Sono Grundkurs

Ultrasound Teaching
Manual
Ein Arbeitsbuch für den Einstieg
The Basics of Performing and Interpreting Ultrasound Scans
Online-Version in via medici
Matthias Hofer Fourth Edition
Matthias Hofer
Mit GIT-Bildmaterial von
Alexiscontributions
With Müller-Marbach
by
Alexis Müller-Marbach and Jasmin D. Busch

4 in 1: SK-Haltung,
Sonobild + Anatomieskizze

10. Auflage

4 in 1:
• Transducer position
• Ultrasound image
• Anatomic diagram
• Illustrative online videos

+ anschauliche
Videofilme online!
 The Most Important Planes in Abdominal Ultrasound

(UA = upper abdomen; LA = lower abdomen)

Sagittal upper abdomen Sagittal upper abdomen Oblique lower abdomen

left paramedian plane right paramedian plane para-iliac plane

Transverse epigastric plane Transverse upper abdomen Oblique right upper abdomen

Right oblique subcostal plane Longitudinal transhepatic plane Transverse right

(hepatic veins) midabdomen

High plane of the left flank Median sagittal suprapubic plane Transverse suprapubic plane

In this book, the point at the end of the position mark on the transducer corresponds to the right edge
of the respective image. Think about which organs will be visualized in which respective imaging plane.
To find the solutions, fold this page out and look on the back.
Standard Planes with Appropriate Transducer Position and Drawing Templates

1. Sagittal upper abdomen,

1
2
3 left paramedian plane (aorta)
13 9 26 Visualized organs and vessels:
23 Skin (1), subcutaneous fatty tissue (2), rectus abdominis
32 a
32 33
17
muscle (3), lung (47), left lobe of the liver (9), stomach
12
34
13
(26) pancreas (33) aorta (1 ) celiac trunk (32) le t gastric
46 artery (32a), superior mesenteric artery (17), superior me-
25 b
47 15 senteric vein (23), diaphragm (13), five hypoechoic „eggs“:
35
35
esophagus (34), crus of diaphragm (13), vertebral body (35)
le t renal vein (2 ) hori ontal part o the duodenum (46)
confluence of the portal vein (12)
2 1
3 < 45° 2. Sagittal upper abdomen,
13
9
26 right paramedian plane (IVC)
11 18 66
47 33 Visualized organs and vessels:
10 Skin (1), subcutaneous fatty tissue (2), rectus abdominis
24 a
9a muscle (3), lung (47), diaphragm (13), right atrium (114),
stomach (26) pancreas (33) caudate lo e o the liver ( a)
16
35 in erior vena cava (16) verte ral ody (3 ) right renal
114 artery (24a), branch of the portal vein (11) with accompa-
47 45 nying ile duct ranch (66) and ranch o the hepatic artery
(18), main vein (10) of the left lobe of the liver (9), acoustic
shadow (45) behind the vertebral bodies (35)
1
2 3. Oblique lower abdomen,
3/4 para-iliac plane
21 21 a Visualized organs and vessels:
22 a
Skin (1), subcutaneous fatty tissue (2), common iliac vein
22 (22), external iliac vein (22a) and internal iliac vein (22b),
22 b common iliac artery (21), external iliac artery (21a) and
21 b internal iliac artery (21b), vertebral body (35), rectus
35
abdominis muscle (3) or oblique muscles (4)

1
2 4. Transverse epigastric region
3
7
(celiac trunk)
8 26 Visualized organs and vessels:
46 18 32
Skin (1), subcutaneous fatty tissue (2), rectus abdominis
9
33
(3), ligamentum teres (7) and falciform ligament (8), liver
11 19 ( ) stomach (26) pancreas (33) duodenum (46) portal
vein (11), hepatic artery (18), splenic artery (19) from the
16
15 20 celiac trunk (32), splenic vein (20), aorta (15), inferior vena
13
13 cava (16) diaphragm (13) verte ral ody (3 )
35

2
1 5. Transverse upper abdomen
3 (renal vein crossing)
7 74 Visualized organs and vessels:
9 8 Skin (1), subcutaneous fatty tissue (2), rectus abdominis
26
(3), ligamentum teres (7) and falciform ligament (8), liver
33 a
33 b ( ) stomach (26) gastric all (74) pancreas (33) duode-
12
17 33 c num (46) con luence o the portal vein (12) superior me-
46 senteric artery (17), splenic vein (20), aorta (15), inferior
16 15 20 vena cava (16) right renal artery (24a) and le t renal artery
13 (24b), diaphragm (13),vertebral body (35)
25 b
35
24 a 24 b

2
1
6. Oblique right upper abdomen
3
7
(porta hepatis)
10
26
Visualized organs and vessels:
11 18
Skin (1), subcutaneous fatty tissue (2), rectus abdominis
33
66 46 20 17 (3) ligamentum teres (7) liver ( ) stomach (26) pancreas
11
25 b
(33) duodenum (46) con luence o the portal vein (11)
11 hepatic artery (1 ) common ile duct (66) splenic vein
15
9 (20), aorta (15), right renal artery (24a) and left renal
16
13
24 b
artery (24 ) in erior vena cava (16) le t renal vein (2 )
35
Standard Planes with Appropriate Transducer Position and Drawing Templates

2
3
1
7. Right oblique subcostal plane
(hepatic veins)
Visualized organs and vessels:
Skin (1), subcutaneous fatty tissue (2), rectus abdominis
9 muscle (3), liver (9), hepatic veins (10), diaphragm (13),
10 13 in erior vena cava (16) acoustic shado (4 ) ehind lung
(47), measurement of width of hepatic veins ( ) in the
45 periphery o the liver < 6 mm
16

47

4
2 1
8. Longitudinal transhepatic plane
showing right kidney
9
43 Visualized organs and vessels:
Skin (1), subcutaneous fatty tissue (2), oblique muscles
29 45
(4), liver (9), hepatic veins (10), diaphragm (13), lung (47),
13 30 31 renal parenchyma (29), medullary pyramids (30), renal
9 44 caliceal system with renal pelvis (31), acoustic shadow
(45) behind colon (43), connective tissue (5), psoas major
47 5
13
35 muscle (44), vertebra (35), diaphragm (13)

1 9. Transverse plane showing right

2
3 kidney and IVC
Visualized organs and vessels:
9 80
26
Skin (1), subcutaneous fatty tissue (2), rectus abdominis
10 17
14 muscle (3), liver (9), hepatic veins (10), gallbladder (14),
46 33
33 gall ladder all ( 0) stomach (26) duodenum (46) renal
29 12 15 25 b parenchyma (29), medullary pyramids (30), renal caliceal
16
30 24 b system with renal pelvis (31), psoas major muscle
13 35
(44), vertebra (35), right renal artery (24 a), right rena
24 a
44
lvein (2 a) in erior vena cava (16) aorta (1 ) con-
fluence of the portal vein (12), pancreas (33), superior
mesenteric artery (17)
2 1
116 10. High plane of the
43 46
left flank (spleen)
13 Visualized organs and vessels:
Skin (1), subcutaneous fatty tissue (2), intercostal muscles
37 (116) lung (47) diaphragm (13) spleen (37) stomach
45 (26) stomach all (74) small o el (46) colon (43) tail
47 74
33 of the pancreas (33), splenic vein (20)
26 Caution:
20 Top edge of image = lateral
Bottom edge of image = medial
1
2
3
48
11. Median sagittal suprapubic plane
46
77
(bladder and uterus)
Visualized organs and vessels:
51 a Skin (1), subcutaneous fatty tissue (2), rectus abdominis
39 38
muscle (3), acoustic shadow (45) behind the small bowel
41 (46) and pu ic one (4 ) ladder (3 ) ladder all (77)
78 43 d
reverberation artifacts (51a), uterus (39), endometrium
45 40
46 46 (78), vaginal portion (os) of cervix (40), vagina (41),
122
rectum (43d), rectouterine pouch of Douglas (122)

1 6
2
12. Transverse suprapubic plane
46
3
(bladder and prostate gland)
Visualized organs and vessels:
38
51 a Skin (1), subcutaneous fatty tissue (2), rectus abdominis
muscle (3) linea al a (6) acoustic shado (4 ) ehind
45 45
the small o el (46) acoustic enhancement (70) ehind
77
the urinary bladder (38) with jets of urine from the ureteric
70 42
orifices, bladder wall (77), reverberation artifacts (51a),
43 d prostate (42) or ovaries (91), rectum (43d)
Ultrasound Teaching
Manual
The Basics of Performing and
Interpreting Ultrasound Scans

Fourth expanded and revised edition

Matthias Hofer, MD, Associate Professor, MPH,

MME (Univ. Bern)
Director of Education at the University Institute
of Diagnostic, Interventional and Pediatric
Radiology (DIPR)
Dept. Head: Univ.-Prof. Johannes Heverhagen,
MD, Inselspital Bern, Bern University, Switzerland

With Ultrasound Images from:

Alexis Müller-Marbach, MD
Head of Dept. of Gastroenterology, Hepatology
and Palliative Care
Helios Hospital Niederberg, Germany

Jasmin D. Busch, MD, Associate Professor

Section Head of Pediatric Radiology,
Inselspital Bern, Bern University, Switzerland

930 Images

Stuttgart · New York · Delhi · Rio de Janeiro

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Title of the German edition: Sono-Grundkurs
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4 Contents

Standard planes (front cover flap) Transverse plane, hepatic veins 52

Right heart failure
Physical principles
Normal variants, fatty liver 53
Image generation, sound transmission, reflection 8
Focal fatty infiltration, focal sparing in 54
Echogenicity, frequency ranges 9 fatty infiltration
Operation and features of ultrasound units 10 Cysts, echinococcosis (CE) 55
Selection of ultrasound units, types of transducers 11 Echinococcosis (CE), hepatic hemangiomas 56
New techniques Focal nodular hyperplasia (FNH) 57
Panoramic imaging, 3D, Clarify Vascular Enhancement 12 Cirrhosis of the liver 58
Harmonic imaging, phase inversion, 13 Hepatocellular carcinomas, liver abscesses 59
Contrast agents 14 Liver metastases, hypervascular metastases 60
Ultrasound CT 15 Hypovascularized liver metastases 61
Pulse compression, precision upsampling 16 Quiz 62
Diagnostic ultrasound catheter 17
Lesson 5
Artifacts
Reverberation, section thickness, 18 Kidneys, Adrenal Glands, Renal Transplants,
acoustic enhancement Spleen
Acoustic shadowing, mirror-image artifacts 19 Anatomy of the kidneys and adrenal glands 64
Side-lobe artifact, quiz for assessing progress 20 Normal findings 65
Practical tips and tricks for the beginner 21 Normal variants, renal cysts 66
Kidney degeneration, nephritis 67
Lesson 1
Urinary obstruction 68
Retroperitoneum, Sagittal plane Differential Diagnosis of Urinary Obstruction 69
Anatomy 24 Renal calculi, renal infarction 70
Upper retroperitoneum, normal findings 25 Benign renal tumors, malignant 71
Lower retroperitoneum, normal findings 26 renal tumors, adrenal tumors
Aortic aneurysm 27 Normal findings 72
Right heart failure 29 Determining the size of a renal transplant, 73
Quiz 30 lymphoceles
Spleen
Lesson 2 Anatomy, examination technique 74
Spleen size, splenomegaly 75
Retroperitoneum, Transverse Plane Splenomegaly, splenic infarcts, practical suggestion 76
Anatomy 32 Lymphomatous infiltration, splenic hematomas, 77
Normal findings 33 hyperechoic lesions, splenic cysts
Age-related echogenicity 34 Quiz 78
Acute pancreatitis, chronic pancreatitis 35
Pancreatic tumors 36 Lesson 6
Retroperitoneal lymph nodes 37 Thyroid Gland, Lymph Nodes,
Quiz 38 Gastrointestinal Tract
Anatomy, volumetric measurements, normal values 80
Lesson 3 Normal findings 81
Porta Hepatis, Gallbladder, Biliary Tract Goiter 82
Anatomy 40 Focal solid nodules, thyroiditis 83
Porta hepatis Lymph nodes
Normal findings 41 Neck: lymph nodes 84
Portal hypertension 42 Differential diagnostic criteria, perfusion parameters 85
Portal vein thrombosis, lymph nodes 43 Differential diagnostic criteria, 86
reactive inflammatory
Gallbladder
Retroperitoneal lymph nodes 87
Cholecystitis 44
Gastrointestinal tract
Differential diagnosis of cholecystitis 45
Anatomy, wall layers 88
Gallstones 46
Gastric tumors 89
Gallbladder polyps, cholestasis 47
Crohn's disease 90
Biliary tract 48
Intestinal intussusception, hernias, 91
contrast enema
Lesson 4
Wall thickening, diarrhea, appendicitis 92
Liver Fecal impaction, colitis, colon carcinoma 93
Anatomy of the segments of the liver 50 Diverticulitis 94
Sagittal plane, organ size, lateral angle 51 Quiz 95
 Physikalische Grundlagen Contents
/ Technik 11
5

Lesson 7
Where Do I Find Which Chapter?
Bladder and Reproductive Organs
Anatomy 98
Bladder
Examination technique, determining postvoiding 99 Physical Principles 7
residual bladder volume
Indwelling catheter and differential diagnosis of 100
cystitis, wall thickening, internal echoes and Lesson 1
sedimentation, ureteral peristalsis
Reproductive organs Retroperitoneum,
23
Prostate and testis 101 Sagittal Plane
Undescended testis, orchitis, hydrocele 102
Endovaginal ultrasound, image orientation 103
Lesson 2
Uterus: normal findings 104
Uterine tumors 105 Retroperitoneum,
Ovaries: volume, menstrual cycle phases 106 31
Ovarian cysts and tumors 107
Transverse Plane
Pregnancy testing 108
Placenta position and gender determination 109 Lesson 3
Quiz 110
Porta hepatis, Gallbladder,
Lesson 8
Biliary Tract 39
FAST, eFAST, Lung, FAST algorithm
eFAST algorithm 112
114 Lesson 4
Seashore sign, barcode sign
Lung mobility, pulmonary pulse 115
Lung point in pneumothorax 116 Liver 49
Pleura 117
Quantifying pleural effusions
Pleuritis, empyema, mesothelioma 118 Lesson 5
Ribs 119
Kidneys, Adrenal Glands,
Costal fractures, costal metastases 63
Lung 120 Renal Transplants, Spleen
Pneumonia, pulmonary infarct, bronchial carcinoma 121
Quiz 122
Lesson 6
Lesson 9 Thyroid Gland, Lymph Nodes,
79
Pediatrics Gastrointestinal Tract
Skull and central nervous system
Anatomy of the CSF spaces 124
Normal findings in the sagittal plane Lesson 7
125
Normal variants 126 Bladder and
Normal findings in the coronal plane 127 97
Cerebral hemorrhage 129
Reproductive Organs
Hydrocephalus 130
Spinal canal 131 Lesson 8
Hip
Preparation and positioning 132 FAST, eFAST, Lung 111
Normal findings 133
Setup and measurement errors 134
Graf`s classification of Infant Hips 135
Kidneys, Bladder, Spleen Lesson 9
Kidneys in newborns 136
Diffusely increased echogenicity, nephrocalcinosis 137 Pediatrics 123
Urinary obstruction and reflux 138
Urinary obstruction, voiding cystourethrogram 139
Renal and adrenal tumors 140
Urachus, ureterocele, spleen size 141
Gastrointestinal tract Appendices 143
Pyloric hypertrophy, reflux, Hirschsprung's disease 142
6 Tips for the Reader

Appendices
Primer of Ultrasound Findings 144
Index 148
Template for Report of Normal Findings 149
Template for Report of Normal Findings 150
Answers to Quizzes 155
Thanks to Contributors, 159
Hands-on Ultrasound Courses
List of Abbreviations 160
Examination Algorithms 161
References 166
Space for Your Notes and Drawing Exercises 167

How can you best profit from this book?

How can you use this manual optimally?
As you work through the individual chapters, you can
benefit from several methodical and didactic features.
Find it quickly ...
Find a chapter: You will find the respective tab for each
chapter on page 5.
Find tough quiz questions for in-depth study.
Find cross-referenced figures: The figures are num-
bered according to the page on which they appear. For
example, Fig. 115.2 is on page 115.
Find an explanatory figure or diagram supplementing
the text. They are highlighted in the accompanying
text in color and are almost always on the same page,
eliminating the need to page through the book look-
ing for them.
Find numbered structures. Their reference numbers
appear in bold in the accompanying text or on the
back cover flap (the same number for each structure is
used throughout the entire book).
Find keywords on page 148 (or on pages 4-6).
Find for each structure normal values and checklists.
These are also provided on laminated, water-resistant,
pocket-sized cards.
Why we call this book a "workbook"?
A unique feature of this book is that you can use each page
as a quiz to test your knowledge. The diagrams contain
reference numbers instead of labels. This means you can
go through the material a second time and use any figure
to test which structures you know and which you still have
to learn. The quiz questions and drawing exercises have a
similar purpose. In this way, you can become familiar with
several efficient study methods that allow you to integrate
new material into your long-term memory faster – even
though this requires you to take a more active approach to
learning. Not only do I wish you good luck with this course,
I also hope you have fun doing it!
Matthias Hofer, MD, Associate Professor, MPH,
MME, Summer 2020
Director of Education at the University Institute of
Diagnostic, Interventional and Pediatric Radiology (DIPR)
Inselspital Bern, Bern University, Switzerland

What does the respective color coding mean in the diagrams?

