Thieme: Abdominal Ultrasound: Step by Step

4 Liver

Organ Boundaries

L E A R N I N G G O A L S� Locate the liver.� Clearly delineate the liver from its surroundings.� Survey the total liver volume in multiple planes.� Recognize portions of the liver that are difficult to scan.

The liver is the dominant organ of the right upper abdomen. It is protected byribs and is covered mainly by the right costal arch. These simple anatomicalfacts are widely known, but they have special significance and implicationsfor ultrasound scanning.1 The liver is so large that cannot be scanned adequately from one approach.

A complete examination of the liver requires scanning from multiple an-gles and directions.

2 The liver cannot be scanned by the shortest route, but only from beneaththe costal arch or between the ribs (Fig. 4.1). This means that while per-forming serial scans, you will view many sections of the liver more thanonce but are apt to miss blind spots if you are not fully familiar with theextent of the organ. Figure 4.2 illustrates this problem with ananalogy.

Locating the liver

Barriers to scanning

� Ribs� A high diaphragm

Optimizing the scanning conditions

To make the liver more accessible, have the patient raise the right arm abovethe head to draw the rib cage upward. Place the patient in the supine positionand have him or her take a deep breath and hold it to expand the abdomen.One disadvantage of holding the breath is that it is followed by a period ofhyperventilation, especially in older patients.

43Block, Abdominal Ultrasound: Step by Step (ISBN 9783131383624), © 2012 Georg Thieme Verlag KG

Fig. 4.1 Approaches for scanningthe liver.

Fig. 4.2 Difficulties of liver scanning.In this analogy, an observer is lookinginto a room through three windows.Moving from window to window, heviews the center of the room severaltimes and sees corners a total of fivetimes. Even so, he is unable to see theman sitting in one corner of the room.

Organ identification

Start with the transducer placed transversely against the right costal arch, atthe level where you would palpate the inferior border of the liver. Mentallypicture the liver lying beneath the ribs, and angle the scan upward. Now askthe patient to take a deep breath, expanding the abdomen, and the liver willappear on the screen as a region of homogeneous echo texture. Figure 4.3illustrates the view of the liver that is acceptable for organ identification.

Imaging the liver in its entirety

Because the liver is so large, it is best to proceed in steps when learning howto scan the entire organ.1 Learn the outlines of the liver:

– the inferior border,– the superior border,– the left border.

2 Survey the liver volume:– in longitudinal sections,– in subcostal transverse and oblique sections,– in intercostal sections.

Outlines of the liver

Defining the inferior border of the liver

The liver tapers inferiorly to a more or less sharp-angled border. This inferiorborder is easy to demonstrate with ultrasound. Place the transducer longitu-dinally on the upper abdomen, slightly to the right of the midline. Press thecaudal end of the transducer a bit more deeply into the abdominal wall thanthe cranial end, so that the scan is directed slightly upward. This should bringthe sharp inferior hepatic border into view (Fig. 4.4a).

Now slide the transducer to the left, keeping it in a longitudinal planewhile following the line of the costal arch as closely as possible. Also, makesure that the inferior border of the liver stays at the right edge of the image.You can do this by varying the pressure on the transducer as needed.

As the transducer moves farther to the left, the cross section of the liver di-minishes in size. Its roughly triangular outline becomes progressively smallerand finally disappears. The image is now dominated by a chaotic pattern ofhighly contrasting light and dark areas with no discernible shape, caused bythe gas and liquid contents of the stomach.

Now return to the starting point and scan past it toward the right side. Asyou track across the abdomen, you will recognize the aorta and then the venacava. As you scan past the vena cava, the gallbladder can be identified as a“black” structure in the fasted patient. With luck, the right kidney may alsobe seen. As the transducer moves farther to the right, the angle of the inferiorhepatic border becomes increasingly blunted (Fig. 4.4b,c).

Visualization often becomes poor at this point, especially in obese patientsand when there is interposed gas in the right colic flexure. It can be helpful tohave the patient breathe in deeply and inflate the abdomen.

The series of images in Fig. 4.4 were selected to illustrate good scanningconditions. You should keep this in mind if you do not achieve the desired re-sult right away. Figure 4.5 shows the appearance of a liver that is difficult toscan. This scan corresponds to the section in Fig. 4.4b.


Fig. 4.3 The liver (L) in upperabdominal transverse section.

T I P S

To define the inferior border of theliver in longitudinal sections, pressthe caudal end of the transducer alittle more firmly into the abdominalwall than the cranial end.

By varying the pressure on thetransducer, you can keep the inferiorborder of the liver at the right edgeof the image.

If there is intervening gas in theright colic flexure, have the patienttake a deep breath to expand theabdomen.

4 Liver

After you have scanned across the inferior border of the liver once for orien-tation, make a second pass while giving attention to details. You have alreadyseen that the inferior border has an approximately triangular shape in the ul-trasound image. The anterior surface of the liver, which lies against the ab-dominal wall, is flat and smooth. The posterior surface is slightly concave inits lower portion and becomes slightly convex superiorly (Fig. 4.6). The anglebetween the anterior and posterior surfaces is 30–45 8 on the left side and 45–708 on the right side (Fig. 4.7). The posterior surface has several concavitiesthat interrupt its triangular shape: the porta hepatis and the impressionsfrom the gallbladder and right kidney.


Fig. 4.4 Demonstrating the inferior border of the liver

a Scan of the left hepatic lobe, withthe transducer placed approximatelyin the midline. Note the sharp angleof the inferior border (›).

b The transducer was moved towardthe right side, approximately to themidclavicular line. The inferior borderappears less sharp (›).

c The transducer was moved fartherto the right. Now the inferior bordercannot be clearly defined. The angleis relatively blunt (›).

Fig. 4.5 The inferior border of thisliver (›) is difficult to scan. Fig. 4.6 Shape of the inferior border.

Note that the posterior surface of theliver is concave below (toward the inferiorborder) and convex above.

Fig. 4.7 Angle of the inferior border

30°–45°

a Left side of the liver.

45°–70°

b Right side of the liver.

Organ Boundaries

Figure 4.8 illustrates a series of longitudinal sections of the inferior hepaticborder obtained by scanning across the liver from left to right. Notice thechanges in the liver outline caused by the gallbladder and kidney.

Abnormalities and variants of the inferior border

Fatty liver. Besides increased echogenicity (see p. 53 ff.), fatty infiltration ofthe liver leads to rounding and broadening of the inferior border (Figs. 4.9,4.10).

Cirrhosis of the liver. The normal liver presents a smooth inferior surface con-tour. With cirrhosis, regenerative nodules in the liver produce a lobulatedcontour (Fig. 4.11).

Riedel’s lobe. Riedel’s lobe is a tongue-like inferior projection of the right lobethat extends well past the lower pole of the kidney (Fig. 4.12).


Fig. 4.8 Longitudinal serial scans ofthe inferior border. The posterior surfaceof the liver bears impressions from thegallbladder (›) and right kidney (››).

Fig. 4.9 Fatty liver. The angle betweenthe anterior and posterior surfaces ofthe liver is broadened (›).

Fig. 4.10 Fatty liver. Note the roundingof the inferior border (›››).

Fig. 4.11 Alcoholic cirrhosis of theliver. The inferior surface of the liverhas a nodular appearance (›››).

Fig. 4.12 Riedel’s lobe. A tongue-likeprojection of the right lobe (›) extendsdown past the inferior pole of the kidney.Mp = psoas muscle, K = kidney.

4 Liver

Defining the superior border of the liver

The superior border of the liver is flat on the left side and convex on the rightside. The scanning technique is similar to that for the inferior border. Placethe transducer longitudinally to the right of the midline just below the costalarch. Angle upward until the superior border of the liver appears on the leftside of the screen. Notice the bright echo return from the diaphragm. The pul-sating heart can be seen cranially (left side of the image).

