Oblique Scanning of the Left External Hepatic Lobe

Oblique liver section • External lobe • Oblique approach

Scanning Method

The patient should be fasted for 8–12 hours and examined in the supine position. Place the ultrasound probe obliquely in the subxiphoid region and angle it toward the left external hepatic lobe. Adjust the probe orientation, angle, depth, and pressure to obtain a clear oblique section of the left hepatic lobe and demonstrate the relevant hepatic and vascular landmarks.

Key scanning point: Begin from the subxiphoid region with the probe oriented obliquely toward the left upper abdomen. Adjust the probe angle to clearly demonstrate the left external hepatic lobe and its adjacent anatomical structures while maintaining a well-defined hepatic parenchymal view.

Ultrasound Image

Figure 1.1 Oblique section of the left external hepatic lobe on subxiphoid scanning. Insert the corresponding ultrasound image in the space above.

Anatomical / Scanning Diagram

Figure 1.2: Diagram space showing the probe orientation, oblique scanning plane, left external hepatic lobe, and labeled anatomical landmarks.

Section Structure

The principal structures demonstrated in this plane are the left hepatic lobe and caudate lobe, with the stomach, pancreas, splenic vein, venous ligament, aorta, and inferior vena cava serving as important adjacent anatomical landmarks.

Structures to identify

• Left hepatic lobe (LL)
• Numbered structure (1)
• Caudate lobe (CL)
• Inferior vena cava (IVC)
• Stomach (ST)
• Pancreas (P)
• Splenic vein (SpV)
• Venous ligament / ligamentum venosum (VL)
• Aorta (Ao)
• Hepatic parenchyma

Abbreviations Used in the Figure

Short form	Full form	Identification
LL	Left lobe	Left hepatic lobe.
1	Numbered structure	Reference structure indicated by number 1.
CL	Caudate lobe	Caudate lobe adjacent to the IVC.
IVC	Inferior vena cava	Major venous landmark posterior to the liver.
ST	Stomach	Gastric structure adjacent to the liver.
P	Pancreas	Pancreatic structure adjacent to the hepatic region.
SpV	Splenic vein	Venous structure coursing posterior to the pancreas.
VL	Venous ligament	Ligamentum venosum between the left lobe and caudate lobe.
Ao	Aorta	Major arterial landmark posterior to the liver.

Measuring Method and Normal

In this oblique subxiphoid plane, measurements may be obtained when clinically indicated. The IVC, SpV, or Ao may be assessed when clearly visualized, using an appropriate standardized caliper technique.

Measurement	Caliper method	Reference / interpretation
IVC	Measure the internal diameter perpendicular to the vessel's long axis when appropriate.	Interpret with respiratory phase and clinical context.
Ao	Measure the aortic diameter at the appropriate level with calipers positioned across the vessel.	Interpret according to the measurement site and clinical context.

Measurement note: Keep the target structure clearly visualized and avoid including adjacent structures in the measurement.

The Clinical Application Value

This plane provides an oblique view of the left external hepatic lobe and demonstrates important adjacent structures including the CL, IVC, ST, P, SpV, VL, and Ao.

• Demonstration of the left hepatic lobe (LL).
• Identification of the caudate lobe (CL).
• Recognition of the IVC as a posterior vascular landmark.
• Visualization of the stomach (ST) and pancreas (P).
• Identification of the splenic vein (SpV).
• Recognition of the venous ligament (VL).
• Identification of the aorta (Ao).
• Assessment of hepatic parenchymal echogenicity and contour.

Quick Scanning Checklist

1	Fast the patient for 8–12 hours when appropriate.
2	Position the patient supine.
3	Place the probe obliquely in the subxiphoid region.
4	Obtain the oblique view of the left hepatic lobe.
5	Identify LL and CL.
6	Identify ST, P, SpV, VL, and Ao.
7	Identify the IVC as a posterior vascular landmark.
8	Assess hepatic contour and parenchymal echogenicity.

Diagnostic Pathology

This oblique subxiphoid view can assist in identifying hepatic, vascular, gastric, pancreatic, and splenic venous abnormalities. Evaluate the LL, CL, IVC, ST, P, SpV, VL, and Ao together with the surrounding anatomy.

Key Sonographic Findings

• Hepatomegaly: Increased hepatic size with altered contour or morphology.
• Hepatic steatosis: Increased hepatic echogenicity with reduced visualization of deeper structures.
• Cirrhotic change: Coarse echotexture, irregular contour, and altered hepatic architecture.
• Focal liver lesion: Focal abnormality differing in echogenicity or architecture from the surrounding liver.
• Caudate lobe enlargement: Enlargement of the CL, particularly in chronic liver disease.
• IVC abnormality: Altered caliber, narrowing, compression, or intraluminal abnormality.
• Splenic vein abnormality: Altered caliber, thrombosis, or abnormal Doppler flow involving the SpV.
• Pancreatic abnormality: Enlargement, altered echogenicity, or focal lesion involving the P.
• Gastric abnormality: Abnormal gastric wall thickening, distension, or adjacent mass effect when adequately visualized.
• Aortic abnormality: Abnormal caliber, wall irregularity, atherosclerotic change, or aneurysmal dilatation involving the Ao.
• Portal hypertensive changes: Enlarged venous structures or collateral vessels may be seen in the appropriate clinical setting.

