The Normal Liver Part 4: Vasculature

Question 1

Liver Vasculature

• In the hepatic portal system, the liver receives a dual blood supply from the _____
portal vein and hepatic _____

• The hepatic portal vein carries _____ blood drained from the spleen,
gastrointestinal tract and its associated organs; it supplies approximately _____% of the
liver’s blood.

• The hepatic arteries supply _____ blood to the liver and account for the remainder
of its blood flow

• The hepatic portal system connects the capillaries of the _____ tract with the capillaries in the liver. Nutrient-rich blood leaves the gastrointestinal tract and is first brought to the liver for processing before being sent to the _____

• A portal system is a venous structure that enables blood from one set of capillary beds to drain into another set of capillary beds, without first returning this blood to the _____. The majority of capillaries in the body drain directly into the _____, so
portal systems are unusual

• Approximately half of the liver’s 02 demand is met by the hepatic _____ vein, and
half is met by the hepatic _____

• Blood flows through the liver tissue and empties into the central _____ of each lobule.
The central veins course into hepatic veins that collect the blood leaving the liver, drains into the _____ which will bring it to the heart

Answer 1

hepatic
arteries
venous
75
arterial
gastrointestinal
heart
heart
heart
portal
arteries
vein
IVC

Question 2

Vascular Supply

I. Vessels

1) Hepatic Artery
2) Portal Venous System
- -_____
- -_____
- -_____

3) Hepatic Veins

II. Has Dual blood supply
> _____ and _____

III. Has Portal Triad
—Branch of hepatic _____,
portal _____ and _____ ducts

—Contained within connective sheath; presenting as echogenic walls of PV when compared to HV

IV. Sono & Distinguishing Appearance
► Distinguishing Portal and Hepatic Veins
Intrahepatic Vessels and Ducts

Answer 2

MPV
RPV
LPV
PV
HA
arteries
veins
bile

Question 3

Hepatic Artery

• Function - carries _____ blood to liver

—Part of the Portal Triad of _____, CD, _____, therefore travels in the sheath which creates echogenic walls

• Anatomy - AO –> CHA —> PHA —> right and left hepatic arteries

SONO
–very small, especially away
from porta hepatis

–Technique - anterior approach

–Doppler - antegrade flow in
diastole, low RI

Answer 3

oxygenated
PV
HA

Question 4

Portal Venous System - Anatomy Aka Portal Triad

Normal placement is w/in the _____ ligament (portion of the lesser omentum extending b/t porta hepatis of liver and the superior part of the duodenum; running inside of it are the structures collectively know as the portal triad)

1) CHD/CBD - Ventral (_____) and _____
2) PHA/HA - Ventral (_____) and _____
3) PV - Dorsal (_____) between _____ and _____

** porta hepatis or transverse fissure of the liver is a short but deep fissure, about ___ cm long. extending transversely beneath LT portion RT lobe of liver, separates the _____ lobe from the _____ lobe

Answer 4

hepatoduodenal
anterior
lateral
anterior
medial
posterior
PHA
CHD
5
quadrate
caudate

Question 5

Portal Venous System - Function
• ____-____% of hepatic blood flow
• Carries incompletely 02 blood from _____, _____, _____,

Portal Venous System - Anatomy

• MPV begins with
the junction of the _____ mesenteric veins and _____ vein, posterior to the neck of the _____

—Travels _____, _____
alongside the HA

• MPV is: _____
to IVC, cephalad to _____ head, caudal to _____ lobe

Answer 5

50
60
spleen
pancreas
GB
superior
splenic
pancrease
superiorly
obliquely
anterior
pancreatic
caudate

Question 6

Portal Triad Localization in Imaging

• Identify _____ in a transverse image of the mid-abdomen
• Follow the SV to its confluence with the _____ = MPV

• _____ will course superiorly and laterally toward the liver
appearing round

• Oblique the transducer _____° (on a line from the right hip to the left shoulder) until the HA and the CHD are seen = Mickey Mouse sign

Answer 6

SV
SMV
MPV
45 degrees

Question 7

Porta Hepatis

• Gate/_____ of liver

• MPV divides into _____ and _____
branches

• the RHA and LHA enters the
_____ parenchyma

• right and left hepatic ducts exit
the liver and form the _____

Answer 7

hilum
right
left
liver
CHD

Question 8

Portal Triad – Differentiating PHA from CHD

• Travels in _____; bright (echogenic) area around it
• Intrinsic pulsations in _____ or _____ ONLY
• A crossing artery can sharply indent a _____ or _____; reverse NOT TRUE
• Duct _____ may vary through exam and along course; arteries are uniform in caliper
• Artery may not _____ vein or may do so for only a short distance; _____ parallels vein closely
• _____ may be tortuous and loop in and out of the scan plane
• Arteries produce _____ Doppler signals; veins produce _____ Doppler signals; ducts produce _____ DOPPLER SIGNAL

Answer 8

sheath
artery
vein
duct
vein
size
parallel
duct
arteries
pulsatile
continuous
NO

Question 9

Right Portal Vein

• Larger more _____
and more _____ branch

• Receives _____ vein
• Divides into

• Anterior branch - central within _____ segment right lobe .
– Posterior branch -
central within _____ segment right lobe