Now scan toward the left in parallel longitudinal sections, following theline of the costal arch, until you reach the end of the liver. Then return to theright and continue the scan along the right costal arch (Fig. 4.13). You willneed to apply firmer transducer pressure in this region in order to scan be-neath the ribs at a relatively flat angle.

Repeat the longitudinal pass along the superior border of the liver, this timenoticing the shape of the hepatic cross section. The superior border of the liv-er is flat on the left side. The heart rests upon the diaphragm in this area. Thesuperior surface of the liver forms a right angle with its anterior surface(Fig. 4.14). The farther the transducer is moved toward the right, the moreconvex the surface becomes. At this point you will have to press harder onthe transducer and scan beneath the ribs at a relatively steep angle to viewthe part of the diaphragm that borders the liver. Even so, it is often not possi-ble to define the full cross section of the liver on the left side of the screen, anda portion of the liver will appear cut off (Fig. 4.15).


T I P

Press firmly with the transduceralong the right costal arch so thatyou can scan beneath the ribs at arelatively flat angle.

Fig. 4.13 Demonstrating the superior border of the liver

a Superior border of the left lobe(›››). The transducer was placed ap-proximately in the midline.

b The transducer was moved to theright. Notice that the liver does nottranscend the left edge of the image,indicating a complete section (›).

c The transducer was moved fartherto the right. Now the anteriorsuperior portion of the liver is notincluded in the image (›). Comparethis scan with Fig. 4.15.

K E Y P O I N T

Anterior and superior portionsof the liver near the diaphragmare often poorly visualized inlongitudinal scans.

Organ Boundaries

Try to picture mentally which portion of the liver is not seen. Recall that in alongitudinal scan, the left side of the screen is cranial and the right side is cau-dal. But as the transducer is angled cephalad, the angle of the scan becomesmore horizontal and this rule becomes less valid. With a flat scanning angle,anterior portions of the liver are displayed on the left side of the screen. Forour purposes, this means that the hidden, “truncated” portion of the livercross section is anterior and superior. This blind spot is shown schematicallyin Fig. 4.16.

Defining the left border of the liver

The left border of the liver was already seen in the longitudinal sections of thesuperior and inferior borders. Now you will also scan down the left border intransverse sections. Place the transducer in a transverse or slightly obliqueposition along the costal arch, a little to the left of the midline. Scan up towardthe liver beneath the costal arch, angling the probe upward until you see thepulsating heart. Scan at a very steep angle so that the left border of the liver isjust visible on the screen. Now scan down the left border by angling the trans-ducer. Notice how the shape of the liver section changes as the scan movesdownward, changing from trapezoidal above (Fig. 4.17a) to triangular below(Fig. 4.17b,c).


°

Fig. 4.15 Superior border of the right lobe. Notice that the anterior border cannotbe adequately defined.

Fig. 4.14 Superior border of the leftlobe. Notice the right angle formedby the anterior and diaphragmaticsurfaces of the liver.

Fig. 4.16 Scanning across the superiorborder of the liver. Notice that theanterior portions of the right lobe arenot visualized.

4 Liver

14 The Sono Consultant

The tables in this chapter serve as a “sono consultant”—a systematicframework for helping the examiner to evaluate specific ultrasound findingsand make a differential diagnosis.

The chapter consists of two parts, which represent the situations thatbeginners will most often encounter in ultrasound examinations:

Part I: The examiner sees an abnormality at ultrasound and wants toanalyze it in a systematic way.

Part II: The examiner is consulted for the ultrasound evaluation of aspecific clinical situation.

Part I, Ultrasound Findings, provides a comprehensive, step-by-step approachfor systematically analyzing an abnormality that is noted during anultrasound examination.

Part II, Clinical Presentation, offers guidelines for interpreting findings andextracting the maximum amount of information that ultrasonography cansupply in a given clinical situation.

Both parts deal with the most common sonographic findings and clinicalsituations that arise in diagnostic ultrasonography. Of course, the exactsequence of steps for interpreting ultrasound findings will vary considerablyfrom one examiner to the next. The goal of this chapter is to provide thebeginner with a logical, structured routine that will train and reinforce acomplete, systematic ultrasound examination.


I Ultrasound Findings

I Ultrasound Findings

1. Aorta: Widening

Finding Interpretation

� Verify, measure in two dimensions

< 25 mm Normal25–30 mm Ectasia> 30 mm Aneurysm> 50 mm High risk of rupture

� Full-length visualization of the aorta

Longitudinal shapen Straightn Curved Kinked?

Walln Circumscribed plaques, diffuse thickening Aortic sclerosis?

Lumenn Echo-freen Echogenicn Floating membrane

Thrombus?Dissecting aneurysm

Locationn Start and end of the dilatationn Relationship to vessels

– Suprarenal– Infrarenal?

Aortic branchesn Vessel originsn Iliac vessels


14 The Sono Consultant

2. Vena cava: Dilatation


� Verify, measure

< 20 mm in late inspiration and end expiration Normal

> 20 mm Suspicious for abnormal dilatationStasis?

� Pulsation, respiration, lumen

Double-beat pattern synchronous with the pulsen Present

n Not present

Physiologic dilation?Young, thin patient?Stasis?

Luminal change with respirationsn Presentn Not present

Physiologic dilation?Stasis?

Lumenn Echo-freen Echogenic

Stasis?Thrombus?

� Other signs of congestive failure

Visualization of all vena cava tributariesn Hepatic veinsn Renal veinsn Iliac vessels

Livern Echo patternn Bordersn Size

Ascites?


II Clinical Presentation

II Clinical Presentation

1. Splenomegaly


� Verify, measure

< 11.5 cm No splenomegaly

> 12.5 cm Splenomegaly?

� Echo pattern

Homogeneous Portal hypertension?Hemolytic anemia?Heart failure?Epstein–Barr virus?Storage disease?

Inhomogeneous Lymphoma?Hematologic disease?

� Look for signs of portal hypertension

Splenic hilar vessels dilated,splenic vein dilated,portal vein dilated,signs of hepatic cirrhosis,ascites on right side

Portal hypertension?

� Look for signs of hematologic disease

Enlarged lymph nodes Lymphoma?Hematologic disease?


Table of Contents

1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

How to Use This Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Examination Technique and Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Who do you examine first when learning to scan? . . . . . . . . . . . . . . . . . . . 2How do you adjust the ultrasound machine? . . . . . . . . . . . . . . . . . . . . . . . . 2What can you do with the transducer? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2 Basic Physical and Technical Principles . . . . . . . . . . . . . . . . . . . . . . . . . 10

Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Propagation of sound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Production and detection of ultrasound waves:

the pulse-echo principle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Diagnostic ultrasound: propagation of ultrasound in biological tissue 11

Producing an Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12A-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12B-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13M-Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Artifacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Noise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Acoustic shadowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Posterior acoustic enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Reverberations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Beam-width artifact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Side-lobe artifact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Mirror-image artifact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Lateral edge shadow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

3 Blood Vessels: The Aorta and its Branches,the Vena Cava and its Tributaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Organ Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Locating the aorta and vena cava . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Demonstrating the aorta and vena cava in their entirety . . . . . . . . . . . . 20

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Demonstrating arterial and venous pulsations . . . . . . . . . . . . . . . . . . . . . . 22Evaluating the vessel walls and lumina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Identifying and defining the branches of the aorta and vena cava . . . . 24

Anatomical Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Relationship of the aorta and vena cava

to the diaphragm, liver, and cardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Area surrounding the celiac trunk and the course of the

hepatic artery, splenic artery, and left gastric artery . . . . . . . . . . . . . 29

VIIBlock, Abdominal Ultrasound: Step by Step (ISBN 9783131383624), © 2012 Georg Thieme Verlag KG

Table of Contents

Superior mesenteric artery, splenic vein, and renal vessels . . . . . . . . . 33Iliac vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Lymph nodes near the retroperitoneal vessels . . . . . . . . . . . . . . . . . . . . . 40

