WFUMB Ultrasound Book 5.

6+ TECHNIQUE OF ABDOMINAL ORGANS

5. A structured systematic ultrasound examination of abdominal organs View enlarged image

(“6+ technique”)
Ingunn Furset, Giovanni Maconi, Odd Helge Gilja

Keywords: systematic ultrasound examination, abdominal organs, 6+ technique

When scanning the abdomen, it is important to do it in a systematic way, particularly

not to overlook important pathology. There are many ways to perform abdominal
ultrasound and here we will present one way to do it, called “6+” (Fig 5.1). This
method is based on the German tradition and further developed at National
Fig 5.1
Centre for Ultrasound in Gastroenterology, Haukeland University Hospital, and at
Overview over the 6 stations
University of Bergen. The examination ”6+” utilizes 6 stations or locations on the where the scanhead is
abdominal surface, from where the probe is positioned (see later), and the “+” refers positioned on a torso.
to scanning of the intestines. The more experienced the sonographer becomes, the
more flexibility he or she can apply during the scanning procedure. 5.2 The ultrasound examination “6+”
5.2.1 Station 1: Transversal scanning in the epigastrium
5.1 Preparations and equipment
Position the probe below the xiphoid process in the epigastrium, using a transverse
The patient should mainly be in a supine position, but moving to the left and right orientation of the ultrasound scan plane (Fig 5.2). In station 1, images of several
semi-lateral position is sometimes advantageous to improve visualization of internal structures will be obtained: The left lobe of the liver, the pancreas, the aorta, the
structures. The patient should preferably be fasting and have a well-filled urinary cava vein, and other vessels, which are also used as landmarks (Fig 5.3).
bladder. However, fasting is not a prerequisite, but will improve imaging by reducing
bowel air and peristalsis.
For the 6+ examination, start with a curvilinear probe (3-5 MHz), which gives the View enlarged image
best overview of abdominal organs, and then after station 6, change to a high-
resolution probe (7-12 MHz) for intestinal scanning.

Tips and tricks

• Be systematic when scanning

• Utilize pressure, rotation, tilting and sliding of the probe to optimize visualization Fig 5.2
An illustration of probe
• Use all 6+ stations for a complete work-up with less risk of missing placement in Station 1.
important pathology The probe is placed in
• Patient fasting will improve a deeper look into the abdomen the epigastrium, below
the xiphoid process in a
horizontal plane.

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WFUMB Ultrasound Book
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Fig 5.3
An overview of Station 1.
The abdominal aorta and the
cava vein are seen centrally
in the picture. Just anterior
to the aorta, the superior
mesenteric artery is visible.
The confluence between the
splenic vein and the inferior
mesenteric vein is seen
posterior to the pancreas
right next to the SMA. The
left lobe of the liver is visible
just anterior to the pancreas
5.2.1.1 The liver
The left lobe of the liver is best visualized during deep inspiration. Fan the probe
upwards and downwards to enable scanning of the entire lobe. Evaluate the surface
of the liver, the echogenicity, and characterize the parenchyma. In a healthy liver,
the parenchyma will be homogeneous and sponge-like, with a smooth surface with
sharp edges. In a fatty liver, the parenchyma will be fine granular, hyperechoic and often
exhibit acoustic attenuation with loss of vessel visibility.
View enlarged image
Fig 5.4
This image shows the left
lobe of the liver, the body
and part of the tail of the
pancreas and the splenic
vein with the confluence.
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5. 6+ TECHNIQUE OF ABDOMINAL ORGANS
5.2.1.2 The pancreas
The pancreas can be viewed through the stomach using the vessels (splenic and
portal vein, superior mesenteric artery) as internal landmarks (Fig 5.4). To improve
imaging the patient may inhale deeply or blow up the belly like a balloon. Furthermore,
the patient may sit in the bed or stand up to enable scanning through the left lobe of
the liver. Moreover, the patient can drink 1-3 glasses of still water/juice, thus utilizing
the stomach as an acoustic window.
The size of the pancreas has large variations, and the most important task is
therefore to evaluate the echostructure, the main duct, and look for possible lesions.
The parenchyma of the pancreas is slightly hypoechoic in young subjects, quite
similar to a healthy liver, but as a result of normal aging, obesity, or if the patient
has diabetes, the parenchyma becomes brighter. Sweep and fan the probe in all
directions to visualize as much of the pancreas as possible. The most distal tail of
the pancreas can often be seen in station 5.
The main pancreatic duct can be visualized as a thin tubular structure with a
hyperechoic wall. In the middle part of the pancreas, it runs horizontally. Normally, it
has a diameter below 2 mm, cut-off for pathology is generally 3 mm. However, the
duct-diameter increases slightly with age.
5.2.1.3 Aorta
The abdominal aorta should be scanned in both transverse and longitudinal sections.
In station 1 sweep the probe in a caudal direction to the bifurcation to exclude any
aneurysm, thrombosis or calliper variations. The normal abdominal aortas diameter is
< 2.5 cm in a male and < 2 cm in a female. Cut-off for pathology is usually 3 cm. Para-
aortal lymph nodes is best seen from station 1 sweeping along the aorta.
5.2.2 Station 2: Longitudinal scanning in the epigastrium
In station 2, the probe has been rotated 90 degrees clockwise from the transversal
position in the epigastrium to obtain sagittal sections where the left lobe of the liver,
the stomach and the large vessels can be observed (Fig 5.5).
5.2.2.1 The liver
Fanning through the left lobe of the liver in the upper epigastrium after deep inspiration
will enable detection of focal lesions and evaluation of the capsule. By sweeping towards
the patient’s right side, segment 1 of the liver (lobus caudatus) is often best observed.
WFUMB Ultrasound Book 5. 6+ TECHNIQUE OF ABDOMINAL ORGANS

