South Egypt Cancer Institute

South Egypt
Cancer Institute
What is Ultrasound?
• Ultrasound is a mechanical, longitudinal wave with a
frequency exceeding the upper limit of human
hearing, which is 20,000 Hz or 20 kHz.
• Typically at 2 – 20 Mhz.

How Ultrasound Image is constructed

What are the factors affecting
Ultrasound waves?
Velocity
• Speed at which a
sound wave travels
through a
medium(cm/sec)
• Determined by
density and stiffness
of media
– Slowest in air/gas
– Fastest in solids
• Average speed of
ultrasound in body
is 1540m/sec
Frequency

Higher the freq Lower

the penetration and
Higher the resolution

Low the freq higher the

penetration and lower the
resolution.
Use in obese patients The Longer it travels the
more less Resolution
Sound interaction with tissue:
Reflection of Ultrasound
Occurs at a boundary between
2 adjacent tissues or media
– The amount of reflection
depends on differences in
acoustic impedance (z)
between media
–ultrasound image is formed
from reflected echoes.
Echogenicity (caused by
Reflection)
Ane-Echoic Hypeo-Echoic
Hyper-Echoic and reflective.
Acoustic Impedance

•Amplitude of returning echo is proportional to the difference

in acoustic impedance between the two tissues
• Velocities:
– Soft tissues = 1400-1600m/sec
– Bone = 4080
– Air = 330
• Thus, when an ultrasound beam encounters two regions of
very different acoustic impedances, the beam is reflected and
cannot penetrate
Reflection beneficial or harmful?
Why we use Jell in US examination?

At tissue-air interface, more than 99.9% of the beam is

reflected so none is available for further imaging
• acts as a special aqueous conductive medium for the
sound waves
Acoustic Shadowing
Sharp edge, pure black
solid or high reflective structure (bone, foreign
body, solid feces, barium or pure gas)
it can “hide” deeper structure
Reverberation
Common artifact
Occurs at highly reflective interface: gas,
metal
Sound bounces back and forth between
reflective surfaces and probe
Tissue Harmonic Imaging
Tissue Harmonic Imaging
Images of two small
hepatic focal
abnormalities (arrows),
thought to be
hemangiomas, obtained
by using fundamental
imaging (a), THI (b). Note
the superior definition of
the liver parenchyma and
focal liver abnormalities in
b in comparison with a.
Mirror image
At reflective Interfac esespecilly
diaphragm/ lung
“mismaps” location based on travel time
Mistake thoracic pathology
Side lobe artifact
Intense echoes from lateral lobes are mismapped
as being within main lobe
Occurs with high reflective interfaces lateral to
anechoic object in main beam
Correct by lower gain, lower frequency,
change orientation or deeper focus
Slice thickness
High reflective structure within “slice” along
with anechoic structure
“pseudo-sludge” in UB/GB
Look for “curved” surface of sludge
Change position of probe, reposition patient.
Refraction
Edge Shadowing
At edge of curved structures
Cystic structures or structures of different acoustic
impedance
Refraction- sound redirected and not returned to
probe
“Loss” of thin wall structure mimic rupture bladder
Change angle of insonation?
TRANSMISSION: sound passes through.
Acoustic enhancement “through transmission”
Structure fluid filled
Low attenuation: increases intensity
of returned echoes
Adjust far field gain
ABSORPTION
Energy lost and converted to heat
Safety considerations
High frequency: greater absorption
Ultrasound
transducers
differ in
•Piezoelectric
crystal
arrangement

•Aperture(
footprint )
•frequency
directly
related
to
penetration
depth )
Imaging Planes

• Transverse
or Axial

• Longitudinal or
Saggital

• Coronal
Probe Orientation
Abdominal US systematic approach:
Liver and Gallbladder
Stomach
Pancreas and Spleen
Left kidney and Left adrenal gland
Urinary bladder
Urethra/ prostate
Medial iliac nodes
Intestine
Mesenteric nodes
Right kidney
Right adrenal gland
Right dorsal liver
Porta hepatis
Duodenum/ papilla
liver
Normal liver
Size:
Lt. Lobe span < 10 cm).
Rt. Lobe span <16 cm)
2. Transverse scan with the probe angled cephalic to
include the superior margin to the inferior margin of the
left and right lobe of the liver.
4. Intercostal scan which is a supplementary view for
examining the right lobe of the liver especially when
the right lobe is well within the rib cage.
3. Subcostal scan to examine the whole of the right
lobe.
Parenchymal organ echogenicity
Renal medulla < renal cortex < liver

Shape and outlines of normal liver : wedged

shape with smooth outline with homogenous
echo pattern.
Criteria for diffuse liver steatosis

Diagnosis of fatty liver based on ultrasound evaluation.