Diagnostic note: Interpret abnormal findings together with the complete abdominal ultrasound, Doppler assessment, clinical history, and laboratory findings. A single sonographic finding should not be used in isolation to establish a diagnosis.

Longitudinal Scanning of the Left Hepatic LobeThrough the Caudate Lobe and Medial Lobe

Longitudinal Liver section • Left Hepatic Lobe • Caudate Lobe and Medial Lobe approach

Scanning Method

The patient should be fasted for 8–12 hours and examined in the supine position. Place the ultrasound probe longitudinally in the midline at the subxiphoid region. Direct the probe to obtain a longitudinal section of the left hepatic lobe through the caudate lobe and medial lobe. Adjust the probe angle, depth, and position to clearly demonstrate the hepatic parenchyma, caudate lobe, medial (quadrate) lobe, and relevant adjacent vascular structures.

Key scanning point: Begin from the subxiphoid midline with the probe oriented longitudinally. Identify the caudate lobe and medial (quadrate) lobe as the principal anatomical landmarks and adjust the probe position to obtain a clear longitudinal view of the left hepatic lobe through these structures.

Ultrasound Image

Figure 1.1 Longitudinal section of the left hepatic lobe through the caudate lobe and medial lobe on subxiphoid scanning. Insert the corresponding ultrasound image in the space above.

Anatomical / Scanning Diagram

Figure 1.2: Diagram space showing the probe orientation, longitudinal scanning plane, left hepatic lobe, caudate lobe, medial lobe, and labeled anatomical landmarks.

Section Structure

The principal structures demonstrated in this plane are the left hepatic lobe, caudate lobe, and medial lobe, with the portal vein, common bile duct, and inferior vena cava providing important anatomical landmarks.

Structures to identify

• Left hepatic lobe (LL)
• Caudate lobe (CL)
• Medial / quadrate lobe
• Venous ligament (VL)
• Common bile duct (CBD)
• Portal vein (PV)
• Inferior vena cava (IVC)
• Hepatic parenchyma
• Adjacent vascular structures

Abbreviations Used in the Figure

Short form	Full form	Identification
LL	Left lobe	Left hepatic lobe.
CL	Caudate lobe	Caudate lobe adjacent to the IVC.
VL	Venous ligament	Ligamentum venosum between the left lobe and caudate lobe.
CBD	Common bile duct	Main extrahepatic biliary duct.
PV	Portal vein	Portal venous structure at the hepatic hilum.
IVC	Inferior vena cava	Major venous landmark posterior to the liver.
1	Numbered structure	Reference point indicated in the diagram.

Measuring Method and Normal

In this longitudinal subxiphoid plane, measurements may be obtained when clinically indicated. The portal vein and common bile duct should be measured only when clearly visualized and using a standardized caliper technique.

Measurement	Caliper method	Reference / interpretation
Portal vein (PV)	Measure the internal diameter with the calipers positioned appropriately across the vessel lumen.	Interpret with Doppler findings and the clinical context.
Common bile duct (CBD)	Measure the duct from inner wall to inner wall at an appropriate visualized segment.	Interpret according to age, clinical setting, and biliary anatomy.

Measurement note: Keep the measured structure clearly visualized and place the calipers perpendicular to its long axis where appropriate. Document the measurement site and technique.

The Clinical Application Value

This plane provides a useful longitudinal view of the left hepatic lobe through the caudate and medial lobes. It allows assessment of the hepatic parenchyma, caudate lobe, venous ligament, portal vein, common bile duct, and IVC.

• Demonstration of the left hepatic lobe in longitudinal section.
• Identification of the caudate lobe.
• Recognition of the medial / quadrate lobe.
• Identification of the venous ligament.
• Visualization of the portal vein and common bile duct.
• Recognition of the IVC as a posterior vascular landmark.
• Assessment of hepatic parenchymal echogenicity and contour.

Quick Scanning Checklist

1	Fast the patient for 8–12 hours when appropriate.
2	Position the patient supine.
3	Place the probe longitudinally at the subxiphoid midline.
4	Obtain the longitudinal view of the left hepatic lobe.
5	Identify the caudate lobe and medial lobe.
6	Identify the VL, CBD, PV, and IVC.
7	Assess hepatic contour and parenchymal echogenicity.
8	Obtain vascular or biliary measurements when clinically indicated.

Diagnostic Pathology

This longitudinal subxiphoid view can assist in identifying hepatic, portal venous, biliary, and IVC abnormalities. Evaluate the left hepatic lobe, caudate lobe, medial lobe, portal vein, common bile duct, and IVC.

Key Sonographic Findings

• Hepatomegaly: Increased hepatic size with altered contour or morphology.
• Hepatic steatosis: Increased hepatic echogenicity with reduced visualization of deeper structures.
• Cirrhotic change: Coarse echotexture, irregular contour, and altered hepatic architecture.
• Caudate lobe enlargement: Enlargement of the caudate lobe, particularly in the setting of chronic liver disease.
• Focal liver lesion: Focal abnormality differing from the surrounding hepatic parenchyma.
• Portal vein abnormality: Altered caliber, course, continuity, or Doppler flow of the PV.
• Portal vein thrombosis: Intraluminal material with partial or complete obstruction of portal venous flow.
• Biliary dilatation: Enlargement of the CBD or intrahepatic bile ducts.
• Choledocholithiasis: Echogenic intraductal focus, often with posterior acoustic shadowing, when a ductal stone is visualized.
• Hilar abnormality: Abnormal tissue or structural distortion involving the portal region.
• IVC abnormality: Altered caliber, focal narrowing, intraluminal material, or compression.
• Venous ligament abnormality: Altered appearance or surrounding structural distortion of the VL.

