Abdomen Complete Protocol

 This protocol includes images of several organs and structures. It has been divided into
sections to assist in determining diagnostic images that should be stored for the physician
o Midline structures (Pancreas, Aorta, and IVC)
o Liver
o Gallbladder and Common Bile Duct
o Kidneys and Spleen
 Physicians may request a full examination of all abdominal organs or only specific
abdominal organs
o Students will be provided separate protocols for organs in addition to this full
examination protocol
 You must always evaluate the entire organ first before you store an image
 You should understand completely why you stored the image and identify everything in
the image
 Multiple breathing techniques and patient positions will be required

Organ/ Scan Label Key Landmarks Identified
Order Plane
 Pancreas head
PANCREAS  Portal splenic confluence
 CBD
o If CBD is enlarged, measure internal AP diameter
Transvers
 Pancreas body
Pancrea e plane
 Aorta
s on the PANCREAS
 Measurement
body o If pancreatic duct is seen measure internal AP
diameter
PANCREAS  Pancreas tail
 Splenic vein
 Proximal aorta
AO SAG
 Celiac axis
PROX
 SMA
Aorta Sagittal  Mid aorta
AO SAG MID
 SMA
AO SAG  Distal aorta as it tapers before bifurcation
DIST
 IVC
IVC Sagittal IVC  Right atrium
 Left lobe
Organ/ Scan Plane Label Key Landmarks
Order Identified
Sagittal LIVER SAG  Left lobe with inferior tip
LIVER
The transducer
Sagittal LIVER SAG  Left lobe
is placed sagittal
in the mid  Caudate lobe
portion of the  IVC
patient’s body LIVER SAG  Right lobe
 Diaphragm

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LIVER SAG  Right lobe superior
SUP  Right hemidiaphragm
Sagittal  Right pleural space
The transducer LIVER SAG  Right lobe mid
LIVER
is placed MID  Main portal vein
Sagittal
sagittal and LIVER SAG  Right lobe inferior
lateral on the INF o Demonstrating largest superior to inferior
patient’s body area
o Measure liver length from superior to inferior
 Right kidney
Transverse  Left lobe
LIVER TX
 Caudate lobe
The transducer
 IVC
is placed
LIVER transverse in the
 Right lobe
Transver mid portion of LIVER TX  Left lobe
se the patient’s HV  Right hepatic vein
body  Left hepatic vein
 Middle hepatic vein
Angulation of the
probe is used for LIVER TX  Right lobe - most anterior portion
right lobe images  Diaphragm
LIVER TX  Right lobe superior
SUP  Right hemidiaphragm
 Right pleural space
LIVER TX  Right lobe mid
MPV  Main portal vein
Transverse
LIVER TX  Right lobe mid
LIVER The transducer MPV  Main portal vein with color Doppler
Transver is placed
se transverse and
lateral on the  Right lobe mid
LIVER TX
patient’s body  Main portal vein with color & spectral Doppler
MPV
o Normal waveform will demonstrate slight
phasic flow toward the liver
LIVER TX  Right lobe - inferior
INF  Right kidney

Organ/ Scan Label Key Landmarks Identified
Order Plane
Gallblad GB SUPINE  Gallbladder body
Sagittal
der SAG  Gallbladder fundus
plane of
GB SUPINE  Gallbladder body
the GB
Patient in SAG  Gallbladder neck
Supine Transvers GB SUPINE  Gallbladder mid body with clear delineation of
position
e plane of TX anterior wall
the GB GB SUPINE  Gallbladder mid body with clear delineation of
TX anterior wall
 Measurement

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o measure anterior wall thickness
GB LLD SAG  Gallbladder body
Gallblad Sagittal
 Gallbladder fundus
der plane of
GB LLD SAG  Gallbladder body
the GB
 Gallbladder neck
Patient in Transvers  Gallbladder mid body
Left lateral
e
decubitus GB LLD TX
position plane of
the GB
Gallblad GB RLD  Gallbladder body
Sagittal
der SAG  Gallbladder fundus
plane of
GB RLD  Gallbladder body
the GB
Patient in SAG  Gallbladder neck
Right lateral Transvers  Gallbladder mid body
decubitus e plane of GB RLD TX
position the GB
Transvers  Portal vein
e plane of CBD TX  CBD
the CBD  Hepatic artery
 Portal vein
Common CBD SAG
 CBD
Bile Duct  Enlarged image
CBD SAG  Portal vein
level of the Sagittal
 CBD
porta plane of
hepatis  Enlarged image
the CBD
 Portal vein
CBD SAG  CBD
 Measurement
o Internal AP diameter