1 – parenchymal hyperechogenicity, 2 – intensified attenuation,
3 – poorly visible vessels, 4 – focal hyposteatosis.
Presence of all four signs leads to diagnosis of fatty liver
Grading of diffuse hepatic steatosis
grade I: diffusely increased hepatic echogenicity
but periportal and diaphragmatic echogenicity is
still appreciable
•grade II: diffusely increased hepatic echogenicity
obscuring periportal echogenicity but
diaphragmatic echogenicity is still appreciable
•grade III: diffusely increased hepatic echogenicity
obscuring periportal as well as diaphragmatic
echogenicity
 Focal fatty sparing of the liver
typically has a geographic appearance and
occurs in characteristic locations 1,3:
•adjacent to the porta hepatis (segment IV)
•gallbladder fossa
•adjacent to the falciform ligament
•subcapsular parenchyma Important features,
along with location and
echogenicity/density/intensity are 2:
•absence of mass effect.
•absence of distortion of vessel.
 Focal hepatic steatosis
Location: the same as that seen in focal fatty
sparing
Ultrasound features include:
•Focal area with geographic borders and
increased echogenicity without mass effect and
no distortion of vessels
Ultrasound features of cirrhosis
•surface nodularity.
•overall coarse and heterogeneous echotexture.
•segmental hypertrophy/atrophy.
•hypertrophy of the caudate lobe and lateral
segments of left lobe (segments II & III) with
concomitant atrophy of the posterior segments (VI
& VII) of the right lobe.
•reduction of the transverse diameter (<30 mm) of
the medial segment of the left lobe (segment IV)
• caudate width: right lobe width >0.65.

•signs of portal hypertension:

•enlarged portal vein: >13 mm
•portosystemic collaterals
Liver cirrhosis with portal vein thrombosis and
portosystemic shunt
Schistosomal
hepatic fibrosis:
(Thickened
portal tracts):
• thickened portal vein
radicles .
we measure the portal
tracts (outer-outer
diameter). If the
diameter is more than
3 mm in more than 3
tracts → “Periportal
Thickening”.
Simple hepatic cyst Ultrasound
•round or ovoid anechoic
lesion (may be lobulated)
•well-marginated with a thin
or imperceptible wall and a
clearly defined back wall
•may show posterior acoustic
enhancement, if large
enough
•a few septa may be possible,
•DD: but no wall thickening
•hepatic abscess(es) •a small amount of layering
•biliary cystadenoma(s)
•choledochal cyst :
debris is possible
•necrotic hepatic metastasis •no internal vascularity on
color Doppler
Hepatic abscess: typically poorly demarcated with a variable
appearance, ranging from predominantly hypoechoic (with some internal
echoes) to hyperechoic. Gas bubbles may also be seen 7. Color Doppler will
demonstrate the absence of central perfusion.
hydatid cyst
Choledochal cyst: it may be discovered at any
age, 60% are diagnosed before the age of 10
years. The key to the diagnosis is a dilated cystic
lesion which communicates with the bile duct and
is separate from the gall bladder.
Typical hemangioma
Atypical hemangioma
Hepatic adenoma
malignant focal lesions
Sonographically the vessels seen visible within the liver
parenchyma are hepatic and portal veins.
Portal vein gas echogenic (bright) walls.
Hepatic arteries and bile ducts not seen unless
abnormally dilated but seen in porta hepatis.
Transverse liver scan
Anatomic landmark
Upper: large hepatic veins
(imperceptible margins) it joint
IVC.

Mid: large central portal veins

(left higher than right).

Lower:
-No large veins.
-Falciform ligament
Anatomic liver segments
Each segment has its own blood supply including
arterial, portal, hepatic venous and biliary drainage.
There are eight segments.
Gall bladder and biliary tree scanning
technique
• patient should fast at least 6 hours.
Transverse diameter of the GB should be <4cm
GB wall thickness ≤3mm
Biliary Sludge
Biliary sludge, also known as biliary sand or
microlithiasis, is defined as a mixture of particulate
matter and bile that occurs when solutes in bile
precipitate.
The sonographic appearance of sludge is that of
amorphous, low-level echoes within the gallbladder
in a dependent position, with no acoustic shadowing.
Gallstone
Sonography is highly sensitive in the
detection of GB stones.
The large difference in the acoustic
impedance of stones and adjacent bile
makes them highly reflective, which results
in an echogenic appearance with strong
posterior acoustic shadowing.
Mobility is a key feature of stones, allowing
differentiation from polyps or other entities.
Various maneuvers may be used to
demonstrate mobility of a stone; scanning
with the patient in the right or left lateral
decubitus or upright standing position may
allow the stone to roll within GB.
Acute Cholecystitis
It is caused by gallstones in more
than 90% of patients.
Sonographic findings in acute
cholecystitis
Cholesterol stones