Tumors Connective tissue, fat
Arteries Liver, thyroid gland
Veins Muscles
Gallbladder wall Gastric lumen
Pancreas Air, bone
Bile Acoustic shadow
Kidney Spleen, lymph nodes
Urine Prostate, uterus, ovary
Introduction Physical Principles and Technical Fundamentals 8
New Techniques 12
Artifacts 18
Quiz 20
Practical Tips and Tricks for the Beginner 21
8 Physical Principles and Technical Fundamentals

Image Generation Sound Transmission in Human Tissue

Ultrasound images are generated not by X-rays but by Air 331 m/s
sound waves that are sent by a transducer into the hu- Liver 1549 m/s
man body and reflected there. In abdominal ultrasound, Spleen 1566 m/s m = 1540 m/s
the frequencies used generally are between 2.5 and 5.0 Muscle 1568 m/s
megahertz (MHz; see p. 11). The primary condition Bone 3360 m/s
required for sound wave reflections is the presence
of so-called "impedance mismatches." These occur at Table 8.1
the interface between two tissue layers with different
sound transmission properties (interfaces in Fig. 8.1).
It is interesting to note that different soft tissues show
Trans- Trans-
only minor differences in the transmission speed of ducer ducer
sound (Table 8.1). Skin Gel
Only air and bone are marked by massively different
sound transmission in comparison with other human
tissue. For this reason ultrasound units can be operated at 2 Interface
a preselected medium frequency of approximately 1540 A

m/s without producing any major inaccuracies in the 2 Interface

calculated origin ("depth") of the echo. B

The processor computes the depth of origin of the echo 2 Interface 45

from the time difference detected between emission of C

the sound impulse and return of the echo. Fig. 8.1 a b

Echoes from tissue close to the transducer (A) arrive
earlier (tA) than echoes from deeper tissues (tB, tC in Fig. 8.1a). The mean frequency is strictly theoretical since the
processor cannot know which type of tissue the sound waves traversed.

Which Component of the Sound Wave is Reflected?

Fig. 8.1a shows on the left three tissue blocks traversed
by sound waves that differ only minimally in their trans-
mission velocity (indicated by similar gray values). Each
interface only reflects a small portion of the original
sound waves ( ) as echo ( ). The right–hand diagram
shows a larger impedance mismatch at the interface A
between the different tissues (Fig. 8.1b). This increases
the proportion of reflected sound waves ( ) in compa-
rison to the tissues shown on the left. However, what
happens if the sound waves hit air in the stomach or a
rib? This causes a so-called “total reflection,” as illustra-
ted at interface B in Fig. 8.2b: The transducer does not
detect any residual sound waves deep to this structure
from which it can generate an image. Instead, the total
reflection creates an acoustic shadow (45).
Conclusion:
Intestinal or pulmonary air and bone are impenetrable
by sound waves, precluding any imaging deep to these
structures. The goal will later be to work around
intestinal air or ribs by maneuvering the transducer. The
pressure applied to the transducer against the abdomi-
nal wall (see p. 21) and the acoustic gel that displaces air
between the surface of the transducer and the patient’s
skin (see p. 22) play a significant role.

From a “Snowstorm” to an Image …

Do not get discouraged if at first you can only make out a blinding "snowstorm" on ultrasound images. You will be
surprised how soon you will learn to recognize the ultrasound morphology of individual organs and vessels. Fig. 8.2
visualizes the gallbladder (14) as a
black structure and shows two round 2 1
polyps (65) within it. The surround- 4
ing gray "snowstorm" corresponds to 5 74
the hepatic parenchyma (9) which 46
80 14
is traversed by hepatic vessels (10, 9
11). How can you quickly work out 65
which structures in the image appear 10 45
bright and which are dark? The key 11
lies in the concept of echogenicity
11 9
(see p. 9). 9 45

Fig. 8.2 a Gallbladder with b

polyps
 Physical Principles and Technical Fundamentals 9

What Does the Term "Echogenicity" Mean? Please use the These fluids are
Tissues or organs with many intrinsic impedance mis- following terms: anechoic (= black):
matches produce many echoes and appear "hyper-
echoic" = bright. In contrast, tissue and organs with few Hyperechoic (= bright) pericardial or
impedance mismatches appear “hypoechoic” = dark. pleural effusion,
Consequently, homogeneous fluids without impedance Hypoechoic (= dark) ascites, cysts,
mismatches (blood, urine, bile, cerebrospinal fluid, blood, urine, bile,
pericardial or pleural effusion, ascites, cyst secretion) Anechoic (= black) cerebrospinal fluid
appear “anechoic” = black. The number of impedance
mismatches does not depend on the physical density (=
mass per unit of volume). This is best illustrated with a fatty liver (9). On this noncontrasted CT scan (Fig. 9.1a), the
parenchyma of a fatty liver appears darker (i.e., less dense) than hepatic vessels or normal liver (Fig. 9.1b).

This is due to the lesser density

of fat in comparison with normal
liver tissue. On ultrasound the fatty
deposits produce more impedance
mismatches (Fig. 9.1c) than in normal
liver tissue (Fig. 9.1d). Consequently,
a fatty liver appears more echogenic
(brighter) on ultrasound despite its
significantly lower physical density.

A common misunderstanding:
What do ultrasound examiners mean Fig. 9.1 a CT: Fatty liver b CT: Normal liver
when they refer to a "dense liver"?
Either they are not expressing them-
selves clearly or they have failed to
grasp the fundamental principle of
ultrasound imaging and how it differs
from radiography. Ultrasound does
not visualize physical tissue densities
but differences in sound transmission
(impedance mismatches) which are
unrelated to density.

Fig. 9.1 c Ultrasound: Fatty liver d Ultrasound: Normal liver

Generation and Frequency Ranges of Sound Waves

Sound waves are generated by the reverse “piezoelectric
effect.” The pressure waves of an echo distort crystals,
causing them to emit an electrical impulse. The reverse
takes place during transmission. A transducer includes
many such crystals. Depending on the impulse applied,
they can produce sound waves of various frequencies
specified in megahertz (MHz). A “3.75–MHz” trans-
ducer does not exclusively emit pressure waves (sound
waves) at a frequency of 3.75 MHz. That is merely the
specified median frequency (= “center frequency”).
In fact, such a transducer may emit sound wave fre-
quencies between, for example, 2 and 6 MHz. So-called
"multi frequency transducers" have the additional
capability to increase or decrease this center frequency
and the surrounding bandwidth of transmitted sound
frequencies. In thin patients or children, for instance,
the bandwidth can be shifted (say 4–8 MHz with a cen-
ter frequency of 6 MHz) to achieve better spatial resolu-
tion. However, this decreases the depth penetration of
the sound waves.
In very obese patients, the use of lower frequencies
(1–5 MHz with a center frequency of 2.5 MHz) can be
appropriate to achieve the necessary penetration, but at
the cost of lower resolution (see p. 11). Newer methods
base their image generation on frequency shifts or har-
monic frequencies of the echo in relation to the original
ultrasound impulse (see p. 13).
10 Physical Principles and Technical Fundamentals
Operating an Ultrasound Unit
Many controls on different ultrasound units are quite similar in function and arrangement regardless of the
manufacturer. Therefore this section will look at the console of one unit supplied by Samsung (Fig. 10.1), which will
then be used to introduce common technical terms.
Selection of Transducer and Preset
After you have switched on the unit (A) and it has boo-
ted, select the appropriate preset (PS) and the appro-
priate transducer for the respective examination and
enter the current patient data (PD). You will usually
select a linear array transducer (L) for evaluating the
thyroid gland and the extremities but a convex array
transducer (C) for abdominal examinations. The sector
transducer (E) is used primarily in echocardiography,
and the endovaginal transducer (G) is used for gyneco-
logic examinations.
Selecting the Image Mode, Gain, and Focus
Usually you will begin with "normal" black and white or
B-mode ultrasound (B), before later possibly switching to
color-coded imaging (C). If you also wanted to obtain a
flow profile from a blood vessel, you would then activate
the Doppler mode (D) as well. This unit is equipped with
control knobs that increase the respective signal (gain)
of the active imaging mode when turned clockwise and
reduce it when turned counterclockwise. The amplificati-
on (gain) can also be adjusted using the depth gain com-
pensation feature (G). The transducer angle (A) must also
be entered to determine flow velocities in Doppler mode.
If you wish to display the change in a line of the image
over time, switch to M-mode (MM). You can also set the
specific depth range that is to have the best spatial reso-
lution; here you use a toggle switch to set one or more
focal zones (FZ) in your penetration depth. A few units also
have a CW Doppler (CW) that measures frequency shifts
(= flow speeds) not by means of depth gain compensation
but as the summation of all speeds over an entire line of
the image.
Magnification and Zoom Function
Especially with smaller target structures, you can signi-
ficantly increase your detection of pathologic changes
by magnifying the target organ (Mag) organ or zoom-
ing (Z) certain parts of the image. One common fea-
ture on almost all units is the position of the freeze or
stop button (St) in the lower right corner of the console.
This freezes the moving image. It is recommended to
rest one finger of your left hand lightly on this button
during the examination to minimize delay in capturing
a desired image.
Size and Distance Measurements
After freezing (St) you can retrieve individual images
from digital storage with the cine loop function: To do
so, turn the trackball (T) to the left to 9:00 o'clock and
go back image by image until you reach the desired
one. Depending on the manufacturer and preset, up
to eight simple measurements (M) can be performed
one after the other on the frozen image. Use the track-
ball (T) and the set button (S) to define the beginning
and end positions of your measured distances. It may
be helpful to switch to double image mode (2x) for
comparative measurements in different planes. Right
next to this on most units is another button for switch-
ing back to single image mode (1x). More complex
measurements such as volume measurements or flow
indexes can be accessed with the measurement pro-
gram (MP).
Helpful Extras
When you want to explain the imaging findings to the
patient or a colleague, it is helpful to activate a pointer
(P) which you can move across the frozen image with the
trackball (T) to point out the findings you are explaining.
If you really want to score points with your patients, in-
stall an additional monitor below the ceiling in their field
of view. Well equipped units also offer automatic image
optimization (QS), several hot keys for frequently used
settings (P1-P3), and also several transducer sockets (SP)
spare you the time and hassle of plugging and unplug-
ging probes.
PS TS
PD F
G EB
D BB
MM C
A
CW
Z
L E
W FK
P V
B
MP
M P1-P2
T QS
S ST
SP
Fig. 10.1 Console and keypad
 Physical Principles
Physikalische
and Technical
Selection of Ultrasound Units
In addition to large color Doppler units, ultrasound units
with connections for several multi frequency transducers
have proven especially useful in a hospital setting. Such
mobile units are easily moved from the ultrasound suite
to the ward or intensive care unit (Fig. 11.1).
The most important precaution when transporting the
unit is to make sure that transducers are safely stowed
so that dangling cables cannot become caught on door-
knobs, gurneys, etc. A transducer that falls on the floor
can easily represent a loss of €3000–7000 ($3300–7700)
depending on the model. For the same reason, the trans-
ducer should never be left unattended on the patient’s
abdomen when the examination is interrupted, for in-
stance by a telephone call. Stowing the transducer in the
frame with the cable hanging avoids unnecessary kinking
that can lead to broken conductors in the cable.
Types of Transducers
Of the many types of transducers, only the three most
important ones will be discussed here (endovaginal
transducers, see p. 103).
A linear array transducer or "parallel scanner" emits par-
allel sound waves into the tissue and produces a rectan-
gular image (Fig. 11.2a). The width of the image and the
number of scan lines remain constant at all tissue levels.
Linear array transducers have the advantage of good
near-field resolution and are primarily used with high
frequencies (5.0–10.0 MHz or higher) for evaluating
soft tissue and the thyroid gland. Their disadvantage
is the large contact surface. This can lead to air gaps
between skin and transducer when it is applied to a
curved body contour (loss of acoustic coupling). Further-
more, acoustic shadowing (45) caused by ribs, lungs,
or intestinal gas can greatly degrade image quality.
Consequently, linear array transducers are rarely used
for visualizing abdominal organs.
Linear
Ribs
45 45
Fig. 11.1 Fig. 11.2 a b
Grundlagen
Fundamentals
/ Technik 11
A sector transducer produces a fanlike image that is
narrow near the transducer and increases in width with
deeper penetration (Fig. 11.2b). This type of transducer
has become established primarily in cardiology with
lower frequencies (2.0–3.0 MHz) allowing deeper
penetration. Due to the fanlike propagation of the sound
waves, the heart can be well visualized through a small
intercostal window without acoustic shadows from
the ribs. The disadvantages of this type of transducer
are their poor near-field resolution and decreasing line
density in the far field with correspondingly decreasing
resolution. Moreover, finding the desired imaging plane
is difficult and takes some practice.
A curved or convex array transducer is a combina-
tion of the two types described above (Fig. 11.2c).
The shape of the monitor image resembles a coffee
filter and combines good near-field resolution with re-
latively good far-field resolution. The major advanta-
ge of the slightly curved contact surface is its ability
to displace interfering intestinal air outside the ima-
ging plane by applying increasing pressure (see p. 21).
With this type of transducer, however, one has to ac-
cept decreasing resolution with increasing depth and,
in certain locations, acoustic shadowing behind the
ribs. This type is usually used in abdominal ultrasound
with center frequencies from 2.5 MHz (in very obese
patients) to 5.0 MHz (in slender patients).
The average frequency (center frequency) is usually
3.5–3.75 MHz. Memory aid: The higher the frequency,
the better the resolution and the worse the penetration.
The best way to remember this is to compare it to that
loud music from your neighbor’s apartment. Which
tones best penetrate even thick walls? The basses. These
lower frequencies travel farther (i.e., penetrate deeper),
see page 9.
Sector Convex (curved array)
45 45
60°
90°
c
12 New Techniques

Panoramic Imaging (SieScape®)

New high-performance image processors generate
extensive ultrasound images from data acquired as the
examiner moves the transducer slowly and continuous-
ly over the region of interest. With some practice, the
examiner can produce impressive and undistorted
images that allow distance measurements accurate to
within 1–3% even on a curved body surface. Fig. 12.1
shows a sagittal scan with massive pleural effusion (69),
compressive atelectasis of the lung (47), and, inferior
to the liver (9), anechoic ascites (68) that appears to
inundate the small bowel (46).
Fig. 12.2 impressively illustrates the position of the
placenta (94) relative to the fetus. The high contrast
resolution even allows evaluation of the interface
between the fetal liver (9) and heart (114).

68
46 94
69
9 9 114
47 16
15

Fig. 12.1 Fig. 12.2

(With kind permission of Drs. C.F. Dietrich and D. Becker, from Farbduplexsonographie des Abdomens, Schnetztor-Verlag, Konstanz, Germany)

3-D Visualization
Especially in obstetrics, the three-dimensional visuali-
zation of fetal facial features improves the diagnosis of
malformations such as cleft lip and palate. This technique
can now visualize the physiognomy of the fetal skull with
amazing accuracy (Fig. 12.3).
Of course, conventional cross-sectional imaging tech-
niques can also detect skeletal and other malformations,
albeit less impressively and clearly than three-dimen-
sional ultrasound.
Fig. 12.3

Clarify Vascular Enhancement Technology

This technique is based on an algorithm that is able to
significantly reduce the blurring on B-mode scans resul-
ting from partial volume or section thickness artifacts.
Flow information from the power Doppler mode is used,
which helps to improve the spatial resolution of vascular
contours on the B-mode image.
The result is significantly improved visualization of
findings such as the contours of hard and soft plaque
in the carotid arteries (Fig. 12.4b) compared with the
visualization achieved by the conventional technique
shown in Fig. 12.4a. It also facilitates evaluation of
peripheral vascular rarefaction in the liver as the lumens
of the hepatic veins and portal venous branches are more
clearly visualized in the hepatic parenchyma (Fig. 12.5).

Fig. 12.4 a "Normal" image of the b … with Clarify Fig. 12.5 Hepatic vessels
carotid artery ...