4 Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

Organ Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Locating the liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Imaging the liver in its entirety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Shape . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Parenchymal pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Vessels of the liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Division of the liver into lobes, segments, and subsegments . . . . . . . . 62The portal vein and its branches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Anatomical Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87Relationship of the left portion of the liver

to the heart and stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Relationship of the central portion of the liver

to the vena cava, stomach, and pancreas . . . . . . . . . . . . . . . . . . . . . . . 90Relationship of the right portion of the liver

to the gallbladder, duodenum, and kidney . . . . . . . . . . . . . . . . . . . . . 93Ascites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

5 Porta Hepatis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Organ Boundaries: Identifying the Vessels in the Porta Hepatis . . . . . . . . 97Vena cava and portal vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Hepatic artery and bile duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98Transverse and longitudinal survey of the porta hepatis . . . . . . . . . . . 99

Organ Details: Details of the Vessels in the Porta Hepatis . . . . . . . . . . . . . . 102Portal vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

6 Gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106

Organ Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Locating the gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Imaging the entire gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108Variable position of the gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111Nonvisualization of the gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114Regions of the gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114Size of the gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114Variable shape of the gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116Gallbladder wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Gallbladder contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119Special acoustic phenomena in gallbladder scanning . . . . . . . . . . . . . . 123

Anatomical Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Relationship of the gallbladder to the liver . . . . . . . . . . . . . . . . . . . . . . . . 126Relationship of the gallbladder to the portal vein . . . . . . . . . . . . . . . . . . 129Relationship of the gallbladder to the antrum, bulb,

and duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

VIIIBlock, Abdominal Ultrasound: Step by Step (ISBN 9783131383624), © 2012 Georg Thieme Verlag KG

Table of Contents

7 Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

Organ Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Locating the pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135Imaging the entire pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Variable shape of the pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Pancreatic parenchyma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141Pancreatic duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145Common bile duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146Measuring the pancreatic diameter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Anatomical Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Relationships of the tail of the pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . 149Relationships of the body of the pancreas . . . . . . . . . . . . . . . . . . . . . . . . . 152Relationships of the head of the pancreas . . . . . . . . . . . . . . . . . . . . . . . . . 156

8 Stomach, Duodenum, and Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . 164

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165Stomach wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165

Organ Boundaries and Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166Esophagus and cardia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166Body of the stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170Antrum and duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

9 Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

Organ Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178Locating the spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178Imaging the entire spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181Shape of the spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181Determining the size of the spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182Echo pattern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Anatomical Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186Relationship of the spleen to the pancreas, kidney, colic flexure,

and stomach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187Relationship of the spleen to the pleura . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

10 Kidneys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Organ Boundaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191Locating the right kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193Imaging the entire right kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195Locating the left kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197Imaging the entire left kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200Size and shape of the kidneys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200Renal parenchyma and renal sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204

Anatomical Relationships of the Right Kidney . . . . . . . . . . . . . . . . . . . . . . . . . 214Relationship of the right kidney to the liver . . . . . . . . . . . . . . . . . . . . . . . 215Relationship of the right kidney to the psoas

and quadratus lumborum muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

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Relationship of the right kidney to the colon . . . . . . . . . . . . . . . . . . . . . . 221Relationship of the right kidney to the gallbladder . . . . . . . . . . . . . . . . . 223

Anatomical Relationships of the Left Kidney . . . . . . . . . . . . . . . . . . . . . . . . . . 226Relationship of the left kidney to the spleen . . . . . . . . . . . . . . . . . . . . . . . 227Relationship of the left kidney to the psoas

and quadratus lumborum muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229Relationship of the left kidney to the colon . . . . . . . . . . . . . . . . . . . . . . . . 229

11 Adrenal Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Organ Boundaries and Anatomical Relationships . . . . . . . . . . . . . . . . . . . . . . 231Ultrasound morphology of the adrenal glands . . . . . . . . . . . . . . . . . . . . . 231Location of the adrenal glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231Right adrenal gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232Left adrenal gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235Abnormalities of the adrenal glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235

12 Bladder, Prostate, and Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236

Organ Boundaries and Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Bladder and prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236Bladder and uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

Organ Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240Prostate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240

13 The Systematic Ultrasound Examination . . . . . . . . . . . . . . . . . . . . . . 241

Topographic Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242Gallbladder and porta hepatis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242Right kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243Left kidney and spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243Epigastrium and pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244Midabdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244Lower abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244

Description of Findings and Nomenclature . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

Written report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246Image documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246

14 The Sono Consultant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

I Ultrasound Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249

1. Aorta: Widening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2492. Vena cava: Dilatation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2503. Liver: Large . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2514. Liver: Small . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2525. Liver: Increased echogenicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2536. Liver: Hepatic veins dilated . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2547. Liver: Circumscribed mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2548. Liver: Echo-free mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

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9. Liver: Hypoechoic mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25610. Liver: Isoechoic or hyperechoic mass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25711. Liver: Hyperechoic mass with an acoustic shadow . . . . . . . . . . . . . . . . . 25712. Ascites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25813. Gallbladder: Stone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25914. Gallbladder: Circumscribed wall changes . . . . . . . . . . . . . . . . . . . . . . . . . 26015. Gallbladder: Thickened wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26116. Gallbladder: Large . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26217. Gallbladder: Echogenic contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26318. Gallbladder: Acoustic shadowing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26419. Common duct: Dilatation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26420. Pancreas: Dilated duct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26621. Pancreas: Cannot be identified . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26722. Pancreas: Increased echogenicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26723. Spleen: Circumscribed changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26824. Spleen: Circumscribed change, echo-free . . . . . . . . . . . . . . . . . . . . . . . . . . 26925. Spleen: Circumscribed changes, hypoechoic . . . . . . . . . . . . . . . . . . . . . . . . 26926. Spleen: Circumscribed changes, hyperechoic . . . . . . . . . . . . . . . . . . . . . . 27027. Spleen: Circumscribed changes, hyperechoic with shadow . . . . . . . . . 270

II Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

1. Splenomegaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2712. Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2723. Heart failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2734. Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2735. Jaundice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2746. Acute viral hepatitis (ultrasound is inconclusive) . . . . . . . . . . . . . . . . . . 2757. Chronic viral hepatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2768. Primary sclerosing cholangitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2779. Proposed laparoscopic cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

10. Postcholecystectomy syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27911. Acute pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27912. Chronic pancreatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28113. Hematuria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28214. Chronic renal failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28315. Chronic renal failure, small to normal-sized kidney . . . . . . . . . . . . . . . . 28316. Chronic renal failure, large kidney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28317. Acute right-upper-quadrant pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28418. Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

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Index

Numbers in italics indicate figures.