Diagnostic note: Interpret abnormal findings together with the complete abdominal ultrasound, Doppler assessment, clinical history, and laboratory findings. A single sonographic finding should not be used in isolation to establish a diagnosis.

Transverse Scanning of the Left Hepatic Lobe Through the Left Portal Vein Branches by Subxiphoid

Longitudinal liver section • Left Portal Vein Branches • Subxiphoid approach

Scanning Method

The patient should be fasted for 8–12 hours and examined in the supine position. Place the ultrasound probe transversely in the midline at the subxiphoid region. Direct the probe to obtain a transverse section of the left hepatic lobe through the left portal vein branches. Adjust the probe angle, depth, and position to clearly demonstrate the left hepatic lobe parenchyma, left portal vein and its branches, and relevant adjacent anatomical structures.

Key scanning point: Begin from the subxiphoid midline with the probe oriented transversely. Identify the left portal vein and its branches as the principal anatomical landmarks and adjust the probe position to obtain a clear transverse view of the left hepatic lobe through the portal venous branches.

Ultrasound Image

Figure 1.1 Transverse section of the left hepatic lobe through the left portal vein branches on subxiphoid scanning. Insert the corresponding ultrasound image in the space above.

Anatomical / Scanning Diagram

Figure 1.2: Diagram space showing the probe orientation, transverse scanning plane, left hepatic lobe, left portal vein branches, and labeled anatomical landmarks.

Section Structure

The principal structures demonstrated in this plane are the left hepatic lobe and the left portal vein and its branches. The portal venous branches provide important anatomical landmarks for confirming the transverse orientation of the left hepatic lobe. The caudate lobe, inferior vena cava, and adjacent hepatic structures may also be visualized.

Structures to identify

• Left hepatic lobe (LL)
• Left portal vein (LPV)
• Left portal vein branches
• Caudate lobe (CL)
• Left hepatic parenchyma
• Left hepatic vein, when visualized
• Inferior vena cava (IVC), when included
• Diaphragm
• Adjacent hepatic vascular structures

Abbreviations Used in the Figure

Short form	Full form	Identification
LTH	Left hepatic lobe	Left hepatic lobe demonstrated in the scan.
LL	Left lobe	Left hepatic lobe region.
LPV	Left portal vein	Main portal venous structure within the left liver.
CL	Caudate lobe	Caudate lobe adjacent to the posterior liver.
IVC	Inferior vena cava	Major venous landmark posterior to the liver.

Measuring Method and Normal

When indicated, measure the left portal vein in the standardized transverse subxiphoid plane. The measurement should be obtained with the vessel clearly visualized and the calipers placed appropriately across the vessel lumen.

Measurement	Caliper method	Reference / interpretation
Left portal vein	Measure the internal vessel diameter with the calipers positioned appropriately across the lumen.	Document the measured diameter and interpret it together with Doppler findings and the overall clinical context.

Measurement note: Keep the left portal vein clearly visualized and avoid including the vessel wall or adjacent structures in the measurement.

The Clinical Application Value

This plane provides a useful transverse view of the left hepatic lobe through the left portal vein branches. It permits assessment of the left hepatic parenchyma, portal venous anatomy, caudate lobe, and adjacent vascular structures.

• Demonstration of the left hepatic lobe in transverse section.
• Identification of the left portal vein and its branches.
• Assessment of portal venous branching anatomy.
• Assessment of left hepatic parenchymal echogenicity.
• Detection of focal hepatic abnormalities within the visualized field.
• Recognition of the caudate lobe and its relationship to the portal structures.
• Assessment of adjacent vascular structures when included in the plane.

Quick Scanning Checklist

1	Fast the patient for 8–12 hours when appropriate.
2	Position the patient supine.
3	Place the probe transversely at the subxiphoid midline.
4	Obtain the transverse view of the left hepatic lobe.
5	Identify the left portal vein and its branches.
6	Identify the caudate lobe and relevant adjacent structures.
7	Assess the portal vein caliber and branching pattern when indicated.
8	Assess the left hepatic parenchyma for focal or diffuse abnormalities.

Diagnostic Pathology

The transverse subxiphoid view through the left portal vein branches can assist in identifying hepatic and portal venous abnormalities. Evaluate the left hepatic parenchyma, portal vein, portal branches, caudate lobe, and adjacent vascular structures.

Key Sonographic Findings

• Hepatomegaly: Enlargement of the visualized hepatic lobe with altered hepatic dimensions or contour.
• Hepatic steatosis: Increased hepatic echogenicity with reduced visualization of deeper structures.
• Cirrhotic change: Coarse hepatic echotexture, irregular contour, and altered hepatic architecture.
• Focal liver lesion: Focal abnormality with echogenicity or architecture different from the surrounding hepatic parenchyma.
• Portal vein dilatation: Increased caliber of the portal vein requiring correlation with Doppler findings and other signs of portal hypertension.
• Portal vein thrombosis: Intraluminal material with partial or complete obstruction of portal venous flow.
• Abnormal portal flow: Altered direction, velocity, or waveform on Doppler assessment.
• Portal venous collateralization: Enlarged collateral vessels that may accompany portal hypertension.
• Caudate lobe enlargement: Enlargement of the caudate lobe, particularly when associated with chronic liver disease.
• Portal branch abnormality: Altered caliber, course, continuity, or Doppler flow within the left portal vein branches.
• Focal portal venous obstruction: Focal narrowing or obstruction of the portal venous lumen.
• Vascular compression: Extrinsic compression of a portal venous structure by an adjacent lesion or altered hepatic anatomy.