The material on the following five pages is not an abso-
lute prerequisite for the first practice sessions and can
be skipped. Beginners may prefer to move from here
directly to the preparations for Lesson 1 (see p. 21).
After some initial practice they should return to these
pages to reinforce their fundamental understanding of
ultrasound imaging.
Tissue Harmonic Imaging (THI): This technique does
not use the fundamental frequency of the original
ultrasound impulse but their harmonics, integer mul-
tiples of the fundamental frequency (for example 7.0
MHz for a fundamental frequency of 3.5 MHz). These
harmonics increase with increasing penetration, but
their amplitude (intensity) remains far less than that of
the base signal. The advantage of these harmonics is
that they hardly arise at all near the transducer, but only
Fundamental frequency
Intensity
Harmonic
frequencies
Skin level Depth
Fig. 13.1
Second Harmonic Imaging: This technique uses only
the doubled frequency of the base signal for imaging.
To avoid any overlapping of the range of the fundamen-
tal frequency (Fig. 13.3a) a narrowband signal must
be used to distinguish the stronger components of the
fundamental frequency from the weaker components
of the harmonic (Fig. 13.3b). However, the narrower
a
Intensity
Fundamental frequency Frequency
b Harmonic
Intensity
frequency range
Frequency
Fig. 13.3
Phase Inversion Technique: A broadband technique
has since become established that allows the use of
dynamically optimized harmonic multiples of the
transmitted frequency with a broader bandwidth (Fig.
14.1c, Ensemble® THI). With this technique, image
optimization no longer depends on the narrow band-
width of the fundamental frequency (Fig. 14.1a) to
cleanly separate it from its harmonics (Fig. 14.1b). Two
successive pulses are transmitted in such a way that
the phase (upward excursion of the pressure = positive,
downward excursion = negative) of the second pulse is
inverted to the phase of the first pulse (Fig. 13.5).
New Techniques 13
develop with increasing penetration depth (Fig. 13.1).
Consequently, they are less affected by the major sources
of scattered image noise, which occurs especially in the
anterior abdominal wall. Why do harmonics develop
only with increasing penetration depth? Ultrasound
waves are distorted as they traverse tissues with varying
acoustic properties. Their pressure waves compress and
relax the tissue as they penetrate it. Compressed tissue
increases the speed of sound. However, as the tissue
relaxes, the speed decreases, causing the trough of the
pressure wave to propagate more slowly. The resulting
distortion of the wave form (Fig. 13.2) induces harmo-
nics. This is a cumulative effect that increases with the
depth of penetration. Consequently, the amplitudes
of the harmonic frequencies initially increase with
penetration depth until this increase is offset by general
absorption (Fig. 13.1).
Sound pressure
+
Depth
ear eld Increasing depth ar eld
Fig. 13.2
bandwidth of the signal leads to a slight reduction in
contrast and spatial resolution. In spite of these short-
comings, this technique has markedly improved the
detection of details (Fig. 13.4b) compared with con-
ventional ultrasound imaging (Fig. 13.4a), especially in
obese patients (whose abdominal wall produces exces-
sive scattering).
Fig. 13.4 a b
Pulse 1
Pulse 2
(inverted)
Sum of
Pulse 1 +2
Fig. 13.5 a Linear b Nonlinear
14 New Techniques

If the echoes of both signals are ad-

ded, the sum equals zero as long as
the signal has not undergone any
changes in the body. As a result,
both fundamental frequency echoes
are suppressed (Fig. 13.5a) whereas Fundamental frequency 2nd harmonic imaging broadband harmonic imaging [MHz]

the second harmonic signal compo-

nents are enhanced (Fig. 13.5b). Fig. 14.1 a b c

Fig. 14.2 depicts a case showing acoustic shadowing

( ) deep to intrarenal calcifications (b) that are
undetectable by conventional imaging (a). In addition,
the renal cyst ( ) appears better demarcated and can be
classified as benign with greater confidence.

Contrast Enhancement
The echogenicity of blood and tissue can be enhanced
with microbubbles with a diameter of 3–5 µm that pass
through the capillaries and create more impedance
Fig. 14.2 a b
mismatches within the blood stream (Fig. 14.3). So far,
several contrast enhancement agents have been intro-
duced and about 50 additional agents are under development. The contrast
agent Levovist® consists of tiny air bubbles ( ) about 3 µm in diameter
(95% < 10 µm), which are stabilized with a thin envelope of palmitic acid
(Fig. 14.4). They are initially bound to galactose microparticles that dissolve
in the blood and release the microbubbles. The dry powder can be mixed
by the examiner in different concentrations. The suspension passes through
the pulmonary circulation, but is only injectable for about 8 minutes after
preparation. Hypergalactosemia is a contraindication. Measuring just a few
millimeters, the microbubbles are comparable in size to erythrocytes (Fig.
14.5), which explains how they are able to pass through the capillaries.
Ultrasound impulses with low sound pressure make these microbubbles vi-
brate at what is known as a low "mechanical index" of 0.05–0.2. Contrast
images are created using the nonlinear resonance frequency exclusively. Al-
ternatively, one can use a higher mechanical index around 1.0–1.5 to cause
the microbubbles to burst and emit a significantly stronger signal (although
Fig. 14.3
only during a single passage).This is known as the burst method.
The contrast agent Sonovue® consists of an aqueous solution of sulfur he-
xafluoride (SF6) stabilized by a phospholipid layer (Fig. 14.6). The median
size of the bubbles is about 2.5 µm (90% < 8 µm) with an osmolality of
290 mOsmol/kg. One possible advantage of this contrast agent is that the Galactose
suspension remains stable for over 6 hours, allowing it to be used for several
applications. The best results are achieved in conjunction with the tissue
harmonic imaging (THI) technique, referred to as "contrast harmonic ima-
ging (CHI)." Frequently, the term contrast-enhanced ultrasound (CEUS) is Fig. 14.4
also used.
A specific sound pressure causes the bubbles to vibrate and emit harmonic echoes. As a result, contrast
harmonic imaging (Fig. 14.7b) can detect multiple liver metastases significantly better than noncontrasted
imaging (Fig. 14.7a).

SF6
SF6

Phospholipid layer SF6

SF6

Fig. 14.5 Microbubbles Fig. 14.6 Sonovue® Fig. 14.7 a Noncontrasted b CEUS
 New Techniques 15

Spatial Compounding (SonoCT®T)

There is another technique for suppressing artifacts.
"Real-time compound imaging" does not scan an image
line by line (Fig. 15.1a), instead it scans from different
angles and merges this data into an image in real time
(Fig. 15.1b). Up to nine different slices can be scanned,
allowing more precise visualization of tissue information.
This is illustrated here by the morphology of arterio-
sclerotic plaque in the carotid artery ( in Fig. 15.2a)
compared with conventional imaging (Fig. 15.2b).

(Conventional) (SonoCT)

Fig. 15.1 a b

This technique has exhibited obvious advantages in ultrasound imaging of the

breast and musculoskeletal system. Fig. 15.3b shows improved visualization
of an entire biopsy needle ( ) in the breast parenchyma in comparison with
conventional imaging (Fig. 15.3a), making it possible to advance the needle to
the suspicious lesion with greater precision. Fig. 15.2 b

Fig. 15.3 a b Fig. 15.4

The combination of SonoCT® scanning with tissue
harmonic imaging (see p. 13) has shown promising
results. It allows detailed visualization of hepatic lesions
(Fig. 15.5) or fetal morphology in prenatal ultrasound
screening (Fig. 15.6). The high performance computer
systems now available can easily combine SieClear® or
SonoCT® with three-dimensional (Fig. 15.7) and pano-
ramic imaging techniques (Fig. 15.4). Here, almost the
entire liver at the level of the hepatic venous system is
visualized (see p. 52).

Fig. 15.5 Fig. 15.6 Fig. 15.7

16 New Techniques

Pulse Compression
This technique is derived from one originally developed
for radar. Its main advantage is improved visualization Transmitted Received
of deep structures. It is not possible to increase pene- chirp pulse chirp pulse
tration depth simply by increasing transmission
power as this would produce undesirable thermal and
mechanical effects. However, it is possible to increase the
duration of the transmitted pulses and to modulate their
frequency in a specific pattern ("chirp coding"). In this Decoded
manner, the individual transmitted impulse has greater received signal
energy although its amplitude remains unchanged (Fig. Variation of
16.1a). The reflected echoes are then decoded by a chirp frequency and amplitude
receiver filter and transformed back into shorter echoes
of correspondingly higher amplitude (Fig. 16.1b). Fig. 16.1 Principle of pulse compression

The result is greater penetration depth with the degree of anatomic detail normally achieved only with lower frequen-
cies and lower (and correspondingly worse) resolution. Fig, 16.2c shows a hypoechoic mass (54) deep to the thyroid
gland (81) which would not have been visualized without pulse compression (Fig. 16.2a).

85 / 90

81

45 54

45

Fig. 16.2 a b c

Precision Upsampling
In conventional image processing techniques with high-frequency transducers, ultrasound echoes are scanned at
a rate of only about 2–5 times the speed of the maximum frequency components of the echo (wide grid in Fig.
16.3a). Consequently, these echoes are only detected at a few points along their curve, and the monitor image
really represents only an approximation of the actual echo signal (Fig. 16.4a). More complex reconstruction algo-
rithms can record the duration and amplitude of the actual echo signal far more accurately (narrower grid in Fig.
16.3b). The result is that the structures of the radial tendon ( ) shown here are visualized with significantly higher
definition (Fig. 16.4b).
Amplitude

Conventional With precision

sampling upsampling

Time

Fig. 16.3 a b

Fig. 16.4 a b
 New Techniques 17

Diagnostic Ultrasound Catheter

Miniaturized transducers are another new develop-
ment. These transducers are available in fine cathe-
ters only 3 mm in diameter that can be rotated 160°
in any direction (Fig. 17.1). Fig. 17.2 shows the size of
an AcuNav probe (= Accurate Navigation by Siemens)
in comparison with a TEE transducer of the type used
within the esophageal lumen. The small size of the
disposable catheter allows it to be advanced into the
heart via the venous system.

Fig. 17.1 Fig. 17.2

This technique can visualize a previously poorly accessib-
le atrial septal defect ( ) in a B-mode scan (Fig. 17.3a)
at higher frequencies around 7.5 MHz. It can also visual-
ize the flow through the shunt on a color-coded Doppler
image (Fig. 17.3b) significantly more precisely than was
previously possible. This also makes it easier to monitor
instrumental closure of the atrial septal defect ( in Fig.
17.3c) and verify the success of the procedure. The ad-
vantages of this technique in comparison with TEE are its
superior image quality and the elimination of the need
for sedation or general anesthesia. This in turn makes it
possible for the patient to cooperate during the examina-
tion (holding breath, Valsalva maneuver, etc.) and makes
the examination less stressful for the patient.

Fig. 17.3 a b c

The catheter system can also be ad-

vanced through the right heart into 46
the inferior vena cava and there be
used to guide insertion of a direct
intrahepatic portosystemic shunt
(DIPS). From the inferior vena cava,
it is possible to visualize adjacent 57
esophageal varices ( in Fig. 17.4)
or retroperitoneal lymph nodes (55)
with very high spatial resolution 55
(Fig. 17.5). Some the nodes shown
here are necrotic (57). Note that the Fig. 17.4 Fig. 17.5
layers of the wall ( ) of the adjacent
duodenum (46) are also shown in
high definition.
18 Artifacts

Reverberation: The monitor image does not always
reflect the true echogenicity. There are visual pheno-
mena that do not correspond to the actual anatomy
that are generally referred to as "artifacts." The image
generation illustrated on p. 8 assumes that the echoes
always return directly from the point of reflection
to the transducer. The processor makes the same
assumption when computing the depth of the site of
reflection. In reality, this is not always the case:
On their way back to the transducer, the reflected
sound waves can encounter impedance mismatches
that reflect some of them back into deeper tissue. There
they are again reflected off an interface and reach the
transducer eventually but with some delay (Fig. 18.1).
The processor evaluates the delayed arrival of the retur-
ning echoes as increased penetration depth, and these
echoes are visualized too far down on the image. Usual-
ly this phenomenon is lost in the background noise of
the image. However, against an anechoic background
such as the lumen of the urinary bladder (38) or gall-
bladder, these reverberations appear as lines parallel to
the anterior abdominal wall (51a in Fig. 18.2). These
sound waves can "bounce back and forth" repeatedly,
producing a series of parallel lines (51a).

2
3
5
Trans-
ducer 46 46
Skin Gel
l
51a
51a
77
Interface A 38
77
45 45
Interface B
51b
70
70

Fig. 18.1 Fig. 18.2 a b

Section thickness artifact: The far wall of the urinary
bladder can appear similarly indistinct. If the bladder wall
(77) or the wall of a cyst or the gallbladder is not perpen-
dicular to the sound lobe but tangential to it, this wall,
too, will be indistinctly visualized (51b in Fig. 18.2). Such
clots, 52 in Fig. 18.3). However, these are usually more
sharply demarcated from the remaining lumen and can
be disturbed with the transducer.
Transducer

section thickness artifacts must be distinguished from

sedimented material (small concrements, sludge, blood
Scatter Refraction

6
2 5

38 64
38

45

70
52
70
46/45 70 45

Fig. 18.3 a b Fig. 18.4

Distal acoustic enhancement: Relative enhancement
of the echoes (70) occurs behind large vessels or
cavities (64) filled with homogeneous (anechoic) (Fig.
18.4). In Figures 18.2 and 18.3 the tissue posterior to
the bladder (38) appears almost white and cannot be
evaluated. How does this happen?
Wherever sound waves travel for some distance through
homogeneous fluid, they are not reflected and do not
attenuate. Thus, behind the gallbladder, bladder, cysts,
or major vessels, there is more “unspent” acoustic
energy than in surrounding areas of the image. This
results in a more hyperechoic (brighter) appearance
(70) of the underlying tissue that does not correspond
to its "true" characteristics. In theses cases, it is advi-
sable to use time gain compensation (TGC) to reduce
the echogenicity of deeper image levels. This acoustic
enhancement can also be a useful criterion for diffe-
rentiating anechoic cysts (which show distal acoustic
enhancement above a certain size) from hypoechoic
hepatic lesions (which do not usually exhibit this
phenomenon).
 Artifacts 19

Acoustic Shadowing
Bands of markedly reduced echo-
genicity (hypoechoic or anechoic =
black) occur deep to strong reflec-
tors such as ribs, concrements, some
ligaments, and gastrointestinal air.
As a result, the inferior ribs or the
pubic bone can obscure deeper
structures in the same manner as air
in the stomach or bowel. The exa-
miner can also exploit this effect to a a
detect calcified gallstones (49) in the
2
gallbladder (14) as in Fig. 19.1, renal 2
1
4 4
calculi (49 in Fig. 70.2), or arterios- 5 5
3 74 2
clerotic plaques (49 in Fig. 29.1). In- 46 26
testinal air can either cast hypoechoic 9 9
9 80
(dark) shadows or cause hyperechoic 10
80
62
(= bright), "comet tail" artifacts due 14 49 14
to vibration of small gas bubbles or 5 49 49
multiple reflection. 45 46
9
Deep to round cavities whose walls 9
45
45 70 45 70
lie tangential to the sound beam,
70 13
edge shadows (45) can occur (Fig.
19.2). These shadows are caused by Fig. 19.1 b Fig. 19.2 b
scatter and refraction (Fig. 18.4). In
the case of the gallbladder (14) in
Fig. 19.2, one must examine the image carefully to correctly identify the acoustic shadow (45) as a gallbladder
edge shadow and avoid mistakenly interpreting it as part of the hypoechoic less fatty portion (62) of the liver (9).
Acoustic shadowing due to duodenal air (46) is commonly misinterpreted as acoustic shadows from stones in the
adjacent gallbladder. Do you remember the phenomenon responsible for the false hyperechoic appearance (70) of
the liver parenchyma deep to the gallbladder (14) in Fig. 19.2?

Mirror-Image Artifact
Strongly reflecting interfaces such as the diaphragm
(13) can deflect sound waves in such a manner that they
mimic a lesion on the other side of the diaphragm (Fig.
19.3). The sound waves are deflected laterally by the dia-
phragm, encounter a reflector (R), and are reflected back
to the diaphragm, which in turn reflects them back to
the transducer. The processor can only base its calcula-
tion of the distance of the object on the time of flight
of the sound pulse. Therefore, the object (R’) incorrec-
tly appears too deep on the image. Fig. 19.4 shows the
inferior vena cava (16) as a mirror image projected above
the diaphragm (16’). Additionally, the mirror image of
the hepatic parenchyma (9) appears on the pulmonary
aspect of the diaphragm (9’). Fig. 53.2 shows another
example of a mirror-image artifact.

3 1/2

11 9

45
10
R
13
16
R’ 9
16'
45
13 9'

Fig. 19.3 Path of sound in a mirror- Fig. 19.4 a b

image artifact
20 Artifacts / Quiz

Side-Lobe Artifact
So far, we have assumed that the sound waves propa-
gate in a straight line from top to bottom in the image
(dark blue lobe in Fig. 20.1). In fact, the sound waves
also propagate in several secondary "side-lobes" that
can cause undesirable scatter and blurring. When such
a side lobe strikes a strong reflector, the processor can
incorrectly assign the obliquely reflected sound waves
to adjacent lines of the image (Fig. 20.2). The farther
laterally the waves are reflected, the longer their path
and time of flight and the deeper the processor will
project the echoes on the image. This often results in
an arclike extension of a strongly reflecting interface
( in Fig. 20.3). This characteristic arc is typical of the
side-lobe artifact.

Transducer
Skin Gel

51c

Fig. 20.1 Side lobes Fig. 20.2 Path of sound in a Fig. 20.3 Example of a side-lobe
side-lobe artifact artifact

Quiz on Technical Fundamentals and Technique

Before beginning practical exercises or Lesson 1, you gaps. You can check your answers by going back to the
are invited to test which information you have really un- previous pages. The answer to image question 4 is on
derstood and are able to recall and where you still have page 154.

1. Which structures are almost always anechoic
(= black) on ultrasound images?
Name four physiologic and four pathologic ones.
Physiologic: Pathologic:
· ·
3. How does the processor compute the depth of the
reflected echo? Can you deduce at least three arti-
facts from this principle and explain them in detail
to a colleague or fellow student?

· ·

· ·

· · 4. Look at Fig. 20.4 and explain the names and origin

of all artifacts you can recognize.

2. Which frequencies do you use for which examina-

tion and why? Specify the respective bandwidth in
MHz and sketch the monitor display of the corres-
ponding type of transducer. When do you use which
transducer? Why?