AA-mode 12, 13abdomen

basic scanning strategies 1lower, examination and reporting 244midabdomen, examination 244topographic units 241, 241, 241–244

abdominal pain, acute right-upper-quadrant 284

abdominal ultrasound, standard scanplanes 6, 6

abscessadrenal 207kidney 207, 207liver 57, 57pancreatic 143, 143spleen 185

absorption, sound 11accessory spleen 42, 42, 183, 183acoustic axis 13, 13acoustic enhancement, posterior 14, 14acoustic impedance 10, 12acoustic shadowing (artifact) 14, 14, 124,

124, 257, 264acoustics 10–12acute pancreatitis see pancreatitisacute renal failure 209, 209acute viral hepatitis 275adenoma

gallbladder 123, 123liver 56, 57prostate 240

adrenal glands 230–235abnormalities 235, 235abscess 207anatomical landmarks 232anatomical relationships 231–234boundaries 231–234carcinoma 235children 233, 233cysts 207, 235details 235dimensions 231in hypertension 273indications for ultrasound 230left 231, 231, 234, 234location 231, 231metastasis 235renal vessels and 232right 231, 231, 232, 232–233, 233

longitudinal scan 232, 232transverse scan 233, 233

tumors 230, 235nonfunctioning 230, 235

age-related changesaorta 21kidney 203, 210pancreas 141

airin bile ducts 60, 60in bowel see bowel gas

alcoholic cirrhosis of liver 46, 46amplitude, echo 12, 13ampullary pelvis 211, 212analgesic nephropathy 210, 210aneurysm, aortic see aortic aneurysmangiomyolipoma, kidney 208, 208angling movement 7, 7, 9, 9antrum see gastric antrum; pyloric antrumaorta 20–21

abnormalities in course 21, 21age-related changes 21anatomical relationships 28–32atherosclerotic plaque 23, 23bifurcation 20, 20, 38

demonstrating 26, 26bowel gas obscuring 20, 20, 21, 21branches 24, 24–26cardia and 28, 28celiac trunk and 25, 25, 32, 32colon and 19diameter 22diaphragm and 28, 28, 176, 176, 177elongation 21gastric antrum and 174gastroesophageal junction and 91, 167in hypertension 273imaging in entirety 249kidney relationship 202kinking 21, 21liver and 28, 28locating 19, 19–20longitudinal section 20, 20–21, 21, 22, 22,

26, 26, 30, 31lumen abnormalities 23–24lymph node distribution 40, 41, 42organ boundaries 19, 19–20pancreas and 136, 136, 137, 139porta hepatis and 96, 97, 99portal vein and 83pulsation 22–24renal vessels and 35, 35, 36splenic vein and 102, 103superior mesenteric artery and 25, 25, 33systematic analysis of findings 249thoracic 20, 20transverse section 20, 20, 21, 25, 26wall 22, 22

abnormalities 23–24widening 249

aortic aneurysm 23, 23–24enlargement/size 24

arterial pulsation 22–24arteries see individual arteriesartifacts 14–18

gallbladder 14, 18, 123, 123–124, 124ascites 54, 95, 95, 258

gallbladder wall thickening 119in hepatic cirrhosis 61between kidney and liver 216spleen and 190, 190

atherosclerotic plaque 23, 23

BB-mode 13, 13beam-width artifact 15, 15, 123bile duct(s) 96, 96

abnormalities 105, 105acute right-upper-quadrant pain 284air in 60, 60dilatation 264dimensions 105interpretation of findings 264–265intrahepatic 60, 60, 277

abnormalities 61, 61

dilated 62, 62in jaundice 274obstruction 105, 105outflow obstruction 105, 265porta hepatis and 96, 96, 98, 99,

100, 100sludge 105, 105, 113, 115stones 105see also common bile duct; common

hepatic ductbiliary sludge 105, 105, 113, 115biliary tract 259bladder 236–237

diverticulum 240hematuria 282longitudinal section 236, 236prostate relationship 236, 236–237, 237transverse section 237, 237uterus relationship 238, 238–239, 239wall thickening 240

blood vessels 19–42see also specific arteries/veins

body composition 11–12bowel gas 20, 124, 124

left kidney scan 229obscuring aorta/vena cava 20, 20, 21, 21right kidney scan 221

breathingliver scans 43, 44porta hepatis scans 97spleen scans 189, 189vena cava scans 22, 22

Budd–Chiari syndrome 104

Ccalcifications

gallbladder 120kidney 209, 209liver see liverpancreas 142, 142spleen 184, 184

carcinomaadrenal glands 235colon, hepatic metastases 56, 56, 59, 60gallbladder 119, 123, 123gastric 41, 165hepatocellular 57, 57pancreatic head 144, 144, 146, 148renal cell, hepatic metastases 56, 56urothelial, liver metastases 55

cardia 166–169anatomical relationships

167, 167–168, 168aorta relationship 28, 28liver relationship 91, 91vena cava relationship 28, 28see also gastroesophageal junction

caudate lobe see liverceliac trunk 24, 24

area surrounding 28, 28–32bifurcation 32, 41branches 28demonstrating 25, 25diaphragm and 177esophagus and 166longitudinal section 28, 28, 30, 31pancreas and 136, 136, 137

cholangitis, primary sclerosing105, 277

cholecystectomyprior, nonvisualization of gallbladder

111, 112proposed laparoscopic, findings 278scars 111, 112


Index

cholecystitisacute 118, 118

gallbladder wall 118, 118chronic 118, 118

gallbladder wall 118, 118cholecystolithiasis 119cholesterol polyps 122, 122cholesterol-rich gallstone 120chronic viral hepatitis 276chyme 174cirrhosis of liver 54, 54

alcoholic 46, 46portal vein cutoff/narrowing 61, 61sonographic findings 61

colic flexure 193impression on liver 215left, left kidney relationship

226, 229, 229right

right kidney relationship 214, 215, 221,221, 222, 222

variable position 221, 221spleen relationship 186, 187,

187–188, 188colon

aorta and 19carcinoma, hepatic metastases 56, 56,

59, 60gallbladder and 126gas see bowel gasleft kidney relationship 226, 229, 229pancreas and 135right kidney relationship

221, 221–222, 222spleen and 181, 187

comet-tail artifact 14, 15common bile duct 146–148,

264–265, 278abnormalities 148, 148dilatation 146, 148, 264gastric antrum and 146in jaundice 274longitudinal sections 147, 147obstruction 148, 265, 274renal veins and 147, 156stone 105, 105transverse sections 146, 147vena cava and 147see also bile duct(s);

common hepatic ductcommon hepatic artery 28, 28common hepatic duct 264–265

bifurcation 105porta hepatis and 96, 96see also bile duct(s)

common iliac artery 38common iliac vein 38, 39congestive heart failure 250, 273coronal section 5, 5costal arch 34, 43, 47, 77, 107costodiaphragmatic recess 186, 189crura see diaphragmCruveilhier-von Baumgarten syndrome 66cyst(s)

adrenal 207extrarenal 209, 209liver 14, 55, 55parapelvic 206, 207, 213, 213pararenal 206parasitic, liver 55, 55renal see kidney, cystssolitary nonparasitic, of liver 55, 55spleen 185

cystic duct 98

Ddiabetes mellitus 285diabetic nephropathy 203, 203, 285diagnostic ultrasound, principles 11–12diaphragm 176–177

aorta and 176, 176, 177celiac trunk and 177crura 28, 30, 176, 176, 177

right, adrenal gland and 233, 233enlarged lymph nodes and 177longitudinal sections 177, 177transverse sections 176, 177vena cava and 176, 176, 177

dissecting aortic aneurysm 23, 23documentation 246–247

image 246–247“double barrel shotgun” sign 62Douglas’ cul-de-sac 238ductus venosus 67–68duodenal bulb 164, 174

gallbladder relationship 132, 132longitudinal section 173pancreatic body relationship 154, 154pancreatic head relationship 156transverse section 175

duodenal diverticulum 173duodenum 164–177, 174

C-loop 161gallbladder relationship 132–134,

132–134gas 15, 124, 124, 132kidney relationship 214liver relationship 93, 93–94, 94longitudinal sections 172–173, 173lumen, hypoechoic, white or

nonhomogeneous 162pancreatic head relationship 160–163,

160–163scan plans 164transverse sections 174–175, 175vena cava and 174, 175

EEchinococcus granulosus, hepatic cysts

55, 55echo 10, 11, 12, 13ectopic kidney 199edge shadow 18, 18epigastric pain 284epigastrium, examination and

reporting 244equipment 2–9

see also transducers; ultrasound machineesophageal hiatus, anatomy 176esophagus 166–169

anatomical relationships167, 167–168, 168

celiac trunk and 166vena cava and 167, 168see also gastroesophageal junction

examinationdocumentation 246–247first subject 2interpretation of findings 248–270principles 10–18specific conditions 271–285systematic 241–247techniques 2–9written reports 246

