.

Riedel's lobe. A.
Topogram from
the patient's CT
scan displays an
elongated inferior
extension of the
right lobe of the
liver (arrows)
characteristic of a
Reidel lobe