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Fig 5.5
An illustration of probe Fig 5.6
placement in Station 2. A longitudinal plane of the
The probe is rotated 90 aorta acquired from Station
degrees clockwise from the 2. The gastric antrum
horizontal section in Station is seen in a transversal
1, to a sagittal section. section.

5.2.2.2 The stomach

View enlarged image
The gastric antrum is nicely visualized in station 2 facilitating standard measurement
of the antral area, where the superior mesenteric vein and the aorta is used as
landmarks. Wall thickness of the stomach may be detected from station 2.

5.2.2.3 The large vessels

To distinguish between the aorta and the cava vein, one can use graded compression
(cava is compressible, but not the aorta), evaluate wall thickness (aorta has thicker
walls) or use the Doppler to measure the velocities and pulsative wave patterns Fig 5.7
(3-phasic in cava and 2-phasic in aorta, which also has much higher velocities). A longitudinal section of
The abdominal aorta is visualized in its entire length looking for pathology (Fig 5.6). the cava vein. The liver,
the portal vein and the
If indicated, the coeliac trunk and the superior mesenteric artery (SMA) is analysed
pancreatic head are also
with colour and spectral Doppler. The cut-off values for significant stenosis are 300 visualized.
cm/sec for the SMA, and 270 cm/sec for the coeliac trunk peak velocities. Make
sure to position and size the Doppler sample volume correctly and to perform angle
correction always having below 60 degrees Doppler angle. 5.2.3. Station 3: Subcostal scanning in oblique sections
The cava vein has a thin wall and is easily compressible with the probe or by
performing the Valsalva manoeuvre (Fig 5.7). The cava vein is a part of a low- Station 3 is well suited to image the gallbladder and almost the whole liver by sliding
pressure system, and therefore it will exhibit calliper variations with inspiration and the probe from the upper epigastrium subcostally to the right (Fig 5.8). By asking
expiration and give rise to a 3-phasic spectral pattern. A non-compressible vein is a the patient to hold the breath in deep inspiration, the upper dome of the liver can be
marker of thrombosis, even not being visible. visualized, particularly important when looking for small focal lesions.

