Abdominal Sonography

Tuesday, March 8, 2022 11:39 AM

Abdominal Ultrasound
• General survey for entire abdominal viscera that contains all solid organs

Indications:
• Localized abdominal pain with indefinite clinical features
• Suspected intra-abdominal abscess (infection or presence of blood). Pyrexia of unknown origin
• Non-specific abdominal mass
• Suspected intra-abdominal fluid (ascites)
• Abdominal trauma

Preparation:
• Fasting gallbladder
• Mild Laxative: to clear stool
○ Dulcolax
○ Castor Oil

Liver-Gross Anatomy
• Largest solid organ in RUQ
• Easiest to scan due to its scan
• Provides good acoustic window
○ Acoustic Window = liver would help us see through other organs
• Morison's Pouch: Hepatorenal Recess or Right Subhepatic Space
○ Between liver and right kidney
○ Free of fluid
▪ If with fluid = blood or ascites
○ Glisson's capsule - fibrous connective tissue that encapsulates the liver
▪ Echogenic capsule or border
○ Falciform ligament: attachment of right and left lobe

Normal Sonographic Appearance

• Liver parenchyma has moderately echogenic and homogenous echotexture
○ Fluid anechoic
• Medium gray tones and only interrupted by blood vessels
• Left lobe is smaller and triangular
• Liver parenchyma is interrupted by the hepatic artery, portal veins

Indications for Liver Ultrasound

• The common indication is Jaundice

Scanning Techniques
• Transducer: 3.5 MHz
• Probe: Longitudinal and Subcostal Approach
○ Vertical
○ Subcostal: scooped inside
• Recommended Standard Positioning: Supine and left lateral decubitus (liver is located at RUQ; to
clear the right side)
○ Can angle towards the right

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Measurement
• Beyond 15cm: hepatomegaly

Hepatic Steatosis
• Due to accumulation of lipids
○ Smoke, heavy drinker
• To determine in UTS, look at echogenicity
○ There is an extreme echogenicity difference of liver from kidney
○ If liver is whiteish = hepatic steatosis

Liver cirrhosis
• Hepatocellular necrosis: some parts of the liver is dead
• No mass but all parts is heterogeneous
• Complex echogenicity
• Fluid-like appearance and solid appearance mix

Hepatic Hemangioma
• Most common benign tumor of the liver
• Heterogeneous and hyperechoic (compared to liver)

Hepatocellular Carcinoma
• Malignant tumor of the liver
• More anechoic than liver
• Complex (dotted echogenic fossa and there's a dark part in masses)

Hepatic Cyst
• Fluid filled mass
• Anechoic
• Rotate the probe longitudinal (humaba - vessel; inikot and no difference - cyst)

Polycystic Liver Disease

• Many cyst

Metastatic Liver Disease

• Multiple masses
• Hypoechoic mass with bull's eye appearance
• Echogenic Calcifications

Liver Schistosomiasis
• Heterogeneous

Gall Bladder
• Pear-shaped muscular organ with a hollow echo-free lumen
• Aid in digestion
• Gall bladder should be filled with bile, thus why we needs to fast
○ If you eat, it will be emptied since it will release bile
• If no bile, it cannot be visualized
• Thin walls with echo lucent
• If onti lang laman = wall is thicker
• Deep suspended inspiration - to be viewed

Main Lobar Fissure

• Echogenic line that connects the gallbladder to the portal vein (transverse and circular, can be

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 • Echogenic line that connects the gallbladder to the portal vein (transverse and circular, can be
mistaken as a cyst; rotate probe humaba - vessel; inikot and no difference - cyst)

Gallbladder Variations
• Bilobed-hourglass shaped - indent in middle; connecting
• Folded Gallbladder
○ Phrygian cap
▪ Fold fundus towards the body
○ Junctional fold
▪ Body and neck
▪ Hartmann's pouch
• Septated (multiple septa)

Indications:
Cholecystitis - inflammation of gallbladder
• Determined in UTS by looking at the wall
• Thickened wall = can suggestive of cholecystitis
○ Nondistended GB thick wall is normal
○ But if distended (fasting) and wall is still thickened, it can indicate cholecystitis

Ascaris: parasitic invasion (worm)

Scanning Techniques
• Transducer: 3.5 MHz
• Position: supine, left lateral decubitus and upright

Gallstones
• Highly reflective echogenic
• Echogenic focus with acoustic shadowing - gallstone
○ Measure gallstone
• Mobile stones and small stones (possibility of blockage in cystic duct)
○ Can cause inflammation

Parasites in the Gallbladder

• Longitudinal echogenic focus
• Spaghetti

Gallbladder polyp
• Medium level echo attached to the wall
• Echogenic but does not cast any shadow