Acalculous cholecystitis Chronic cholecystitis

Secondary gallbladder involvement
Systemic diseases such as hepatic dysfunction, heart failure, or renal failure
may lead to diffuse gallbladder thickening

Liver cirrhosis Congestive right heart failure

Drug-induced hepatitis with diffuse

gallbladder wall thickening
Gangrenous cholecystitis Perforated GB with abscess

Emphysematous cholecystitis Porcelain gallbladder with a calcified

gallbladder wall
Adenomyomatosis
The sonographic finding of
cholesterol crystals, shown as
'comet-tail' reverberation
artifacts , within a thickened
wall of the gallbladder
strongly suggests this
diagnosis.
Air may produce a similar
artifact, however, patients
with emphysematous
cholecystitis are usually ill in
contrast to those with
adenomyomatosis.
Gallbladder polyps
GB mass
Biliary ducts
The extrahepatic common duct is measured from inner wall
to inner wall at the level of the crossing of the right hepatic
artery. The diameter at this level should not exceed 6 mm.
Causes of biliary obstruction
Choledocholithiasis

longitudinal ultrasound
imaging in the porta Multiple intraductal stones. Longitudinal
shows a dilated ultrasound shows a dilated duct (arrow) filled
common duct with multiple shadowing stones
obstructed by stone (arrowheads) in multiple ducts in this patient
with posterior acoustic who had longstanding cholecystitis and
shadow cholangitis
Cholangiocarcinoma.

longitudinal ultrasound image

shows multiple dilated ducts with
an ill-defined discrete low
attenuation mass with obstruction
and dilatation of the ducts of the
left lobe
Pancreatic carcinoma. Transverse ultrasound image
shows a markedly dilated common duct that
terminates abruptly at the level of a slightly
hypoechoic, rounded mass. (B) Transverse image
through the body of the pancreas shows a dilated
pancreatic duct (arrowhead), indicating that the level
of obstruction is in the pancreatic head.
pancreas
Essential landmarks while scanning pancreas are
superior mesenteric artery and splenic vein
 normal measurements in adults are:
•Head 35mm (anterior to posterior)
•Neck 10-15mm
•Tail 20mm
Acute pancreatitis
Pancreatic pseudocyst

Chronic pancreatis
spleen

Measurement:
Normal
Spleen Size
<13 cm
superior to
inferior axis
6-7cm in the
medial to
lateral axis
Simple splenic cyst septated splenic cyst Calcified splenic cyst

Pancreatic tail pseudocyst

that could be mistaken an
splenic abscesses Perisplenic abscess abscess in the splenic hilum
Splenic hemangioma
Splenule

Splenic metastases
 History of truma

perisplenic hematoma
splenic contusion splenic hematoma

Splenic rupture with a large Splenic infarct with a wedge shaped non
perisplenic hematoma vascularized spenic lesion
Renal parenchymal changes
Multiple renal cysts:
APKD Adult polycystic kidney disease
MCDK multi-cystic dysplastic kidney
Adult polycystic disease with polycystic kidneys and
polycystic liver
Ultrasound
Simple renal cysts will appear anechoic with well-defined
imperceptible walls, posterior acoustic enhancement
(amplification) and lateral shadowing (extinction) .

Cysts with hemorrhage or infection will demonstrate

echogenic material within the cyst, without internal blood
flow. Calcification may develop. Renal cell carcinomas in
contrast, although usually cystic in the setting of ADPKD, will
have solid components of thick septa with blood flow.
Complicated polycystic kidney disease
 Multicystic dysplastic kidney
The diagnosis of MCDK is often
made antenatally. A normal life
expectancy can be expected
as long as the contralateral
kidney is normal. Bilateral MCDK
is fatal.

