EASTERN FLORIDA STATE COLLEGEDiagnostic Medical Sonography Program

ULTRASOUND PROTOCOLS Harry H. Holdorf PhD, MPA, RDMS, RVT, RT/ARRT(rt.), LRT(AS)

ABDOMEN/LIVER

No physician necessary during routine exam.

1. Sagittal or longitudinal views including:a. Liver R&L lobes – measure mid sagittal diameter of right lobe.b. Aortac. IVCd. Portal v.(s)e. Gallbladder and extrahepatic biliary tractf. Bilateral kidneys (lateral, mid (measurement) medialg. Lateral right lobe (diaphragm)h. Spleen – measure

2. Transversea. Hepatic veinsb. Right and left lobe liverc. Portal vein (Porta hep.)d. Gallbladdere. Bilateral kidneys (upper pole, mid, lower pole)f. Pancreas (measure head and body AP)g. Spleen

EQUIPMENT: The most useful clinically appropriate transducer should be used – linear or sector usually 2.25 to 5 MHz – Utilize auto optimization and/or coded harmonics routinely.

Preparation: Usual/NPO for 8 hours

DecubitusRotated or upright views of RUQ especially when evaluating GB are required.

**See protocol for specific organ when abdominal request emphasizes a particular organ.

RIGHT UPPER QUADRANT/BILE DUCTS (CBD) (BILIARY STUDY)

Use same procedure as abdomen, when bile ducts are specified, include views of pancreas with attention to pancreatic head except kidneys, aorta and spleen.

Demonstrate extent of any ductal dilation and caliber of the intra and extra hepatic common bile duct.

Equipment and preparation same as abdomen.

GALLBLADDER

LONGITUDINAL

1. Long axis fundus/neck (with measurement, if enlarged)2. Intrahepatic ducts

TRANSVERSE

1. Diameter – (include measurement of increased wall thickness) (Anterior wall or if area is specified).

2. Portahepatitis3. Portal vein4. Pancreas (measure head and body)

Include views of CBD with measurement and hepatic artery.

LEFT LATERAL DECUBITUS

Document movement (i.e. stones) within gallbladder

All three views are necessary regardless of findings. Use erect or RLD positions if necessary.

Upright views, if necessary

EQUIPMENT: Use the highest clinically appropriate frequency transducer, 2.225 MHz or higher. Please utilize auto optimize and or coded harmonies routinely.

PANCREAS

Transverse/Oblique

a. Head +measure – body + measure – tail Pancreatic duct when seen

b. Adjacent visceral vessels (splenic vein, portal vein, portahepatis)

c. CBD at level of head of pancreas (if possible)

d. Gallbladder

Longitudinal

a. Gallbladder

Patient Preparation:

NPO for over 8 hours

Equipment:

Same as liver

HELPFUL HINTS: 1. Oral distention with +16 oz. Water3. Place patient in upright position.

PYLORIC STENOSIS

1. Preferably perform study following instant feeding.

2. Scan child in a semi-oblique fashion, right side down.

3. Measure:a. Length of pylorusb. Muscle thickness (outer wall to lunar)c. Diameter (transverse)

*Upper limits of normal - confer with Radiologist

KIDNEYS (RENAL)

Longitudinal (Coronal or sagittal)

a. Lateralb. Mid- long axis – cortex (compare to liver and spleen texture when possible) – Measure

on two planesc. Renal pelvis (compare to liver and spleen texture when possible)

Transverse:

a. Upper poleb. Mid (Attention peri-renal space) Measure one plane c. Lower pole

Occasionally prone views may be helpful.Sagittal and transverse images of urinary bladder to be obtainedIf hydronephrosis is seen please include post void bladder images

Equipment:

The clinically most useful transducers should be used. Usually 2.25-5 MHz sector probes (linear is helpful for prone views) higher frequency transducers for newborn and pediatric patients when possible.

Patient Preparation:

No prep required

AORTA

1. Sagittal or coronal views

a. Attempted from diaphragm to bifurcation including proximal iliac.

b. Any major branches when seen.