Fig. 20.4

Spatial Orientation
Before beginning practical exercises in a practice setting
or an ultrasound workshop, you should first become
familiar with spatial orientation in the three-dimensio-
nal space of the abdomen. To make the first step easy,
we will initially consider only two perpendicular planes,
the vertical (sagittal) imaging plane and the horizontal
(transverse) plane. Your active participation is now
required to ingrain these two planes in your memory.
Step 1: Take a (European) coffee filter (there is no hos-
pital where you will not find one) or draw the outline of
a coffee filter on a piece of paper. Most filters have the
same general shape as an ultrasound image generated
by a convex transducer (see p. 11).
Now imagine along which margin of the image
(= edge of the coffee filter) the patient’s respective
anterior, posterior, left, right, cranial, and caudal
structures must lie when you view the imaging plane
from the patient’s right side according to international
convention (Fig. 21.1a).
Hold the coffee filter against your abdomen and
imagine that the sound waves propagate from the linea
alba toward the spine. Write down four of the six possible
directions on the edges of the coffee filter or your
drawing. Two will be wrong, but why? (It is worth your
while. You will always remember this if you figure it
out for yourself.)
How Much Pressure Should I Apply to the Transducer?
The beginner is usually concerned about causing discom-
fort to the patient and does not press the transducer
firmly against the abdominal wall. As a result of this
hesitation ( ), the air normally present in the lumen
of the stomach or bowel (26) remains in place and its
acoustic shadow (45) obscures the view of the pancreas
(33) and adjacent vessels posterior to it (Fig. 21.2a).
The extrahepatic common bile duct (66) and the por-
tal vein (11) are also often obscured by gastric or duo-
denal air. The solution in adults is to apply measured,
slowly increasing pressure ( ). Do not apply pressure
1
1
74 2 9
9
11 26
66
33
45
16 16
35 36 35 36 35
35
Fig. 21.2 a Slight pressure b Greater pressure
Practical Tips and Tricks for the Beginner I 21
Step 2: Before you look up the answer, repeat the
exercise for the short-axis (transverse) plane. Here,
the convention is that the image is displayed on the
monitor as viewed from the caudal perspective (from
the patient’s feet) (Fig. 21.1b). Again write down four
of the six possible directions on the back of the filter.
Again two will be wrong, but different ones this time.
Once you have thought about your results, check the
answer on page 155.
The next problem will be the acoustic shadow created by
superimposed intestinal air. The solution is usually not to
use more gel (as many beginners think) but to vary the
pressure applied to the transducer.
Fig. 21.1 a Sagittal plane b Transverse plane
too suddenly so as not to startle the patient or cause
unnecessary pain (Fig. 21.3). The trick is to maintain
this pressure. That will increasingly and gently displace
intestinal air from the imaging plane. The acoustic
shadow (45) will disappear and the pancreas (33) and
other vessels will be clearly visualized (Fig. 21.2 b).
This principle is especially helpful for visualizing re-
troperitoneal lymph nodes and vessels in the mid and
lower abdomen as well. In infants, this maneuver is
usually superfluous and counterproductive because of
their lower pain threshold and defensive reaction.
2
74
33
26
11
66
16
36
36 35 35
Fig. 21.3 Applying pressure
22 Practical Tips and Tricks for the Beginner II

Relevance of adequate breathing instructions: Be-
ginners are naturally reluctant to give the patient very
direct instructions. Nonetheless, almost all patients
are very cooperative when you explain the following
situation to them: Image quality (and therefore the
validity of your findings) in the upper abdomen is
often markedly improved when the patient inhales
very deeply to displace the liver caudally. Why?
In a neutral breathing position (Fig. 22.1a), portions
of the liver (9) and spleen are not the only structures
obscured by acoustic shadows of the caudal lung
segments. Often the pancreas (33) and its surround-
ings cannot be visualized because of the air content
of the stomach (26). However, when the liver (9) in
maximum inspiration (Fig. 22.1b) is displaced caudally
( ), the air-filled bowel and stomach (26) are also
displaced caudally, allowing a good view of the pan-
creas and important lymph nodes. The same principle
greatly improves visualization of the kidneys and
hilum of the liver (see below). Please use clear breathing
instructions such as: "Take a deep breath with your
mouth open [pause] and now please hold your breath."
Remember to instruct the patient immediately to
exhale after an adequate pause (on average 10 to
12 seconds, but maximum of 20 seconds) or as soon
as you have frozen the image. This instruction is not
nearly as trivial as you may think.

Good breathing instructions are

1 1 not only well received by the
2 2 patient, they also avoid undue
strain on the patient’s respiratory
9 9
74
system and expedite the exami-
74 74 nation of the upper abdomen
26 26
26
significantly. These maneuvers
are superfluous when examining
9
45
33 9
45
33 45 the lower abdomen.
15 15

Fig. 22.1 a Neutral respiratory b After deep inspiration

position

Visualizing the hilum of the liver:

Should you be unable to visualize the
hilum of the liver despite the tricks
discussed above, try to visualize the
porta hepatis through an intercostal
window in expiration (Fig. 22.2). If
this is also unsuccessful, place the
patient in the left lateral decubitus
position (Fig. 22.3). The liver’s own
weight will shift it closer to the an-
terior abdominal wall, displacing
bowel loops and exposing the porta Fig. 22.2 Visualization through Fig. 22.3 Left lateral decubitus
an intercostal window position
hepatis with its important vascular
structures (see p. 41).

Test your skills: Please look at Figures 22.4 and 22.5. Both show poor-quality images. Determine which was
obtained with too little gel and which with too little pressure. Fig. 22.6 shows an optimal image obtained with proper
pressure and an adequate amount of gel. All three images were obtained in the same patient in rapid succession. The
answer can be found on page 155.

Fig. 22.4 Fig. 22.5 Fig. 22.6

 Lesson 1 Anatomy 24
Normal Findings 25
Retroperitoneum,
Aortic Aneurysm 27
Sagittal Plane
Right Heart Failure 29
Quiz 30

With images from

Matthias Hofer and
Alexis Müller-Marbach

rights
24 Retroperitoneum, Sagittal Plane Lesson 1

Anatomy
In the posterior section of the cranial retroperitoneum,
the pulsing aorta (AO, 15) and the inferior vena cava (IVC,
16) with its typical "double-beat" sign are the primary
vascular structures (Fig. 24.1) that facilitate orientation.
At the aortic origin of the celiac trunk (32), where it
branches into the splenic artery (19), hepatic artery (18),
and left astric artery (32a) as well as in the vicinity of the
superior mesenteric artery (17), there are regional lymph
nodes that represent common sites for lymph node
metastases of the stomach, liver (9), gall bladder (14),
and pancreas (33) as well as both adrenal glands (155)
and both kidneys (29).
However, in contrast to the drawing shown here, there
is a relevant lateral distance between the aorta and
the inferior vena cava known as the aortocaval space in
which abnormally enlarged lymph nodes can also occur.
Fig. 24.2 shows the immediate topographic relationship
to the porta hepatis (slightly further posterior), where
the hepatic artery (18) and the common bile duct (66)
obscure the portal vein (11) which courses posterior to
them. You will find these and all other numbers on the
legend on the back cover flap, and the numbers shown
there match every page in the book.

34
155 16 155
13 13
13
18 10 34
27 17 47 10
24a 29 19 37
25a 150 9 11 16 32a
25b 66a 20
28 15 18 32 19
150 66b 33c
33b
21 22 21 66 46
44 14 43b
b a
43 33a
75 46 43c
43
22a 22b 17
23
38

Fig. 24.1 Posterior retroperitoneum Fig. 24.2 Anterior retroperitoneum

(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3rd ed. Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)

Video Clips and Clinical Examinations

The accompanying video clips for Lesson 1 contain in-depth information on ultrasound anatomy (Video clip 1.1a)
as well as practical tips for performing a meticulous, uniform scan of the upper retroperitoneum in sagittal planes.
Clinical considerations are not limited to the detection and diagnostic classification of enlarged lymph nodes. The
examination is also intended to exclude disorders such as aortic aneurysm (see p. 27–28) or pelvic venous thrombosis
ascending into the inferior vena cava as well as to assess whether in the setting of acute right heart failure the inferior
vena cava (16) and hepatic veins (10) are dilated (see p. 29).

The examination involves the practical challenge of having to displace gastrointestinal air in the duodenum (46),
transverse colon (43b), and in the anteriorly located stomach (not shown here) out of the respective imaging plane
by applying adequately dosed pressure, strong enough in order to visualize the posterior retroperitoneal vascular
structures and lymph nodes.
Video clip 1.1b shows you some helpful hints that are focused on transducer position and application of pressure,
whereas Video clip 1.1c explains the resulting ultrasound images in greater detail.
Lesson 1 Upper Retroperitoneum 25

Normal Findings
Before you work through this page, please complete the
exercise on page 21 to familiarize yourself with spatial ori-
entation in sagittal planes. You should only proceed here
when you are completely familiar with this orientation and
the physical principles discussed on pp. 8–11. From here
on, you will be assumed to have this basic knowledge.
vertebra. At the left margin of the image you will see the
thin hyperechoic line of the diaphragm (bare area, 13)
that exhibits a hypoechoic muscular extension (13 a)
at the anterior margin of the aorta, which can easily be
mistaken for a retroperitoneal lymph node, just like the
esophagus (34).

The goal of examining the retroperitoneum goes
beyond evaluation of the retroperitoneal vessels. It is
also intended to exclude disorders such as aortic an-
eurysm or thrombosis of the vena cava. An additional
goal is to become familiar with the vascular anatomy of
this region because obliquely imaged vessels can easily
be mistaken for oval lymph nodes, which are also hy-
poechoic. Correct identification of the individual vessels
also greatly facilitates
spatial orientation and
provides landmarks to
aid in identifying other
structures later. The
transducer is placed
along the linea alba
perpendicular to the
abdominal wall, and the
Fig. 25.1 beam is swept through
the upper abdomen in a fanlike motion (Fig. 25.1).
For now, commit only the normal anatomy in sagittal
planes to memory: When you tilt the transducer to the
patient’s right side (Fig. 25.2a), you will find the liver (9)
the aorta (15), the celiac trunk (32), and the superior
mesenteric artery (SMA, 17) on the left anterior to the
Farther inferiorly, crossing between the superior mesen-
teric artery (17) and the aorta (15) is the obliquely visual-
ized left renal vein (25b). Beginners often misinterpret the
hypoechoic oval shape of this vein as a pathologic lymph
node. Compare this to the cross section at the same level
(Fig. 33.3) and the anatomic sketch in Fig. 32.1. Farther
anteriorly (closer to the transducer) at the posterior mar-
gin of the pancreas (33), you will find the confluence of
the portal vein (12). Air in the stomach (26) can produce
acoustic shadows at the inferior margin of the liver.
Now tilt the transducer to the patient’s left side (Fig.
25.3a) to visualize the inferior vena cava (IVC, 16) in a
right paravertebral location and its junction with the
right atrium (114). The diameter of the aorta and inferior
vena cava are measured perpendicular to their longitu-
dinal axes (see pp. 27–29). Within the liver (9) hepatic
veins (10), branches of the left portal vein (11), and (an-
terior to it) the hepatic artery (18) may be distinguished.
In this plane the caudate lobe (9a) is separated from the
rest of the hepatic parenchyma (9) by a thin hyperechoic
septum. The maximum craniocaudal diameter of the
caudate lobe should measure less than 5.0 cm and its
anteroposterior diameter less than 2.5 cm.

2 1
6
5
3
23 26
13 74
115 9
11 33 46
17
10
11 32 12
25b
13
35
34
114 15 36
36 45

Fig. 25.2 a b Longitudinal section of c

the aorta

5 1 2
3

13 11
26
18
10 66 33
9
11
9a
114

16 24a
35
47 45
13
45
Fig. 25.3 a b Longitudinal section of the c
inferior vena cava
26 Lower Retroperitoneum Lesson 1

Normal Findings
After you have examined the upper retroperitoneum,
move the transducer along the aorta and inferior vena
cava (Fig. 26.1a) inferiorly ( ). In addition to visualiz-
ing the lumens of these major vessels, the examiner
must also tilt the transducer (Fig. 25.1) to search for
enlarged perivascular lymph nodes on either side of the
vessels. Enlarged lymph nodes will invariably appear as
hypoechoic oval structures (see pp. 87 and 37). Abnor-
mally enlarged lymph nodes can also occur anterior and
posterior to the major vessels as well as in the aortocaval
space. In the absence of a retroaortic mass, the distance
between the posterior wall of the aorta and the anterior
margins of the vertebrae should not exceed 5 mm, if
there is no aortic kinking in patients with chronic arterial
hypertension. It is always best to perform this examination
in two planes (see pp. 32 and 33).
The iliac vessels arising caudal to the aortic bifurcation
are identified in the same manner and examined in two
planes (see Video clip 1.2c):, parallel to the axis of the
vessel (Fig. 26.2) and perpendicular to it (Fig. 26.3).

Fig. 26.1 a b c

The confluence of the external iliac vein (22a) and inter-
nal iliac vein (22b) is a common site for enlarged regional
lymph nodes (Fig. 26.2). The iliac artery (21) is anteri-
or to the vein (above it on the image). When in doubt,
a simple compression test can help you distinguish the
two vessels. Because of its lower intraluminal pressure,
the vein is more easily compressed with the transducer
than the artery. On the transverse image (Fig. 26.3), one
can often distinguish iliac vessels from hypoechoic bowel
contents in loops of the small bowel (46) by intestinal
peristalsis alone.
If necessary, one can try to induce peristalsis by rapidly
varying the pressure applied to the transducer.

4
2 46
5 74
46
74
46 46 21a
46
46
21
22a
22
21b

35 22b
35

Fig. 26.2 a b c

1
4
4 2
46
46 74
46
46 46

74
46

46 * 74 22
21 45
46 35

Fig. 26.3 a b c
Lesson 1 Retroperitoneum 27

Aortic Aneurysm
Circumscribed dilations of the vascular lumen usually
occur as a result of arteriosclerotic lesions and local-
ized weakening of the arterial wall, and, less often,
secondary to trauma. Ectasia is defined as a dilati-
on of the aortic lumen greater than 25 mm and less
than 30 mm. It can also occur in combination with an
aneurysm (Fig. 27.1), which is defined as a diameter
greater than 30 mm in the suprarenal abdominal aorta
or 40 mm in the aortic arch. The dilation can be fusi-
form or saccular. Complications can include dissection
of the layers of the aortic wall (dissecting aneurysm)
or mural thrombosis (52), which can lead to peripheral
or abdominal emboli. Risk factors for rupture include
increasing aneurysm size, diameter exceeding 50 or 60
mm, respectively, and outpouching of the wall resem-
bling a diverticulum. A concentric lumen in a throm-
bosed aneurysm can have a protective effect, whereas
an eccentric lumen is deemed to be at increased risk
of rupture. As a rule, the risk of rupture increases with
aneurysm size. However, the indication for surgical in-
tervention depends on many individual factors so that
it is not possible to define an absolute threshold. Any
ultrasound evaluation of an aneurysm must determine
the following crucial facts: The maximum craniocaudal
length of the dilation (Fig. 27.2), its maximum trans-
verse diameter (Fig. 27.3), and any dissections, throm-
bosis, and involvement of visceral branch arteries (celiac
trunk, superior mesenteric artery, renal arteries, and
iliac arteries). The primary artery supplying the spinal
cord (great radicular artery of Adamkiewicz) is variable
in its segmental level, and because of its narrow caliber
it is not usually detected on ultrasound images. Supple-
mentary spiral CT or angiography (DSA) are usually re-
quired to visualize the arterial supply to the spinal cord.

2 1
Checklist Aortic diameter
5 3
46
Suprarenal aorta < 25 mm 46
Infrarenal aorta < 20 mm
Distance to spine
15
Posterior wall Vertebra < 5 mm 45
Memory aid: 2.5–2.0 = 0.5 45
70
Aortic ectasia 25–30 mm
Aneurysm > 30 mm 45

Table 27.1 Normal values for Fig. 27.1 a Aortic aneurysm b

abdominal aorta

2 1
3 6 3
74 74
46 5 46

45
52
45

15

53 45
45

Fig. 27.2 a Sagittal plane b Partial thrombosis c

2 1
3 3
6
74 46
5
46
74
52
45

15
45

35

Fig. 27.3 a Transverse plane b Crescentic thrombus c

28 Retroperitoneum Lesson 1

Aortic Aneurysm
Aside from the quantitative estimation of whether the
finding still represents aortic ectasia (luminal diameter
less than 2.5 cm in the abdomen, Fig. 28.2) or must
be classified as an aortic aneurysma (Fig. 28.3) with a
luminal diameter exceeding 3 cm, partially thrombosed
or dissected aortic aneurysms require the evaluation of
additional interpretation criteria:

Questions about aortic

aneurysms:
• Craniocaudal length?
• Aortic origins of other arteries
involved?
• Dissection: Which origins of
true false lumens?
• Partial thrombosis:
Concentric eccentric?
• Signs of contained rupture?