Diagnostic note: Interpret abnormal findings together with the complete abdominal ultrasound examination, Doppler assessment, clinical history, and laboratory findings. A single sonographic finding should not be used in isolation to establish a diagnosis.

Transverse Scan of the Left and Right Liver Through the Porta Hepatis on Subxiphoid

Transverse liver section • IPorta Hepatis • Subxiphoid approach

Scanning Method

The patient should be fasted for 8–12 hours and examined in the supine position. Place the ultrasound probe transversely in the midline at the subxiphoid region. Direct the probe to obtain a transverse section of the left and right hepatic lobes through the porta hepatis. Adjust the probe angle, depth, and position to clearly demonstrate the liver parenchyma, portal vein and porta hepatis, together with the relevant adjacent structures.

Key scanning point: Begin from the subxiphoid midline with the probe oriented transversely. Identify the porta hepatis and portal vein as the principal anatomical landmarks, then adjust the probe position to obtain a clear transverse view of both the left and right liver.

Ultrasound Image

Figure 1.1 Transverse section of the left and right liver through the porta hepatis on subxiphoid scanning. Insert the corresponding ultrasound image in the space above.

Anatomical / Scanning Diagram

Figure 1.2: Diagram space showing the probe orientation, transverse scanning plane, left and right liver, porta hepatis, portal vein, and labeled anatomical landmarks.

Section Structure

The principal structures demonstrated in this plane are the transverse sections of the left and right hepatic lobes through the porta hepatis. The portal vein and its relationship to the common bile duct and hepatic artery provide important landmarks for confirming the correct transverse orientation.

Structures to identify

• Left hepatic lobe
• Right hepatic lobe
• Porta hepatis
• Main portal vein
• Common bile duct
• Hepatic artery
• Gallbladder, when included in the plane
• Quadrate lobe
• Caudate lobe
• Inferior vena cava (IVC), when included
• Adjacent hepatic parenchyma

Abbreviations Used in the Figure

Short form	Full form	Identification
QL	Quadrate lobe	Hepatic lobe anterior to the porta hepatis.
CHD	Common hepatic duct	Main biliary duct at the porta hepatis.
RPV	Right portal vein	Right portal venous branch.
LPV	Left portal vein	Left portal venous branch.
LL	Left lobe	Left hepatic lobe.
RL	Right lobe	Right hepatic lobe.
CL	Caudate lobe	Caudate lobe adjacent to the IVC.
IVC	Inferior vena cava	Major venous landmark posterior to the liver.
1–5	Numbered structures	Reference numbers corresponding to the labeled diagram.

Measuring Method and Normal

In this transverse subxiphoid plane, measurements may be obtained for the main portal vein and, when indicated, the common bile duct. Measurements should be performed with the vessel or duct clearly visualized and the calipers appropriately positioned.

Measurement	Caliper method	Reference / interpretation
Main portal vein	Measure the internal diameter perpendicular to the long axis of the vessel, preferably with the vessel clearly demonstrated.	Record the measured diameter and interpret it with the clinical context and Doppler findings.
Common bile duct	Measure the duct lumen from inner wall to inner wall at an appropriate location without including the duct wall.	Interpret according to age, clinical setting, and biliary anatomy.

Measurement note: Keep the porta hepatis clearly visualized and place the calipers perpendicular to the structure being measured. Record the measurement location and technique.

The Clinical Application Value

This plane provides a useful transverse view of both hepatic lobes through the porta hepatis. It allows assessment of the liver parenchyma, portal vein, common bile duct, hepatic artery, and adjacent hilar structures.

• Demonstration of the left and right hepatic lobes in transverse section.
• Identification of the porta hepatis as the principal anatomical landmark.
• Visualization of the main portal vein and its branches.
• Assessment of the common bile duct and hepatic artery.
• Assessment of hepatic parenchymal echogenicity and focal abnormalities.
• Recognition of the quadrate and caudate lobes.
• Assessment of hilar vascular and biliary relationships.

Quick Scanning Checklist

1	Fast the patient for 8–12 hours when appropriate.
2	Position the patient supine.
3	Place the probe transversely at the subxiphoid midline.
4	Obtain the transverse view of the left and right liver through the porta hepatis.
5	Identify the main portal vein and porta hepatis.
6	Identify the common bile duct and hepatic artery.
7	Assess the liver parenchyma, hilar structures, and vascular relationships.
8	Obtain portal vein or bile duct measurements when clinically indicated.

Diagnostic Pathology

The transverse subxiphoid view through the porta hepatis can assist in identifying hepatic, biliary, and vascular abnormalities. Evaluate both hepatic lobes, the portal vein, common bile duct, hepatic artery, and surrounding structures.

