sono graphic examination (updated)

8/3/2019 Sono Graphic Examination (Updated)

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Objectives of sonography are;

To learn the normal cross sectional anatomy &structural details (normal sonographic findings of thepatient).

To find out the abnormalities observed onsonographic examination.

To co-relate the sonographic examination findingswith physical examination

To confirm the diagnosis sonographically

To categorize the trauma patients as per organ traumascore as first line assessment

To diagnose and to plan sonographic management inselected patients

To find out innovations in both clinical & sonographicexaminations

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OBJECTIVES

Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

Sonographic

Examination


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SONOGRAPHIC

EXAMINATION IN

GENERALMuhammad Shuja Tahir, FRCS (Eden), FCPS Pak (Hon)

Sonographic examination is performed with the help of anultrasound machine. It can be performed for most of thebody parts but requires different probes and machines. Itused to be performed by specialists of the field during lastfew decades.

Now a days, most of the doctors are able to performsonography on their own with reasonably accurateinterpretation. The skill can further be improved if thesonography is learnt at earlier stage (during studentyears) as it has become an essential part of diagnosticwork up.

The time has come that medical students start learningsonographic examination as adjuvant to clinicalexamination. It should be performed in a structuredmanner so that omissions can be avoided.

It has reasonably high sensitivity and specificity. It hasmuch higher accuracy rate. It achieves nearly 100%accuracy when combined with clinical examination.

INTRODUCTION AND COUNSELINGOne must introduce him/herself to the patient and shouldplan whether the patient will go to the ultrasoundexamination room or the examination will be conducted

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on the bedside in the ward (in case of a seriousand heamodynamically unstable patients. The

patient should be informed about the mechanicsof the examination so that patient

clothes with jelly.

clearly knowswhat exactly is going to happen to him/her,which of the body parts are to be uncovered andhow much and for how long. One should be verypolite and decent during the examination. Emergency, trauma or serious haemo-

dynamically and unstable patients who can notThe examination is conducted at an appropriate be shifted to ultrasound room are examined onand comfor table room temperature. The the bedside by bringing the machine to the sidecontact gel is applied to the area to be examined of the bed.sonographically.

No special preparation is required for most ofNever forget to clean and cover the uncovered the conditions. Gall bladder examination is doneparts of patients at the end of examination. The on a fasting patient and pelvic examination ispatient is informed about completion of conducted on patient with full urinary bladder.examination.

The sonographic examination is performed in aSPECIAL INTERVIEW methodical and structured form to avoidRelevant history should be asked from the missing important observations.patient so that the sonographic examination isconducted objectively. History of Jaundice, painin epigastrium or right hypochondrium, nausea,

vomiting, abdominal pain, distension or traumashould be asked. History of last menstrualperiod, menstrual abnormalities (Amenorrhea,heavy menstrual bleeding) should be noted.History of abdominal masses should be asked.Dysuria, pain in lumber area and haematuria arealso noted if present.

EXPOSURE AND POSITIONElective examination is conducted in ultrasoundexamination room. The patient is asked to lie

down on the examination couch.

The patient should preferably wear the hospitalgown after removing the shirt to facilitate thesonographic examination and to avoid soiling of

The patient lies in supine position on the couch

and the abdomen is exposed from lower chestto the lower abdomen. The thighs and genataliaremain covered. Patient is shifted to right or leftlateral positions as required for examination.

SONOGRAPHIC EXAMINATIONThe machine is checked for normal functioning.

Its computer attachments are checked foraccepting photographs. Printer and its papersare checked and one is ready for conducting

Normal abdominal sonography

SURGERY - CLINICAL EXAMINATION SYSTEM 21

SONOGRAPHIC EXAMINATION IN GENERAL 03


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sonography. The gall bladder is recognized and seen. Itsphotograph is taken. Cystic duct, hepatic ducts

The jelly is put over the probe and examination is common hepatic duct and common hepaticstarted in a well organized and structured duct and common bile duct and intra hepaticmanner. It is started from right hypochondrium. biliary ducts are examined.The probe is moved from right hypochondriumto epigastrium and then to left hypochondrium. Abnormalities of biliary tree are noted and

photographs are taken of stones or any othersolid mass present in gall bladder or biliary tree.The examination is conducted in bothlongitudinal and transverse views.