Ffalciform ligament 62, 63fatty liver 46, 46, 53, 54

focal sparing and 57, 57

fibrolipomatosis, pancreatic 142, 142findings, description 245fissure, interlobar 127, 127, 128, 128focal nodular hyperplasia (FNH), liver

56, 57food, bolus in duodenum 124, 124frequencies 4, 10fusiform aortic aneurysm 23, 23

Ggallbladder 106–134

acoustic phenomena/artifacts 14, 18, 123,123–124, 124

acoustic shadowing 264acute right-upper-quadrant pain 284acute viral hepatitis 275adenoma 123, 123anatomical relationships 125–134anterior approach 106in ascites 119barriers to scanning 106beam-width artifact 15, 123, 123bed, liver relationship 126, 126, 128, 128body 114, 114boundaries 106calcification 120carcinoma 123, 123

wall thickness 119caudate lobe of liver and 68cholecystectomy and 111, 112cholesterol polyps 122, 122colon and 126contents 119–122, 263, 278

abnormal 120–122, 120–122see also gallstones

details 114–124dimensions 114duodenum relationship 132–134,

132–134echogenic 122, 122echogenic contents, interpretation 263edge shadows 18, 123, 123enlargement 115, 115

interpretation 262examination procedure 242fundus 114, 114, 116, 131

stones 121, 121gastric antrum relationship 132, 132,

133, 133in hepatic cirrhosis 61hepatic vein and 79hydropic 115imaging in entirety 108–110, 108–110infundibulum 114, 114

stones 121, 121intercostal flank scans 109–110, 110interlobar fissure and 127, 127, 128, 128kidney (right) relationship 214,

223–225, 223–225landmarks for 106, 127, 127lateral approach 106lateral edge shadows 18, 123, 123ligamentum teres and 64, 64, 67, 128liver relationship 93, 93–94, 94, 107,

126–128, 126–128in liver scan 44locating/identifying 106–107, 107lower right chaotic image 125, 125, 126neck 114, 114, 129, 130

artifacts 124polyp 124, 124

nonvisualization 111–113, 112normal 115, 115, 119obesity and 112, 112


Index

pancreas and 126, 126“Phrygian cap” 116, 116polypoid lesions 122, 122–123, 123polypoid sludge 123polyps 122, 122, 124, 124porcelain 119, 119portal vein relationship 83, 85, 129,

129–131longitudinal section 129, 131, 131transverse section 129, 130, 130

postprandial contraction 105, 112,112, 117

pseudosludge 15regions 114, 114reporting guidelines 242–243, 242–243S-shaped 116sand 122, 122sediment in 115, 115shape variations 116, 116shrunken 113, 113, 121size 114, 114–115, 115, 259sludge 115, 121, 121splenic vein and 129stones see gallstonessuperior mesenteric vein and 129, 133systematic analysis of findings

259–264upper abdominal longitudinal scans

109, 109, 114, 125, 129, 134upper abdominal transverse scans

108, 108, 114, 125, 129, 133variable position 111, 111vena cava and 132, 133, 134wall 117, 117–119, 278

abnormalities 117–119, 118circumscribed changes 260gangrenous 118, 118thickened, interpretation 261thickening in ascites 119thickness, measurement 117

gallstones 37, 113, 120, 120–121, 259calcium-rich 120characteristics 259cholesterol-rich 120false-positive/false-negative

diagnosis 121infundibular 121, 121large solitary 120multiple 120in right kidney scan 224

gas see bowel gasgastric antrum 172–175, 174

aorta and 174common bile duct and 146duodenum and 172–175, 172–175gallbladder relationship 132, 132,

133, 133kidney and 215liver relationship 92, 92, 172, 173longitudinal sections 172, 172–173pancreas and 163spleen and 187transverse sections 174, 174–175, 175vena cava and 174, 175see also pyloric antrum

gastric artery, left 24, 24course 28, 28–31

gastric carcinoma 41, 165gastric cardia see cardiagastroesophageal junction 28, 91


aorta and 91, 167longitudinal section 166, 166

oblique longitudinal scan 164structures to left 168, 168structures to right 168, 168transverse sections 169, 169

Glisson’s triad 60glomerulonephritis

acute 203, 203, 209, 209chronic 210, 210

Hheart, liver relationship 88, 88–89, 89heart failure

congestive 250, 273findings 273right-sided 24, 24

hemangiomaatypical, of liver 56liver see liver, hemangiomasplenic 184, 184, 185

hematomaintrahepatic 57, 57splenic 185subcapsular (renal) 207, 207

hematuria 282hepatic artery 24, 24, 60, 82, 98, 98

aorta and 24course 28, 28–32longitudinal section 31, 31normal 60porta hepatis and 96, 96, 98, 98, 99, 100,

100, 101, 101portal vein and 82transverse section 32, 32

hepatic cysts 14, 55, 55hepatic duct

bifurcation 105, 105see also common hepatic duct

hepatic veins 26, 26, 60, 60, 71, 71, 251abnormalities 61, 61demonstrating 26–27, 27diameter 60dilatation 61, 61, 254gallbladder and 79in hepatic cirrhosis 61left 75

longitudinal sections 78, 78, 81middle 77

longitudinal sections 79, 79, 81narrowing 61, 61normal 60right 77

compression 55longitudinal sections 80, 80, 81

transverse sections 74, 74hepatic vessels 60, 60–62

chronic viral hepatitis 276normal 60see also hepatic artery; hepatic veins

hepatitis (viral)acute 275chronic 276chronic hepatitis C 41

hepatocellular carcinoma (HCC) 57, 57hepatomegaly 251hepatorenal recess, ascites 95, 95Hodgkin’s disease, spleen 183horseshoe kidney 42, 42hydronephrosis 212, 212

causes 212differential diagnosis 213, 213grades 212, 212

hypernephroma 202, 202, 209, 209hypertension 273hyperventilation 43

Iiliac arteries 24, 24iliac veins 26, 26iliac vessels 38–40

frontal view 38longitudinal section 38, 40, 40lymph node distribution 40transverse section 38, 39, 39

image(s)documentation 246–247producing 12–13quality 3, 4

impedance, acoustic 10, 12“impedance mismatch” 12incidentaloma 235infectious mononucleosis,

splenic enlargement 182inferior vena cava see vena cavainfundibular stones 121, 121intercostal space

gallbladder scans 109–110, 110liver scans and 52, 52

interlobar fissure, liver 127, 127, 128, 128intrauterine device 240

Jjaundice 274–275

Kkidney 191–229

abnormalities 199abscess 207, 207acute right-upper-quadrant pain 284adrenal gland relationship 232, 232,

234, 234age-related changes 203, 210agenesis 199analgesic nephropathy 210, 210angiomyolipoma 208, 208aorta relationship 202ascites and 216boundaries 191–199calcifications 209, 209colon relationship 214, 221,

221–222, 222cortex 204, 204corticomedullary junction 210, 210cysts 206, 206, 207, 225

calcification 209, 209hemorrhagic 209, 209large 207parapelvic 206, 207, 213, 213pararenal 206polycystic disease 208, 208

details 200–213dimensions 200dromedary hump 201, 201duplex 211, 211ectopic 199enlargement 203, 203, 209, 209gastric antrum and 215glomerulonephritis

see glomerulonephritishematuria 282hilum 36, 37, 204horseshoe 42, 42, 202, 202hydronephrosis see hydronephrosishypernephroma 202, 202, 209, 209in hypertension 273large, chronic renal failure 283left 36

anatomical relationships226, 226–229

anatomy 197, 226


Index

barriers to scanning 197colon relationship 226, 229, 229duplication of collecting system 201examination procedure 243hilum 199identification 197, 197imaging in entirety 198, 198–199, 199locating 197, 197longitudinal flank scan 198, 198,