Key Sonographic Findings

• Hepatomegaly: Increased liver size with altered hepatic morphology.
• Hepatic steatosis: Increased parenchymal echogenicity with reduced visualization of deeper hepatic structures.
• Cirrhotic liver: Coarse echotexture, irregular contour, and altered hepatic architecture.
• Focal liver lesion: Focal area with echogenicity or architecture different from the surrounding hepatic parenchyma.
• Portal vein dilatation: Increased portal vein caliber that may require correlation with Doppler findings and other signs of portal hypertension.
• Portal vein thrombosis: Intraluminal material with partial or complete obstruction of the portal venous lumen.
• Portal hypertension: Portal venous abnormalities with associated collateral vessels, splenomegaly, or other supportive findings.
• Biliary dilatation: Enlargement of the common bile duct or intrahepatic bile ducts.
• Common bile duct obstruction: Dilated duct with possible obstructing stone, lesion, or other abnormality when visualized.
• Choledocholithiasis: Echogenic intraductal focus, often with posterior acoustic shadowing, when a ductal stone is visualized.
• Hilar mass: Focal abnormal tissue involving or adjacent to the porta hepatis, potentially affecting vascular or biliary structures.
• Vascular abnormality: Abnormal caliber, course, or Doppler flow involving the portal vein or hepatic artery.

Diagnostic note: Interpret abnormal findings together with the complete abdominal ultrasound examination, Doppler assessment, clinical history, and laboratory findings. A single sonographic finding should not be used in isolation to establish a diagnosis.

Longitudinal Scanning of the Liver Through the Inferior Vena Cava on Subxiphoid

Longitudinal liver section • Inferior Vena Cava • Subxiphoid approach

Scanning Method

The patient should be fasted for 8–12 hours and examined in the supine position. Place the ultrasound probe vertically in the midline at the subxiphoid region. Direct the probe to obtain a longitudinal section of the liver through the inferior vena cava (IVC). Adjust the probe angle and depth to clearly demonstrate the liver parenchyma, IVC, and relevant adjacent anatomical structures.

Key scanning point: Begin from the subxiphoid midline with the probe oriented longitudinally. Identify the inferior vena cava (IVC) as the principal anatomical landmark and adjust the probe position to obtain a clear longitudinal view of the liver through the IVC.

Ultrasound Image

Figure 1.1 Longitudinal section of the liver through the inferior vena cava (IVC) on subxiphoid scanning. Insert the corresponding ultrasound image in the space above.

Anatomical / Scanning Diagram

Figure 1.2: Diagram space showing the probe orientation, scanning plane, liver, inferior vena cava (IVC), and labeled anatomical landmarks.

Section Structure

The principal structures demonstrated in this plane are the longitudinal section of the liver and the inferior vena cava (IVC). The IVC serves as an important vascular landmark for confirming the correct longitudinal orientation. Depending on probe position and angulation, adjacent hepatic and vascular structures may also be visualized.

Structures to identify

• Liver, particularly the left hepatic lobe
• Inferior vena cava (IVC)
• Hepatic veins entering the IVC
• Caudate lobe
• Right hepatic lobe, as visualized
• Diaphragm
• Hepatic parenchyma
• Portal vein or its branches, when included in the plane
• Adjacent upper abdominal structures

Abbreviations Used in the Figure

Abbreviation	Full form	Identification
QL	Quadrate lobe	Hepatic lobe shown in the scan.
MHV	Middle hepatic vein	Hepatic vein draining toward the IVC.
CBD	Common bile duct	Biliary duct adjacent to the portal vein.
PV	Portal vein	Main portal venous structure.
IVC	Inferior vena cava	Major venous landmark posterior to the liver.
CL	Caudate lobe	Hepatic lobe adjacent to the IVC.

Measuring Method and Normal

Measure the anteroposterior (AP) diameter of the inferior vena cava (IVC) in the appropriate longitudinal subxiphoid plane. The measurement should be taken perpendicular to the long axis of the IVC, avoiding the hepatic veins and other adjacent vascular structures.

Measurement	Caliper method	Reference / interpretation
IVC AP diameter	Measure the IVC diameter perpendicular to its long axis in the standardized subxiphoid longitudinal plane.	Document the diameter together with the respiratory phase, as IVC caliber varies with respiration.

Measurement note: Keep the IVC clearly visualized in the longitudinal plane, place the calipers perpendicular to the vessel walls, and record the respiratory phase with the measurement.

The Clinical Application Value

This plane provides a useful longitudinal view of the liver through the inferior vena cava (IVC). It permits assessment of the hepatic parenchyma, liver contour, IVC, hepatic veins, and adjacent vascular structures in a standardized subxiphoid orientation.

• Demonstration of the liver in a longitudinal subxiphoid plane.
• Identification of the inferior vena cava (IVC) as an anatomical landmark.
• Assessment of the IVC caliber and respiratory variation when clinically indicated.
• Visualization of the hepatic veins entering the IVC.
• Assessment of liver size, shape, contour, and parenchymal echogenicity.
• Recognition of the caudate lobe adjacent to the IVC.
• Assessment of adjacent portal and biliary structures when included in the plane.

Quick Scanning Checklist

1	Fast the patient for 8–12 hours when appropriate.
2	Position the patient supine.
3	Place the probe vertically at the subxiphoid midline.
4	Obtain the longitudinal liver view through the IVC.
5	Identify the IVC and hepatic veins.
6	Identify the caudate lobe and other relevant hepatic structures.
7	Assess IVC caliber and respiratory variation when indicated.
8	Assess liver size, contour, and parenchymal echogenicity.