Gallbladder Adenomyomatosis
• Comet tail reverberation artifact

Bile Sludge
• Non-shadowing, low-level, gravity dependent echoes
• Biliary sand / biliary sediments
• Appear as sand
• Moves along the bile

Portal Triad
• Portal vein, hepatic artery, common bile duct
• Transverse scanning = mickey mouse appearance
• To determine - color doppler

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 • To determine - color doppler
○ Artery and vein will color
○ CBD: bile

Abdominal Aorta (AA)

• Continuation of thoracic aorta at the level of T12 vertebrae
• Largest artery of the body
• Situated at the abdomen at T12-L4
○ Above T12 - thoracic aorta
○ Below L4 - AA bifurcates into L and R iliac artery that supplies blood to the lower part of the
body
• Asses entire length of AA
• First to look into in scanning
• Part of routine

Scanning technique
• Longitudinal Scanning
○ Move it downward
○ Thin echogenic walls and anechoic contents
• Transverse Scanning
○ Cross sectional diameter of aorta at various levels
○ Appearance would be circular
○ Epigastric up to Umbilicus
○ Compress part of the abdomen

Aneurysm: weakened wall and it has tendency to bulge/loosen

• Requires careful examination
• Never compress the abdomen if there's a suspected aneurysm; any pressure would cause rupture

Atheromatous
• Caused by old age or increase amount of fatty deposits in vessel caused by poor diet
• Uneven walls
• Fatty deposit or flake would bulge through the wall (stenosis)
• Measure inside (the black part)

PANCREAS
• Next to scanning AA
• Posterior to the stomach
○ Difficult to image especially if stomach is filled with gas
• Head - largest in diameter
• Tail - smallest in diameter
• Discourage to smoke or chew gum before the procedure

Physiology of Pancreas
• Exocrine Function: trypsin
• Endocrine function: insulin

Scanning Technique
• Transverse scanning
○ Possibility that duodenum gas obstructs head of pancreas
○ Pancreas is best viewed and scanned by using left lobe as the acoustic window and the
splenic vein is the acoustic marker
• Longitudinal Scanning
• Decubitus Scanning

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 • Decubitus Scanning
• Erect scanning
○ Water loading technique
○ Instruct patient to drink water as it can act as an acoustic window
▪ UTS travel long distances in fluid

Sonographic appearance of Pancreas

• Echogenic; hyperechoic compared to kidneys spleen and liver
• Can be isoechoic to liver and spleen
• Echogenicity from hyperechoic or hypoechoic depending on age

Acute Pancreatitis
• Inflammation of pancreas
• If it becomes swollen = hypoechogenic
• Often find fluid surrounding the pancreas
• Dotted hyperechogenic focus

Pancreatic Tumor
• Solid organ

SPLEEN
• To assess damage; due to extreme conditions

Indication
• Splenomegaly: enlargement of spleen

Scanning Technique
• Longitudinal and transverse
• Supine or oblique or Right Lateral Decub
• Follow orientation of ribs

Homogeneous Splenomegaly
• Infection

Echonococcal (Hydatid) cyst

• Parasitic

Splenic Abscess
• Fluid structure
• Echoic; echolucent
• Hypoechogenic

KUB
• Routine abdominal scanning or separated
• UTS cannon asses renal function
• Full bladder is advised - drink lots of fluid if KUB
• Isolated renal UTS - no need to full the bladder
• Abdominal UTS - full bladder before scanning
• Catheter clamped 1h before examination; drink 1 litre of fluid
• 3.5-5MHz Curvilinear probe
• Adults:" 3.5MHZ (Normal/obese)
○ 5 MHz (slim)

Kidneys

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Kidneys
• T12-L3 depending on body habitus
• Bean-shaped

Renal Capsule/rind
• Echogenic

Renal Cortex
• Filtration
• Hypoechoic or isoechoic to liver or spleen

Renal Sinus
• Greatest echogenicity

Renal Pyramids
• Hypoechoic to anechoic areas
• Equally spaced

Transverse axis: round or c-shaped

Entire cortical to sinus - parenchymal thickness

Away from ribs to get better FOV

Scanning technique
• Supine
• L and R lateral decubitus
• Spleen: posterior approach; partially acoustic window
• Right Kidney: anterior, lateral, posterior
• Left kidney posterior approach

Supine
• Angle 10-20 degrees to avoid rib shadow
• Tilt/fan anteriorly and posteriorly

Severe hydronephrosis - bear claw sign

Acute: cannot be seen in UTS

Chronic: remarkable thickening in wall

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