227, 227psoas muscle relationship 226, 229quadratus lumborum muscle and

226, 229reporting guidelines 243scanning approach 193, 193spleen relationship 227, 227–228, 228transverse flank scan 199, 199,

228, 228locating 191longitudinal flank scan 200longitudinal/transverse axes

191, 191–192, 192medulla 204, 204medullary pyramids 204, 204, 207

hypoechoic 207, 207, 209, 209normal 201obesity and 216parenchyma 204, 204–210

abnormalities 206–210age-related changes 203, 210bands 211, 211circumscribed lesions 206–209cortex and medulla 204, 204diffuse changes 209–210diseases with increased echogenicity

209–210hypoechoic 205thinning 203, 210, 210, 212, 212width 205, 205

parenchymal lobule 202, 202parenchyma–pelvic ratio 205perirenal fat 216polycystic disease 208, 208portal vein and 85renal pelvis see renal pelvisrenal sinus see renal sinusright

anatomical relationships 214, 214–225anatomy 193, 214barriers to scanning 193colon relationship 221, 221–222, 222examination procedure 243frontal view 214gallbladder relationship 223–225,

223–225hilum 196identification 194, 194imaging in entirety 195, 195–196, 196lateral approach 193liver relationship 93, 93–94, 94, 214,

215–217, 215–217locating 193, 193–194, 194longitudinal flank scan 195, 195, 215,

215–216, 216, 219, 219, 222, 222,224, 224

psoas muscle relationship 218–220,218–220

quadratus lumborum musclerelationship 218–220, 218–220

reporting guidelines 243scanning approach 192, 192transverse flank scan 196, 196, 215,

217, 217, 220, 220, 225, 225scanning approaches 193, 192, 192–193

scars 208, 208shape 200

changes 201, 201shrunken 203, 203size, determining 200, 200small 203, 203

chronic renal failure 283sonographic anatomy 204, 204spleen relationship 186, 187, 187–188,

188, 198, 199stones 209, 213, 213subcapsular hematoma 207, 207transverse flank scan 200see also entries beginning renal

Llateral edge shadow 18, 18, 123learning goals, of book 1leukemia, chronic lymphoblastic 185level-oriented scanning strategy 1ligaments see individual ligamentsligamentum teres 60, 60, 63, 63

fissure 67, 68gallbladder and 64, 64, 67, 128longitudinal section 65–67, 66, 67, 81quadrate lobe scans 65, 65transverse section 63–64, 64, 65, 65,

75, 76ligamentum venosum 67–68, 68

fissure 67–68, 68longitudinal sections 70, 70transverse sections 69, 69

lipomatosis, pancreatic 137, 142, 142liver 43–95, 87

abscess 57, 57acoustic window for stomach/

duodenum 164acute right-upper-quadrant pain 284acute viral hepatitis 275adenoma 56, 57adrenal gland relationship 232, 232alcoholic cirrhosis 46, 46anatomical relationships 87, 87

central portion 90–92, 90–92left portion 89, 89longitudinal sections 89, 89, 91, 91right portion 93, 93–94, 94tangential scan 89, 89transverse sections 89, 89, 91, 91see also specific organs (under liver)

angle of inferior border 45, 45anterior surface 45, 45anterior view 62–63, 63aorta relationship 28, 28ascites and 95barriers to scanning 43blind spots 43, 48, 51boundaries 43

inferior border 44–46, 45, 46, 46, 111left border 48–49, 49, 88, 88superior border 47, 47–48, 48

calcification 54, 54simple 59, 59

carcinoma 57, 57cardia relationship 91, 91caudate lobe 62, 67–68, 68

fissure 67–70, 68, 69, 70longitudinal section 70, 70transverse sections 69, 69

center, transverse section 51, 51central portion, relationships 90–92,

90–92chronic viral hepatitis 276cirrhosis see cirrhosis of liver

cystic 55, 55cysts 14, 55, 55details 53–86duodenum relationship 93, 93–94, 94enlarged 251examination procedure 241fatty 46, 46, 53, 54focal nodular hyperplasia (FNH) 56, 57focal sparing 57, 57gallbladder and 44, 107gallbladder relationship 93, 93–94, 94,

126–128, 126–128gastric antrum and 92, 92, 172, 173heart failure and 273heart relationship 88, 88–89, 89hemangioma 58, 58

atypical 56calcified 59, 59

hematoma 57, 57hepatic vessels see hepatic artery;

hepatic veinsidentification 44imaging in entirety 44–52increased echogenicity 253inferior border 44–46, 45

abnormalities/variants 46angle 45, 45gallbladder position and 111, 111longitudinal scans 46, 46

inferior surface 126, 126intercostal scans 50, 50, 52, 52interlobar fissure and 127, 127, 128, 128jaundice causes 275kidney relationship 93, 93–94, 94,

215–217, 215–217, 224, 224left border 48–49, 49, 88, 88

trapezoidal shape 48–49, 49left lobe 45, 62, 63

heart and stomach relationship 89, 89pleural effusion and 190superior border 47, 48upper portion 67, 68

lobes 62–81locating 43–44, 44longitudinal scans 45, 47, 50, 50, 51in lymphoma 272mass

circumscribed 254echo-free 255hyperechoic 257hyperechoic with acoustic

shadow 257hypoechoic 256isoechoic 257

metastases 54, 54, 55highly echogenic 59, 59, 60hyperechoic 59, 59hypoechoic 56, 56isoechoic 58, 58

normal echo pattern 53normal variant 53, 54optimization of scanning conditions 43outlines 44–49pancreas relationship 90, 90, 92, 92

pancreatic body 153, 153, 154, 154,155, 155

parasitic cysts 55, 55parenchymal pattern 53–60

abnormalities 53–60circumscribed changes 54–60, 254diffuse changes 53–54, 54echo-free lesions 55, 55, 255highly echogenic lesions

59, 59–60, 60


Index

hyperechoic non-shadowing 58, 58,59, 257

hyperechoic with acoustic shadow59, 59–60, 60, 257

hypoechoic lesions 56, 56–57, 57, 256isoechoic lesions 58, 58, 257

posterior surface 45quadrate lobe 62, 63, 63, 64, 76

longitudinal section scans 65–66, 66transverse section scans 65, 65

renal impression 215, 217renal tumor infiltrating 202reporting guidelines 241right lobe 62, 63


superior border 47, 48transverse section 51, 51

scanning approaches 43, 43segmental anatomy 71, 71–73, 72

anterior segment (VIII, and V)73, 77, 77

lateral segment (II and III) 73, 75,75, 81

longitudinal sections 78–81, 78–81, 81lower 72, 72medial segment (I and IV) 73, 76, 76numbering system 73, 73posterior segment (VII, and VI)

73, 77, 77transverse sections 74–77, 74–77upper 71, 71–72

shape 53, 251size 53small 252stomach relationship see stomachsubcostal transverse/oblique scans

50, 50, 51, 51superior border 47, 47, 47–48, 48systematic analysis of findings 251–257transverse scan 63vena cava relationship 28, 28, 90–91,

90–91, 94vessels of 60–62

see also individual blood vesselsvolume, systematic survey 50, 50–52

longitudinal section 5, 5lymph nodes

benign vs malignant 41diaphragm scans and 177inflammation 41, 41intra-abdominal 40–42in lymphoma 272metastatic 41, 41near retroperitoneal vessels 40–42parietal 40, 41visceral 40, 41

lymphoma 41, 42Hodgkin’s, spleen 183lymph nodes in 41, 42of pancreatic body 144, 144signs 272spleen 183, 183see also non-Hodgkin’s lymphoma

