abdominal ultrasound - livingstonbrightoned.webs.com · biliary scanning - longitudinal •for the...
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Abdominal UltrasoundDiane Hallinen, MD
Bloodroot
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Abdominal Ultrasound
• Vasculature
• Hepatobiliary
• Spleen
• Kidney
• Bladder
• Bowel
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Where to put the probe?
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Vasculature
We are going to
talk about …
Celiac Trunk
Superior
Mesenteric
Artery
Portal Veins
Hepatic Veins
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Celiac, SMA
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Celiac Trunk and SMA
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Transverse Celiac
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Transverse SMA-
Bull’s Eye
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Biliary Scanning - Longitudinal
• For the gallbladder start with
the probe marker pointing to
the head, in the mid-clavicular
line. Move the probe toward
the midline until you find a
gallbladder looking structure.
• Rotate the probe so you get a
long-axis view.
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Transverse Approach
from Superior to Inferior
• Hepatic veins
• Portal vein
• Then locate the most
anterior cystic
structure… the
gallbladder.
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Some questions…
• Who are you going to scan?
• What are you going to do with the information? What if you get “no” information?
• When are you going to do it? Before you order labs? After everything comes back?
• Does everybody need a “formal exam?”
• What are you going to say to the patient?
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My Answers
• I haul the machine in if the triage note makes
me think gallbladder.
• I do it right away since I may order lots or
little based on what I see in conjunction with
the H & P.
• I’ll order a formal exam on everybody who
needs to see a surgeon, or if I’m not sure.
• I tell patients this is a focused exam, and they
may need more “stuff done” later.
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Biliary Colic Workup
Emergency Ultrasound Ma and Mateer 2003
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Thickened Gallbladder Wall
• Measure the
anterior wall.
• Normal less than
2mm.
• Need to be fasting.
• Thick wall seen in
jaundice, hepatitis,
ascites, etc.
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Thick Gallbladder Wall
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Pericholecystic Fluid and other
findings
• http://www.med-ed.virginia.edu/courses/rad/edus/index6.html
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Posterior Shadow
• Stones send back
all the sound waves
to the transducer,
thus they make a
shadow…posterior
shadowing.
• Stones also move if
they are not stuck.
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A Layer of a Whole Bunch of
Small Stones
• There is a
multiple tiny
stones producing
this posterior
shadowing.
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SONOGRAPHIC MURPHY
• See liver, or bowel, or
whatever.
• Press on it.
• Does it hurt?
• See gallbladder.
• Press on gallbladder.
• See it move.
• Does that hurt?
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Sonographic Murphy’s Sign,
• A positive sonographic Murphy’s sign,
defined as the presence of maximal
tenderness elicited by direct pressure of the
transducer over a sonographically localized
gallbladder, is present in most patients with
acute cholecystitis.
• The positive predictive value of sonographic
Murphy’s sign combined with the presence
of gallstones is reported to be 77% to 92%.
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Negative Sonographic Murphys
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Wall Echo Sign
Happens when the
gallbladder is full of
stones, or when it has
one big one.
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Wall Echo Sign-Multiple Stones
• Note the hypoechoic
(black) stripe
between the wall and
stones. This
represents bile.
• Important to know
about since it can be
confused with gas
filled bowel.
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Portal Vein
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CBD
anterior
to Portal
Vein
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Portal Vein
• Visualize the portal vein
in a long axis view.
• Anterior to the PV,
(towards the skin) you
should see the bile duct.
• Portal vein has brighter
(more echogenic) walls
compared to hepatic
veins.
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Find that CBD
Follow the
gallbladder neck to
the portal triad. The
main lobar fissure
should take you there
(present in about
70% of people).
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Main Lobar Fissure
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Porta Hepatis=Portal Triad
• Rotating the probe on the portal vein should bring the common bile duct, hepatic artery and portal vein into view.
• The probe marker should be pointing to the patient’s right.
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Mickey Mouse
• If the CBD is
dilated than the
rodent has a swollen
right ear.
• If you forget which
ear is which, you
can doppler the big
one.
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Dilated Common Bile Duct
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CBD- Measure the Internal
Diameter.
• Mean diameter is 4 mm, more than 7 mm is
dilated.
• CBD diameter increases with age, up to 10
mm in the elderly .
• In general it should be 1/10th the patient’s
age.
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Acute Cholecystitis
• The solid arrows
are pointing to the
thickened
gallbladder wall.
• What are the open
arrows pointing
to?
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Polyps
• Non-mobile
• No posterior
shadowing
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Gallbladder Sludge
• Mobile
• Non-
shadowing
• Dependent
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Phrygian Cap
Transverse
congenital septum
in the fundus
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Pitfalls in Gallbladder Imaging
• Misidentification of the gallbladder. A loop of
bowel or the IVC can look like a gallbladder. Gut
does peristalsis, IVC has flow on doppler. If
possible you should show that the gallbladder
communicates with main portal triad via the major
lobar fissure.
• Bowel gas, try left lateral decubitus position.
• Contracted gallbladder in non-fasting patient.
• Lack of power to penetrate adipose.
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The Liver
• Interesting findings can be seen in many
patients…including
– portal hypertension
– cirrhosis
– fatty liver
– bile duct obstruction
– cysts
– tumors
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Vena Cava and Hepatic Veins
• There are three main
hepatic veins, right, left and
middle.