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Fig 5.8
An illustration of subcostal
probe placement in Station 3
5.3.3.1 The liver
While fanning through the hepatic segments evaluate the parenchyma, the
surface, the vessels, and bile ducts, making sure not to ignore any pathology. The
hepatic veins converge into the cava vein and are best seen subcostally from the
epigastrium. The hepatic veins have thinner walls with less echo and form sharp
angles when joining as compared to the portal vein (Fig 5.9).
View enlarged image
Fig 5.9
In this image the right lobe of
the liver is seen from Station
3. Hepatic vessels are visible
inside the liver with the right
and middle hepatic veins
seen most distinctly.
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5. 6+ TECHNIQUE OF ABDOMINAL ORGANS
The portal vein enters in the liver hilum and soon divides into a right and left branch.
Normally, the portal vein has fairly constant flow at velocities 15-40 cm/sec (cut-off
13 cm/sec) and the diameter should be below 13 mm. Low portal flow velocity and
large diameter indicate portal hypertension as often seen in cirrhosis. The hepatic
artery and the common bile duct are often best viewed in the liver hilum.
Typically, the common bile duct is below 6 mm in diameter in a patient below 60
years of age.
The size of the liver can be measured subcostally by placing the probe vertically in
the midclavicular line. Rock the probe until the diaphragm and the inferior capsule
is observed, then measure the maximal antero-posterior diameter. Normally, the
size will be 13-16 cm in males, and 12-15 cm in females.
5.3.3.2 The gallbladder
In most patients, station 3 will be the optimal station to examine the gallbladder (Fig
5.10). The size of the gallbladder should be measured in a transverse diameter
(normally less than 4 cm) and the wall thickness should be less than 4 mm. Fan and
sweep through the whole gallbladder looking for stones and polyps.
View enlarged image
Fig 5.10
The right lobe of the liver
viewed from Station 3. A
medium-filled gallbladder is
seen just above the centre of
the image. The right kidney in
a transverse section is visible
posterior to the liver.
WFUMB Ultrasound Book
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Fig 5.11
An illustration of probe
placement in Station 4.
The probe is placed in an
intercostal position.
5.3.4. Station 4: Scanning from the right side
In the fourth station, it is advantageous to have the patient’s arm stretched upwards
and to change hand grip on the probe. Place your elbow on the patient’s hip or at
the bed and hold the probe with the four fingers underneath and the thumb above
the probe (Fig 5.11). This will give more stability when fanning and sliding vertically.
5.3.4.1 The liver
Start by placing the probe intercostally and fan through the liver (Fig 5.12). Identify
the portal vein and use the colour Doppler to evaluate flow direction and spectral
Doppler to measure the velocity. This view also gives good access to the hepatic
artery and the common bile duct. By sliding the probe anteriorly, the gallbladder
is usually visualized from this position and serve as a “back-up” station, if the
gallbladder is not adequately visualized from station 3.
5.3.4.2 The right kidney
By sweeping the probe posteriorly and slightly caudally, the right kidney can be
examined in both transversal and longitudinal sections. First, compare parenchymal
echogenicity of the liver and the kidneys (Fig 5.12).
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5. 6+ TECHNIQUE OF ABDOMINAL ORGANS
These will be quite similar to each other in a healthy person or slightly more
hypoechoic in the kidney. In fatty liver, the contrast will typically be greater, and
in chronic renal diseases the kidney parenchyma will often be more hyperechoic
compared to the liver. Second, measure the size of the kidney. As a rule of
thumbs, the kidney should be more than 10 cm in the longitudinal section and the
parenchymal width should be over 10 mm in a healthy subject. Eyeballing is for the
experienced operator. Third, fan and sweep through the kidney in both directions
looking for cysts, solid tumours, stones, and hydronephrosis. The renal vessels and
origin of the ureter is also nicely viewed in station 4 (Fig 5.13).
View enlarged image
Fig 5.12
An image of the right kidney
and the liver acquired from
Station 4. A shadow from a
costa is visible centrally in
the image. To the right in the
image, the gas-filled right
colonic flexure is observed.
The right adrenal gland may sometimes be seen as a small and thin structure
cranially to the kidney, particularly in cases with tumours expanding the organ.
5.3.5. Station 5: Scanning from the left side
In station 5, the probe is positioned in left lateral side, obliquely and intercostally
and tilting to look for the spleen. Then moved caudally and posteriorly to scan the
left kidney (Fig 5.14).
WFUMB Ultrasound Book
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Fig 5.13
The central vessels of the
kidney highlighted with colour
Doppler.
View enlarged image
Fig 5.14
An illustration of probe
placement in Station 5.
The probe is placed in an
intercostal position; behind
the mid-axillary line to view
the normal-sized spleen.
5.3.5.1 The spleen
Move the probe over to the left lateral side and shift hand grip back to the “pencil-
grip”. Hold the probe obliquely, intercostally and fan the probe searching for the
spleen, which typically is positioned more cranially and posteriorly than intuitively
thought (Fig 5.15).
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5. 6+ TECHNIQUE OF ABDOMINAL ORGANS
View enlarged image
Fig 5.15
The image shows the spleen
acquired from Station 5.
The length of the spleen is
indicated between the two
measurement points (yellow
crosses).
If not spotted immediately, ask the patient to raise the left arm and take a deep
breath. Measure the maximal length (generally below 12 cm) as splenomegaly is
an important disease marker. Subsequently, fan through the spleen in search for
cystic and solid lesions.
5.3.5.2 The left kidney
Next, move the probe caudally and posteriorly to scan the left kidney in longitudinal
and transversal sections. In a few cases, the probe needs to be placed on the
patient’s back to visualize the kidney properly. Fan and sweep through the left
kidney as described in station 4.
5.3.5.3 The pancreas
The pancreatic tail is often nicely viewed in station 5 using the spleen as an
acoustic window. Use the colour Doppler to detect the splenic vein and the tail of
the pancreas can be visualized close to the vein as a hyperechoic fine-granulated
structure adjacent to the spleen, kidney and the left colonic flexure.
WFUMB Ultrasound Book
5.3.6. Station 6: Scanning in the suprapubic region.
At this station, start in the midline using transversal planes and angle the probe
downwards until you observe the urinary bladder (Fig 5.16). Optimal visualization
requires a full bladder.
View enlarged image
Fig 5.16a
An illustration of probe
placements in Station 6,
showing both a transverse
and a sagittal section.
View enlarged image
Fig 5.16b
An illustration of probe
placements in Station 6,
showing both a transverse
and a sagittal section.
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5. 6+ TECHNIQUE OF ABDOMINAL ORGANS
5.3.6.1 The urinary bladder
Fan through the bladder both in transversal and longitudinal sections (Fig 5.17).
Evaluate if there is any retention, stones, or tumours. Most scanners have built-in
software for volume calculation by utilizing height, width and depth of the urinary
bladder.
View enlarged image
Fig 5.17
An image of the urinary
bladder in a transverse plane
5.3.6.2 The genitals
In males, examine the prostate gland behind the bladder and look for hyperplasia
(above 4 x 4 cm) and possible lesions. In females, the body of the uterus is most
often lying on top of the bladder with the cervix just posterior to the bladder (Fig
5.18). However, the position of the uterus varies substantially and can sometimes
be blurred by air in the sigmoid colon. Similarly the ovaries can be difficult to detect,
but is often seen on each side of the uterus in transversal sections. The operator
should sweep and fan through the genitals looking for cystic and solid lesions as
well as assessing pregnancy, if relevant. The vagina is positioned posterior to
the urinary bladder and is viewed as a multi-layered tubular structure. Finally, the
rectum is imaged through the vagina or prostate, respectively, looking for increased
wall thickness, rectal content and tumours. Often the rectum contains air or faeces
precluding a good view to the posterior wall. However, luminal air may aid in
detecting the mucosa-lumen interface of the anterior wall of the rectum.
WFUMB Ultrasound Book 5. 6+ TECHNIQUE OF ABDOMINAL ORGANS

