Claus Niederau, M.D. Amnon Sonnenberg, M.D. Jurgen E. Muller, M.D. Joachim F. Erckenbrecht, M.D. Theo Scholten, M.D. Wolf P. Fnitsch, M.D.

Sonographic Normal

Index system,

terms: (CI system, normal variants, 70.130; ultrasonography. 7[0].1298) #{149} Liver. ultrasound studies #{149} Pancreas, ultrasound studies Portal vein, ultrasound studies #{149} Spleen, ultrasound studies Radiology

1983;

Liver, Spleen,

Portal

Normal values and upper limits (95th percentile) of liver, spleen, pancreas, and portal vein size were determined prospectively with ultrasound in 915 healthy subjects. Sex, age, weight, height, and body surface area were determined in each case. Since correlation of longitudinal and transverse organ diameters with physical data was poor (r 0.3), the authors do not consider it necessary to correct the measurements accordingly. However, the liver is oriented longitudinally in slender subjects and transversely in heavy subjects; thus both longitudinal and anteropostenior diameters need to be measured, since the longitudinal diameter alone will give too high or too low a value, respectively. GI

149: 537-540

M

Measurements

Pancreas,

and

Vein1

EASUREMENTS

cussion

radiography

of

and

and

radiation

(1-10).

reliable;

however,

generally Previously, mogeneous cluding conducted

of the

pancreas, and are inaccurate

liver,

palpation

radionuclide

studies

Ultrasound

has

despite

been

spleen and

expose found

widespread

size based unreliable,

the

patient

on

perwhile

to gamma

to be both

accurate

and

use,

know

of no

clinical

we

accepted standards of liver, pancreas, and spleen size. ultrasonic dimensions have been determined in inhopopulations or small groups of subjects, sometimes inpatients with gastrointestinal diseases (1 1-17). We therefore a prospective study of a large group of healthy subjects to

correlate

organ

size

with

sex,

age,

weight,

height,

and

body

surface

area.

MATERIAL

AND

METHODS

Subjects: One thousand consecutive blood donors were examined by ultrasound between August and December 1981. There were 160 women and 840 men 18-65 years of age. All gave informed consent, and the study was approved by the Ethics Committee of this institution. Eighty-five subjects were excluded because of (a) a history of hepatic, biliary, or pancreatic disease [n 55] or suggestive ultrasonic, clinical, or laboratory findings, (b) upper abdominal surgery [n 10], or (c) alcohol consumption of more than 60 g/day in men and 20 g/day in women [n 20]. Sex, age, weight, height, body surface area, medical history, and results of the physical examination were mecorded, along with erythrocyte sedimentation rate, hematocrit, white cell count, platelet count, SGOT, SGPT, HBs-Ag, anti-HBs, and senologic tests for syphilis. All subjects had normal chest radiographs. Ultrasound Examination: We employed a high-resolution real-time scanner with a 3.5-MHz transducer (Siemens Imager). Subjects were examined (a) supine, (b) with the right side elevated to demonstrate the porta hepatis, and (c) with the left side elevated to show the iongitudinal axis of the spleen. Length was measured to the nearest millimeter with dividers. Longitudinal scans of the liver were obtained in the midclavicular line and midline, measuring the longitudinal and anteropostenior (AP)

diameters

as shown

in Figures

1-4.

In the midclavicular

line,

the

upper portion of the liver was partly masked by the air inside the lung, so that the margin between lung and liver was used as the upper limit of the longitudinal diameter (Figs. 1, 2, and 4). In the midline, the upper margin of the liver under the dome of the diaphragm served as the upper limit of the longitudinal diameter (Figs. 1 and 3). The AP diameters were measured at the midpoint of the longitudinal i

From

Department

of Medicine

D, University

of

D#{252}sseldorf, Federal Republic of Germany. Received Jan. 26, 1983; revision requested April 15; revision received May 10 and accepted June 7. Supported by a grant from the Minister f#{252}r Wissenschaft und Fonschung des Landes Nordrhein-Westfalen. sjh

diameters

deep

(Figs.

inspiration

2-4).

in

Both

order

the

liver

eliminate morphological variation tional area of the liven was calculated diameters using the equation (longitudinal

diameter

and

to minimize

X AP

due

diameter)/2

spleen

were

masking

measured

by

the

to respiration. The from the longitudinal

cross-sectional

during

lung

and

cross-secand Al?

area

537

I.