• They have thin, hypoechoic
walls, and converge on the
vena cava.
• Remember that the portal
vein has hyperechoic walls.
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Bunny Sign
• The rabbit’s head is the vena cava, the ears are the middle and left hepatic veins.
• Use m-mode to observe the change in diameter of the vena cava with respiration
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Transducer Parallel to the Costal
Margin
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Portal Hypertension
• Usually seen in the
setting of cirrhosis.
• The portal vein is dilated
to more than 15 mm.
• Often seen with ascites
and splenomegaly.
Note the portal vein’s
hyperechoic walls.
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Cirrhosis-Early Stage
• Loss of peripheral
hepatic vessels
• Increased echogenic
wall of the portal vein.
• Hepatomegaly
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Cirrhosis Advanced Stage
• Nodular liver
contour.
• Contracted liver.
• Usually ascites
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Fatty Liver
Focal Fatty Liver. Diffuse Fatty Liver
• Results in increased echogenicity (brighter).
Best compared to right kidney cortex.
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Bile Duct Obstruction
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Liver Cysts-Benign
• To be called a cyst
it must have
– echo free content
– spherical shape
– smooth outline
– distal acoustic
enhancement
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Liver Tumors
• The liver is a favorite
site for metastatic
tumors. GI tract,
breast, lung, and the
esophagus are the
usual primaries.
• Note the hypoechoic
halo.
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Renal Ultrasound
• Hydronephrosis
• Cysts including polycystic kidney disease
• Stones
• Wilm’s tumor
• Measuring Bladder Volume
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The Normal Kidney
• The echogenicity
(brightness) of the
renal cortex should
be less than that of
the liver or spleen.
• In other words the
kidney should be a
tad darker than the
liver.
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Kidney Size
• Size is best evaluated as
length, which should be
10 to 12 cm in adults.
• Each kidney should be
within 2 cm of each
other in length.
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Approach
• Use the liver as
your window on the
right.
• The left can be
harder.
• Try prone.
• Breath holding
helps.
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Hydronephrosis Grades - Mild,
Moderate, Severe
I spraying
II bear claw
III severe, loss
of renal
parenchyma
This is grade 2.
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Bear Claw- Hydronephrosis
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Simple Cyst Seen while doing a
FAST
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Polycystic Kidney
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Nephrolithiasis
• CT is better, but there
is a place for doing a
focused ED U.S.
• Someone with known
stones to look for
obstruction.
• Pregnancy.
• When AAA is in the
differential.
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Seeing the Stone
• Stones are
rarely seen
in the
ureter, but
they are
visible in
the kidney,
bladder and
UVJ. Note
distal
shadowing
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Ureteral Jets
• Color Doppler probe is
used to find urine
squirting from the
ureter into the bladder.
• If the jet is present then
there is no obstruction
on that side.
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Wilm’s tumor
• Younger than
6.
• Have a flank
mass and
hematuria.
• Mass is solid
on U.S.
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Urinary Bladder
• Female patient
(note the uterus).
• Top image is a
longitudinal view.
• Bottom is
transverse.
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Measure urine volumeWhy only one “up down” measurement and two “side
to side”?
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Bladder volume
is estimated by
measuring
maximal
anteroposterior,
coronal, and
craniocaudal
measurements
and multiplying
by pi/6 (0.52)
Measure Urine Volume
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Spleen Viewing Position
Best seen from the
a posteriolateral
approach, with the
probe position in
between the ribs.
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Spleen
• A spleen looks like
a crescent moon.
• Usually best seen
halfway between
full inspiration and
expiration.
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Splenomegaly
• The “normal” spleen
measures less than 12
cm long, 5 cm thick
and 7 cm in breadth.
• It can be hard to get
the whole spleen on
the screen if your
probe’s footprint isn’t
big enough.
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Bowel Obstruction/Ileus
• I mention this because
you will run into while
looking for a AAA.
• Usually bowel isn’t seen
since gas disperses the
beam. But in obstruction
the bowel has a lot of
fluid in it.
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Bowel Obstruction
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Bowel Obstruction
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Appendicitis
Greater than 6 mm in diameter
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Press Down
The image on the
right is obtained by
pressing down on
the probe. Note the
appendix does not
compress.
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Appendicitis
Wall is greater than
3 mm thick.
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Appendicolith
• Note the
posterior
shadowing.
• Exam is done
with a high
frequency
probe.
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How to use this skill clinically.
• 17 year old girl
• C/O RLQ pain.
• HCG –
• Appendicitis
versus tubo-
ovarian
abscess?
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Mesenteric Adenitis
• Often seen in
children after
a viral illness.
• Often
confused with
appendicitis
on clinical
exam.
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References
References:
Abdominal Ultrasound CD by Mark Deutchman
(great resource)
Emergency Ultrasound by Ma and Mateer
Ultrasound in Emergency and Ambulatory Medicine
by Simon and Snoey
Ultrasound Teaching Manual by Hofer
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Web Pages
• http://www.gemedicalsystems.com/inen/rad
/us/education/msucmehd.html
• http://www3.medical.philips.com/en-
us/secure/photohome/index.asp