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Fig 5.18
The urinary bladder and the
uterus in a sagittal section. Fig 5.19
The body of the uterus is Illustration of the path of
visible superior (to the left in the probe for investigation
the image) to the bladder, and of the large intestine. The
the vagina is seen posterior transducer is moved from
to the bladder. The rectum the right iliac region and
with some gas is visualized tracks the colon distally to
posterior to the vagina the rectum

5.3.7.2 The small intestine

5.3.7. Station +: Scanning of the bowels
The examination of the small bowel is challenging due to its length and tortuous course.
Actually, scanning of the bowels starts in station 6 using a low-frequency curvilinear The terminal ileum is a convenient starting point and should be followed proximally
probe to image the rectum. Thereafter, the probe is exchanged to a high-frequency until it disappears. Subsequently, vertical, parallel and overlapping scanning planes,
(7-12 MHz) scan-head to enable scanning of finer details of the intestinal loops. like mowing the lawn, are performed with the linear transducer looking for thickened
Start in the lower right part of the abdomen by identifying the iliac vessels and the walls, target lesions (pseudo-kidney sign) and dilated bowel loops.
psoas muscle and then sweep the transducer towards the umbilicus to define the
terminal ileum and possibly the appendix (Fig 5.19). The image quality and access
View enlarged image
to deeper structures can be improved by applying gradual compression with the
ultrasound probe. Subsequently, sweep the probe cranially to detect the ileocecal
valve and the coecum.