Diagnostic Pathology

The longitudinal subxiphoid view through the inferior vena cava (IVC) can assist in identifying hepatic and vascular abnormalities. Evaluate the liver parenchyma, contour, caudate lobe, hepatic veins, and IVC for abnormal findings.

Key Sonographic Findings

• Hepatomegaly: Increased liver size with possible inferior or anterior extension.
• Hepatic steatosis: Increased parenchymal echogenicity with reduced visualization of deeper structures.
• Cirrhotic liver: Coarse echotexture, irregular/nodular contour, and altered hepatic morphology.
• Focal liver lesion: Focal abnormality differing in echogenicity or architecture from the surrounding hepatic parenchyma.
• Caudate lobe enlargement: Enlargement of the caudate lobe may be associated with chronic liver disease.
• Hepatic venous abnormality: Altered caliber, flow-related appearance, or nonvisualization of hepatic veins.
• IVC abnormality: Abnormal caliber, collapse pattern, intraluminal material, or focal narrowing.
• IVC thrombosis: Intraluminal echogenic material with partial or complete loss of the normal venous lumen.
• IVC obstruction/compression: Focal narrowing or external compression with possible upstream venous dilatation.
• Congestive hepatic changes: Dilated IVC and hepatic veins with associated hepatic parenchymal changes, particularly in the appropriate clinical setting.

Diagnostic note: Abnormal findings should be interpreted together with the complete abdominal ultrasound examination, Doppler assessment, clinical history, and laboratory findings. A single sonographic sign should not be used in isolation to establish a diagnosis.

Longitudinal Scanning of the Liver Through the Abdominal Aorta

Longitudinal liver section • Abdominal aorta • Subxiphoid approach

Scanning Method

The patient should be fasted for 8–12 hours and examined in the supine position. Place the ultrasound probe vertically in the midline at the subxiphoid region. Adjust the probe to obtain the longitudinal section of the left hepatic lobe together with the abdominal aorta and the relevant adjacent structures.

Key scanning point: Start from the subxiphoid midline with the probe vertically oriented. The abdominal aorta is used as an important anatomical landmark for establishing the longitudinal plane.

Ultrasound Image

Figure 1. Longitudinal section of the liver and abdominal aorta. Insert the corresponding ultrasound image in the space above.

Anatomical / Scanning Diagram

Figure 1.2: Diagram space for the probe orientation, scanning plane, liver, abdominal aorta, and labeled anatomical landmarks.

1.1.2 Section Structure

The principal structures demonstrated in this plane are the longitudinal section of the left hepatic lobe and the abdominal aorta, with an oblique section of the esophagus. The adjacent vascular structures help confirm the correct anatomical orientation.

Structures to identify

• Left hepatic lobe
• Abdominal aorta
• Esophagus (oblique section)
• Celiac artery
• Splenic artery
• Splenic vein
• Superior mesenteric artery
• Pancreatic body
• Left atrium

Abbreviations Used in the Figure

Abbreviation	Full form	Role / identification
LL	Left lobe	Longitudinally visualized left hepatic lobe.
CA	Celiac artery	Arterial branch arising from the abdominal aorta.
LA	Left atrium	Cardiac structure included as an adjacent landmark in the depicted plane.
PB	Pancreatic body	Part of the pancreas seen adjacent to the vascular structures.
SpV	Splenic vein	Venous structure coursing toward the portal venous system.
SpA	Splenic artery	Arterial branch related to the celiac trunk.
SMA	Superior mesenteric artery	Arterial branch arising inferior to the celiac artery.
Ao	Aorta / abdominal aorta	Major arterial landmark used to establish the scanning plane.
E	Esophagus	Obliquely visualized esophageal section.

Measuring Method and Normal

Measure the anteroposterior (AP) diameter of the left hepatic lobe from the top of the anterior hepatic capsule to the posterior capsule in the appropriate longitudinal section.

Measurement	Caliper method	Reference value from the supplied source
Left hepatic lobe AP diameter	Measure from the top of the anterior capsule to the posterior capsule.	< 7 cm in the normal liver.

Measurement note: Keep the measurement in the standardized longitudinal plane and document the plane and measurement direction with the value.

The Clinical Application Value

This plane is described as a standard section for measuring the anteroposterior diameter of the left liver lobe. It also permits assessment of the liver's size, shape, and parenchymal echogenicity.

• Standard plane for left hepatic lobe AP measurement.
• Assessment of left-lobe size.
• Assessment of hepatic shape and contour in the demonstrated plane.
• Assessment of hepatic parenchymal echogenicity.
• Recognition of the abdominal aorta as a major orientation landmark.
• Recognition of the adjacent celiac, splenic and superior mesenteric vessels.

Quick Scanning Checklist

1	Fast the patient for 8–12 hours.
2	Position the patient supine.
3	Place the probe vertically at the midline of the subxiphoid region.
4	Obtain the longitudinal left-lobe view with the abdominal aorta.
5	Identify the labeled vascular and adjacent structures.
6	Measure the AP diameter of the left hepatic lobe from anterior to posterior capsule.
7	Compare the measurement with the supplied reference of <7 cm.
8	Assess liver size, shape and parenchymal echogenicity.

Diagnostic Pathology

The longitudinal subxiphoid view through the abdominal aorta provides an important anatomical orientation for assessing the liver and adjacent upper abdominal structures. This plane can demonstrate hepatic parenchymal abnormalities as well as abnormalities involving the aorta and nearby vascular structures.

