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syndrome)

Esophageal varices (by endoscopy)

Dilatation of the portal vein

After the porta hepatis has been evaluated, the liver itself is methodically visualized on transverse images and subcostal oblique images parallel to the right costal arch. What is wrong with the position of the transducer shown in Fig. 25.1? The answer can be found in the left lower corner of this page.

The right subcostal oblique image (Fig. 25.2a) is particularly suitable for visualizing the hepatic veins lengthwise

(10) and their confluence with the obliquely visualized inferior vena cava (16).

Fig. 25.1

If the inferior vena cava is borderline in diameter and the maneuver to test the caval collapse with forced inspiration is unsuccessful (see p. 15) or inconclusive, the luminal diameter of the hepatic veins is best measured at this level. The maximal diameter of a peripheral hepatic vein should not exceed 6 mm (Fig. 25.2). Measuring the hepatic veins at the confluence with the inferior vena cava has the disadvantage of wide anatomic variations and corresponding false measurements. For instance, the hepatic veins of the patient with no cardiac problems shown in Fig. 25.2 measure 10 mm directly anterior to the vena cava while the peripheral hepatic veins measure only 3-5 mm. With venous congestion proximal to the right atrium secondary to right-sided heart failure, the hepatic veins are dilated (Fig. 25.3) and lack any respiratory changes.

This image section also allows the exclusion of a right pleural effusion, which appears as echo-free fluid between the diaphragm (13) and the acoustic shadow of the lung (47). Vascular rarefaction along the periphery of the liver can be a sign of advanced cirrhosis. Hepatic vein thrombosis (Budd-Chiari syndrome) can be diagnosed on the oblique subcostal image with color Doppler sonography, which can determine velocity, profile, and direction of the intravascular blood flow.

Fig. 25.2a Fig. 25.2b Fig. 25.2c

Normal values:

Hepatic veins (peripheral): < 6 mm Answer to quiz. Fig. 25.1:

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Normal values:

Hepatic veins (peripheral): < 6 mm Answer to quiz. Fig. 25.1:

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