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RADIO

250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013


OUTLINE
I.
Ultrasound Principles
II.
Ultrasound Methods
III.
Image Interpretation
IV.
Advantages and Disadvantages
V.
Applications
A. Abdomen

B.
C.
D.
E.
F.
G.

Obstetrics and Gynecology


Thyroid
Scrotum
Breast and Musculoskeletal
Doppler Imaging
Interventional Procedures


Paayos ng page numbers saka last page

I. PRINCIPLES OF ULTRASOUND
A. What is Ultrasonography
Use of sound waves beyond the audible frequency (>20,000 Hz)
for diagnostic purposes
Can be used for therapeutic purposes by using larger and
continuous dosages as in:
o Generation of heat treatment of low back pain and muscle
strains, promotion of tissue generation
o Pulverization of kidney stones
B. Basic Physics

Probe
holding a piezoelectric crystal that changes

electrical current into sound waves and vice
TRANSDUCER
versa
Generates the sound wave
Are generated, reflected off tissues and echo
SOUND WAVES
back
Then they are picked up by the transducer and
converted to electrical activity

Image generated depends on the time it takes the sound waves to


return to the transducer and the amplitude of the sound wave
o Fat or bone is a reflective surface
o Air or water does not reflect sound very well
o Shorter the time, the nearer the body part is to the transducer.
o Stronger amplitude, the better reflector is the body part such as
bone, fat, and calcification.

II. ULTRASOUND METHODS
A. Pulse Echo

A MODE Amplitude Modulation
Echoes are displayed in graphic form, such as in echocardiogram
Not used anymore

o Dynamic doctor does the procedure and results are


interpreted right there

M MODE Motion Mode
First ultrasound modality to record display moving echoes from
the heart. Good to get heart tone
o Thus the motion could be interpreted in terms of myocardial
and valvular function
Combination of A and B modes
Determines velocity of a specific organ


Figure 2. M-mode trace. The echo intensity is displayed as
brightness and the trace is swept across the screen so that the x-axis
represents time. This is an M-mode echocardiogram showing the
rapid movement of the mitral valve apparatus within the left
ventricle (LV), with thicker proximal and distal moving bands
representing the myocardium. RV = right ventricle.


Figure 1. A-mode trace. The A-mode is a trace indicating echo
intensity tissue with depth. In this example, there is a fluid space (6
10 cm) from which no echoes arise. Tissues superficial and deep to
this produce echoes of varying intensities and there is a particularly
strong echo from the skin (05 cm). The time gain compensation
(TGC) curve is also shown.

B. Doppler Method
For vascular ultrasound
Sound waves bounced off of different objects have different
frequencies use of these frequencies to check flow through
arteries and vein
With Doppler ultrasound, these different frequencies are
transformed into audible sounds, of different frequency.
The different frequencies can also be mapped to give a visual
representation as well as an audible one
Can assess patency of arterial grafts, obstruction to flow by
thrombi or atherosclerosis
Arterial flow can often be heard in cases where it cannot be
palpated
For moving objects, the velocity of the sound waves will depend on
the velocity of the moving object
Renal artery stenosis is diagnosed when velocity is more than 300
m/s.
Carotid artery stenosis if more than 100 m/s

III. Image Interpretation


Sagittal View
Entering beam is along the long axis of the patient

B MODE Brigthness Modulation


Echoes are displayed as different intensities of brightness, giving a
2D cross sectional image (picture)
Can be static or dynamic (real time)
o Static med tech does the procedure then results are
interpreted by doctor

Shah Regina Isa Gee


UPCM 2016 1: XVI, Walang Kapantay!

1 of 9

RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013
Figure 3. Ultrasound, sagittal view

Axial View
Beam is along the transverse (short) axis

Liver Cirrhosis
Small liver
Heterogenous

Figure 4. Ultrasound, axial view

Fatty liver (Steatosis)


Appear bright
(hyperechoic)


B. Information Provided
Evaluate the size, shape and parenchyma of solid organs
Categorize lesions into solid (usually malignant), cystic (usually
benign) or complex (mixed)
Determine vascular supply of organs or masses
Localize site for biopsy, aspiration or interventional procedures

IV. ADVANTAGES AND DISADVANTAGES
Advantages
Non-invasive, simple and inexpensive
No ionizing radiation
Diagnosis is made during the procedure, unlike in x-ray
Infinite number of sections, not limited to sagittal and axial views
Portable machine, handheld even

Disadvantages
Operator dependent
Gives only a morphologic diagnosis, the size and shape, but not
the function, e.g., kidney may appear normal but may have high
creatinine already; same goes for liver
Cannot penetrate air or bone so do only chest ultrasound if youre
suspecting pleural effusion and joint effusion, bursitis, etc. Bone
tumors, marrow pathologies, dont use ultrasound
Requires good contact of transducer with skin: this is a problem
for burn patients especially if with bandage and infection