5.3.7.1 The large intestine Fig 5.20

Illustration of the sweep
path of the transducer while
The examination of the large bowel is performed by scanning systematically from
investigating the small
the coecum following its course in distal direction via the ascending and transverse intestine. Starting at the right
colon. The flexures often need to be scanned from an intercostal position. The iliac region, the transducer
descending colon is found in the left flank and can be scanned continuously down is moved upwards in a back-
to the sigmoid colon, which is easily identified when crossing the iliopsoas muscle and-forth motion (“mowing
and the iliac vessels (Fig 5.20). the lawn”), covering as much
of the small intestine as
possible

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WFUMB Ultrasound Book
5.3.7.3 The appendix
The appendix is classically positioned between the distal ileum and the psoas muscle
and can be viewed as a sausage-shaped organ originating at the coecum with a
normal transversal diameter less than 6 mm. However, quite often the appendix is
located elsewhere in the abdomen and is difficult to scan adequately, particularly
when lying retro-coecally. Having detected the appendix, graded compression is
used to evaluate pain response, and to look for wall thickness, distention, fecaliths
and tumours.
The 6+ stations to scan the abdomen systematically:
• Station 1. Epigastric transverse scan planes: Pancreas, large vessels,
left liver, gastric antrum
• Station 2. Epigastric sagittal sections: Aorta, cava vein, antrum, left
liver, pancreas
• Station 3. Liver, gallbladder, hepatic veins, portal vein
• Station 4. Liver, kidney, portal vein, hepatic veins, bile ducts
• Station 5. Spleen, kidney, pancreatic tail
• Station 6. Urinary bladder, uterus, ovaries, prostate, rectum
• Station + Small and large intestines, appendix, mesentery
5.4 General comments
The indications for performing a 6+ ultrasound examination of the abdomen varies
a lot, but frequently pain is a key symptom, sometimes acute, sometimes sub-
acute and sometimes chronic pain. Accordingly, time does not always allow a
complete 6+ examination if the pain is highly acute and strenuous; then a focused
point-of-care-ultrasound (POCUS) using only one or a few stations should be
performed. Furthermore, the eFAST protocol for emergency conditions can easily
be incorporated in 6+ as four of the stations are similar.
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5. 6+ TECHNIQUE OF ABDOMINAL ORGANS
Under other circumstances, the clinical request is often a simple one: is there
ascites? Any hydronephrosis? Are there gallbladder stones? Any splenomegaly?
In cases like this, a focused POCUS examination using only 1-2 stations is often
adequate to detect or rule out diseases.
Remember
• If time or pressing symptoms in patient do not allow for a complete 6+
examination, then POCUS or eFAST with fewer stations can be performed
Recommended reading
• Atkinson NSS, Bryant RV, Dong Y, et al. How to perform gastrointestinal
ultrasound: Anatomy and normal findings. World J Gastroenterol 2017;
23:6931-6941.
• Dietrich CF, Hoffmann B, Abramowicz J et al. Medical Student Ultrasound
Education: A WFUMB Position Paper, Part I. Ultrasound Med Biol. 2019
Feb;45(2):271-281.
• EFSUMB Course Book on Ultrasound. Ed CF Dietrich. 2012. 821 pages, ISBN
978-0-9571581-0-8.
• Hoffmann B, Blaivas M, Abramowicz J, et al. Medical Student Ultrasound
Education, a WFUMB Position Paper, Part II. A consensus statement of
ultrasound societies. Med Ultrason. 2020 May 11;22(2):220-229.
• Nylund K, Maconi G, Hollerweger A, et al. EFSUMB Recommendations and
Guidelines for Gastrointestinal Ultrasound - Part 1: Examination Techniques
and Normal Findings (Long version). Ultraschall Med. 2017 Jun;38(3):273-284.
• Ødegaard S, Gilja OH, Gregersen H. Eds. of book: Basic and New Aspects
of Gastrointestinal Ultrasonography (502 pages). Publisher: World Scientific.
Singapore. 2005. ISBN 981-238-845-1.
• Ødegaard S, Gilja OH, Matre K. Editors. Innføring i abdominal ultrasonografi.
2009, 1-160. Fagbokforlaget. ISBN 978-82-450-0727-5.
• Schmidt G, Greiner L, Nuernberg D. Differential diagnosis in ultrasound
imaging. 2nd edition. Georg Thieme Verlag ISBN-13: 978-3131318923, 2015.
WFUMB Ultrasound Book 5. 6+ TECHNIQUE OF ABDOMINAL ORGANS

5.5. Videos

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