AP view.

1 = midclaviculan longitudinal of the liver; 3 midline longidiameter of the liver; 5 diameter of the spleen; 6

diameter tudinal

transverse longitudinal diagonal

diameter diameter

of the spleen; of the spleen.

7

Figures

1 and

2 U

U 0 0 0 0 0 0

=

The

upper regions of the liver and the spleen are located in the dome of the diaphragm and hidden by the air in the lung, so that their sured lung.

2.

Lateral

longitudinal only as

diameters as the

can margin

be meaof the

of the liver in the midclavic= midclavicular longitudinal diameter; 2 = midclavicular AP diameten, measured at the midpoint of the longitudinal diameter. The upper region of the liver is masked by the air in the lung. ulan

view plane.

far

0 0

1

2.

Figures 3-5

3. 3.

4.

5.

4. Midline gitudinal

5.

longitudinal diameter;

scan of the liver. 3 midline longitudinal diameter; 4 = midline AP diameter, measured at the midpoint of the lonD diaphragm; L liven; ST stomach (target); P pancreas; A aorta. The upper margin of the liver, under the dome of the diaphragm, served as the upper limit of the longitudinal diameter. Longitudinal scan of the liven in the right midclaviculan plane. I = midclaviculan longitudinal diameter; 2 midclaviculan AP diameter, measured at the midpoint of the longitudinal diameter; L liven; G gallbladder. The margin between the lung and liver was used as the upper limit of the longitudinal diameter, since the upper region of the liver was partly masked by the air in the lung. Longitudinal scan of the spleen. 5 = transverse diameter; 6 longitudinal diameter; 7 = diagonal diameter; S = spleen; K kidney. The margin between the lung and spleen served as both the transverse diameter and the upper limit of the longitudinal diameter.

Figure 6

Figure 7

LIVER

The spleen was viewed along its longitudinal axis. Transverse, longitudinal, and diagonal diameters were measured from the image showing the maximum cross-sectional area as shown in Figures 1 and 5. The margin between lung and both the transverse limit of the longitudinal cross-sectional using all three

spleen served diameter and diameter.

diagonal /(transverse2

The

scan. 8 maximum AP diameter of the pancreas; 9 maximum AP diameter of the body of the pancreas; PV = portal vein; SMA superior mesenteric artery; Ivc = inferior vena cava; A aorta. The portal Transverse of the head

and splenic nor (dorsal) not

veins, which boundaries

included.

represent of the

the postepancreas,

are

Radiology

#{149}

maximum

pancreas verse/oblique abdominal The portal

was

comprise boundaries were not

the

X

area Al? diameter

of the

measured on a transscan, using the upper blood vessels as landmarks. and splenic veins, which

regular posterior (dorsal) of the body of the pancreas, included (Figs. 6 and 7); nor

was the tail of the pancreas measured, since it is not often visible and varies widely in shape. The maximum diameter

538

calculated

+ longitudinal2)/2 =

Transverse scan. 8 maximum AP diameter of the head of the pancreas; 9 maximum AP diameter of the body of the pancreas; L = liver; Pv = portal vein; IVC inferior vena cava; SMA = superior mesentenic vein; A = aorta; SP = spine. The upper abdominal vessels served as pancreatic landmarks. The portal and splenic veins are not included.

was

diameter diameters:

as the The

of the

portal

vein

and

the

November

diameter

1983

I:

TABLE

Mean

Organ

Diameters Diameter (mean

Midclavicular longitudinal diameter of the liven Midclaviculan AP diameter of the liver Midline longitudinal diameter of the liven Midline AP diameter of the liven Transverse diameter of the spleen Longitudinal diameter of the spleen Diagonal diameter of the spleen Maximum diameter of the head of the pancreas Maximum diameter of the body of the pancreas Maximum diameter of the portal vein Diameter of the portal vein at the porta hepatis

II:

TABLE

Correlation

with

Physical

(cm) ± S.D.)