V. APPLICATIONS
Abdominal
Obstretics and Gynecology
Small organs:breast, thyroid, scrotal, musculoskeletal
Neurosonology for pediatric patients, if fontanels are still open;
for adults can also look at Circle of Willis; not used to visualize
brain parenchyma
Vascular
Interventional procedures

A. Abdomen
Liver

Cystitic Lesion
Hypo- or anechoic (dark)
with thin walls

Posterior acoustic
enhancement (PAE):
since sound waves
passes through fluid
only, they are not as
attenuated as passing
through a normal liver
parenchyma

Abscess looks similar
Masses/ Modules
Picture:liver metastasis
of a colon carcinoma

Also hypoechoic BUT
NO PAE

Calcifications
Picture: arrows point to
a liver calcification
secondary to a CMV
infection
Hyperechoic followed
by hypoechoic portion


Pancreas

Describe the parenchyma


Normal
Appear homogenously
grey
Blood vessels are dark

Shah Regina Isa Gee


UPCM 2016 1: XVI, Walang Kapantay!

2 of 9

RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013


Polyps
Nodular structure, not
dependent on gravity
Wall-adherent,
hyperechoic with no
shadow



Ascariasis
Calcified if dead







Figure 5. Pancreas

Usually taken in axial view
Tadpole-shaped, with the spleen on the left
Hypoechoic relative to others
Organ is anterior to the splenic artery and portal vein (markers)
Any structure anterior to your splenic vein is the pancreas.

Spleen

Also homogenously gray
May be compared with liver,
but smaller





Figure 5 (left). Normal spleen
ultrasound.

Gallbladder and Biliary Tree
Normally, gallbladder is thinwalled.
If painful, gallbladder is edematous.

Calcification (Stones)

Picture: cholelithiasis with
mobile gallstones
Hyperechoic with shadow
Settle on the dependent
portion
Presence of stones but px
is asymptomatic, gall
bladder would have thin
walls
(+) stones & (+) symptoms

(pain, etc), gall bladder
would be thick walled
Crystals (e.g
Cholesterolosis)
Picture: cholesterol
crystals in the
intrahepatic bile ducts in
a patient after
cholecystectomy
Hyperechoic with comet-
tail artifact
Not seen on CT or MRI,
only in UTZ

Shah Regina Isa Gee


Cholecystitis
Wall thickening (gray)


Doppler
Uncolored
tubular
structure above colored
tubular structure (portal
vein) is the common bile
duct.
To look for the common
bile duct, look for the
portal vein first. The
portal vein is parallel to
the common bile duct. It
would be helpful to trace
the bileduct to the
pancreas since most
pathologies are found in
that location.

Gastrointestinal Tract

Ultrasound is usually not used for the gastrointestinal tract


because it is mostly air-filled structures


Figure 6. GI tract
1st figure: sagittal view; 2nd figure: axial view; 3rd figure: thickening
of wall

Appendix

UPCM 2016 1: XVI, Walang Kapantay!

3 of 9

RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013


MEDULLARY
NEPHROCALCINOSIS

A blind-ending non-compressible structure that does not exceed 6


mm in length
If structure is very firm, more than 6 mm, and
hypervascular/hyperemic (in doppler) consider appendicitis
Negative ultrasound result does not rule out appendicitis.
If appendix is retrocecal in location, it cannot be visualized in UTZ

RENAL CYSTS

Calcified renal
medulla
Seen in distal
renal tubular
acidosis, renal
tuberculosis
and medullary
sponge kidney
disease

Picture: multiple
renal cysts in right
kidney

Figure 7. Appendix
TOP: Normal (left) versus inflamed (right) appendix.
BOTTOM: thickened appendix (you know because it is a dead end).
Only find it if it is inflamed

END-STAGE KIDNEY


Kidney

NORMAL KIDNEY

STAGHORN CALCULI

Homogenous
parenchyma with
uniform contour
Central echocomplex
(corresponds to
pelvocalices; only
seen when dilated)
Hypoechoic focus in
the middle (medulla
with collecting
tubules) with grey in
the periphery (cortex
with glomeruli)


Hyperechoic parenchyma (significantly more echogenic than
adjacent liver parenchyma)
Differentiation of cortex from medulla, and even from the
renal sinus, is lost
Irregular kidney borders + small kidney size
Etiology: Infection, hypertensive nephropathy, diabetes

There are normal variants of the kidney. Such are the Dromedory
humps and hypertrophied column of Bertin

Ureter
Normally should not be distended
it cant be seen in the UTZ if there are no pathologies
Calculi (stones) of the ureters are usually detected through UTZ

Large calculi that


takes the shape of
the medulla
Figure 8. Ureteral Stones.
Image at Left is a stone in the ureterovesical junction

HYDRONEPHROSIS


Urinary Bladder

Distension and
dilation of the renal
pelvis and calyces

Normally should not be distended


If there is cystitis, the urinary bladder can have thick walls.
Hemorrhage in the urinary bladder will appear hyperechoic

Shah Regina Isa Gee


UPCM 2016 1: XVI, Walang Kapantay!