2. Transverse:

a. At intervalsAll abnormalities assessed including surrounding tissue

3. Measurements: largest diameter outer to outer

Aneurysm measurements (Max)

a. Longb. Transversec. AP (outer to outer)d. Residual lumen (smallest diameter)

4. Location of aneurysm in relationship to renal vessels and bifurcation. Measured in cm longitudinally.

Equipment: The clinically most useful transducer should be used – usually linear or sector 2.25 – 3.5 MHz

Patient preparation: Light diet abstaining from gas producing foods. NPO one hour before exam.

SMALL PARTS GUIDELINES FOR GENERAL EVALUATION

It is necessary to have a radiologist present during or prior to completion of all small part exams unless otherwise advised by the responsible radiologist.

THYROID:

1. Sagittala. Right lobeb. Left lobe

Long axis upper and lower polesMedial and lateral lobe

2. Transverse

a. Right and left lobe – inferior, mid and superior glandb. Isthmusc. Adjacent extraglandular abnormalities evaluated

3. Measurements – both lobes/defined massesa. Long axisb. Transverse (compare size and texture to its opposite sidec. AP

4. Equipment – A high frequency small parts transducer is generally used 5.0 – 7.0 -14 MHz.

5. Helpful hintsa. Hyperextend neckb. Stand off when necessary

No patient preparation is necessary for this exam.

TESTICULAR

1. Longitudinala. Right testisb. Left testis

Long axis, medial, lateral include epididymis

2. Transversea. Upper – epididymal head if possibleb. Transversec. Lower pole

3. Additional projectional view or positioning can be implemented as needed.

Evaluate extratesticular structures or collectionsCompare texture and size to its opposite side

4. Measurements – both testiclesa. Long axis and epididymal headb. Transversec. AP (thickness of epididymis when prominent

5. Doppler with wave form. If no color utilize power doppler

6. Helpful hints:a. Suspend and support scrotumb. Valsalva or standing position to evaluate varicocele

7. Equipment – High frequency small parts transducer is generally used 5.0 – 7.5 MHz. Equivalent or lower frequency sector and linear probes can be useful in some circumstances.

No patient preparation is necessary for this examination.

APPENDIX

Perform routine pelvic ultrasound (see guidelines for pelvic)

1. Multidirectional survey of the right lower quadrant with attention to any non-compressible bowel structure. Compress all bowel structures and observe for peristalsis.

2. If an appendix is identified image in long axis and transverse diameter – note any surrounding fluid.

3. Measure long axis transverse and AP

4. Equipment – 5.0 – 7.5 mHz small parts transducer

5. Optimal color doppler

6. Radiologist should be present for correlation between physical exam and Ultrasound findings if ultrasound is equivocal. If clearly +ve or –ve radiologistneed not be present.

Patient preparation same as pelvic sonogram. Patient may void after routine pelvic sonogram.

BREAST

Examination requirement:

Mammographic or palpable abnormality is usually a necessary prerequisite for this examination. Infrequently performed in young women without focal abnormality.

Radial scanning survey of entire breast from nipple outward with attention to areas of a suspected abnormality.

Label image location or position based on face of clock and distance from nipple. (Note patient’s examination position if other than spine).

In patients with multiple simple cysts only largest cysts need be measured and exam should focus on area of interest.

Measure all masses in three dimensions

Helpful hints:a. Stand off padb. Isolate palpable masses between fingersc. Patient position change/sponge or pillow support

Equipment: Small part transducers that routinely differentiate small cystic from solid lesions. Usual frequency – 7.5 MHz.

No patient preparation necessary.

PROSTATE

A radiologist is required during or prior to completion of exam. Patient is placed in a left decubitus or lithotomy position. Demonstrate all prostate abnormalities in two directions.

1. Coronala. seminal vesicles (vas deferens if possible)b. base of glandc. mid gland (entire right and left side-note rectal wall)d. apex

Insert approximately prepared and lubricated condom covered probe into rectum With transducer crystal facing prostate.