10.5 8.1 8.3 5.7 5.5 5.8 3.7

Percentile (cm)

1.5 1.9 1.7 1.5 1.4 1.8 1.0

12.6 11.3 10.9 8.2 7.8 8.7 5.4

± 0.3

2.6

1.8 ± 0.3 1.2 ± 0.2

2.2 1.4

1.0 :1: 0.2

1.2

2.2

± * ± ± ± ± ±

95th

Data* Body

Surface

Sex

Age

Weight

Height

Midclaviculan longitudinal diameter of the liver Midclaviculan AP diameter of the liver Midline longitudinal diameter of the liven Midline AP diameter of the liven Transverse diameter of the spleen Longitudinal diameter of the spleen Diagonal diameter of the spleen Maximum diameter of the head of the pancreas

-0.10 -0.14 -0.10 -0.21 -0.02 -0.03 -0.07 -0.23

-0.23 -0.05 -0.20 +0.06 -0.10 -0.20 -0.09 +0.17

-0.02 +0.03 -0.12 +0.28 +0.18 +0.14 +0.23 +0.30

+0.29 +0.09 +0.23 +0.12 +0.12 +0.16 +0.15 +0.17

+0.10 +0.06 +0.01 +0.25 +0.17 +0.16 +0.22 +0.28

Maximum Maximum

-0.28 -0.23

+0.10 +0.12

+0.23 +0.23

+0.16 -0.05

+0.23 +0.26

-0.22

+0.17

+0.26

-0.05

+0.27

Diameter *

For

diameter diameter of the -0.12

of the body of the pancreas of the portal vein portal

r

vein

+0.12,

at the p

0.001;

at the porta hepatis were with the inner dimensions

for sonographic

porta

hepatis

for -0.09

measured, being used

RESULTS Mean values, standard deviations, and upper normal limits of all diametens are shown in TABLE I, and the diameters are correlated with the physical data in TABLE II. The diameters

smaller

in women

than

in men

and demonstrated a positive correlation with height and surface area. Liver and spleen diameters decreased with age, while pancreatic and portal vein diameters increased with age. Liver diameters in heavy and slender subjects are shown in TABLE III. In thin persons, the longitudinal diameter was large and the AP diameter small, whereas in heavy subjects the reverse was true. This indicates that the liver is oriented longitudinally in thin persons and transversely in heavy subjects.

Volume

149

+0.09,

p

0.01.

III:

TABLE

Light

and Heavy Midline

assessment.

Statistics: Statistical calculations were performed on a Telefunken TR 440 computer using a routine program. Linear regression analysis was carried out for age, sex, weight, height, surface area, and all diameters. The 95th percentile was considered the upper limit of normal, i.e., 95% of all measurements lay below this point. Results of the x2 test were evaluated using Yates’ correction.

were

r

Number

2

Subjects Longitudinal of the Liven

95 kg)[n 39] x2 Test* *

Calculated

using

0.001).

>Mean

40 (919)

30 (77%) x2 = 20.27

9 (23%) (p 0.001)

x2

p was spleen

between the was 0.4 (p

midclavicdiam-

while that was 0.20 a significant

was

0.001). No significant found between any diameters. Correlation

two pancreatic 0.001). There

diameters was a weak

positive correlation between pancreatic and portal vein diameters (r 0.20; p 0.001). Correlation between the two portal vein diameters was highly significant (r 0.75; p 0.001). Correlation tional areas the

physical

between of the liver data

did

4 (9)

9 (23%) = 36.58

30 (p

(77C7)

0.001)

correction

correlation between the longitudinal and transverse diameters of the spleen (r 0.42; p 0.001) and between each of these measurements and the diagonal diameter (r 0.63 and 0.61, respectively; correlation liver and

AP Diameter of the Liven Mean

33 (75%)

Yates’

There

Midline

Diameter

11 (25%)

Correlation between the ular and midline longitudinal eters of the liver (r) was 0.61, between the two Al? diameters

(p

Area

the cross-secand spleen and not

differ

from

that for the individual diameters. No additional information could be gained by using the cross-sectional areas instead of the diameters.

