It has been indicated in the literature that constant costal compression on the liver my lead to hepatic deformation in the form of the so-called corset liver. This may it turn result in subcapsular hepatic fibrosis at the site of compression(1,2). This complication usually does not occur if compression is only temporarily or occurs with varying intensity. However, literature data on this subject is sparse and mostly refers to abdominal CT in an attempt to explain the development of the so-called hepatic pseudolesions resulting from costal compression(3–7). Our preliminary case report related to the importance of ultrasonography in explaining pain due to rib compression of the liver(8). The aim of the present paper is to present a morphological and dynamic assessment of the so-called musculocartilaginous complex, i.e. a structure composed of cartilaginous, osseous and muscular elements, which is located at the thoracoabdominal junction, at the level of the right costal arch.
A total of 1000 patients (566 females and 434 males aged between 35 and 82 years, mean age 52 years) with various clinical symptoms underwent ultrasound examination between 2006 and 2015. No significant upper abdominal pathologies were found in any of the enrolled patients based on clinical and imaging data. A consent from the head of department and an oral consent from the patients were obtained prior to the study. An assessment of the musculocartilaginous complex at the level of the right costal arch was performed as an additional component of ultrasound examination. In the first stage of the study, ultrasound scans were performed to determine normal ultrasonographic structure of the musculocartilaginous complex. We analyzed images in a group of 30 patients aged between 18 and 59 years (mean age 38 years), and then compared these images with textbook anatomical data(9). The musculocartilaginous complex was evaluated using 3–6 MHz convex transducers and 7–12 MHz linear transducers for slim patients. The transducer was first positioned longitudinally, i.e. parallel to the body axis, to visualize costal arch cartilages and the insertions of the lateral abdominal muscles, and then moved from the axillary midline to the midline of the body. Musculocartilaginous compression of the liver was defined as an extrahepatic area more than 10 mm in thickness showing no vascular flow in Color Doppler, associated with the chest throughout the breathing cycle, and showing varying configuration during deep inhalation and exhalation phases as well as during free breathing. The same technique was used in the next stage of the study to assess the behavior of the described cartilaginous/hepatic conflict in patients in a sitting position and with forward trunk inclination of 45°. The obtained imaging data was recorded on sonograms as well as short video sequences in some patients (video recording 1 – available at
A scheme for the measurement of the musculocartilaginous complex in a patient in sitting position and with forward trunk flexion
The analysis of the ultrasonographic structure of the musculocartilaginous complex under normal conditions in a group of 30 patients correlated with textbook anatomical data showed that costal arch cartilages are covered anteriorly by the external oblique muscle and posteriorly by the transverse abdominal muscle. The internal oblique muscle is located between these two muscles and attached to the lower edge of the cartilages of ribs 10–8. Also, intercostal muscles can be visualized at the level of the axillary line (Fig. 2). Although the 10th rib cartilage is often hypoplastic, the thickness of the inserts of the interior oblique and the transverse abdominal muscle bundles, which attach to this site, is impressive and causes an overall thickening of the musculocartilaginous complex (Fig. 2 and Fig. 3A). Dynamic analysis showed particular thickening of the insertion of the transverse abdominal muscle and the internal intercostal muscle, which penetrate the liver, during exhalation and forward trunk inclination (Tab. 1). This was accompanied by costal cartilages being pulled dorsally (Fig. 3B and Fig. 3C). Figure 3B shows variable activity of the intercostal muscles at different respiratory phases. Occasional calcifications in the central portions of cartilages significantly impaired assessment of this area. The use of convex transducer did not allow for the discrimination between the individual components of the musculocartilaginous complex (Fig. 4).
Summary of statistical data on the thickness of the musculocartilaginous complex at different testing stages in 178 patients
Stage | Mean | Stage | Mean |
---|---|---|---|
Inhalation | 14.5 mm | Exhalation | 21.5 mm |
Inhalation | 14.5 mm | Sitting | 17.0 mm |
Inhalation | 14.5 mm | Flexion | 25.4 mm |
Exhalation | 21.5 mm | Sitting | 17.0 mm |
Inhalation | 21.5 mm | Flexion | 25.4 mm |
Sitting | 17.0 mm | Flexion | 25.4 mm |
A 20-year-old athlete examined in a supine position during free breathing. Right costal arch area.