Table 28.1 Interpretation criteria Fib. 28.2 Aortic ectasia Fib. 28.3 Aortic aneurysm

Where the patent, perfused arterial lumen is encased within circular mural thrombosis, the generally hard thrombus
provides a certain degree of protection against rupture of the concentric lumen. However, in the case of eccentric or
peripheral thrombus (52) as in Fig.
5 1/2 28.4, there is an increased risk of rup-
3
ture. With very hypoechoic thrombi,
9
32 the extent of the thrombosis is often
17
15 underestimated or the lesion is even
13 missed entirely on B-mode scans
45 (Fig. 28.5a) and supplementary
15 52
35 color-coded studies (Fig. 28.5c) are
required to define the demarcation
35
45 between the perfused aortic lumen
45 (15) and a crescentic thrombus (52)
45
such as that shown here.
Fib. 28.4 a Sagittal plane b

1/2
3/5
9
46 26
17
33a 12
11 15
16 33c
9 52 45
155 24a 13
35
29 49

Fib. 28.5 a Transverse plane b c Color-coded study

Indication for Contrast-Enhanced Ultrasound

When in doubt, contrast-enhanced ultrasound (CEUS,
see p. 14) can help to determine which arteries arise
from the true lumen and which from the false one in a
dissection. It can also demonstrate a contained rupture
( ) in the periaortic retroperitoneum (Fig. 28.7a) which
a noncontrasted or color-coded duplex scan would have
failed to detect ( in Fig. 28.7b).

Fib. 28.7 a CEUS with b

aneurysm
Lesson 1 Retroperitoneum 29

Systematic examination of the retroperitoneum must
include evaluation of the venous system in addition to
any changes in the aorta and lymph nodes. The inferior
vena cava (IVC) can be distinguished from the aorta by
its anatomic location (right prevertebral location, not
left). A further distinguishing characteristic is its typical
precordial double pulse (as opposed to the single pulse
of the aorta). Along the wall of the aorta (15) in older
patients you will often find echogenic arteriosclerotic
plaques (49). When calcified, these lesions can create
acoustic shadows (45) (Fig. 29.1).
Right Heart Failure
When evaluating the inferior vena cava (16), be alert
to any dilation exceeding 20 mm (25 mm in young
athletes) as this suggests venous congestion proximal
to the right atrium consistent with right heart failure
(Fig. 29.2). It is important to obtain the measurements
perpendicular to the longitudinal axis of the vein. Be
careful to avoid exaggerating the size of the lumen of
the vena cava by mistakenly including hepatic veins (10)
that enter the vena cava inferior to the diaphragm (Fig.
29.2). When in doubt, perform the vena cava collapse
test during forced inspiration. Instruct the patient to
inhale as deeply as possible through the nose with the
mouth closed. The sudden drop in intrapleural pressure
collapses the subdiaphragmatic vena cava or at least
briefly reduces its diameter to one-third or less of its
initial value (see Video clip 1.1c). The challenge for the
examiner is to maintain the imaging plane in the center
of the inferior vena cava during the sudden expansion
of the chest on inspiration. Alternatively, this test can
be performed when imaging the upper abdomen in
the transverse plane, or the diameter of the peripheral
hepatic veins may be evaluated (see p. 52).
Do you remember the reason why the liver tissue in
Fig. 29.2 posterior to the distended inferior vena cava
appears to be more hyperechoic than anterior to it? If
not, please review the artifacts on page 18 and name
this phenomenon. Secondary to an inguinal puncture,
images of the distal iliac vessels (Fig. 29.3) can occa-
sionally show a hematoma (50) in the vicinity of the iliac
artery (21) or vein (22). Persistent blood flow into the
hematoma through a patent communication with the
arterial lumen is referred to as a “false aneurysm.” This
is distinguished from a true aneurysm by the fact that
there is no outpouching of all layers of the vascular wall
but a perivascular hematoma secondary to a full thick-
ness tear in the wall (Fig. 29.3). A differential diagnosis
must distinguish subacute or chronic inguinal hernias
from psoas major abscesses within the true pelvis, lym-
phoceles, synovial cysts in the hip and larger ovarian
cysts, and from metastases with central liquefactive
necrosis (57).
Checklist for right heart failure
• IVC dilated > 20 mm or
> 25 mm in young athletes
• Dilated hepatic veins > 6 mm in the periphery
of the liver
• IVC does not collapse on forced inspiration
• Possible pleural effusion, often initially unilateral
on the right
Table 29.1 Interpretation criteria for right heart failure

a a a
1 1/2 1
3 2
3 2
74 9 26 21 a
5 21

46 22
10 22 a
13 45 49 44
15 16 44
49 22 b
49 57 50
10
49 16 45

70 35
45 45 45
70
47 9 45
13

Fig. 29.1 b Arteriosclerotic plaques Fig. 29.2 b Engorged inferior Fig. 29.3 b Para-iliac lymph nodes
vena cava
30 Quiz Lesson 1

Before proceeding to the material in Lesson 2, you can
test whether you have really mastered the learning
points and contents of Lesson 1 by answering the ques-
tions below. Pursued with a little determination, this
self-evaluation can effectively prevent you from simply
skimming through this workbook superficially without
any long-term benefit from your reading. Enjoy the test.
You will find the answers to questions 1 through 6 on the
preceding pages. You may look up the answers to the
image in question 6 on page 156 later.

1. Which anatomic direction corresponds to the left

edge of the image on sagittal scans? For practice,
label the coffee filter shown here. Remember which
of the following six anatomic directions cannot
appear on the edges of the filter: anterior, posterior,
left, right, cranial, caudal.

2. What is the maximum normal luminal diameter of

the inferior vena cava and abdominal aorta? What is
Suprarenal aorta < mm Infrarenal aorta < mm
the definition of aortic ectasia and aortic aneurysm?
What questions would you as an examiner seek to
answer using ultrasound images? What are the
IVC (in athlete) < mm Aortic ectasia ~ mm
limits of ultrasound imaging (when would supple-
Aortic aneurysm > mm
mentary CT or DSA be better)?

a)

b)
3. Which five physiologic structures can mimic hypo-
echoic lymph nodes on a sagittal image of the upper c)
abdominal aorta? Please specify all five and draw
their position in the standard imaging plane from d)
memory.
e)

a)
4. Which two supplementary ultrasound examinations
do you perform to quickly exclude or confirm right b)
heart failure suggested by a borderline diameter of
the inferior vena cava and suspicious clinical signs
(without ECG or echocardiography)?

5. Look at the three transducers shown here (Fig.
30.1). Please write each one’s name above it and its
frequency ranges and areas of application below it.
Can you give reasons for your answers?
6. Evaluate this quiz image step by step (Fig. 30.2).
Which imaging plane is shown here? Which organs
and/or vessels are visualized? Try to name all the
structures in the image. How does this image differ
from normal findings? Please provide a differential
diagnosis.

Fig. 30.1 Fig. 30.2

 Lesson 2 Anatomy 32
Normal Findings 33
Retroperitoneum,
Pancreatitis 35
Transverse Plane
Pancreatic Tumors 36
Retroperitoneal Lymph Nodes 37
Quiz 38

With images from

Matthias Hofer and
Alexis Müller-Marbach
32 Retroperitoneum, Transverse Plane Lesson 2

Anatomy
The problem for the examiner performing transverse
scans of the upper abdomen is that these imaging planes
show numerous arteries, veins, bile ducts, and lymph
nodes in close proximity to each other, all of which
must be differentiated from each other despite similar
echogenicity. Unfortunately, lymph nodes are often
very hypoechoic and mimic transversely or obliquely
visualized blood vessels. Refresh your knowledge of
topographic anatomy of the upper abdomen on trans-
verse images by labeling all the numbered structures in
Fig. 32.1. Next, compare your answers to the legend on
the back cover flap and make any necessary corrections.

9
10
11
13 13
10 14
34
16
47 10
37 17
9 11 16 32a 18
66a 20
18 32 19 19
66b 33c 20
33b 23
66 46 32
14 43b
32a
33a 33
43
75 34
46
43c 37
43
17
23 46
66
75
Fig. 32.1 Topography of the porta hepatis and pancreas Table 32.2 Anatomy refresher
(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3rd ed. Stuttgart: Thieme, 2020.
Illustrations by M. Voll, K. Wesker.)

Before you work through the next few pages, you should
first review two-dimensional orientation in the transverse
imaging planes. This is best done either by drawing the
standard imaging planes four (plane of the celiac trunk)
and five (plane of the renal vein crossing) yourself from
memory or by labeling the figures on page 151 in detail.
A little determination on your part will be quite helpful in
learning and retaining this material. Should you continue
to encounter difficulties, you will find helpful information
on page 21 and the solutions to these questions on page
153 and on the front cover flap, which you can use to
check and complete your answers.

Video Clips and Clinical Examinations

For Lesson 2 as well, the accompanying video clips contain in-depth information on ultrasound cross-sectional
anatomy (Video clip 2.1a) as well as practical tips for performing a meticulous, uniform scan of the upper retro-
peritoneum and pancreas in the transverse plane. The primary clinical goal is to exclude inflammatory changes in the
pancreas (see pp. 34–35) and pancreatic tumors (see p. 36). We also want to detect enlarged lymph nodes (see p. 37)
in the transverse planes and correctly classify them (see in-depth information on pp. 84–87).

Displacing gastrointestinal gas from the stomach, duodenum, and transverse colon out of the imaging plane by
applying measured but strong lateral and caudal pressure is a challenging manual technique that is explained in
Video clip 2.1b. Video clip 2.1c also shows the algorithm for systematic scanning of the pancreas along with the
resulting ultrasound images.
Lesson 2 Retroperitoneum, Transverse Plane 33

Normal Findings
Usually you begin by instructing the patient to take a
deep breath and hold it so as to shift the liver caudally and
create a better acoustic window for imaging the pancreas,
lesser sac, and origins of the major vessels (see p. 22). The
hyperechoic skin (1), the hypoechoic subcutaneous fatty
tissue (2), and the two rectus abdominis muscles (3) are
directly beneath the transducer. The cranial transverse
plane (Fig. 33.1) visualizes the celiac trunk (32) with two of
its branches, the common hepatic artery (18) and splenic
artery (19). Their configuration often resembles the fluke
of a whale. Posterior to the linea alba (6) and farther
caudally (Figs. 33.2 and 33.3) lies the rhomboid extension
of the ligamentum teres (7) and the obliterated umbilical
vein. The lesser sac appears as a narrow cleft posterior to
the liver (9); the pancreas (33) lies immediately posterior
to it. The tail of the pancreas (33c) is often obscured by
acoustic shadows (45) from gas in the stomach (26).
The splenic vein (20) invariably courses directly along the
posterior aspect of the pancreas. The left renal vein (25b)
lies farther posterior between the superior mesenteric
artery (SMA, 17) and the aorta (15), but farther caudal
(Fig. 33.3). Between these two planes, the superior me-
senteric artery (17) arises from the aorta (15). Here one
will occasionally find an atypical origin of the hepatic artery
arising from the superior mesenteric artery. The origins
of the celiac trunk and superior mesenteric artery often
lie immediately beneath one another; please check this
on the sagittal section as well (Fig. 25.2). Note that this
projection inverts the position of all the organs and
vessels. The teardrop-shaped inferior vena cava (16) is on
the left side of the image, the round aorta (15) on the right,
anterior to the anterior margin of the vertebra (35). The
head of the pancreas (33a) typically surrounds the conflu-
ence (12) of the portal vein (11), which is often obscured
by duodenal air (46) at the porta hepatis.

2 3
5 3 6 74
7
9
8 26
18 33 b

19
11
32 45
33c
16 15
13
20
9 35

Fig. 33.1 a Origin of the celiac trunk b cc

2 1 5
3 3

80
8 9
14
18
11 17
16 5 74
13 15
9 26
45
45
35

Fig. 33.2 a Origin of the superior b c

mesenteric artery

2 3
3
1 74
7 9
8 26

11 33 a 20
12 17 33 c 45
9
15
16 24 b
24 a 13 25 b
29
35 29
Fig. 33.3 a Renal vein crossing b c
34 Retroperitoneum, Transverse Plane Lesson 2

Age-Related Echogenicity
The echogenicity of the pancreatic parenchyma changes
with increasing age. In young and slender patients (Fig.
33.3b), the pancreatic tissue (33) is hypoechoic (dark)
like the hepatic tissue (9). In middle-aged or obese
patients a uniform increase in echogenicity of the
pancreas (it appears brighter) occurs with age, which is
referred to as pancreatic lipomatosis (Fig. 34.1). Often it
is not accompanied by acute disease.

2 1
5 Normal values for the pancreas
3
74
8 6 Head < 3.0 cm
9 26
Body < 2.0 cm
66 45
12 Tail < 2.5 cm
33 a 46
33 c
20
Duct < 1–2 mm
16 45
15 17
5
9
35

Fig. 34.1 a Pancreatic b Table 34.2 Normal values

lipomatosis for the pancreas

The normal maximum anteroposterior diameter of 75

the pancreas is somewhat variable; in the head it is 33 c
46
< 3.0 cm, in the body < 2.0 cm, and in the tail < 2.5 cm 33 b
(Table 34.2).

If you would like to visualize the pancreas parallel to its 10°-15°

long axis to be able to measure all three parts of the 33 a
46
organ in one imaging plane, turn the transducer to
match the oblique position of the pancreas in the left
upper abdomen (Fig. 34.3). 17
23
To do so rotate it counterclockwise about 10 to 15
degrees out of the transverse plane ( in Fig. 34.4a). Fig. 34.3 Anatomy of the pancreas
(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3rd ed.
Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)

1 2/5
3 3

8 9 74
74 26
46
12
33 c 45

45 16 15

20
35
24 b
Fig. 34.4 a Turning the transducer b Longitudinal section of the pancreas
c

It often helps to keep pressure on the transducer ( ) for a few seconds during this maneuver because it takes a short
time for the air in the lumen of the stomach (26) to shift laterally in response to the pressure. This is particularly
important when the patients pause to breathe. Here instead of reducing the pressure, the examiner should gently
press the transducer farther posteriorly (see Video clips 2.1b and 2.1c) to prevent the gastrointestinal air that was
so carefully displaced previously from returning.
Lesson 2 Retroperitoneum, Transverse Plane 35

Acute Pancreatitis
Acute pancreatitis can initially occur without any Ultrasound is important in excluding other disease
ultrasound imaging correlate. However, progressive entities in a differential diagnosis such as cholecystitis
inflammation is accompanied by a markedly hypo- (see p. 44–45) or aortic aneurysm (see p. 27–28) and
echoic edema, and the pancreas (33) may be poorly in excluding complications secondary to pancreatitis.
demarcated from its surroundings (Fig. 35.1). Intense These include pseudocysts, lines of necrosis in the
tenderness to palpation combined with the presence of necrotizing form of the disease, and thrombosis of the
stomach and bowel gas often render clinical ultrasound splenic vein (Fig. 35.2). Here, the thrombus (52) in the
evaluation difficult, requiring additional laboratory tests splenic vein (20) appears so dark that it could easily be
and enzymatic serum tests to confirm the diagnosis. mistaken for a patent vessel.

2 1
3
7 3
74 d
9
74 c
26
33 b 74
12 52
9 33 a
45 20
17

16 25 b
15
24 a 13 24 b 33 c
35

Fig. 35.1 a Acute pancreatitis b Fig. 35.2 Splenic vein thrombosis

Chronic Pancreatitis
Chronic pancreatitis on the other hand is characterized of the entire organ consistent with atrophy. Scarring
by inhomogeneous multifocal fibrosis of the pancreas can often cause the pancreatic duct (75) to exhibit an
as seen in Fig. 35.3. As the disease progresses, areas of irregular luminal diameter resembling a string of pearls.
nodular calcification (53) with posterior acoustic shadows The normal duct is smoothly demarcated with a luminal
(45) occur and the organ acquires an undulating, irregular diameter of 1–2 mm (Table 34.2).
contour (Fig. 35.4). Later findings include shrinkage

Signs of acute pancreatitis

• Organ appears hypoechoic
• lll-defined organ borders
• Organ is thickened
• Tenderness to palpation
• Increased gas in stomach and
duodenum
• Complications such as
thrombosis of the splenic vein
a
1
a 1 Table 35.5
3
5 2 3 3
74 2 Signs of chronic pancreatitis
26 3 74
46
5 26
33 b
6 • Inhomogeneous fibrosis
9
75 • Nodular calcifications
12 53
53 33b • Undulating organ contour
17
5 45 • Irregular dilation of bile duct
17 66 16
45 15 45 • Organ appears narrowed
9 13 24 b
16 15 20 • Pseudocysts may occur
35
35 45 70 45 45

Fig. 35.3 b Fibrosis Fig. 35.4 b Calcifications Table 35.6

36 Retroperitoneum, Transverse Plane Lesson 2

Pancreatic Tumors
Pancreatic tumors (54) are often more hypoechoic than requires you to shift to the high plane of the flank. The
the rest of the pancreatic tissue (33) and are difficult to beam passes through the parenchyma of the spleen (37),
distinguish from adjacent bowel loops (check for peris- to the tail of the pancreas (33c) along the splenic vein
talsis) or peripancreatic lymph nodes (Fig. 36.1). Visual- (20) as in (Fig. 36.2). This example shows a homoge-
izing tumors located in the tail of the pancreas often neously hypoechoic tumor (54) around the splenic vein.

a a a
1 1
2
2 4 74 51
3 6
3
7 26 47 46 46
5 74
33 b 37 5
9 45
43 33 c 54 46
20
54 45
46 45 20
45 54
17 54 45 46
45 45
20
16 15 13
45

Fig. 36.1 b Pancreatic tumor ... Fig. 36.2 b … in the tail of the Fig. 36.3 b Endoscopic Ultrasound
pancreas

Because of their peripheral hormonal effect, endocrine tate acoustic coupling with the duodenum or posterior
pancreatic tumors are often smaller when diagnosed gastric wall (74). Because of the close proximity of the
and are better visualized on endoscopic ultrasound. target organ, higher frequencies with higher spatial
An annular transducer on the tip of an endoscope is resolution can be used. This makes it easier to detect
advanced into the stomach or duodenum. The trans- even small tumors (54) like this one near the tail of the
ducer is surrounded by a water-filled balloon to facili- pancreas (33c) in Fig. 36.3.