Organ/ Scan Label Key Landmarks Identified
Order Plane
RT RT KID SAG  Renal parenchyma and capsule
Kidney LAT
RT KID SAG  Renal parenchyma and capsule
Sagittal MID  Renal sinus
plane of  Renal parenchyma and capsule
the RT KID SAG  Renal sinus
kidney MID  Measurement
o Length measurement from superior to inferior pole
RT KID SAG  Renal parenchyma and capsule
MED  Renal sinus at hilum
Transver  Renal parenchyma and capsule
RT KID TX
se plane  Renal sinus
SUP
of the  Liver
kidney RT KID TX  Renal parenchyma and capsule
MID  Renal sinus at hilum to include renal vessels
RT KID TX  Renal parenchyma and capsule

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INF  Renal sinus
LT KID SAG  Renal parenchyma and capsule
LAT
LT KID SAG  Renal parenchyma and capsule
LT Sagittal MID  Renal Sinus
Kidney plane of  Renal parenchyma and capsule
the LT KID SAG  Renal Sinus
kidney MID  Measurement
o Length measurement from superior to inferior pole
LT KID SAG  Renal parenchyma and capsule
MED  Renal sinus at hilum

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LT KID TX  Renal parenchyma and capsule
Transver SUP  Renal sinus
se plane LT KID TX  Renal parenchyma and capsule
of the MID  Renal sinus at hilum to include renal vessels
kidney LT KID TX  Renal parenchyma and capsule
INF  Renal sinus
 Spleen mid
SPLEEN SAG  Left hemidiaphragm
Sagittal  Left pleural space
plane of  Left kidney (if not seen, may require extra image)
the  Spleen mid with splenic hilum
spleen  Left hemidiaphragm
SPLEEN SAG
Spleen  Left pleural space
 Measurement
o Length measurement from superior to inferior
Transver  Spleen mid
se plane
SPLEEN TX
of the
spleen

Normal Measurement Ranges

Structure Area of Plane Measureme Comments
Interest nt
Aorta Superior, Mid Sagittal 3 cm or less  Only performed if abnormalities
and Inferior are suspected or if required by site
 Measured in AP dimension
 Measurements taken
perpendicular to the axis of the
lumen
 Calipers placed on outer edges of
walls so that walls are included in
the measurement
 Aorta should taper as you move
distally
Pancreas Head Transver Head 2-3.5  Only performed if abnormalities
se plane cm are suspected
on the
body
Pancreatic Body of the Transver 2 mm or less  Only performed if abnormalities
Duct pancreas se plane are suspected
on the  If duct is enlarged measure
body internal duct diameter anterior to
posterior
Common Bile Level of Porta Long <7-8 mm  Measure inner wall to inner wall
Duct Hepatis Axis  If duct is enlarged:
o Look for and document any
intrahepatic ductal dilatation

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o Follow CBD to pancreatic head
 If GB removed, CBD may be
enlarged (up to 11 mm)
Gallbladder Anterior Wall Transver <3 mm  Calipers are placed outside to
wall se inside of the anterior wall
Liver RT Lobe Sagittal 15-17 cm  Measure superior to inferior
Inferior through the liver
Main Portal Porta Hepatis Transver Normal AP  Internal AP diameter where MPV
Vein se plane measurement crosses the IVC
on the is <13mm o Only performed if abnormalities
body/ are suspected
long axis Normal flow  Flow should be phasic and toward
on the velocity is 20- the liver
vessel 40 cm/s
Kidneys Mid Sagittal 10-12 cm  Measure from superior pole to
inferior pole through the kidney
Spleen Mid Sagittal 8-13 cm  Measure superior to inferior
through the spleen
 Hilum should be demonstrated