4 of 9

RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013

NORMAL PROSTATE

NORMAL BLADDER

Appears hypoechoic
with well-defined
borders

Picture: arrows
point to each
lobe of the
prostate

Picture: large
bladder carcinoma
with bladder wall
invasion

BENIGN PROSTATIC
ENLARGEMENT

BLADDER TUMORS

Usually located
on the central
zone

PROSTATIC CARCINOMA

STONES

Picture: mobile
bladder stones
Hyperechoic with
posterior shadowing

Picture: note hypoechoic nodule (arrow) located on the


peripheral zone

CALCIFICATIONS

CYSTITIS

Cystitis: irregular
thickening of wall,
balloon of foley
catheter is seen at
the right.

FOLEY CATHETER BALLOON


Picture: balloon
catheter placed in
the vagina and not
in the bladder



Prostate

Two views: transrectal (good view since few structures are in the
way) and transabdominal (bladder must be full)
Central (slightly hypoechoic) and peripheral (hyperechoic) gland
can be seen
Normal volume: 20 cc

Appear as
hyperechoic foci
usually from 4-7
mm in the inner
gland of the
prostate and
also along the
prostatic
urethra


B. Obstetrics and Gynecology

Transabdominal vs. Transvaginal Ultrasound

Table 1. Comparison between transabdominal and transvaginal UTZ.
TRANSABDOMINAL
TRANSVAGINAL
Distended urinary bladder
Low frequency transducer
(up to 5)
For visualizing the global
picture
Poor resolution

Empty urinary bladder


High frequency transducer (up to
7.5)
Limited range (8 to 10 cm away
from probe only)
Excellent resolution
Long axis and short axis
orientation

Shah Regina Isa Gee


UPCM 2016 1: XVI, Walang Kapantay!

5 of 9

RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013

Figure 9. Transabdomial VS Transvaginal


Figure 13.
TOP: 19-week baby boy showing turtle sign on ultrasound. BOTTOM:
20-week baby girl showing hamburger sign on ultrasound.

Figure 10. Transabdominal orientation

C. Thyroid

Very radiosensitive organ, hence best examined through UTZ

Figure 11. Transvaginal orientation

NORMAL THYROID


The Fetus

GRAVES' DISEASE

UTZ is useful for visualizing fetal organs (feet, genitals, face,


cranium, hands, etc.)
Fetal assessment for sex:
o Not easily detectable, can take up to 30 minutes
o Turtle sign is for male, hamburger sign is for female

Figure 12. Early Intrauterine

Picture: right
lobe of
thyroid
relative to
other organs
Homogenousl
y gray
Hyperechoic
when
compared to
muscle
Normal size
threshold: 5
cm
Picture:
hyper-
vascularized
thyroid gland
(thyroid
inferno) on
color Doppler
Enlarged and
relatively
hypoechoic
heterogenous
parenchyma,

>5cm,
isthmus and
AP diameter
are measured

Shah Regina Isa Gee


UPCM 2016 1: XVI, Walang Kapantay!

6 of 9

HASHIMOTO'S THYROIDITIS

Enlarged and
non-
homogenous;
hypervascular
in its acute
stage
Hypoechoic
compared to
normal
thyroid with

lobulations
inisde

BENIGN THYROID MASS

RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013

Picture:
hyperplastic
adenomatous
nodule with a
slightly
hyperechoic
vascularized mass


Figure 14. ????

Cyst most likely benign


Thin rim calcification ath the PERIPHERY benign


Colloid nodule: with internal reticulations, no calcifications
Ultrasound guided FNAB slide: Anything you can ultrasound, you
can biopsy

Picture:
nonhomogeneous
hypervascularized
solid and partly
cystic thyroid
mass that proved
to be extensive
papillary
carcinoma

D. SCROTUM

Ovoid,
homogenously
gray
No calcifications
or
masses
within

NORMAL TESTIS

THYROID CARCINOMA

VARICOCOELE

Picture:
varicocoele with
dilatated venous
plexus
and
reflux
during
straining
Looks like bag
of worms
Hypervascular
with
dilated
vessels
Can
cause
infertility

ORCHITIS

COLLOID NODULE

Picture: orchitis
with a focal
hypoechoic area
with increased
flow
Whole
testis
enlarged,
hypervascular,
not
homogenous


