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Liver Protocol (Hepatic or RUQ)
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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/
Order
Pancreas
Organ/
Order
Scan Plane
Transverse plane
on the body
Key Landmarks Identified
PANCREAS
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PANCREAS
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PANCREAS
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Pancreas head
Portal splenic confluence
CBD
o If CBD is enlarged, measure internal AP diameter
Pancreas body
Aorta
Measurement
o If pancreatic duct is seen measure internal AP diameter
Pancreas tail
Splenic vein
Scan Plane
Label
Sagittal
LIVER SAG
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Left lobe with inferior tip
The transducer is
placed sagittal in the
mid portion of the
patient’s body
LIVER SAG
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Left lobe
Caudate lobe
IVC
Right lobe
Diaphragm
Right lobe superior
Right hemidiaphragm
Right pleural space
Right lobe mid
Main portal vein
Right lobe inferior
o Demonstrating largest superior to inferior area
o Measure liver length from superior to inferior
Right kidney
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Left lobe
Caudate lobe
IVC
Right lobe
Left lobe
Right hepatic vein
Left hepatic vein
LIVER SAG
LIVER
Sagittal
LIVER SAG SUP
Sagittal
The transducer is
placed sagittal and
lateral on the
patient’s body
LIVER
Transverse
Label
LIVER SAG
MPV
LIVER SAG INF
Transverse
LIVER TX
The transducer is
placed transverse in
the mid portion of
the patient’s body
LIVER TX HV
Angulation of the
AK\backup\Abdomen I\Protocols
Key Landmarks Identified
probe is used for
right lobe images
LIVER TX
LIVER TX SUP
LIVER TX MPV
LIVER
Transverse
Transverse
The transducer is
placed transverse
and lateral on the
patient’s body
LIVER TX MPV
LIVER TX MPV
LIVER TX INF
Organ/
Order
Scan Plane
Gallbladder
Sagittal plane of
the GB
Patient in
Supine position
Transverse plane
of the GB
GB SUPINE
SAG
GB SUPINE
SAG
GB SUPINE TX
Patient in Left
lateral
decubitus
position
Gallbladder
Patient in Right
lateral
decubitus
position
GB LLD SAG
Sagittal plane of
the GB
Transverse
plane of the GB
Sagittal plane of
the GB
level of the
porta hepatis
GB LLD SAG
GB LLD TX
GB RLD SAG
GB RLD SAG
Transverse plane
of the GB
GB RLD TX
Transverse plane
of the CBD
CBD TX
Common
Bile Duct
CBD SAG
Sagittal
plane of the CBD
CBD SAG
CBD SAG
AK\backup\Abdomen I\Protocols
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Middle hepatic vein
Right lobe-most anterior portion
Diaphragm
Right lobe superior
Right hemidiaphragm
Right pleural space
Right lobe mid
Main portal vein
Right lobe mid
Main portal vein with color Doppler
Right lobe mid
Main portal vein with color & spectral Doppler
o Normal waveform will demonstrate slight phasic flow
toward the liver
Right lobe-inferior
Right kidney
Label
GB SUPINE TX
Gallbladder
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Key Landmarks Identified
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Gallbladder body
Gallbladder fundus
Gallbladder body
Gallbladder neck
Gallbladder mid body with clear delineation of anterior wall
Gallbladder mid body with clear delineation of anterior wall
Measurement
o measure anterior wall thickness
Gallbladder body
Gallbladder fundus
Gallbladder body
Gallbladder neck
Gallbladder mid body
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Gallbladder body
Gallbladder fundus
Gallbladder body
Gallbladder neck
Gallbladder mid body
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Portal vein
CBD
Hepatic artery
Portal vein
CBD
Enlarged image
Portal vein
CBD
Enlarged image
Portal vein
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CBD
Measurement
o Internal AP diameter
Anatomical/ Image Correlation
CBD
Hepatic artery
CBD measurement
Inner wall to inner wall
Where it enters the liver
Portal vein
Transverse Portal triad
Mickey Mouse sign
Anterior GB wall measurement
Outer wall to inner wall
Normal Measurement Ranges
Structure
Common Bile Duct
Area of Interest
Level of Porta Hepatis
Plane
Long Axis
Measurement
<7-8 mm
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Gallbladder wall
Anterior Wall
Transverse
<3 mm
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Liver
Pancreas
RT Lobe Inferior
Head
15-17 cm
Head 2-3.5 cm
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Pancreatic Duct
Body of the pancreas
Sagittal
Transverse
on the
body
Transverse
on the
body
2 mm or less
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Transverse
on the
body/ long
axis on the
vessel
Normal AP
measurement is
<13 mm
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Normal flow
velocity is 20-40
cm/s
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Main Portal Vein
Porta Hepatis
AK\backup\Abdomen I\Protocols
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Comments
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)
Calipers are placed outside to
inside of the anterior wall
Measure superior to inferior
Only performed if abnormalities
are suspected
Only performed if duct is
visualized
Measure internal duct diameter
anterior to posterior
Internal AP diameter where MPV
crosses the IVC
o Only performed if
abnormalities are suspected
Flow should be phasic and
toward the liver
Liver Protocol
Common Laboratory Values to be Reviewed prior to Examination
Lab Value
Amylase
Lipase
AST (SGOT)
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Organ
Pancreas
Pancreas
Liver
Level
Increased
Increased
Increased
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Indication or Association
Pancreatitis or other pancreatic disease
Pancreatitis or other pancreatic disease
Hepatitis, fatty liver, cirrhosis other liver disease
ALT (SGPT)
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Liver
Increased
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Jaundice or hepatitis
Alkaline phosphatase
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Liver
Gallbladder
Liver
Gallbladder
Increased
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Biliary obstruction or metastases
Increased
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Jaundice, liver damage or obstruction
Bilirubin
Tips
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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
AK\backup\Abdomen I\Protocols