Common Laboratory Values to be Reviewed prior to Examination

Lab Value Organ Level Indication or Association
Amylase  Pancreas Increased  Pancreatitis or other pancreatic disease
Lipase  Pancreas Increased  Pancreatitis or other pancreatic disease
Hematocrit  Aorta (or Decreased  Vascular rupture, bleeding, hemorrhage,
any etc.
vessel)
AST (SGOT)  Liver Increased  Hepatitis, fatty liver, cirrhosis other liver
disease
ALT (SGPT)  Liver Increased  Jaundice or hepatitis
Alkaline phosphatase  Liver Increased  Biliary obstruction or metastases
 Gallbladd
er
Bilirubin  Liver Increased  Jaundice, liver damage or obstruction
 Gallbladd
er
Blood urea nitrogen  Kidneys Increased  Renal failure or renal disease
(BUN)
Creatinine  Kidneys Increased  Renal failure or renal disease
White blood cell  All organs Increased  Indicates infection
count (WBC)

Tips
 Patient should be NPO for this study to reduce the amount of gas present and to prevent
contraction of the GB

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 Have patient poke out their abdomen or take in a deep breath if having trouble seeing the
pancreas
 Pancreatic tail may be evaluated using the spleen as a window
 Sit the patient erect for scanning if suspicious for stones stuck in the neck that weren’t
confirmed in LLD or RLD
 Watch your gain settings:
o Making the GB lumen too dark with TGC can mask pathology
o Using too much gain can give the appearance of pathology
 If the GB appears to have artifacts, change to a higher frequency, use harmonics, use a
different window, or have the patient poke out their abdomen
 If the GB is enlarged make sure to evaluate the ducts for signs of stones. These can
obstruct the ducts
 To find the CBD:
o Scan from the GB in transverse and follow it to the neck and cystic duct, you will
see CBD
o Follow the portal vein from the portal confluence. The CBD will be anterior to the
vein
 If the GB has been surgically removed (postcholecystectomy), document a “GB FOSSA”
image (main lobar fissure near porta hepatis) instead of the gallbladder images
 Roll the patient up LLD and RLD, if necessary, to see kidneys better
o Use the liver on the right as a window
o Use the spleen on the left as a window
 If urinary obstruction is a concern, use color Doppler to look for bladder jets to verify open
ureter

Coronal Scanning

o Sometimes, especially on the left, the kidney can be seen best scanning coronally.
Anterior and posterior images can be obtained from the coronal scan plane.
The medial and lateral images cannot be obtained from this plane.
Therefore, anterior, mid, and posterior images in coronal should documented.
 The renal parenchyma, sinus, and capsule will be seen in each image
 Label Coronal - Anterior, Mid, or Posterior

Pathology Seen

o Gray scale sagittal and transverse images
o Gray scale sagittal and transverse images with 3 measurements (length, width, and
height)
o Color Doppler image to document the presence of blood flow
o Spectral Doppler image to document type and velocity of blood flow
o If aortic aneurysm suspected
Measure transverse aorta from outer wall to outer wall (this measurement is
perpendicular to your AP measurement)
Document location in relation to renal and iliac arteries
Use color Doppler to assess thrombus formation
Use spectral Doppler to show patency
o If aortic dissection suspected
Demonstrate beginning and end of intimal flap (may not be able to follow it
all the way superiorly if it originated in thoracic aorta)
Demonstrate any branch vessel involvement

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Use color and spectral Doppler to document true and false lumens
o If the GB wall measures greater than 3 mm, color Doppler can be used to confirm
increased flow in the wall due to cholecystitis.
o If the patient has gallstones and/or gallbladder wall thickening, they should be
evaluated for a positive Murphy’s sign (extreme tenderness upon transducer or manual
pressure in the RUQ). This needs to be reported to the interpreting physician as it
indicates acute cholecystitis.
o Must attempt to demonstrate movement of any pathology seen in the GB – sludge and
stones will move – masses will not!!
o If the CBD is enlarged at the porta hepatis, it should be followed to the pancreatic head
to evaluate for stones or an obstructive lesion
o For hydronephrosis, demonstrate connection of the dilated pyramids to the renal pelvis
and include ureter images if the ureter is dilated.
o For renal calculi, move the focal zone to the level of the calculus to aid in
demonstrating posterior shadowing

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