When sonographic examination of gall bladder

is done on a fasting patient, the stones show ashyperechoic shadow. The mass has a posterioracoustic shadow confirming the diagnosis.Thick walled gall bladder with other suggestivefeatures is seen in cholecystitis.

Sonographic Murphys test is positive whengentle examination of gall bladder is so painfulas to stop breathing momentarily. It is seen in

BILIARY SONOGRAPHY acute cholecystitis or empyema of gall bladder.It is performed for the diagnosis of following

conditions; The hyperechoic shadow of billiary stones seen! Cholecystitis in jaundiced patients in common bile duct is! Cholelithiasis called choledocholithiases. It is usually

! Choledocholithiasis

ABDOMEN AND PELVISThese patients usually don't require any specialpreparation normally. The patients who presentfor biliary examination should be fasting for 6-12 hours so that the gall bladder is distended at

the time of examination.

The pelvic examination is performed with fullbladder. The pelvic organs are better examinedin the presence of distended urinary bladder.

One should know the patient's problem before afruitful examination is conducted.

Abdominal and pelvic sonography



Cholelithiasis


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associated with dilated proximal bil liary The liver may show mixed echopattern, discretecanaliculi to suggest obstructive jaundice. opacities or masses with increased vascularity

in case of primary liver tumour such asPresence of stones in the gall bladder help to Hepatoma.simplify the diagnosis in a patient having severecolic. Small stone or even gravel can be picked The liver may show tears of different size (lengthup on sonography. and depth) following liver trauma. Sonographic

examination helps in assessing the liver injuryLIVER score. It also helps in regular monitoring ofSonographic examination of liver helps in trauma patients who are managed non-diagnosis and assessment of extent of liver operatively.problem.

Sonographic examination is performed

Liver (Cross sectional anatomy ) is examined regularly, daily or even twice or three times afrom front, lateral and posterior aspect forparenchymal inspection. Abnormalities arenoted. Size of liver is assessed. Presence orabsence of ascities is noted.

The liver parenchyma is normally grey onscanning. It shows intra hepatic billiary ducts,intra hepatic portal tributaries and intra hepaticarterial tributaries. The liver parenchymachanges to hyper echoic form in cases of liver

damage and resulting fibrosis in case of posthepatitis-C cirrhosis (Chronic liver disease).

It may show isolated hyperechoic mass ormultiple masses in cases of secondary tumours(deposits) in liver when primary tumour issomewhere else in the body.

Liver may show isolated hypoechoic area ormultiple hypoechoic areas in the liver in cases ofvarious types of liver abscesses (Amoebic or

pyogenic).

Multiple hypoechoic areas (Multiple unilocularor multilocular cystic areas) are seen in cases ofhydated cysts of liver.

Normal Liver ultrasound

Hydatid cyst liver




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day. Sonographic assessment may be required SPLEENin case of haemodynamically compromised The spleen is nearly of the same size as of the

patients. kidney (1x3x5 inches). The parenchyma isappreciated and noted. All abnormalities of

SONOGRAPHY FOR ASCITES spleen are noted and photographs are taken forSonography reveals this problem easily. The record.presence of fluid (even very small amount) canbe diagnosed. The intra peritoneal fluid may be It can be seen on sonographic examinationpresent in pelvis or in the peritoneal cavity. which reveals its anatomical landmarks clearly.

The size can be measured. Any sign of injury,tear, hematoma, cystic mass or abscesses canbe diagnosed.

The sonography helps in monitoring of splenicinjury in patients on (NOM) non operativemanagement. Sonographic injury grading canalso done.