Ultrasound: Lobulated renal

contour with multiple internal cysts of
varying sizes and shapes, cysts
typically non-communicating with
the ureter and between each other.
The renal parenchyma is usually
fibrous and echogenic with absent
or small hilar vessels. .
Ultrasound of renal cyst:
Bosniak classification system of renal cyst
 Complex
renal
cysts:
Bosnia 3
Mural nodule
Thick septation

Multilocular cyst with thin

septations

Calcified
Benign calcifications: small
punctate and milk of on CT hyperdense
calcium......Ignore 27 HU on a NECT

Very small non enhancing

nodules.....Follow
 LEFT: NECT with a smooth linear
calcification and nodular
calcification.RIGHT: Enhanced CT
shows enhancement ...... Excis

Enhanced CT shows enhancement of a

thick wall and a central area.....excise
Significant enhancement:
Unenhanced CT: 44 HU (left)Enhanced
scan: 61 HU (right) ..... Excise
Cystic lesion with a big Multiloculated cystic mass on US and
enhancing nodule ..... on CT..... Excise
Excise

The ultrasound image on the left shows

a thick septation.
There is a cystic lesion with a thin There is also a nodule in the wall of the
smooth non enhancing septation that cyst.
we can ignore. So we have two reasons to excise this
The other case is a thick enhancing cystic lesion.
septation that has to be excised.
Back pressure changes before and after
bladder evacuation
Urinary tract stones
Renal parenchymal calcification
Diffuse bladder wall thickening
bladder outlet obstruction
neurogenic bladder
infectious cystitis
cystitis from radiation or chemotherapy
Bladder volume can be
calculated by scanning
the bladder transversely
and longitudinally
Volume =
height × width × depth ×
0.5236
Bladder stone Stone in ???

Calcified
bladder mass
ureterocele Bladder diverticulum

Bladder hematomas
prostate
It typically
weighs
between 20-30
grams with an
average size
of 3 x 4 x 5 cm.
30 cc is a
commonly
used upper
limit for normal
volume
•there is an increase volume exceeding 30 mL
(width x height x length x 0.52)
•the central gland is enlarged, and is hypoechoic
or of mixed echogenicity
•calcification may be seen.
•post-micturition residual volume is typically
elevated
Seminal vesicle

the mean length was

estimated to be
around 3 cm with the
mean width at
around 1.5 cm
TAS: uterus in a 4-year-old girl.
The cervix is larger than the body of the uterus.
Pre-pubertal
uterus
• Tubular in shape .
• Cervix to corpus ratio
. 1/1
• Thin endometrial
stripe
Normal uterus
Size: Varies with age and parity .
• Average:
o Length=6– 8 cm .
o Ap = 3-4 cm .
o Transverse= 5cm
The small sized uterus is subdivided into
hypoplastic and infantile uterus.
Infantile uterus
• 17ys female with primary amenorrhea
The uterine hypoplasia is found in an array of
endocrine disorders, the uterine body/cervix
ratio is 2:1 in the majority of cases.
Endometrial appearance

According to phase
AP diameter
Proliferative 4-8 mm
Periovulatory 6-10mm
Secretory 7-14mm
How to measure endometrium
Normal ovaries
Appendix
•Begin scaning at the hepatic flexure down to the caecum
by placing the transducer in a transverse position and
applying deep graded compression to the displace the gas
and bring the bowel closer to the probe.
•The patient should point to the location of pain .
• we should include the entire pelvis of all females with right
lower quadrant pain and scanning the renal and biliary
systems of all patients with a normal appendix.
ULTRASOUND CRITERIA TO
DIAGNOSE APPENDICITIS
when the outer diameter of
the appendix measures
greater than 6 mm
•Echogenic inflammatory
periappendiceal fat
change
•The wall thickness can
Acute appendicitis.
measure almost 3 mm or Noncompressible, inflamed
greater appendix (arrowheads) lies next
to the normal well-
•An appendicolith may be compressable ileum. The lumen
present which will cast an is dilated and the diameter is 11
by 13 mm. Note the fluid-debris
acoustic shadow. level within the lumen.
Appendiceal mass

progressed
appendicitis can
demonstrate
a large
noncompressable
inflammatory mass
consisting of the
inflamed appendix,
mesentery and
omentum.
•perforated
appendix is
demonstrated when
the appendicular
wall has ruptured
producing fluid or a
newly formed
abscess.

•free fluid in the

periappendiceal
region
Transvaginal US orientation
 The transvaginal ultrasound probe is
placed in the anterior or posterior fornix.
This allows the probe to push up against
the side of the cervix.

Anteverted uterus. Probe in anterior Retroverted uterus. Probe in posterior

fornix. fornix.
This is how you obtain a
sagittal image of the uterus
Rotate probe 90
degrees to obtain a
transverse image
 cervix

fundus
bladder
endometriu
m
uterus vagina

These images are from the same patient. Notice the greater image
resolution with transvaginal imaging. You can better delineate the
endometrium, internal os, and character of the myometrium.