DISCUSSION Liver and spleen size may give information about the diagnosis and course of gastrointestinal and hematologic diseases, while the pancreas is enlarged in acute and chronic pancreatitis. In addition, pancreatic tumors are sometimes manifested by a localized increase in size, and the diameter of the portal vein is helpful in evaluating spleno-portal complications. Thus determination of normal organ

size

can

previous tamed subjects,

and

be significant.

In contrast

studies, our data from a large group so that standard

upper

limits

of normal

to

were obof healthy deviations

were

Radiology

gen539

#{149}

erally smaller than those reported by other authors (11, 15-18). The lack of correlation between liver and spleen size may also be due to this fact. We employed only simple and commonplace methods of measurement. Determination of the midclavicular and midline longitudinal diameters of the liver is still the predominant clinical method of estimating its size. Since the liver may vary widely even in healthy subjects, the AP diameter

and

cross-sectional

as well. respiration

area

were

measured

Morphological variation due to was eliminated, and mea-

sured diameters were correlated with the physical data to assess changes attributable to the patient’s sex, age, weight, height, or surface area. The volume of the liver and spleen were not measured, because this is too difficult and time-consuming for routine clinical use (12, 14, 19-21); perhaps the computer may be helpful in future volume determinations. Measurements

of the

transverse

ameters spleen

and along

and

longitudinal

cross-sectional its longitudinal

di-

area of the axis have

been shown to be an accurate and reliable method of estimating its size (13). In the case t- the pancreas, only the maximum AP diameter was measured on a transverse/oblique scan, since previous

studies

fenence

between

have

found

no

dif-

out loss of information. Longitudinal and transverse diameters are sufficient to estimate the size of the spleen, since both measurements correlate well with the diagonal diameter and cross-sectional area. Measurement of the midclavicular and midline longitudinal diameters suffices to estimate liver size in most cases; only in slender on heavy subjects need the AP diameter be measured, since the longitudinal diameter alone will give too high or too low a value, respectively. The portal vein is sufficiently represented by either well

scans

in

Prof. Herbert partment of dorf also

organ

size

Berndt

men

have

larger

gans

than

women

and spleen the pancreas with age, studies of the 23). Nevertheless,

24).

increases

large varia(24, 25). As found that The

540

correct

Radiology

#{149}

liver

and pancreas most diameters

related poorly with the physical We feel that it is not necessary tinely

the

measured

3.

4.

6.

or-

decrease with age, while and portal vein increase corroborating previous spleen

of the

Department

Biometrics

for

We

13.

14.

are and

16.

17.

of Medical their

help

with

analysis.

19.

20.

gastrointestinal (23,

his cooperation. Angelika Niederau

(17, con-

data. to rou-

diameters

7.

8.

9.

Pfahler GE. The measurement of the liven by means of roentgen rays based upon a study of 502 subjects. AJR 1926; 16:558563. Zelman S. Liver and spleen visualization by a simple roentgen contrast method. Ann Intern Med 1951; 34:466-478. Nimeh W. New method for the determination of the size of the liver and spleen. Am I Gastroentenol 1955; 23:147-156. Fionioli W. A method for the clinical determination of liver size. Triangle 1960; 4: 286-288. Yagan R, Maclntyne WJ, Christie JU. Estimation of liver size by the multiple cut off scintillation scanning technique. AJR 1962; 88:289-295. Naftalis J, Leevy CM. Clinical estimation oflivensize. Am J Dig Dis 1963; 8:236-243. Peternel WW, Schaefer JW, Schiff L. Clinical evaluation of liven size and hepatic scintiscan. Am J Dig Dis 1966; 11:346-350. Walk L. Roentgenologic determination of liven volume. Simplified method of caiculation. Acta Radiol [Diagn] 1967; 6.369371. Castell DO, O’Brien KD, Muench H, Chalmers TC. Estimation of liven size by percussion in normal individuals. Ann Intern Med 1969; 70:1183-1189.