2 1
3 5
3
6
11
66 9 74
26

46 33 b
33 a 12
54 45
9 45 45
16 15

Fig. 36.4 a Carcinoma of the b

35
c Pressure and zoom factor
head of the pancreas

A particular problem with tumors in the head of the pancreas (33a) is that
air in the duodenum (46) or stomach (26) produces acoustic shadows (45)
that obscure the view of the pancreas (Fig. 36.4a). In such cases you can try 77
increasing pressure on the transducer and using a higher zoom factor (Fig. 59
36.4c) to better visualize the tumor (54). As the tumor increases in size, it
11
often compresses the pancreatic duct, occasionally requiring placement of a
stent (59) in the dilated pancreatic duct (77) as in Fig. 36.6. 16 15

Fig. 36.5 Stent in cholestasis and

dilation of pancreatic duct
Lesson 2
Retroperitoneal Lymph Nodes
Do you already know the criteria for distinguishing in-
flammatory enlarged lymph nodes from lymphomatous
lymph nodes and nodal metastases of other primary
tumors? If not, see pages 84–87 and review the
differential diagnostic possibilities discussed there.
Especially under conditions not conducive to ultrasound
examination (such as in very obese patients), it is impor-
tant to reliably distinguish physiologic vessels imaged
end on or obliquely (15, 16) from pathologic lymph
nodes (55) (Figs. 37.1 and 37.2). Precise knowledge
of normal vascular anatomy is crucial. Markedly hypo-
echoic lymph nodes lacking a hyperechoic hilum that
displace but do not invade adjacent veins (Fig. 37.2)
suggest lymphoma such as in chronic lymphatic leuke-
mia (if this repetition bores you, then you have already
mastered one of the learning points ...).
Fig. 37.2 shows a pathologic lymph node (55) directly
to the right of and anterior to the bifurcation of the
celiac trunk (32) into the common hepatic artery (18)
and splenic artery (19). The mass effect of the lymph
node has caused the celiac trunk to lose its typical shape
resembling the fluke of a diving whale. In Fig. 37.1
a lymph node conglomerate (55) has displaced the
hepatic artery (18) so far anteriorly that the segment
near the celiac trunk exhibits an atypically elongated
and straight course.
a a
1 1
3
2 3
74
3 3
26
9 55
9
55
74 18
46 11
55 55 19
45
32
11
16
13 15
45 35
9
16
45
Fig. 37.1 b Fig. 37.2 b Fig. 37.3
Retroperitoneum, Transverse Plane 37
Lymph node conglomerates can occasionally encase
retroperitoneal or mesenteric vessels. In such cases,
readily identifiable lymph nodes are measured and
documented on the image so that follow-up studies can
determine the extent of growth in the interim.
One rule of thumb to remember is to measure the size
of the liver and spleen whenever enlarged intraabdo-
minal or retroperitoneal lymph nodes are encountered.
Both organs should then be carefully examined for inho-
mogeneous infiltrations. Harmonic imaging techniques
in combination with contrast agents (see pp. 85–86)
can be helpful in such cases.
Without these methods, diffuse lymphomatous infiltra-
tion of the spleen will not necessarily produce detect-
able morphologic changes in the splenic parenchyma.
An infiltrated spleen can appear normal or may only
show diffuse enlargement on noncontrasted ultrasound
images (Fig. 76.1).
The cervical, axillary, and inguinal nodes must also be
examined for possible enlargement. Rarely, paralytic
fluid-filled bowel loops can be mistaken for mesenteric
lymph nodes. A bowel diverticulum (54) can also mimic
a tumor or an enlarged lymph node (Fig 37.3).
Occasionally, the differential diagnosis can be clarified by
alternately applying and relieving compression with the
transducer to provoke peristaltic activity in a paralytic
bowel loop.
a
2 3
2
6 74
5/6
9 26
8 74
5 33
19 54
55 46 20
18 32 15
16
45 45
15 35
35
b
38 Quiz Lesson 2

After this lesson, we will have to add oblique planes to
the more readily understandable sagittal and transverse
planes we have been using. This makes identifying the
individual structures in three-dimensional space consi-
derably more demanding for the examiner. Do yourself
a favor and do not begin Lesson 3 until you can easily
answer all of the following questions, even if it requires
some practice. Here is a tip for time management: Do
not spend more than two minutes on any one exercise
(you will not retain anything after that anyway). Allow
at least two hours between exercises and do other
things in the interim (interval method). You will find the
answers on the preceding pages.

1. On a separate sheet of paper, please draw the 5. What is the maximum length of the long axis of
approximate course of the most important upper retroperitoneal lymph nodes that may still be
abdominal blood vessels in relation to each other regarded as physiologic? Name the diagnostic
and to the pancreas. Do this entirely from memory criteria for classifying lymph nodes and their
without consulting this workbook or any other respective normal values. What is the value of
references. Label each structure with the custo- follow-up examinations in the presence of
mary abbreviations. abnormally enlarged lymph nodes?
Compare your drawing to Fig. 32.1. Consult the
legends on the back cover flap to resolve anything
you are uncertain about or have forgotten. Keep
repeating this exercise with a little determination until
you can complete it without making any mistakes.

Plane of the celiac trunk

2. Consolidate your knowledge of tomographic ana-
tomy by drawing (from memory, of course) the
standard transverse planes through the celiac trunk
and at the level where the renal vein crosses. Com-
pare your sketches with the drawings shown on
page 150. You will only permanently remember
those structures whose contours you can draw
correctly in both position and size.

Renal vein crossing

3. How does the echogenicity of the pancreatic paren-

chyma change with advancing age and in obesity?
What trick do you know to improve visualization
of the tail of the pancreas? What other imaging
modalities are available for evaluating the pancreas?

4. Name every vessel and every other structure on the

image shown in Fig. 38.1. Which vessel appears
dilated or congested? What do you think could
cause this? Is this a pathologic finding? The solution
to question 4 can be found on page 156.

Fig. 38.1
 Lesson 3 Anatomy 40
Porta Hepatis:
Porta Hepatis, Normal Findings 41
Gallbladder, Biliary Tract Portal Hypertension 42
Lymph Nodes, Portal Vein Thrombosis 43
Gallbladder:
Cholecystitis 44
Gallstones 46
Polyps 47
Cholestasis 47
Biliary Tract 48
Quiz (after Lesson 4) 62

With images from

Matthias Hofer and
Alexis Müller-Marbach
40 Porta Hepatis and Gallbladder Lesson 3

Anatomy
Within the lesser omentum the portal vein (11) lies im-
mediately posterior to the proper hepatic artery (18)
and the common bile duct (CBD, 66). It courses from
its confluence behind the junction between the head
of the pancreas (33a) and the body (33b) to obliquely
enter the hilum of the liver (9) (Fig. 40.1). A short portion
of the portal vein is in contact with the inferior vena
cava (16), which lies slightly posterior to it. The vein's
angle of entry into the liver varies with respiration; in
deep inspiration it is nearly horizontal due to the caudal
displacement of the liver, whereas in expiration it is
more oblique.
Coming from the gallbladder (14), the cystic duct (66b)
merges with the hepatic duct (66a) coming from the liver
to form the common bile duct (66). This then courses
posterior to the duodenum (46) through the head of the
pancreas (33a) to the papilla of Vater. Shortly before it
drains into the duodenum via the papilla, the common
bile duct merges with the pancreatic duct (75) coming
from the pancreas (Fig. 40.2). Therefore, a gallstone that
lodges before the papilla of Vater will cause congestion
not only of bile but also of pancreatic secretions, possibly
leading to pancreatitis (see p. 35). The numbers not
mentioned here may be found in the legend on the back
cover flap.

13
66b 66a
9 9
8
14 19 37
18
32a
46
66 13 80
11 15 19
16
66
33b 26 43c 14 75
46

33a

43a
46

Fig. 40.1 Anatomy of the porta hepatis Fig. 40.2 Anatomy of the bile ducts
(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3 ed. Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)
rd

Three Options for Positioning the Transducer

In most adults, the porta hepatis is visualized after deep inspiration in the epigastric angle and can be scanned in the
oblique right upper abdominal plane (Fig. 40.3a). If air in the stomach or duodenum interferes with visualization,
you can fall back on an intercostal plane in a neutral breathing position or in expiration (Fig. 40.3b). If this is also
unsuccessful, place the patient in the left lateral decubitus position (Fig. 40.4c), in which the liver’s own weight will
shift it closer to the anterior abdominal wall, displacing air-filled bowel loops. Now position the transducer in an
oblique epigastric plane as in the first option (see Video clips 3.1b and c).

Fig. 40.3 a Oblique right upper b Visualization through an c Left lateral decubitus position
abdomen intercostal window
Lesson 3 Porta Hepatis 41

Normal Findings
To obtain the standard plane for the porta hepatis, the
transducer is rotated a few degrees clockwise (Fig.
41.1a) out of the previous transverse plane until it is
parallel to the left costal arch. This positions it parallel
to the course of the portal vein in the lesser omentum.
Occasionally the transducer must be angled slightly
cranially (Fig. 41.1b) to follow the course of the portal
vein (11) from the hilum of the liver all the way to the
confluence (12 in Fig. 41.2b). The porta hepatis is best
visualized in most patients on deep inspiration (don’t
forget the breathing command!), which displaces the
liver and porta hepatis caudally and out from under the
acoustic shadow of the ribs and lung.
Three hypoechoic vascular structures can be identified in
the porta hepatis: The portal vein (11) normally lies imme-
diately anterior to the obliquely sectioned (oval) inferior
vena cava (16). The common bile duct (66) and common
or proper hepatic artery (18) lie immediately anterior to
the portal vein, just above it on the image. The hepatic
artery and its branches are visualized only in segments
because of their undulating course. These sectioned
segments appear as round or oval structures (Fig. 41.2b)
and must not be mistaken for periportal lymph nodes.
The common bile duct in a normal patient is often so
narrow that it may only appear as a thin hypoechoic line
or may not be identifiable at all. Its normal diameter
should be less than 6 mm. In postcholecystectomy
patients, it partially assumes the reservoir function of the
resected gallbladder and can dilate up to 9 mm without
signifying cholestasis. Borderline dilation of the com-
mon bile duct directly at the hilum, or cholestasis, such
as in obstruction caused by a stone, can then no longer
unmistakably be differentiated from the adjacent blood
vessels. In this situation, the entire length of all three
vascular structures must be systematically visualized
to determine their origin and with it their identity. The
hepatic artery is traced to the celiac trunk, the portal
vein to its confluence and to the splenic vein, and the
common bile duct to the head of the pancreas. When
visualizing the common bile duct, one can also identify
or exclude intraductal stones (see p. 46). Color Doppler
duplex sonography, if available, can be used as an
alternate or supplementary modality to differentiate
these vascular structures.
The normal diameter of the portal vein (11) measured
perpendicular to its longitudinal axis at its widest point
at the porta hepatis is usually less than 13 mm in adults.
Dilation should only be suspected where the diameter
exceeds 15 mm. Measurements in between fall into the
“gray area” of physiologic variation. Isolated dilation
of the portal vein is a relatively unreliable criterion for
portal hypertension. Positive evidence of portocaval
collateral circulation is a more accurate criterion. The
porta hepatis must be systematically scanned to detect
atypical periportal vascular convolutions (see p. 42).

Checklist portal vein

Normal diameter < 13 mm
Gray area 13–15 mm
Suspected portal > 15 mm
hypertension
Common bile duct
Normal diameter < 6 mm
Status post < 9 mm
cholecystectomy
Fig. 41.1 a Rotating the transducer b Cranial angulation Table 41.3 Normal values for
the porta hepatis

5
3
6
33 26
18 45
10 12 17
11 25 b
15
9
16 24 b
24 a
13 35 13
11
Fig. 41.2 a Oblique right upper b Porta hepatis c
abdomen
42 Porta Hepatis Lesson 3

Portal Hypertension
The most common cause of increasing pressure in the teres from the hilum of the liver to the umbilicus
portal venous system is impaired drainage secondary (Cruveilhier-Barmgarten disease). Where this collateral
to cirrhosis of the liver. Direct compression of a branch circulation is well established (Fig. 42.2), the often
of the portal vein by an adjacent tumor is less common. tortuous umbilical vein can develop into a
Dilation of the portal vein (11) to more than 15 mm in subcutaneous periumbilical venous plexus referred to
diameter suggests portal hypertension (Fig. 42.1). The as “caput medusae” (Fig. 42.3).
lumen of the portal vein is measured perpendicular to When in doubt, color duplex sonography can be used
the vessel’s longitudinal axis, which is usually oblique on to detect either a reduced flow rate below 10–15 cm/s
the ultrasound image. or even retrograde (hepatofugal) flow in the portal
venous system.
Bear in mind that splenomegaly of other etiology can
also dilate the splenic vein to more than 12 mm or the
portal vein to more than 15 mm even in the absence of
portal hypertension. Isolated dilation of the portal vein Checklist for portal hypertension:
to more than 13 mm is a relatively unreliable criterion
for portal hypertension. Important additional criteria • Diameter of portal vein at the
include congestive splenomegaly (Fig. 76.2), ascites porta hepatis > 15 mm
(see p. 58), and above all portocaval anastomoses at • Portocaval collaterals at the porta hepatis
the porta hepatis. These collaterals usually drain blood
from the congested portal system via the greater cur- • Reduced flow speed
vature of the stomach and the dilated left gastric vein in portal veine < 10–15 cm/s
to the esophageal venous plexus. From there the blood • Dilation of splenic vein > 12 mm
drains via the azygos and hemiazygos veins into the • Splenomegaly
superior vena cava. Possible clinical complications
include bleeding esophageal varices. • Ascites detected
Occasionally, small venous connections between the • Recanalized umbilical vein
splenic hilum and left renal vein expand, allowing (Cruveilhier-Barmgarten disease)
venous drainage directly into the inferior vena cava • Esophageal varices (bleeding)
(spontaneous splenorenal shunt). A less common
occurrence is recanalization of the umbilical vein,
which courses along the margin of the ligamentum Table 42.4

a a a
2 1 2
2 46 5
3
33 b 26 11 a
9 74
9 11 a
45 11a
11 5 45 96
2 70
11 15 11a
13 3 70
16 46 5
35 11a
11 70

45 9
9 45
70 55

Fig. 42.1 b Suspected portal Fig. 42.2 b Cruveilhier-Barmgarten Fig. 42.3 b Caput medusae
hypertension disease
Lesson 3 Porta Hepatis 43

Portal Vein Thrombosis

Cirrhotic transformation of the liver characterized by a the portal vein or even complete thrombosis of the vein
finely undulating surface ( ) as in Fig. 43.1 is often later itself (Fig. 43.2). As the disease progresses, partial
accompanied by a reduced flow rate or the retrograde recanalization or dilation of vasa vasorum or adjacent
flow in the portal vein (11) described above. This entails accompanying veins can lead to cavernous transformation
the risk of thrombi (52) developing in the branches of with numerous small venous collaterals ( in Fig. 43.3).

a a a

1 1
5 4 2 2
2 1 4
4 74 46
4 4
46
74 74
26 9
11 9
5
9 43
33 c 66 /
9
33b 20 10 11 66 46
11 18 17 25 b 11 /
66 33 45
12 5 13 96 45
15 96
13 11 46
5 5
5 46
11 24 a 11 / 52 45
16
45 45
10 13 35 47
16 45

Fig. 43.1 b Patent portal vein in Fig. 43.2 b Portal vein thrombosis Fig. 43.3 b Cavernous
cirrhosis of the liver transformation

Possible clinical complications include recurrent bleed- see Color Duplex Sonography Teaching Manual) to
ing esophageal varices. This often requires placement of reduce pressure in the portal vein.
a TIPSS (transjugular intrahepatic portosystemic shunt,

Lymph Nodes
Evaluation of the porta hepatis should not focus solely on the portal vein, but should specifically confirm or exclude
enlarged periportal lymph nodes. This requires systematic scanning of the porta hepatis to detect oval hypoechoic
lymph nodes (see Video clip 3.1c). Inflammatory nodal enlargement (55) frequently accompanies hepatitis,
cholecystitis (see pp. 44–45), or
1
pancreatitis (see p. 35).
3
3 2 Positive findings (Fig. 43.4) invariably
47 5 74 26
require evaluation of other lymph
9 45 node groups and measurement of
45
33 b
spleen size (see p. 75) to provide
17 20 baseline data so that subsequent
55
18 12 15 follow-up studies can provide valid
66 information about progression or
11 5
13 regression of the disorder.
16 35
5
Fig. 43.4 a Periportal lymph b
nodes
44 Gallbladder Lesson 3

Cholecystitis
A normal preprandial gallbladder (14) has a thin, single
-layer wall (80) less than 4 mm thick. Cholecystitis is
most often caused by stones (49) in the gallbladder
(see p. 46).
Pain can be the only finding in early cholecystitis, and
ultrasound studies may be unremarkable as in Fig. 44.1.
This woman only exhibited tenderness to palpation in
the right midclavicular line at the costal arch, whereas
ultrasound findings were normal.
It was only 48 hours later that inflammatory edema of
the gallbladder wall (80) developed. This characteristic
thickening of the wall appears on the sagittal image as
two hypoechoic layers (Fig. 44.2) and on the transverse
image at the neck of the gallbladder as a multilayered
hyperechoic structure (Fig. 44.3).

a a a
1 2 1 1
2 2
5 5
3
33 74 3 3
7 74
9 80 9
6
14 46 11 10 46 10/11
11 26
9 10
9 15 14 80 26
16 66 80 45 11 45
14
25a 11 16 15
29 35 18 74
74 29
43 31 29
44 9 30 35
47 13 45 44 31

Fig. 44.1 b "Normal" gallbladder Fig. 44.2 b Mural edema Fig. 44.3 b Mural edema on the
at onset transverse scan

In progressive acute inflammation, findings include is a rim of fluid around the gallbladder (68). In some cases, fluid
is also detected in the hepatorenal fossa (pouch of Morison) between the caudal and posterior margin of the liver
and the right kidney (see Fig. 112.5c). Finally, the outline of the gallbladder can become blurred along the adjacent
hepatic parenchyma (9) (Fig. 44.4).