Key Sonographic Findings

• Hepatomegaly: Increased liver size with altered hepatic dimensions or contour.
• Hepatic steatosis: Increased hepatic echogenicity with reduced visualization of deeper structures.
• Cirrhotic liver: Coarse parenchymal echotexture, irregular contour, and altered hepatic morphology.
• Focal liver lesion: Focal area with echogenicity or architecture different from the surrounding liver.
• Abdominal aortic dilatation: Increased aortic caliber that may indicate aneurysmal dilatation.
• Aortic aneurysm: Focal or diffuse enlargement of the abdominal aorta with assessment of lumen and aortic wall.
• Aortic dissection: Visualization of an intimal flap separating true and false lumens, when present and adequately visualized.
• Aortic mural thrombus: Echogenic material along the aortic wall projecting into the lumen.
• Aortic atherosclerotic change: Wall thickening, irregularity, or calcified atherosclerotic plaques.
• Periaortic abnormality: Fluid collection, mass, or other abnormal tissue surrounding the aorta.
• Adjacent pancreatic abnormality: Altered echogenicity, enlargement, or focal lesion when the pancreas is included in the scanning plane.
• Vascular abnormalities: Abnormal caliber, course, or Doppler flow in the abdominal aorta and adjacent vessels.

Diagnostic note: Interpret abnormal findings together with the complete abdominal ultrasound examination and, when indicated, Doppler assessment, clinical findings, and additional imaging. A single sonographic finding should not be used alone to establish a diagnosis.

Ultrasound Scanning technique for liver

SONOACADEMY

CLINICAL ULTRASOUND

QUALITATIVE • QUANTITATIVE • INTERVENTIONAL ULTRASOUND

Liver Ultrasound Scanning Technique

PATIENT PREPARATION • EQUIPMENT • IMAGE OPTIMIZATION • SYSTEMATIC SCANNING • DOPPLER • DOCUMENTATION

ULTRASOUND SCANNING TECHNIQUE

SEARCH LIVER SCANNING TECHNIQUE

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SYSTEMATIC SCANNING PRINCIPLE: Use a consistent sequence so that the liver is assessed in multiple planes and approaches. Adapt patient position, respiration and probe approach according to visualization, body habitus and clinical requirements.

Longitudinal Scanning of the Liver Through the Abdominal Aorta

Longitudinal Scanning of the Liver Through the Inferior Vena Cava on Subxiphoid

Transverse Scan of the Left and Right Liver Through the Porta Hepatis on Subxiphoid

Transverse Scanning of the Left Hepatic Lobe Through the Left Portal Vein Branches by Subxiphoid

Longitudinal Scanning of the Left Hepatic Lobe Through the Caudate Lobe and Medial Lobe

Oblique Scanning of the Left External Hepatic Lobe

Oblique Scanning of the Left Hepatic Lobe and Caudate Lobe

Longitudinal Scanning of the Hepatic Left Lobe and the Ligamentum Teres Hepatis by Subxiphoid

Oblique Scanning of the Ligamentum Teres and the Left Liver by Subxiphoid

Oblique Scanning of the Liver Through the Gallbladder and Inferior Vena Cava by the Right Subcostal Margin

Oblique Scanning of the Liver Through the Hepatic Veins and the Second Porta Hepatis on Subxiphoid

Transverse Scanning of the Upper Part of the Porta Hepatis

Transverse-Oblique View of the Left Liver Through the Longitudinal Section of the Left Hepatic Vein on the Subxiphoid

Oblique Scanning of the Right Liver Through the Porta Hepatis

Longitudinal Scanning of the Liver Through the Middle Hepatic Vein on Subxiphoid

Longitudinal Scanning of the Right Liver Through the Porta Hepatis

Oblique Scanning of the Right Anterior Liver and the Left Medial Lobe of the Liver by Right Intercostal Space

Oblique Scanning of the Dome Area in the Right Liver from the Right Intercostal Space Approach

Oblique Scanning of the Right Liver Through the Right Portal Vein by the Right Subcostal Space Approach

Longitudinal Scanning of the Right Liver and Right Kidney from the Right Subcostal

Oblique Scanning of the Right Liver Through the Right Hepatic Veins on Subxiphoid

Longitudinal Scanning 1 of the Right Liver Through the Porta Hepatis on the Right Subcostal

Longitudinal Scanning 2 of the Right Liver Through the Porta Hepatis

Transverse Scanning of the Porta Hepatis from the Right Subcostal

Transverse Scanning of the Right Liver and the Right Kidney from the Right Subcostal

Oblique Scanning of the Right Liver Through the Dome of the Right Diaphragm from the Right Subcostal

Longitudinal Scanning of the Common Hepatic Artery and Splenic Artery from the Upper Abdomen

Common Hepatic Artery Blood Flow Spectrum

Longitudinal Scanning of the Proper Hepatic Artery from the Upper Abdomen

Proper Hepatic Artery Blood Flow Spectrum

Portal Vein Blood Flow Spectrum from the Right Subcostal Margin

PRE-EXAMINATION PRINCIPLE

Follow the local examination protocol and clinical indication. Explain the examination to the patient and obtain relevant clinical history before scanning.

Confirm patient identity and examination indication.

Review relevant clinical history, symptoms and previous imaging when available.

Explain the liver ultrasound examination to the patient.