STOMACH

Normally an empty stomach cannot bevisualized on sonographic examination. It canbe seen when filled with fluids. The diseasedstomach may reveal complex mass if it ispresent in the stomach. Gastric outletobstruction can be diagnosed as large amountof fluid keeps the stomach distended even afterfew hours fasting. APPENDICITIS

When appendix is infected, sonography helps toPANCREAS confirm the diagnosis. The probe is put at MacThe pancreas is seen normally when the probe Burneys point in right iliac fossa and moderatelies over epigastrium. It can be easily

degree of pressure is exerted. The appendix isappreciated when enlarged and inflamed or seen, fecolith may be seen or inflammatorywhen a tumour, cyst or psuedocyst of pancreas mass with bull's eye appearance is seen.is present.

Sometimes free fluid around appendix is seen.

Rupture spleen on sonography



Ascites on ultr asound examination


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ureteric area. Presence of hydronephrosis orhydroureter indicates the diagnosis.

Right lumber area is examined in bothlongitudinal and transverse views. Right kidney,right diaphragm upper part of right ureter andright side of large gut are seen. Intra peritonealfluid (Ascities), blood and leaked intestinalsecretions are seen.

Left lumber area is examined in the similarfashion in both views. Left kidney, diaphragm,stomach, left large gut and spleen are seen.Fluid collection under the diaphragm orLoops of small bowel may be seen adherent toperitoneal cavity is seen.the appendix.

The supra pubic and umbilical areas areSonographic MacBurneys test is positive whenexamined. Distended bladder is seen then other

minor pressure at MacBurneys point causesintra peritoneal viscera are seen. Uterus andsevere pain at right iliac fossa.ovaries are seen in female patients. Normaluterus usually has empty cavity. Normal ovaries

KIDNEYshow differently during changing period ofUltrasonography helps in differentiatingmenstrual cycle. During midcycle, follicles are

between different causes of acute abdominalseen. The ovaries are smaller and atrophic in oldemergencies such as;menopausal women.

The sonography shows abnormal findings ofINTERVENTIONAL SONOGRAPHYurinary tract. It shows presence of stone or anyIt is microinvasive method of treatment in the

other cause of obstruction in the renal orpatients with trauma or deep abscess such as

Normal kidney on ultrasound examination Core needle biopsy under ultrasound guidance

Appendicitis on sonography




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LUMPSonography is helpful in improving thediagnosis of a lump which may be present either

subcutaneously or deep in the body. It may berelated to viscera or abdominal wall orperitoneal, thoracic or pelvic cavity.

Correct size of the lump can be measured invarious dimensions.

Nature of lump can be assessed. Whether it issolid, cystic or of mixed type of tissues.

It further helps to assess the nature of adjacentliver abscess, subphrenic abscess, breasttissues and helps to verify any abnormalityabscess perinephric abscess and pelvicpresent or associated with the lump.abscess. Sono-graphic guided biopsy from

primary, secondary or metastatic deposits canbe obtained with precision and higher accuracy.

FOCUSED ABDOMINAL SCAN FOR TRAUMAF.A.S.TUltrasound guided aspiration or drainage ofhaematoma or abscess can be performed withminimum trouble to patient.

FAST has almost replaced diagnostic peritoneallavage to detect haemoperitoneum.

Ultrasound has made a lot of impact in themanagement of seriously injured patients. Intraperitoneal or intrathoracic collection andhaemorhage can be detected easily in severelyinjured patient who is not fit for any otherdiagnostic procedure.

RESPIRATORY SYSTEM (CHEST)Sonography for respiratory system isperformed occasionally when there is strongsuspicion of fluid or blood collection in thepleural cavity. It does not help in assessment ofnormal respiratory functions or anatomy ofthorax.

Focused Abdominal Scan for Trauma (FAST)

Ultrasound examination for pleural effusion




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SONOGRAPHIC EXAMINATION IN GENERAL

Preparation How to prepare a patient for sonography of;

Gall bladder

Kidneys

Bladder

Uterus

Prostate

F.A.S.T What is F.A.S.T?

Intervention How liver abscess is drained under ultrasound guidance?

Completion

Cleaning the patient

Covering the patient

Counseling

sono graphic examination (updated)

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