2. Sagittala. midline include base to apexb. sweeps through entire right and left gland image 20 to 40 degrees

from midline and peripheral zone edge. Include sagittal images ofseminal vesicals including several vesicle prostate angles – documentany visible lymph nodes

3. Measurements

a. midline long axisb. transverse largest diameter (all focal lesions)c. AP

4. Equipment – 5 – 9 MHz endocavity probe, sagittal and coronal capable or

individual probes.

5. Helpful hints – A digital rectal exam before preparing the ultrasound is often beneficial.

Patient Preparationa. Liquid dietb. Fleet enema 1 to 2 hours before exam or as prescribed

PELVIC(ABDOMINAL APPROACH)

Sagittal – a. midline (uterus with endometrial canal, cervix and vagina) with and without AP & long

measurementsb. right and left of midline (both ovaries and adenexa)

*note bowel peristalsis*note relationship of ovaries to vessels

c. measure endometrial stripe on sagittal imageTransverse segmental images documenting all pelvic structures.

Measurement –a. long axis uterus and ovariesb. transverse uterusc. AP uterus

All pelvic masses in three dimensionsAlso: Type in Date of LMP or “Post-menopausal”, as appropriate

Equipment – Use highest frequency linear or sector transducer typically 2.25 to 5 MHz

Patient preparation – a distended urinary bladder usually +250 cc (32 fluid ounces) 1 to 1 ½ hours before exam is usually sufficient.

*If an ovary is not identified (regardless of patient’s age) and is known not to have been removed, perform transvaginal study

*If there is any possible congenital abnormality of uterus or pelvic mass, kidneys must be imaged (sagittal)

*If patient has had a hysterectomy, note presence or surgical removal of ovaries as well

Abnormal pelvic studies may require supplemental transvaginal study.

*For suspected ovarian torsion and ovarian masses or enlargement utilize color/spectral Doppler and/or power Doppler

ENDOVAGINAL

1. This exam is performed as an adjunct to the transabdominal pelvic exam unless otherwise directed.

2. Insert lubricated condom protected, endovaginal probe into vagina. Identify endometrium and contents of uterus. If required, sweep right and left to image ovary and adnexa. Adjust or rotate probe as necessary to image in other planes

3. Equipment – a. 5.0 mHz endovaginal probeb. protective condom

4. Patient must void completely. The exam is usually performed with patient in lithotomyPosition. Measure all relevant structures.

HELPFUL HINTS: pillow under pelvis.

NEONATAL HEAD

Coronals: Frontal lobes, anterior horns, lateral ventricles at foramen of Monroe, lateral and third ventricles, occipital horns, occipital lobes

Sagittal: Midline, right and left lateral ventricle, lateral to ventricles.

VENOUS DOPPLER – Call physician

Lower extremity: Longitudinal and transverse with and without compression of common femoral, superficial femoral, profunda

Femoral and popliteal veins – real time and DopplerBlood flow augmentation by manual squeezing of lower calf.

OB Guidelines first trimester

Note date of LMP on images Longitudinal and transverse images of uterus and relevant adnexal structures.

I. DOCUMENTATION:

A. Location of gestational sac and its integrityB. The presence of an embryo and number seen (*Note multiple sac like

structures do not necessarily mean multiple gestations). Image fetal pole yolk sac when seen.

C. Fetal heart movement – with M Mode documentationD. Evaluations of uterus and (adnexal structures)?

1. Presence, location and size of myomas2. Collection or fluid in uterus or cervix3. Surrounding free fluid4. Abnormal appearance endometrial appearance.

II. MEASUREMENT

A. Gestational sac – Refer to appropriate standard tableB. Crown-rump length for datingC. Long axis of uterusD. Abnormal structures in adnexa

III. ENDOVAGINAL EXAM: Usage as follows unless otherwise directed or

indicated.

A. A fetal pole with uncertainty of viabilityB. Gestational sac with no fetal pole identified during abdominal exam.C. A positive pregnancy test with no gestational sac on abdominal exam

(*with or without suspicious adnexa)D. A requested alternative with radiologist approval.