Answer 9

posterior
caudal
cystic
anterior
posterior

Question 10

Left Portal Vein

—Enters left lobe and joined by paraumbilical veins and ligamentum _____

—Smaller more _____ and cranial branch

—Initially (horizontal portion) anterior to caudate lobe —> ascending branch runs within left intersegmental fissure separating left medial from left lateral segments

Left Portal Vein

Divides into

• –Medial branch - central within _____ segment left lobe
• –Lateral branch - central within _____ segment left lobe

Depending on the angle or position of probe, the LPV may look differently

Answer 10

teres
anterior
medial
lateral

Question 11

Portal Venous System - Technique

• MPV and LPV - _____ approach; “Recumbent H” = initial LPV, ascending branch LPV, medial and lateral and additional posterior/lateral branch (oblique-cranially-angled, subxiphoid)
• RPV - right _____ approach; “Recumbent H” = sagittal or oblique

Answer 11

anterior

intercostal

Question 12

Portal Venous System - Doppler

• _____ velocity continuous flow toward liver (hepatopedal)
• occasionally may see mild undulations due to _____
• Velocity _____ during inspiration and post-prandially

Answer 12

low
heartbeat
increase

Question 13

Hepatic Veins, Anatomy

• Function
—Carries _____ blood from liver
to IVC

• Anatomy
•Vary in number and position, generally 3 major - _____, _____, _____
–No _____

• Technique
• Transverse scan plane high in _____

Answer 13

deoxygenated
right
middle
left
valves
epigastrium

Question 14

Hepatic Veins, Anatomy:

—RHV, MHV, LHV join and enters the _____

—3 upper hepatic veins which drain the liver of _____ blood into the IVC

Right Hepatic Vein (RHV)

—-Single lies w/in _____ intersegmental fissure
Short hepatic vein

—separates RT lobe into _____ and _____ segments

Middle Hepatic Vein LHV)

> Forms common trunk w/in _____

—-lies within _____ lobar fissure

► separates _____ lobe from _____ lobe

Left Hepatic Vein

> The cephalad boundary dividing LT lobe
into _____ and _____ segments

Answer 14

IVC
deoxygenated
right
anterior
posterior
LHV
main
right
left
lateral 
medial

Question 15

Main Lobar Fissure

> a plane which can be
approximated by drawing a line connecting the
_____ bed and _____

> Bright (echogenic) line
seen connecting GB bed/fossa to _____

— Divides _____ and _____ lobes of
liver

—The middle hepatic vein
courses within the _____ lobar fissure

Answer 15

gallbladder
RPV
RPV
right
left
main

Question 16

Hepatic Veins Doppler

• Blood flow toward _____
• Characteristic _____ waveform or a “W” reflective of cardiac activity

Answer 16

IVC

triphasic

Question 17

Hepatic Vein:

• -Interlobar and _____
• -Drain towards _____ atrium
• -Caliper _____ as approach diaphragm and IVC
• -_____ reflective walls
• -Branch _____
• -Caliper varies with _____
• -With an oblique coronal supxiphoid view, form a “___”, _____ shape, or “_____ bunny” sign

Portal Veins:

• -Branches of RPV and _____ intrasegmental
• -Originate from porta _____
• -Caliper _____ near porta hepatis
• -Echogenic, _____ walls
• -Branch _____

Answer 17

intersegmental
right
increases
No
longitudinally
respiration
W
star
playboy
LPV
hepatis
greater
reflective
horizontally

Question 18

RHV = Location: _____ intersegmental fissure; Usefulness: Divides cephalic aspect of right lobe into _____ and _____ segments

MHV = Location: _____ lobar fissure; Usefulness: separates _____ and _____ lobes

LHV = Location: _____ intersegmental fissure; Usefulness: divides cephalic aspect of left lobe into _____ and _____ segments

RPV = Location: _____ intersegmental fissure; Usefulness: Divides anterior and posterior segments of _____ lobe

RPV - anterior branch = Location: Intrasegmental in _____ segment of right lobe; Usefulness: Courses centrally within _____ segment of right lobe

RPV - posterior branch = Location: Intrasegmental in _____ segment right lobe; Usefulness: Courses centrally within _____ segment of right lobe

LPV - horizontal segment = Location: _____ to caudate lobe; Usefulness: Separates caudate lobe _____ from medial segment of left lobe _____

LPV - ascending segment = Location: _____ intersegmental fissure; Usefulness: Divides medial from _____ segment of left lobe

LPV - Medial branch = Location: Intrasegmental in _____ segment left lobe; Usefulness: Courses centrally within _____ segment of left lobe

LPV - Lateral branch = Location: Intrasegmental in _____ segment left lobe; Usefulness: Courses centrally within _____ segment of left lobe

GB fossa = Location: _____ lobar fissure; Usefulness: Separates _____ and _____ lobes

Fissure for Ligamentum Teres = Location: _____ intrasegmental fissure; Usefulness: Divides caudal aspect of left lobe into _____ and _____ segments

Answer 18

right
anterior
posterior
main
right
left
left
medial 
lateral
right
right
anterior
anterior
posterior
posterior
anterior
posteriorly
anteriorly
Left
lateral
medial
medial
lateral
lateral
main
right 
left
left
medial 
lateral