Picture: cystic changes in an adenomatous nodule (colloid
nodule) in the right thyroid lobe
Looks like sponge (multiple small internal cystic structures)
Does not warrant a biopsy



Thyroid Lesions: Benign vs. Malignant

PARAMETER
Height vs. width
Capsule
Edge of mass

BENIGN
MALIGNANT
Wider than tall
Taller than wide
(usually ovoid)
Usually present
Usually absent
Smooth,
well-
Poorly defined
defined

Intra-lesional
peripheral vascularity

Absent

Present

Calcifications

Positioned
peripherally (egg-
shell configuration)

Located inside
the mass

Hyperechoic benign
Hyperechoic + crystals benign

Shah Regina Isa Gee


UPCM 2016 1: XVI, Walang Kapantay!

7 of 9

RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013
EPIDIDYMITIS WITH ABSCESS

Musculoskeletal

Spermatocoele vs. Epididymal Cysts

Figure 17.
Fibroadenoma
with a hypoechoic
slightly lobulated
oval lesion with
sharp margins.

Picture: arrow
points
to
abscess below
an
inflamed
epididymis
Hyperemic wall

Cannot be distinguished via ultrasound

TENOSYNOVITIS


Figure 15. Epididymal cyst or spermatocele in the epididymal head.


Testicular Tumors
HIGH
Solid palpable
Complex
cystic palpable

PROBABILITY OF MALIGNANCY
INTERMEDIATE
LOW
Solid non-
Simple cystic
palpable
palpable
Complex cystic

non-palpable

VERY LOW
Simple cystic
non-palpable

*Complex: presence of both solid and cystic parts

NEONATAL UTZ

Microlithiasis and Seminoma


Microlithiasis: post-infection, hypoechoic with microcalcifications
must follow-up for possible seminoma
Seminoma: hyperechoic, highly vascularized
Torsion: hypovascular
Infarct: avascular

Figure 16.
Testicular
microlithiasis
and a
seminoma with
a vascularized
hypoechoic
mass.

Picture:
tenosynovitis of
the
flexor
digitorum
tendons
Abnormal fluid
collection
within
synovium
around

covering
of
tendon
Picture:
hemangioma
with
a
hypechoic
compressible
highly
vascularized
lesion
UTZ
probe
made to pass
through

fontanelles


F. CRANIAL
Assessed in neonates through the fontanelles.
Used just to rule out pathologies especially in preterms
UTZ can rule out intracranial hemorrhages.

E. BREAST AND MUSCULOSKELETAL

Figure 18. Cranial UTZ


LEFT: Subarachnoid Hemorrhage: RIGHT: Hydrocephalus

Breast
UTZ usually for fibroadenomas
o Flat ovoid masses with smooth well-defined borders
o Solid nodule with PAE (an exception! Recall that solid masses
in the GI tract do not have PAE)
o No need for biopsy, may regress normally

Shah Regina Isa Gee




G. DOPPLER IMAGING

Standard Doppler Imaging
Flow direction and velocity must be shown on the color Doppler
image by shifting and changing shade method
Different colors are used to represent different frequencies and
color gets lighter as the frequency increases
o Color used can be changed by the technician

UPCM 2016 1: XVI, Walang Kapantay!

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RADIO 250: ICC in Radiology and Nuclear Medicine


LEC 09: Basic Ultrasound
Exam 1 | Dr. Pauig| October 23, 2013

o Usual color spectrum:


Blood coming TOWARDS the probe appears blue
Blood going AWAY FROM the probe appears red
NOT red = artery, blue = vein!
Shows direction of blood BUT is not sensitive to slow movements

Figure 22. Prostate Biopsy


Paracentesis: evacuation of fluid within the cavity, avoid
puncturing bowels
Thoracentesis: evacuation of fluid within the pleural cavity; avoid
puncturing diaphgram


END

Figure 19. Standard Doppler Imaging


Power Doppler Flow Imaging


Frame rate is too slow and cannot provide flow direction and
velocity
Sensitive to even slow movements
Does not assign direction
Any flowing blood is yellow.

Figure 20. Power Doppler Flow Imaging



Resistive index, acceleration index. Insert slide- no pic L

H. INTERVENTIONAL PROCEDURES

Treatment Modalities Utilizing Ultrasound

Biopsy
Aspiration
Thoracentesis / Paracentesis
Percutaneous biliary drainage
Nephrostomy / Cystostomy
IV insertion / central venous lines

Ultrasound-Guided Procedures: Examples


Liver abscess aspiration: Abscess appears hypoechoic. Vascularity
is only in the periphery. You see a collapsed wall after aspiration.

Figure 21. Liver abscess aspiration



Prostate biopsy

Shah Regina Isa Gee


UPCM 2016 1: XVI, Walang Kapantay!

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