Legend: downwards arrows – the external oblique muscle; upwards arrows – the transverse abdominal muscle; asterisk – the internal oblique muscle; a diamond at the top of the figure – the external intercostal muscle; a diamond at the bottom of the figure – the internal intercostal muscle; c – costal cartilages, L – liver
A 46-year-old female examined using a 3–6 MHz convex transducer in a supine position during inhalation and exhalation. Minor musculocartilaginous compression of the liver occurs during exhalation; however, precise determination of musculocartilaginous components is not possible
Costal cartilage compression of the liver at the level of the right costal arch was identified based on ultrasound scan in 182 out of 1000 patients. Women (mean age 49 years) clearly predominated in this group (
Ultrasonographic characteristics of the musculocartilaginous complex in 182 patients
Feature | Number of patients | Percentage |
---|---|---|
|
121 | 66.5 |
|
35 | 19.2 |
|
26 | 14.3 |
|
182 | 100.0 |
|
182 | 100.0 |
|
152 | 83.5 |
|
30 | 16.5 |
Comparison of the thickness of the musculocartilaginous complex during inhalation, exhalation, supine position, sitting position and forward trunk flexion in 178 patients
Feature | Thickness range | Mean SD | Feature | Thickness range | Mean SD |
---|---|---|---|---|---|
Inhalation | 11–28 mm | 14.5 mm +/− 2.4 | Exhalation | 12–40 mm | 21.5 mm +/− 3.3 |
Sitting | 11–31 mm | 17.0 mm +/− 2.9 | Flexion | 20–40 mm | 25.4 mm +/− 3.5 |
Significantly deeper, focal musculocartilaginous compression of the liver (arrows)
Very deep penetration of the costal arch (A) dividing the liver into two parts (L)
The cartilaginous tip of the xiphoid process (XP) compressing the left hepatic lobe (L)
Non-contrast-enhanced and contrast-enhanced CT scans demonstrated that costal compression of the liver may appear in the form of pseudolesions in the subcapsular hepatic region, which are seen as an absence of perfusion, usually during the venous phase, less often in the arterial phase(3–7). Such perfusion defects were found in 2–14% of patients in these studies. The total number of cases of costal compression was significantly higher, e.g. Nishie
Perhaps such a pathology could be detected by contrast-enhanced ultrasound. On exhalation, the liver retracts cephalically, allowing the rib to return to the baseline position, thus increasing the penetration. The difference between these techniques further depends on the methodology used. In computed tomography based on axial cross-sections, ribs were evaluated for bone parts, whereas ultrasound scans were performed via the costal arch, using longitudinal sections, and therefore involved a different part of the chest and the liver. Our preliminary study on the ultrasonographic anatomy of the thoracic-abdominal junction at the level of right costal arch showed that liver compression is due to the thickening of the musculocartilaginous complex, with the transverse abdominal muscle being the direct compression structure. It was found in the analyzed group of 1000 patients that clear liver/costal arch conflict affects about 18% of adults, with the highest incidence among hyposthenic women (96%). The conflict may cause pain in the region of liver in about 10% of these patients. In this situation and in the absence of lesions, mainly in the liver, bile ducts, stomach and duodenum, the conflict should be included in the differential diagnosis, especially if indicated by medical history. The location of liver compression should be clarified. The costal arch, which is comprised by the cartilages of ribs 8 through 10 does not connect directly to the sternum, but though a syndesmosis with rib 7 and the interchondral articulation. Our study demonstrated that this site shows poor stability, which may often lead to deformation of the chest cartilage and, consequently, liver compression. Furthermore, the study confirmed the important role of the internal oblique muscle, the transverse abdominal muscle and the internal intercostal muscle in the mechanism of exhalation and trunk flexion(9,10). Examining patients in this position resulted in the thickening of the insertions of these muscles, which consequently led to liver compression. The degree of liver compression is proportional to the degree of anterior trunk inclination and mostly affects hyposthenic women. The relationship between pain in the liver projection and such a configuration of the costal arch may be explained in two ways. Meuwly
Splenic compression (S) by the musculocartilaginous complex on the left (arrows) in a sitting position (left side of the figure) and forward trunk flexion (right side of the figure); G – stomach
Musculocartilaginous compression of the liver affects about 18% of patients and is more common in hyposthenic women (96%). The disorder may cause pain in the right upper abdomen (depending trunk position) in about 10% of patients.
The musculocartilaginous complex compressing the liver usually shows irregular echostructure. It may cause focal or segmental compression, which may penetrate deep into the liver.
Musculocartilaginous compression of the liver is most pronounced during exhalation and forward trunk flexion.