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After the liver (9) has been scrutinized on transverse and subcostal image sections, it is further evaluated sagittally, also in deep inspiration (Fig. 26.1a). It is important to keep the patient cooperative by allowing adequate time intervals for normal breathing. The best method seems to be a two-stage evaluation with a slow, continuous sweeping of the transducer. First, the left hepatic lobe is screened to the level of the inferior vena cava, followed by a break for normal breathing while the transducer is moved from the midline to the right MCL. The patient takes another deep breath and the right hepatic lobe is now methodically screened applying the same sweeping motion (Fig. 26.1a) to the transducer.

The size of the liver is assessed by measuring the anteroposterior (sagittal) and the superoinferior diameters in the right MCL (Fig. 26.2a, Fig. 26.3a). To encompass an enlarged liver, the transducer has to be angled superiorly and inferiorly (Fig. 26.1b). Measurements are taken in inspiration. The normal craniocaudal diameter should be less than 13 or 15 cm, depending on the patient s body habitus. It is important to watch for the acute angle formed by the inferior margin of the right hepatic lobe. In hepatic congestion or hepatomegaly, this angle exceeds 45° and becomes blunted. The normal lateral margin of the left hepatic lobe also should form an acute angle measuring less than 30°.

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Fig. 26.1b

The normal gallbladder wall (80), which should only be evaluated when the gallbladder (16) is not contracted (the patient must be NPO), can measure up to 4 mm in thickness (Fig. 26.3). The postprandial gallbladder is generally too contracted to exclude edematous wall thickening, stones, or a tumor with any degree of certainty.

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