Prompt detection of gas within the gallbladder or in its wall (mural emphysema) is important as infection with a
gas-forming organism has a poor prognosis and is associated with a higher risk of perforation.

2
Here, hyperechoic gas bubbles
1
3 must be differentiated from stones
(49) which can also lead to acoustic
9 shadows (45) (Fig. 44.4). A trans-
68 verse diameter of the gallbladder of
68 more than 4 cm indicates hydrops.
80 16 Another sign is the change from
67
49
14 a typical pear shape to a biconvex
68 70 spherical shape.
45 35 70

Fig. 44.4 a Acute cholecystitis ... b ... with danger of perforation

Lesson 3 Gallbladder 45

Differential Diagnosis of Cholecystitis

A thickened gallbladder wall is not necessarily attribu-
table to cholecystitis. Thickening of the gallbladder wall
(80) is also seen in ascites (68) but without inflammatory
infiltration (Fig. 45.1).
Other common causes include congestion in the veins of
the liver and gallbladder in right heart failure (see p. 52)
or hypoalbuminemia. The postprandial gallbladder in its
contracted, empty state often exhibits a kink reminiscent
of a beret (Fig. 45.2).
The concave side can show an indentation ( ) that should
not be misinterpreted as a septum.

Note: Always rule out congestion of hepatic veins due to right heart insufficiency,
before you call a gall bladder wall thickening an acute cholecystitis!

a a a
1 1 2 1
2 74 2
4 5
74 3
3 7
68 46
46
74 46
11
80
10 9 80 5
80
43
14 45
10 9
14 45
43/46
45
11 74 45
11 80 68
11
9 45
45 16

Fig. 45.1 b Gallbladder in ascites Fig. 45.2 b Postprandial kink Fig. 45.3 b "Porcelain gallbladder"

Chronic cholecystitis can lead to a contracted gallblad-
der or "porcelain gallbladder" (Fig. 45.3).
The two forms are often difficult to differentiate on
ultrasound, because a completely calcified gallblad-
der wall can reflect sound waves like air in the hepatic
flexure of the colon or in small bowel loops. Thus, it is
easy to miss a "porcelain gallbladder" on ultrasound. The
diagnosis is often made on the basis of clinical findings
in combination with laboratory tests or a supplemental
CT study (Fig. 45.4).

Checklist for Acute Cholecystitis

• Thickened, multilayered wall
• Fluid rim around gallbladder
• Indistinct border between gallbladder and liver
• Wall thickness > 3 mm (preprandial)
> 5 mm (postprandial)
• Tenderness to palpation with transducer in right midclavicular line
• Hyperperfusion on color duplex sonography

Fig. 45.4 CT in "porcelain gallbladder" Table 45.5 Signs of acute cholecystitis

46 Gallbladder Lesson 3

Gallstones
Stones in the gallbladder (gallstones) form because
of altered composition of the excreted bile when the
solubility product for certain crystals is exceeded.
Depending on their size and composition, gallstones
(49) can totally reflect sound waves directly at their
surface, or only in their center as in Fig. 46.1, or they
can be nearly completely permeable for sound waves
(see Fig. 47.1).
Many patients with gallstones carry one or more of them
for years or even decades without developing clinical
symptoms. Yet where there are many small stones (Fig.
46.2), they can enter the bile duct where mechanical
irritation can cause paroxysmal contractions of the
smooth musculature of the wall ("biliary colic"), which
can be extremely painful. Some stones lodge in the
common bile duct where they cause cholestasis, cholan-
gitis, or pancreatitis (see pp. 47 and 35).
Depending on the specific case, removal of the stone
can be attempted by extracorporeal shock wave litho-
tripsy (ESWL), ERCP (see p. 48), or cholecystectomy.
The composition of the bile can also be influenced by
medication and change of diet, making it less conducive
to stone formation.

a a a
1 1
2 2
3 1
2 3 3/4 3 5
74
74 46 46
9
46
9 80
8 14
11 49 51a
45 45 9 14
14 49
80
11 43/46 43 45
70 9 67
70 9
11
45 45 45' 70
45

Fig. 46.1 b Single gallstone Fig. 46.2 b Multiple gallstones Fig. 46.3 b Sludge

These stones must be differentiated from thickening of

Risk factors for gallstones: 5 x “F” the excreted bile ("sludge," 67), which typically causes
acoustic shadowing and commonly occurs in intensive
• Female
care patients receiving parenteral feeding (Fig. 46.3).
• Forty (40 years or older) These patients lack the temporary contraction stimulus
• Fertile (mother) for the gallbladder provided by a full stomach.
The prevalence of gallstones is about 15% in the
• Fat (obesity)
German population, with older women more often
• Fair (blonde) affected (see Table 46.4).

Table 46.4 Risk factors for gallstones

Lesson 3 Gallbladder 47

Gallbladder Polyps
Gallstones must be differentiated from polyps (65), which typically do not cast acoustic shadows and arise
from the gallbladder wall (80). When an edge shadow (45, see p. 19) simulates an acoustic shadow from
a stone (Fig. 47.1), one can reposition the patient or repeatedly apply pressure with the transducer in an
attempt to dislodge the stone from the wall.

1
Gallbladder polyps should be
2 3 monitored to exclude progressive
47 74 growth. One can then opt for
46 prophylactic cholecystectomy
9 10 80 to prevent malignant trans-
45 14 formation. When in doubt,
45
color duplex sonography (CDS)
65 can be used to demonstrate
65 central perfusion ( ) in the
10 10
45 80 70 polyps (Fig. 47.2).

Fig. 47.1 a Polyp on the b

gallbladder wall

1/2
4
74
9 65
46
14

80

46 / 43 74 45 45

Fig. 47.2 a Gallbladder polyp b c Color duplex sonography

(noncontrasted scan) demonstrates perfusion

Cholestasis
At the level of the lesser omentum at the porta hepatis, the common
bile duct (66) normally measures up to 6 mm in diameter, although
diameters between 7 and 9 mm are still within the normal range, parti-
cularly in postcholecystectomy patients (Fig. 48.1). The bile duct (66)
is almost invariably visualized anterolateral to (above) the portal vein
(11) (see pp. 32 and 40). Even when the distal common bile duct near
the head of the pancreas is obscured by duodenal air (see Fig. 32.1),
ultrasound can reliably differentiate proximal obstructive jaundice
(such as from hepatic metastases with intrahepatic biliary obstruction)
a from distal obstructive jaundice (such as from a gallstone lodged at
1 the papilla or a carcinoma of the head of the pancreas). In a proximal
3 2
3 obstruction, neither the gallbladder (14) nor the common bile duct
74
26 (66) are congested.

9
The small intrahepatic bile ducts course parallel to the branches of the
66
33 12 portal vein (11) and are normally visualized as fine structures or not at
25 all. In obstructive cholestasis these dilated ducts are visible alongside
11 15 the portal veins. This creates what is known as a "double-barrel shotgun
16 24 a 45 sign" (Figs. 48.1 and 48.2).
9
35 In about 90% of all cases, ultrasound can make the important distinction
13
between obstructive cholestasis (with dilation of the bile ducts) and
hepatocellular cholestasis (without obstruction).
Fig. 47.3 b Common bile duct at
the hilum of the liver
48 Biliary Tract Lesson 3

Cholestasis
Mechanical obstruction (Fig. 48.1) typically leads to a
pattern of dilation resembling the antlers of a deer in the
intrahepatic bile ducts (66); the pattern may also resemble
the knotty branches of an olive tree or a bonsai tree. Such
congestion does not automatically suggest bile duct
compression or obstruction by a malignant tumor such as
a carcinoma of the head of the pancreas or a bile duct.
Stones (49) may also be present in the bile ducts (Fig. 48.2).
In such cases the bile congestion can either be managed
by ERCP (= endoscopic retrograde cholangiopancreatico-
graphy) by means of a catheter (59) in the duodenum or
percutaneously with a transhepatic drain (Fig. 48.3).

a a a
1 2 1 1
2 3 2
3
47 3 4
5
9
9 66 9
11
11
80 49
66 59 11
14
45 45
9
45 45
13 11 66 70
11
9
13
13
Fig. 48.1 b Typical bile duct dilation Fig. 48.2 b Stone in intrahepatic Fig. 48.3 b Catheter placed in
bile duct bile ducts
Where the B-mode scan suggests bile duct congestion and Fig. 48.5c) can quickly determine whether the
at the hilum (Fig. 48.4a) or within the liver (Fig. 48.5a), congestion involves branches of the portal vein (11, color
the use of color duplex sonography (CDS, Fig. 48.4c coded) or the bile ducts (66, without color coding).

2 1
3
5

9
74
18
66 46 / 26 45
66
11
16
5
80 45

Fig. 48.4 a Suspected cholestasis b c Confirmation by Color duplex

at the hilum sonography
2 3
7
3
66 9
18 10
11 66
10

63 9 74
43 / 46
5

Fig. 48.5 a Suspected intrahepatic b c Evaluation by Color duplex

cholestasis sonography
 Lesson 4 Anatomy of the Segments of the Liver 50
Organ Size and Lateral Angle 51
Liver
Hepatic Venous Star, Right Heart Failure 52
Normal Variants, Fatty Liver 53
Focal Fatty Infiltration 54
Hepatic Cysts 55
Hepatic Hemangiomas 56
Focal Nodular Hyperplasia (FNH) 57
Cirrhosis of the Liver 58
Hepatocellular Carcinoma, Liver Abcessese 59
Liver Metastases 60
Quiz (Lessons 3 and 4) 62

With images from

Matthias Hofer and
Alexis Müller-Marbach
50 Liver Lesson 4

Anatomy of the Segments of the Liver

The liver (9) is conjoined with the diaphragm (13) via its
bare area and the two triangular ligaments and normally
moves several centimeters with respiration. The examiner
can take advantage of this by examining responsive pa-
tients in deep inspiration to displace the liver caudally out
of the acoustic shadow of the ribs and sternum (see p. 22).
The liver is divided by the falciform ligament (7). In the fetal
period, the umbilical vessels (96) coursed to the umbilicus
(Fig. 50.1) along the caudal margin of this structure.
The segmental division of the liver includes eight liver
segments (I-VIII) and follows clockwise the course of the
intrahepatic vessels: Segment I corresponds to the caudate
lobe, which in this anterior view lies hidden posterior
to segments IVa and IVb. Clockwise from here, the left
lateral portions of the left hepatic lobe are designated
segments II and III. Segment IV then follows, which
is subdivided into its cranial portion IVa and its caudal
portion IVb (Fig. 50.2). Next, lateral to the central
branch of the hepatic vein along the caudal margin of the
right hepatic lobe, come segments V and VI at the right
lateral margin of the liver. The subdiaphragmatic
segments VII (right lateral) and VIII complete the circle
and are separated from each other by the right branch of
the hepatic vein. The border between the cranial row of
liver segments (VII, VIII, IVa, and II) and the caudal row
(III, IVb, V, and VI) is formed by the main intrahepatic
branches of the portal vein (11).

13
IVa II
VII VIII

III
8
9 IVb

7 / 96
V
VI
14 Branches of the hepatic veins (10)
Branches of the portal vein (11)
Branches of the proper hepatic artery (18)
Branches of the hepatic duct (66)

Fig. 50.1 Anterior view of the liver Fig. 50.2 Segmental division of the liver
(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3rd ed. Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)

Ultrasound anatomy
17
The standard planes shown here again illustrate the identification of the III
individual liver segments. In the left sagittal paramedian plane (Fig. 50.3) 33
II
they appear above the aorta (15) and in the right sagittal paramedian
plane (Fig. 50.4) above the inferior vena cava (16). In the two right oblique
subcostal planes, the caudal row of segments (Fig. 50.5) appears around the
15
branching of the portal vein (11) and the cranial row (Fig. 50.6) between the 114
hepatic veins (10).

Fig. 50.3 Sagittal plane above

the aorta

13 33
IVb
IVa IVa
11 11 II
III 10
IVb VIII
I 24a 16 114
16 V
VII
VI

Fig. 50.4 Sagittal plane above the Fig. 50.5 Subcostal caudal row Fig. 50.6 Subcostal cranial row
inferior vena cava
Lesson 4 Liver 51

Examination in the Sagittal Plane

Lesson 4 is devoted to the systematic scanning of the
entire liver in two planes. This is best done in deep in-
spiration (see p. 22). We recommend always following
a standard system: Begin in the sagittal plane using the
inferior vena cava (IVC, 16) as a demarcation line as
shown in Fig. 25.3. From there, scan to the left lateral
margin of the liver and back to visualize the left hepatic
lobe (see Video clip 4.1a–b).
As you pause to let the patient breathe, decrease the
magnification 1–2 steps to visualize the larger right
lobe at its posterior margin. Then continue by scanning
the right hepatic lobe the same way, slowly and conti-
nuously sweeping the transducer ( in Fig. 51.1a).
The main problem for the examiner is visualizing the
cranial subdiaphragmatic segments of the liver. The
patient must be instructed to inhale as deeply as pos-
sible and the transducer must be tilted cranially ( in
Fig. 51.1b). Because of the larger size of the right lobe,
this maneuver must usually be performed once for the
cranial segments and then, after allowing the patient
to catch his or her breath, repeated for the caudal
Fig. 51.1 a b
segments. Keep in mind that the portal venous
branches (11) in the hepatic parenchyma (9) are always
surrounded by a hyperechoic "embankment", a rim
created by the adjacent bile ducts, hepatic arteries, and
periportal connective tissue (5). In contrast, the hepatic
veins (10) are usually visualized without a hyperechoic
border; they show one only when they are perpendicular
to the sound beam (see Video clip 4.1c).
Organ Size and Lateral Angle
Measuring the craniocaudal and anteroposterior dia-
meter of the liver (Fig. 51.2) in the right midclavicular
line to determine the size of the organ has fallen from
favor in recent years because of the poor reliability of
such measurements. The normal craniocaudal dia-
meter measures between 11 and 15 cm in adults but
varies greatly with the depth of inspiration because of
the elastic adaption of the hepatic parenchyma (9) to
the shape of the chest cavity in vivo. It is more helpful
to evaluate the inferior angle of the right lobe, which
should be less than 45°. This angle appears rounded in
a congested liver, hepatomegaly of another etiology, or
cirrhosis of the liver. The lateral inferior angle of the left
lobe should be less than 30° and is normally more acute
than the caudal margin of the liver.
The gallbladder (14) on the caudal margin of the liver can
be evaluated at the same time. The gallbladder should
be evaluated in a fasting patient (Fig. 51.3) as it is then
easier to assess the wall thickness (80) and one can
better exclude focal mural lesions (see pp. 44–47).

2 1 3

10 74
14 43/46
80

9 11

45
10

47/45
13 9

Fig. 51.2 a b c 13

1
2
4 5 4

10
11 14 46

80

10
45
11 9
43
13
47

Fig. 51.3 a b c
52 Liver Lesson 4

Examination in the Transverse Plane

After the liver has been scanned in the sagittal plane, the left lobe is now
systematically scanned craniocaudally ( ) in the transverse plane to detect
any possible focal masses (Video clip 4.2a–b). For practical reasons it is best
to visualize the right lobe in an oblique subcostal plane parallel to the right
costal arch (Fig. 52.1). Looking at this figure, can you imagine what mistake
is commonly made when holding the probe? (The answer is in the lower
left-hand corner of this page.)

Hepatic Venous Star Fig. 52.1 Oblique subcostal plane

This right oblique subcostal plane (Fig. 52.2) is espe-
cially useful for visualizing the normally long straight
courses of the hepatic veins (10) and their star-shaped
confluence with the inferior vena cava (16). The diameter
of the peripheral hepatic veins is measured in this plane
distal to the second last confluence before the conflu-
ence with the inferior vena cava, in Fig. 52.2c at the
marked locations ( ). It should not exceed a normal
value of 6 mm. A value of 7 mm or more suggests
congestion in the hepatic veins in the setting of right
heart failure. Measuring the central hepatic veins closer
to the vena cava is problematic due to the wide range
of physiologic variation; 10 to 12 mm can be perfectly
normal at this location.

Right Heart Failure

Where the inferior vena cava exhibits a borderline diame-
ter and the vena cava collapse test during forced inspira-
tion (see Video clip 1.1c) is inconclusive, the diameter
of the peripheral hepatic veins (see above) can provide
additional evidence to confirm or exclude right heart
failure. Fig. 52.3 shows the typical picture of overt right
heart failure with congested hepatic veins (10) and an
engorged inferior vena cava (16). In right heart failure,
a pleural effusion can also be confirmed in this imaging
plane behind (on the image beneath) the hyperechoic
border of the diaphragm (13). At this site there are
normally only acoustic shadows (45) behind pulmonary
air (47) or a mirror-image artifact caused by the liver (9).
Note that here the sound waves strike some of the
hepatic veins at 90° ( ) and only then do these veins
exhibit a thin hyperechoic border (5) such as that other-
wise seen only with the branches of the portal vein (11)
(Fig. 52.2). Peripheral vascular rarefaction in the liver would
be an indirect sign of cirrhosis of the liver (see p. 58).