MM-mode 13, 13metastases

adrenal glands 235hepatic see liver, metastasesspleen 184, 184

midabdomen, examination 244mirror-image artifact 17, 17monitor, adjusting 4

Morrison’s pouch, ascites 95, 95muscles see individual muscles

Nnephritis, acute 203, 203nephrocalcinosis 209, 213, 213nephropathy

analgesic 210, 210diabetic 203, 203, 285

noise 14, 14nomenclature, for findings 245non-Hodgkin’s lymphoma 41, 42

spleen in 183, 234, 272see also lymphoma

Oobesity

kidney scans 216liver scans 44nonvisualization of gallbladder 112, 112pancreas scans 141pancreas visualization problems 137

optimization of scanning conditionsgallbladder 107kidney 193, 197liver 43pancreas 135spleen 178

organ-oriented scanning strategy 1

Ppancreas 30, 135–163

abscess 143, 143in acute pancreatitis 143, 143, 279–280acute right-upper-quadrant pain 284adrenal gland and 231age-related changes 141anatomical landmarks 136, 136, 138,

138, 139anatomical relationships 149–163anatomy 141aorta and 136, 136, 137, 139barriers to scanning 135body 145

anatomical relationships 152–155,152–155

diameter 148, 148liver relationship 153, 153, 154, 154,

155, 155longitudinal scans 155, 155stomach relationship 153, 153, 154,

154, 155, 155transverse scans 153, 153, 154, 154

boundaries 135–137calcifications 142, 142carcinoma see pancreatic carcinomaceliac trunk and 136, 136, 137in chronic pancreatitis 142, 142,

281–282colon and 135common bile duct 146–148, 147, 148details 141–148diameter, measurement 148, 148dimensions 138, 148duodenum relationship 160–163,

160–163edematous swelling 143examination procedure 244fasting before scans 135, 153fibrolipomatosis 142, 142gas obscuring 137head 126, 126, 145

anatomical relationships 156–163anatomy 156

carcinoma 144, 144, 146, 148common bile duct course 146, 147diameter 148, 148duodenum relationship 160–163,

160–163longitudinal scan 139, 139, 159, 159,

162, 163portal vein relationship 157–159,

157–159splenic vein relationship 157–159,

157–159superior mesenteric vein relationship

157–159, 157–159topography 156, 160transverse scan 138, 158, 158, 161,

161, 162vena cava relationship 157–159,

157–159identification 136, 136

difficulties 137, 137imaging in entirety 138–140increased echogenicity 267left kidney relationship 226lipomatosis 137, 142, 142liver relationship 81, 90, 90, 92, 92locating 135, 135, 137lymphoma 144, 144normal 141, 142obesity and 137, 141parenchyma 141–144

abnormalities 142–144porta hepatis and 101portal vein relationship 157–159,

157–159pseudocysts 143, 143, 280pyloric antrum and 163pylorus and 156renal vessels and 140reporting guidelines 244salt-and-pepper pattern 142, 142shape variations 140, 140size 138, 148spleen relationship 186, 187,

187–188, 188splenic vein and 137, 138, 150, 151

course 149, 149pancreatic head 157–159, 157–159

stomach relationship 153, 153, 154, 154,155, 155

systematic analysis of findings 266–267tail

anatomical relationships 149–151,149–151

diameter 148, 148longitudinal scan 139, 139, 151, 151spleen relationship 150, 150transsplenic approach 140, 150, 150transverse scan 138, 150, 150

upper abdominal longitudinal scans139, 139, 139–140, 140

upper abdominal transverse scans138, 138, 139

vena cava and 139, 157–159, 157–159, 163visualization problems 137, 137, 267

pancreatic carcinoma 105, 144, 144gallbladder enlargement 115

pancreatic duct 145–146, 265abnormalities 146, 146accessory 146acute pancreatitis 280chronic pancreatitis 281dilatation 146, 266dimensions 145irregular walls 146


Index

measuring 145outflow obstruction 266

pancreatic lipomatosis 137, 142, 142pancreatitis

acute 143, 143findings 279–280

chronic 142, 142, 146, 146findings 281–282

parallel artifacts 14, 15perirenal fat 216pheochromocytoma 207, 235“Phrygian cap” gallbladder 116, 116piezoelectric crystal 11pleura, spleen relationship 189, 189pleural effusion, spleen and 190pleural space 189polycystic kidney disease 208, 208porta hepatis 28, 28, 96–105

acute viral hepatitis 275aorta and 96, 97, 99boundaries 97–100chronic viral hepatitis 276examination procedure 242gallbladder relationship 129, 129in jaundice 274longitudinal sections 101, 101, 129lymph nodes 41pancreas and 101primary sclerosing cholangitis 277reporting guidelines 242–243stomach and 101transverse sections 99, 99–100, 100, 129vena cava and 96, 96, 97, 97, 100, 100, 101,

101, 102vessels in see bile duct(s); hepatic artery;

portal veinportal hypertension 61, 183, 190, 190

signs 271portal vein 31, 37, 60, 82–86, 82–86, 102–104

abnormalities 61, 61, 104, 104aorta and 83branches 82–86cavernous transformation 104, 104cutoff 61, 61dilatation 104, 104dimensions 102gallbladder and see gallbladderhepatic artery and 82in hepatic cirrhosis 61identifying 97, 97left branch 75

longitudinal sections 82–83, 82–83transverse sections 84, 84

locating 82, 82pancreatic head relationship

156, 157–159, 157–159porta hepatis and 96, 96, 99, 100, 100,

101, 101right branch 76, 79

longitudinal sections 85, 85, 131transverse sections 86, 86, 130

thrombosis 104, 104portal vessels, bright, normal liver 53, 54postcholecystectomy syndrome 279posterior acoustic enhancement 14, 14power output 3prepyloric antrum, pancreatic body

relationship 154, 154, 155primary sclerosing cholangitis 105, 277prostate 236–237

adenoma 240details 240dimensions 237hematuria 282

hyperplasia 240longitudinal section 236, 236transverse section 237, 237

pseudocysts, pancreatic 143, 143, 280pseudosludge 15, 15psoas muscle 195, 197, 218, 218

identification 219, 220left kidney relationship 226, 229right kidney relationship 214, 218–220,

218–220pulse-echo principle 11pyelonephritis 201pyloric antrum

pancreas and 163pancreatic body relationship

154, 154, 155see also gastric antrum

pyloruspancreas relationship 155, 156pancreatic head relationship 156

Qquadrate lobe of liver see liverquadratus lumborum muscle 214, 218, 218

identification 220left kidney relationship 226, 229right kidney relationship 218–220,

218–220

Rrectum 238, 239, 240reflection, sound 10refraction, sound 10renal arteries 24, 24, 33, 33, 34

adrenal glands and 232, 233demonstrating 26, 26left 33

longitudinal section 36longitudinal section 35, 35–37, 36pancreas and 140right 33, 33, 140, 232, 233

longitudinal section 37stenosis 203

renal cell carcinoma, hepatic metastases56, 56

renal disease, chronic 203renal failure

acute 209, 209chronic 283

renal parenchyma see kidney, parenchymarenal pelvis 204, 204, 210

“ampullary” 211, 212congenital cystic dilatation 211, 211cystic dilatation 212, 212fluid in 211, 211hydronephrosis 212, 212normal 211, 211stone 212

renal scanning 192, 192renal sinus 204, 204–213, 210–213

abnormalities 211–213echo-free structures 213increased fluid 211, 211normal 210, 210sonographic anatomy 204, 204

renal stones 209, 213, 213renal veins 26, 26, 33, 33, 34

adrenal gland and 232common bile duct and 147, 156congestion 33demonstrating 26–27, 27left 33, 36longitudinal section 35, 35–37, 36right 33–34, 232

renal vessels 33, 33, 36, 204, 204anatomical relationships 33, 33longitudinal section 35, 35–37, 36, 37transverse section 33, 33–34, 34

reporting guidelinesepigastrium and pancreas 244gallbladder and porta hepatis 242–243left kidney and spleen 243liver 241lower abdomen 244right kidney 243

reports 246reverberations 14, 15ribs, intercostal scan of liver 52, 52Riedel’s lobe 46, 46rocking movement 7, 7, 9rotational movement 7, 7, 9