Sullivan S. Krasner N, Williams R. The clinical estimation of liver size: a companison of techniques and an analysis of the source of error. Br Med J 1976; 2:10421043. Sapira JD, Williamson DL. How big is the normal liver? Arch Intern Med 1979; 139: 971-973. Koischwitz D. Sonographische Lebervolumenbestimmung. Problematik, Methodik

und

References

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by autopsy,

with studied it was

and

for

12.

15.

correlates

We wish to thank Theodor Br#{252}ster of the DeBlood Transfusion of D#{252}sselto

11.

Germany

5.

possible

each

10.

18.

weight

made

since other.

Department of Medicine D University of D#{252}sseldorf Moorenstr. 5 D-4000 D#{252}sseldorf

2.

was

Ehle

the statistical

with height and body surface area. Our results are in accord with previous estimates of liver size by clinical methods, autopsy, and ultrasound (9, 11, 22-24). Some of these authors noted stronger correlations than we did because exact measurement of liver or because children tions in height were in autopsy studies,

University grateful

Statistics

(16).

that

diameter, with the

Acknowledgments:

transverse/oblique

and longitudinal pancreatic size

We

shown

for physical data; moreover, calculations of the cross-sectional area of the liver and spleen may be omitted with-

21.

22.

23. 24.

25.

praktische

Bedeutung

den Quantifi-

zienung des Lebenvolumens. ROFO 1979; I 31 :243-248. [Ger) Koga T, Monikawa Y. Ultrasonic determination of the splenic size and its clinical usefulness in various liver diseases. Radiology 1975, 115:157-161. Kardel T, Holm HH, Rasmussen SN, Mon. tensen 1. Ultrasonic determination of liver and spleen volumes. Scand J Clin Lab Invest 1971; 27:123-128. Weill F, Schraub A, Eisenscher A, Bourgoin A. Ultrasonography of the normal pancreas. Success rate and criteria for normality. Radiology 1977; 123.417-423. de Graaff DS, Taylor KJW, Simonds BD. Rosenfield AJ. Gray-scale echography of the pancreas. Re-evaluation of normal size. Radiology 1978; 129:157-161. Zimmermann W, Frank N, Weiss-Simon C, Burkhard B, Seidel F. Das normale Pankreas. Darstellung im Sonognamm in Abhangigkeit zum Lebensaiter. Fortschr Med 1981; 99:1 178-1 182. [Ger] Haber K, Freimanis AK, Ashen WM. Demonstration and dimensional analysis of the normal pancreas with gray-scale echography. AJR 1976; 126:624-628. Cam D, Duncan JG, Railton R, Smith CB. Liver volume determination by ultnasound: a feasibility study. Br J Radiol 1976; 49: 776-778. Rasmussen SN, Christensen BE, HoIm HH, Kardel 1, Stigsby B, Larsen M. Spleen volume determination by ultrasonic scanning. Scand J Haematol 1973; 10:298-304. Rasmussen SN. Liver volume determination by ultrasonic scanning. Dan Med Bull 1978; 25:1-46. Stahl WR. Organ weights in primates and other mammals. Science 1965; 150:10391042. DeLand FH. Normal spleen size. Radiology 1970; 97:589-592. DeLand FH, North WA. Relationship between liver size and body size. Radiology 1968; 91:1195-1198. Holder LE, Strife J, Padikal TN, Perkins PJ, Keneiakes JG. Liver size determination in pediatrics using sonognaphic and scintigraphic techniques. Radiology 1975; 117: 349- 353.

November

1983