IV. Equipment for abdominal or vaginal exam.Use probes that give superior resolution and still provide sufficient penetration. Abdominal use linear or sector transducers 2.25 to 5 MHz.

Patient Prep: A distended urinary bladder – 24 to 32 oz. Fluid one hour before exam.

The radiologist should be notified when a fetal demise is suggested. (A fetal pole with a Crown rump of over seven weeks no fetal heart should be of suspect).

Difficult documentation

HELPFUL COMMENTS:

A. If free fluid is seen, scan Morrison’s pouch especially if an ectopic pregnancy is Suspected.

B. An overdistended urinary bladder can distort the lower uterine segment. A partialvoid can be helpful when evaluating for previa or compatance of cervix.

COMMENT: It is recognized that placental position in early pregnancy is equivocal Often does correlate well with placental position in later pregnancy.

SECOND AND THIRD TRIMESTER

I. Documentation Long image of uterus and variable planes images. Lower uterine segment and fundus include:

a. Fetal position and numberb. Internal os (cervical integrity)c. Placenta locations, appearance (include grading), and relation to internal os.d. Representative image(s) of amniotic fluid, enabling a subjective quantification for

the pregnancy state.e. Documentation of Date of LMP and prior studies (if available).

II. Geatational growth parameters

a. Biparietal diameter – outer to inner with appropriate cerebral landmarks. Use cephalic index if dolichocephaly or brachycephaly is suspected.

b. Head circumference – the outer circumference at same level as biparietal.

c. Femur length

d. Abdominal circumference at level of umbilical vein and portal sinus.

e. Derive mean growth from available parameters.

f. Estimate fetal weight calculated from Biparietal and abdominal circumference.

g. Growth retardation refer to standard deviation chart is asymmetrical growth is suspected.

h. Evaluate interval growth. (Calculate predicted age from previous ultrasounds). Note this whenever prior examination exists.

Refer to accepted standard charts in use at clinical affiliations.

III. Other Anatomy (routine)

a. Stomachb. Kidneysc. Urinary bladderd. Anterior abdominal wall (umbilical insertion site) Evaluation of umbilical cord.e. Diaphragmf. Aortag. Heart (four chamber view noted)h. Genital (not always necessary for routine exam)i. Entire spine

Always document myomas size and location and adnexal masses.

Comment:

A more comprehensive evaluation should be performed with suspected abnormalities orwhen specifically requested.

Comment:

It is generally recognized that not all malformations of organ systems such as spine can be detected ultrasonically. Nevertheless, a careful anatomical survey may allow diagnosis of certain birth defects which otherwise go unrecognized. From ALUM/ACR

guidelines.

IV. Use same guidelines as first trimester pregnancy for equipment, Patient prep and requirement for presence of a radiologist.

MULTIPLE GESTATION

A. Both heads and abdomens in single image.B. Document a septum, if applicableC. Number and location of placenta(s)D. Amniotic fluid in each sac, if applicable

IDENTIFICATION OF TWIN FOR DOCUMENTATION *TWIN A

A. The fetus with head in lowest cephalic position with preference to fetus on right.

B. If both are transverse; the fetus in lowest positionC. Both are breech –fetus on right side is twin A

BIOPHYSICAL PROFILE

Same as third trimester pregnancy plus:

A. Doppler – umbilical artery flowB. Placental grading and volumeC. Fetal tone – body movementsD. Fetal motion – limbsE. Cardiac motion – note cardiac rate changesF. Respiratory motionG. Amniotic fluid

A RADIOLOGIST SHOULD BE INFORMED WHEN ONE OF THE FOLLOWING SITUATIONS IS PRESENT

1. An organ “cyst” that does not fulfill complete criteria (anechoic, through transmission, smooth back wall) – radiologists option

2. Any study for which ultrasound was recommended for correlation with a different imaging study if technologist requires assistance.

3. Early pregnancy w/o a fetal heart beat.

4. Biophysical profile...

5. Any pregnancy with a low-lying placenta, vaginal placental previa or placenta previa, if requires clarification. Polyhydramnios, Oligohydramnios.