Ssaccular aortic aneurysm 23, 23scan planes, abdominal ultrasound 6, 6scatter, sound 11section-thickness (beam-width) artifact

15, 15, 123seminal vesicles 236, 237side-lobe artifact 16, 16sliding on edge movement 7, 7, 8, 8sliding on the flat movement 7, 7, 8, 8small intestine

pancreas and 149see also duodenum

sono consultantclinical presentation 271–285ultrasound findings 248–270

soundpropagation 10–11pulses 11, 12velocity 12

spinal column 101diaphragm and 177left adrenal gland and 234

spleen 178–190abnormalities 190, 190abscesses 185accessory 42, 42, 183, 183acute viral hepatitis 275adrenal gland relationship 234, 234anatomical relationships 186, 186–190ascites and 190, 190barriers to screening 178, 186during breathing 189, 189calcifications 184, 184chronic viral hepatitis 276circumscribed changes 184, 268, 269colic flexure relationship 186, 187,

187–188, 188colon and 181, 187constrictions 181, 181cysts 185details 181–185diffuse changes 183, 183dimensions 182echo-free lesions 185, 185, 268, 269echo pattern 183–185echogenic lesions 184, 184enlarged 182, 182focal changes 184, 184–185gastric antrum and 187hemangioma 184, 184, 185hematoma 185Hodgkin’s disease 183hyperechoic changes 268, 270hyperechoic changes with shadow

268, 270


Index

hypoechoic lesions 185, 185, 268, 269identification 179imaging in entirety 179, 179–180impressions from other organs 181, 181infarction 185infectious mononucleosis 182kidney relationship 186, 187, 187–188,

188, 198, 199, 226, 227, 227–228, 228locating 178, 178–179longitudinal flank scans 179, 179, 180,

182, 188in lymphoma 183, 234, 272metastases 184, 184non-Hodgkin’s lymphoma

183, 234, 272normal 182pancreas relationship 186, 187,

187–188, 188pancreatic tail relationship 150, 150pleura relationship 189, 189pleural effusion 190renal impression 227, 228reporting guidelines 243rupture 185shape 181size determination 182, 182–183stomach relationship 186, 187,

187–188, 188systematic analysis of findings 268–270transverse flank sections 180, 180

splenic artery 24, 24course 28, 28–31longitudinal section 28, 28, 30, 30porta hepatis scans 100, 100transverse section 32, 32

splenic vein 30, 33, 33, 36, 188anatomical relationships 33, 33aorta and 102, 103gallbladder and 129longitudinal section 102, 102, 136pancreas and 137, 138, 150, 151

course 149, 149pancreatic head relationship 157–159,

157–159porta hepatis scans 99, 100, 100, 101, 101superior mesenteric vein and 102, 102thrombosis 190transverse section 33, 33–34, 103, 103

splenomegaly 182, 183, 271in hepatic cirrhosis 61

staghorn calculus 213stomach 164–177

anatomical relationships 166–171antrum see gastric antrumbody 170, 170–171

filling with fluid 132, 135, 171, 171longitudinal sections 170, 170transverse sections 171, 171

boundaries 166–171carcinoma 41, 165cardia see cardiadetails 165esophageal junction see gastroesophageal

junctionleft kidney relationship 226liver relationship

central portion 90–92, 90–92left portion 88, 88–89, 89

pancreas relationship, pancreatic body153, 153, 154, 154, 155, 155

porta hepatis and 101pyloric antrum see gastric antrum;

pyloric antrumpylorus see pylorusscan plans 164spleen relationship 186, 187,

187–188, 188wall 165, 165

changes 165, 165hypoechoic 145

subphrenic space, ascites 95, 95superior mesenteric artery 21, 24, 24, 33,

33–34anatomical relationships 33, 33demonstrating 25, 25longitudinal section 102, 102portal vein and 102, 102renal vessels and 35, 35, 37transverse section 33, 33–34, 34, 136

superior mesenteric vein 156gallbladder and 129, 133longitudinal section 102, 102pancreatic head relationship 157–159,

157–159splenic vein and 102, 102transverse section 103, 103

symphysis pubis 236, 236, 238systematic ultrasound examination

241–247

Tthrombosis

partial, of aortic aneurysm 23, 23vena cava 24, 24

tilting (angling) movement 7, 7, 9, 9time-gain compensation 3tissue density 12tissues, ultrasound propagation in 11–12transducers 3–4

curved array 3, 4designs 3linear 3, 3mechanism of action 11movements 7, 7–9, 8, 9position 4–6sector 3, 3selector switch 3

transverse section 4, 4triangular ligament 95tumors see carcinoma; specific tumors

Uultrasound

acoustics 10–12artifacts see artifactsdefinitions 10image production 12–13principles 3, 10–18production/detection 11propagation in tissues 11–12

ultrasound machine 2, 2–3adjusting method 2–4control panel 2, 2–3

ultrasound system 2umbilical vein 66upper abdominal longitudinal scans 192

gallbladder 109, 109, 125, 129left adrenal gland 234, 234pancreas 137, 139, 139–140, 140right adrenal gland 232, 232see also specific organs

upper abdominal transverse scans 192gallbladder 108, 108, 125, 129left adrenal gland 234, 234pancreas 138, 138, 139right adrenal gland 233, 233see also specific organs

ureters 282proximal 211

urothelial carcinoma, liver metastases 55uterus

anteflexed 240bladder and 238, 238–239, 239details 240

Vvagina 238, 238, 239veins see individual veinsvena cava 20–21, 68

adrenal glands and 232, 233anatomical relationships 28–32artifacts 16bifurcation 38bowel gas obscuring 20, 20, 21, 21breathing and 22, 22cardia and 28, 28common bile duct and 147compressibility 24diameter 22, 24diaphragm and 28, 28, 176, 176, 177dilatation 250duodenum and 174, 175esophagus and 167, 168gallbladder and 107, 107, 109, 109, 132,

133, 134gastric antrum and 174, 175heart failure and 24, 24, 273hepatic artery and 31hepatic veins and 73, 73, 79, 80liver relationship 90–92, 90–92, 94

caudate lobe and 70, 70locating 19, 19–20longitudinal section 20, 20–21, 22,

22, 27lumen abnormalities 24lymph node distribution 40, 41, 42organ boundaries 19, 19–20pancreas and 139, 163pancreatic head relationship 156,

157–159, 157–159porta hepatis and 96, 96, 97, 97, 100, 100,

101, 101, 102portal vein and 82, 82, 85, 102, 102,

103, 103pulsation 22–24renal vessels and 35, 35, 37systematic analysis of findings 250thrombosis 24, 24transverse section 20, 20, 27tributaries 26, 26–27wall 22, 22

abnormalities 24venous pulsation 22, 22–24ventricle 33


Preface to the Second Edition

The first edition was published in 2004 as The Practice of Ultrasound. My goalat that time was to walk the user through the basic principles of upper ab-dominal ultrasound scanning. I am pleased that this concept is being revivedand that a second edition of the book can now be published. Once again theauthor recommends keeping the book close at hand during the ultrasoundexamination.

The closing chapter of this edition serves as a “Sono Consultant.” It hasbeen designed to provide systematic guidance in interpreting suspiciousfindings and determining how ultrasound can be applied to specific clinicalquestions.

Several of my colleagues supplied me with valuable ultrasound images forinclusion in the previous edition. For the current edition I am particularly in-debted to Dr. Johannes Linder, who has again provided me with high-qualityimages drawn from his clinical practice.

I wish my readers success in learning this modality and hope that they en-joy the practice of abdominal ultrasound scanning.

Berthold Block, Braunschweig, Germany

VBlock, Abdominal Ultrasound: Step by Step (ISBN 9783131383624), © 2012 Georg Thieme Verlag KG

Thieme: Abdominal Ultrasound: Step by Step

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