Use appropriate fasting instructions according to local protocol and clinical circumstances.

Position the patient comfortably, usually supine initially.

Be prepared to use left lateral decubitus or other positional changes when required.

Ask the patient to cooperate with respiration and breath-holding when necessary.

Expose the examination area appropriately while maintaining patient privacy.

Apply adequate ultrasound gel to obtain consistent acoustic coupling.

Use additional positioning or respiratory maneuvers when the liver or dome is poorly visualized.

Select an appropriate abdominal curvilinear transducer.

Use a suitable frequency range for the patient's body habitus and required penetration.

Inspect the transducer surface and cable before use.

Confirm adequate acoustic coupling and apply sufficient gel.

Preset the ultrasound system for abdominal/liver examination when available.

Confirm the correct patient information on the ultrasound system.

Prepare Color Doppler and Spectral Doppler modes when vascular assessment is required.

Ensure measurements and image storage functions are available.

Select an appropriate monitor display and examination environment.

Optimize the system before acquiring the final diagnostic images.

1. Probe Orientation and Contact

Maintain correct probe orientation and consistent acoustic contact. Use sufficient gel and adjust probe pressure according to the target structure and patient's body habitus.

2. Depth Optimization

Adjust depth so the liver and relevant surrounding anatomy are appropriately displayed without excessive unused field of view.

3. Overall Gain Optimization

Adjust overall gain to produce a balanced grayscale image. Avoid excessive gain or insufficient gain that suppresses useful information.

4. Time Gain Compensation — TGC

Adjust TGC controls to compensate for depth-dependent attenuation and maintain relatively consistent image brightness through the liver.

5. Frequency Optimization

Select the highest practical frequency that provides adequate penetration and image quality. Lower frequencies may be required when deeper penetration is necessary.

6. Dynamic Range and Compression

Adjust dynamic range/compression to obtain useful grayscale separation and appropriate visualization of hepatic parenchyma.

7. Reject / Suppression Optimization

Use reject or suppression controls carefully. Excessive suppression may remove clinically useful low-level information.

8. Zoom and Field-of-View Optimization

Use an appropriate field of view. Magnify the region of interest when detailed assessment or measurement is required.

9. Color Doppler Optimization

Optimize the color box, scale, gain, wall filter, persistence and color priority according to the vessel and clinical question.

10. Spectral Doppler Optimization

Optimize the sample gate, Doppler scale, baseline, wall filter, gain and sweep speed. Apply appropriate angle correction when velocity measurement is required.

11. Measurement Optimization

Place measurement calipers precisely on the intended anatomical landmarks using an appropriate imaging plane and magnification.

12. Image Documentation

Save representative images documenting the liver, relevant vascular structures, measurements and Doppler findings according to protocol.

Vessel / Assessment	Technique Focus
Common Hepatic Artery	Obtain a suitable longitudinal view and optimize color and spectral Doppler for assessment of arterial flow.
Proper Hepatic Artery	Identify the vessel and acquire an appropriate spectral Doppler tracing after image optimization.
Portal Vein	Assess the portal vein from an appropriate subcostal approach and document the blood-flow spectrum according to protocol.
Hepatic Veins	Use appropriate subxiphoid or other suitable approaches to visualize hepatic venous anatomy and flow when required.
Color Doppler	Adjust scale, gain, wall filter, box size and other controls to demonstrate vascular flow without excessive background noise.

DOPPLER NOTE: Use Doppler settings and velocity/flow measurements required by the clinical indication and local laboratory protocol. When velocity measurement is required, use appropriate angle correction and maintain a suitable Doppler angle according to the examination protocol.

Select the appropriate anatomical plane before placing calipers.

Magnify the target structure when necessary.

Place calipers precisely on the intended anatomical margins.

Avoid oblique measurements when a standardized plane is required.

Record measurements with the correct units.

Repeat measurements when the first acquisition is technically suboptimal.

Document the image plane or anatomical reference when appropriate.

Use consistent technique for follow-up examinations whenever possible.

Document representative images of the left hepatic lobe.

Document representative images of the right hepatic lobe.

Document the porta hepatis when assessed.

Document relevant hepatic veins and portal venous structures.

Document the gallbladder relationship when relevant to the scanning sequence.

Document the liver–right kidney relationship when obtained.

Document the hepatic dome when adequately visualized.

Save appropriate Color Doppler images when vascular assessment is performed.

Save appropriate Spectral Doppler tracings.

Save measurement images with visible calipers and labels.

Use appropriate anatomical labels and patient identifiers according to local protocol.

Ensure stored images are technically adequate before completing the examination.

LIVER SCAN COMPLETION CHECKLIST

Confirm that the required liver regions, scanning planes, vascular structures, measurements, Doppler assessments and representative images have been completed according to the clinical indication and local examination protocol.

Left hepatic lobe assessed.

Right hepatic lobe assessed.

Caudate/medial region assessed where required.

Porta hepatis assessed.

Hepatic veins assessed where required.

Portal vein assessed where required.

Hepatic arterial Doppler completed where indicated.

Right hepatic dome assessed where technically possible.

Right liver–kidney relationship documented where required.

Required measurements completed.

Required Doppler spectra documented.

Final images reviewed for technical quality.

SONOACADEMY • CLINICAL ULTRASOUND

Liver Ultrasound Scanning Technique • Systematic • Practical • Diagnostic