3 1/2

9
5

11
10
5
16
10
13
9
47

Fig. 52.2 a Hepatic venous star b with confluence of the c korrekte Messposition
hepatic veins
2 1
Normal values 3/5

for hepatic veins: < 6 mm

(periphery) 11
10 10 13
Answer to Fig. 52.1:
the costal arch (see small arrow). 9

be moved medially and closer to 10

far laterally and caudally. It should 16

The transducer is positioned too

9 45
13

Table 52.4 Fig. 52.3 a Engorged liver veins b in right heart failure
Lesson 4 Liver 53

Normal Variants
Systematic examination of the liver
can reveal normal variants that mi-
mic focal masses. For instance, along
the diaphragmatic margin of the
liver (9) in athletic patients one may
occasionally observe hyperechoic
strictures ( ) that appear to extend
from the diaphragm (13) and indent
the hepatic parenchyma (Fig. 53.1).
These apparent lesions represent
thickened muscular bands in the 1 2
1 2
4 4
diaphragm that extend from the 47 5
4
bare area of the liver to the caudal
ribs and lumbar vertebrae, creating 9
a series of cord-like impressions in 11
13 10
the liver. Such a muscular band (13) 9
11
may also occur in isolation (Fig. 13 45

53.2) and be projected as a mirror- 45

13 9
image artifact (51) on the pulmo- 13 51
47 47
nary side (47) of the diaphragm
(see p. 19).
Fig. 53.1 b Diaphragmatic Fig. 53.2 b ... with mirror image
impressions ... artifact

Fatty Liver
A fatty liver (hepatic steatosis) is characterized by
diffusely increased echogenicity in the liver (Fig. 53.3).
This increase in echogenicity is best demonstrated by
comparison with the adjacent kidney (29).
Normally there is hardly any difference in the echogeni-
city of the two organs (see Fig. 65.3). In very advanced
cases of fatty liver, sound reflection from the hepatic
tissue (9) can be so pronounced as to effectively prevent
evaluation of the deeper layers of the liver. Fig. 53.4
shows acoustic enhancement (70) immediately posterior
to the gallbladder (14). However, the posterior portions
of the liver on the lower edge of the image are no longer
visualized despite depth gain compensation. Fatty infil-
tration of the liver can also occur as a focal process (see p.
54) or even a multifocal process (63) (Fig. 53.5). In these
cases, a supplementary contrast-enhanced ultrasound
examination must be performed to exclude the differen-
tial diagnosis of metastases (see pp. 60–61).

1 1/2
2 4 4 2
3 5
5 74 63
9 14 46
9 43
10
80 63 45
10 29 9
30 70 13
11
9
45 13 9 43
31
9 47
45 47
45 45
27 13
47 13 45 45 45

Fig. 53.3 b Fatty liver Fig. 53.4 b Posterior acoustic Fig. 53.5 b Multifocal fatty
shadow infiltration
54 Liver Lesson 4

Focal Fatty Infiltration

Fatty liver is not necessarily a diffuse
process involving the entire organ;
infiltration can also be confined to
individual segments of the liver.
Such focal fatty infiltration (63)
shows a predilection for the gallblad-
der bed and the area anterior to the
intrahepatic branching of the portal
vein (11). These zones of increased
fat deposition are more hyperechoic a a
than the rest of the parenchyma (9) 1 1
2 2
and are invariably sharply demar- 46 3 6
cated. They can exhibit bizarre geo-
graphic configurations (Fig. 54.1) 9 9
18
but lack any signs of a mass effect. 63 10 8 5
Adjacent hepatic veins (10) and portal 11
vein branches (11) are not displaced. 63 5
15
10
These areas of focal fatty infiltration 45 9
45
must be distinguished from the 16
11
falciform ligament (8) whose 10
9 13 35
9
connective tissue and surrounding 9
fatty tissue can appear as a similarly
hyperechoic and sharply demarcated Fig. 54.1 b Focal fatty infiltration Fig. 54.2 b Falciform ligament
structure interrupting the normal of the liver
hepatic parenchyma (Fig. 54.2).

Focal Sparing in Fatty Infiltration

Fatty infiltration can also spare individual portions of the liver, creating focal areas of reduced infiltration (62).
These zones often occur in the immediate vicinity of the portal vein (11) or gallbladder (14) and can occasionally
exhibit a round shape, in which case they can resemble metastases (Fig. 54.4). The important thing is that there
are no signs of a mass effect here either. Adjacent hepatic veins (10) are not displaced (Fig. 54.3) but exhibit their
normal straight course. Peripheral
areas of focal sparing do not cause
any outward bulging or project into
the gallbladder as is often observed
with focal malignancies.
The branches of the portal vein
(11) can be distinguished from
hepatic veins by a hyperechoic
border. This "embankment" is
caused by impedance mismatches
between the walls of the portal
venous branches, the accompa-
nying bile ducts, and the arteries.
The "embankment" (5) often 2 2
4 4
appears thicker in the vicinity of the 5 5
hilum (Fig. 54.2) and should not be
mistaken for focal fatty infiltration. 9
10 9
Because the hepatic veins (10) 51
62 29
course through the parenchyma 31
62
(9) without accompanying arteries, 9 11 14
10
they do not exhibit these impedance 62
27

mismatches. The vascular wall 10

70
produces a bright echo only when 47
13
16
9 11
major hepatic veins are visualized
perpendicular to the sound beam Fig. 54.3 b Focal sparing at the Fig. 54.4 b Round area of reduced
(see p. 52). margin of the liver fatty infiltration
Lesson 4 Liver 55

Hepatic Cysts
The most common focal lesions in the liver are benign
cysts (64). These can be congenital or acquired. The
latter can be distinguished from congenital dilation of
the bile ducts (Caroli disease) because they contain no
bile but only serous fluid (Fig. 55.1). Congenital liver
cysts are usually of no clinical significance. The following
cyst criteria make it easier to differentiate benign cysts
from other hypoechoic masses (Table 55.2): These
include anechoic content, spherical shape, sharp and
smooth demarcation, and distal acoustic enhancement
in the case of larger cysts (70, see p. 18). Occasionally
there are edge shadows (see p. 19) and accentuated
entry and exit echoes (where the incident sound waves
hit the cyst wall at a 90° angle).

1 2
4
5
Checklist of Cyst Criteria
• Spherical shape
9 • Anechoic contents
13 • Sharply demarcated
64 • Distal acoustic enhancement
47 47 • Edge shadow
70 • Accentuated entry and
70
exit echoes

Fig. 55.1 a Benign liver cysts b Table 55.2 Cyst criteria

The internal echoes occurring in hemorrhagic cysts can Where this is the case, parasitic infestation of the liver
present difficulties for a differential diagnosis because must be excluded.
these cysts can also exhibit indentations or fine septa.

Echinococcosis (CE)
The most common cause of parasitic liver disease is
enteral infection with the dog tapeworm (Echinococcus
cysticus), which in its initial stage CL or CE1 initially pro-
duces a singular cyst with a noticeably thickened wall
structure (Fig. 55.3) or forms mural "hydatid sand." Stage
CE 2 is characterized by multiloculated cysts (Fig. 55.4).
Such cysts should not be aspirated so as to avoid rupture
with subsequent seeding of the abdominal cavity with
the pathogen or anaphylactic shock. Under albendazole
therapy, involution of the cysts can occur in Stage CE 3a
as evidenced by the "waterlily sign" (Fig. 55.5); however,
viable pathogens are probably still present.

1 1
2 2 2
3 3 4/5
80
4
9 14
9 13
14 64 9 74
74 46
46 11
54 64 43
64 45
13 43 43 43
64 64
54
45 9 43 64
47
47 45
47

Fig. 55.3 b Echinococcus CE 1 Fig. 55.4 b Multiloculated cysts Fig. 55.5 b Waterlily sign
in CE 2
56 Liver Lesson 4

Echinococcosis (CE)
Under ongoing therapy, the cysts 2 1
3
in Stage CE 4 become increasingly 5
solid and the cystic portions
decrease. This is difficult to distin-
guish from the less common fox 54
tapeworm (Echinococcus alveolaris)
on ultrasound scans. Findings 54
frequently include a mixed solid, 13 45
partially liquid, and cystic mass
(54 in Fig. 56.1). One can assume 9
that a cyst in Stage CE 5 is inactive 47
only where extensive circular Fig. 56.1 a Differential diagnosis b45 47
calcifications are present (not between echinococcus
shown here). alveolaris and stage CE 4

Hepatic Hemangiomas
Smaller hemangiomas (61) of the
liver consist of convoluted blood
vessels and therefore are usually
homogeneously hyperechoic (bright)
in comparison with normal hepatic
parenchyma (9), sharply demarcated,
and lack a hypoechoic rim (Fig.
56.2). They typically occur in the
vicinity of a draining hepatic vein
(10) as in Fig. 56.3.
Hepatic hemangiomas can also 2 3
2
be multifocal and larger. They 47 5 5 74 4
5
are then often inhomogeneous, 46
68
making them difficult to distin- 9 9
guish from other focal hepatic 47 10
lesions. Do you notice any other
10 13 61
pathologic findings in this figure (see
p. 157 for the answer)? 45 11 10
45 68
When in doubt, contrast-enhanced 9
ultrasound (CEUS) or a dynamic 61
45
47 13
contrast CT study (Fig. 56.4) is 13
69
performed to determine whether
a bolus injection of contrast agent Fig. 56.2 b Small hemangioma Fig. 56.3 b Larger hemangioma
produces the "iris sign" typical of a
hemangioma. Here, the enhancement in the early arterial phase (Figs. 56.5a and b) progresses from the peripheral
zone to the center in the portal venous phase (Fig. 56.5c). In the late venous phase (Fig. 56.5d), the entire
hemangioma (64) even in its center appears more hyperechoic than the normal adjacent hepatic parenchyma (9).

64

9 9

Fig. 56.4 Iris sign on CT Fig. 56.5 a b Early arterial c Portal venous d Late venous
phase phase phase
Lesson 4 Liver 57

Focal Nodular Hyperplasia (FNH)

Focal nodular hyperplasia is a benign primary tumor of
the liver that most commonly occurs in women and can
exhibit a mixed isoechoic or inhomogeneous internal
structure (Fig. 57.1), which can make it difficult to dif-
ferentiate from other focal hepatic lesions. Particularly
when the FNH exhibits a hypoechoic border as in Fig.
57.3, it becomes difficult to distinguish it from liver
metastases (see pp. 60-61).
When in doubt, a proven technique for a differential
diagnosis is to examine the vascular architecture of the
focal hepatic lesion on color Doppler ultrasound (Fig.
57.3) or using contrast agents (see p. 14). A central star
figure (Fig. 57.2) is pathognomonic for FNH, but not
always present.

1
2
3/4 5
74
80 14
46

10
13 11
54 10
47

45
45 9 13
35

Fig. 57.1 a Example of b Fig. 57.2 Central star figure on CEUS

inhomogeneous FNH (C. F. Dietrich)

2 1
5 3

9
54 11
10
11

10 10
11 16

Fig. 57.3 a FNH with hypoechoic b c Peripheral perfusion on

border on color duplex scan
noncontrasted scan

Occasionally focal nodular hyperplasia (54) can even
exhibit a mass effect and adjacent hepatic arteries (18)
supplying the area or hepatic veins (10) are displaced in
convex arc (Fig. 57.4). When color duplex sonography
demonstrates individual vessels ( ) coursing to the cen-
ter of the lesion (Fig. 57.4), then it becomes very difficult
to distinguish the lesion from a hepatocellular carcinoma
(see p. 59). The perfusion pattern on contrast-enhanced
ultrasound can then resolve the issue.

2
4
47 4
10

45 11

45
46
54
47 16
13 45
47

Fig. 57.4 a FNH with mass effect b c Central vessel on color

on noncontrasted scan duplex scan
58 Liver Lesson 4

Cirrhosis of the Liver

In addition to occurring as a late sequela of viral
hepatitis or chronic alcohol abuse, cirrhosis of the liver
may be caused by metabolic disorders or exposure
to environmental toxins. Latent early-stage cirrhosis
without clinical signs of hepatic decompensation can
be present in the absence of morphologic changes on
ultrasound studies. Findings in the initial stage may
include only peripheral vascular rarefaction (Fig.
58.1), which can differ greatly from normal findings
(see Fig. 52.2).
Where the cirrhotic changes progress, the hepatic
parenchyma initially acquires a finely undulating surface
that later becomes coarsely nodular (Fig. 58.2). Initially
this is particularly clearly detectable on the visceral
(posterior) margin of the liver ( ) at the appropriate
magnification setting (Fig. 58.3).

Fig. 58.1 Peripheral vascular Fig. 58.2 Finely undulating organ Fig. 58.3 ... on the posterior margin
rarefaction contour ...

Checklist of Cirrhosis Criteria

• Absence of thin hyperechoic capsule line
• Peripheral vascular rarefaction
• Widened angle of the hepatic veins > 45°
• Abrupt caliber changes of the portal vein
• Possible enhanced "embankment" of the portal vein
• Regenerating nodules with displaced vessels
Additional Findings in the Late Stage
• Rounded organ shape (obtuse marginal angles)
• Shrinkage of the liver
• Signs of portal hypertension

Fig. 58.4 Widened angle Fig. 58.5 ... with variable Table 58.6
of the hepatic veins ... caliber

As the disorder progresses, the presence of regenerating
nodules causes widening ( ) of the normally acute
angle (compare to Fig. 50.6) of the confluences of
the hepatic veins (10); one observes wider confluence
angles (Fig. 58.4) in these veins, which under magnifi-
cation often exhibit irregular vascular contours ( ) as
well (Fig. 58.5).
The late stage characterized by shrinkage of the liver of-
ten includes portal hypertension (see p. 42) with ascites
(68). The altered surface of the organ is thus obvious at
first glance (Fig. 58.7a) or at the latest with appropriate
magnification (Fig. 58.7c), which inexperienced exami-
ners should always use if they do not want to overlook
cirrhosis of the liver. Compensatory hypertrophy of the
caudate lobe can also be a sign of liver damage.

2
4

68

13 9
80

68
11 14
5
47 45 11 46
5 74
Fig. 58.7 a Liver shrinkage with b c Magnified surface
ascites
Lesson 4 Liver 59

Hepatocellular Carcinomas
Aside from complications such as portal hypertension
and portal vein thrombosis (see pp. 42–43), malignant
liver tumors often occur as late sequelae of cirrhosis
of the liver. Therefore it is important to inspect every
cirrhotic liver carefully and thoroughly for focal masses
(see Video clip 4.1c) to detect a hepatocellular
carcinoma (54) as early as possible (Fig. 59.1). When in
doubt, perfusion of the focal lesion is evaluated using
contrast-enhanced ultrasound (CEUS) with a contrast
agent (see p. 14). Typical findings in the early arterial
phase include peripheral enhancement with individual
radial vessels extending into the center of the tumor
(Fig. 59.2a). Any central necrosis (57) in the tumor will
not enhance during the arterial phase (Fig. 59.2b) and
portal venous phase (Fig. 59.2c).
A typical feature of hepatic malignancies is that arte-
riovenous shunts within the tumor tissue lead to an
early washout phenomenon in the late venous phase
in comparison with the normal hepatic parenchyma
(Fig. 59.2d), making the tumor area appear more
hypoechoic, although not as early and as markedly as
with liver metastases (see pp. 60–61).

2 1
4 5
4 2

9
54
68 57
68

54
18 9

Fig. 59.1 a Hepatocellular b Fig. 59.2 a Early arterial perfusion phase

carcinoma

Fig. 59.2 b Arterial phase c Portal venous phase d Late venous phase

Liver Abscesses
As abscesses can also develop a central necrosis, they
represent an important differential diagnosis to he-
patic malignancies. An acute liver abscess (58) can
exhibit a pronounced reaction in adjacent tissue or
none at all (Fig. 59.3). Chronic abscesses frequently
develop a double wall and show internal echoes within
the lesion (Fig. 59.4). In the presence of clinical signs
of infection, one must be careful to actually scan the
entire liver so as not to miss any subphrenic abscesses
(Fig. 59.5).

2
3
9 45

18 58

14 43/46

Fig. 59.3 Acute liver abscess Fig. 59.4 Chronic abscess Fig. 59.5 Subphrenic location
60 Liver Lesson 4

Liver Metastases
The liver is the site of metastases not only of gastric
and colorectal carcinomas but often also metastases
from hematogenous seeding in patients with bronchial
and breast carcinomas. Metastases (56) in the hepatic
parenchyma (9) are highly variable in their ultrasound
morphology. Typically, but by no means invariably, they
exhibit a hypoechoic perifocal halo in the tissue adjacent
to the metastasis as in Figs. 60.1 and 60.2. The echo-
genicity of metastases varies from more hypoechoic
lesions to ones with hyperechoic centers (Fig. 60.1) to
more hyperechoic lesions (Figs. 60.2 and 60.3).
Depending on the type of tumor, the speed of its
growth, and/or the immune response or chemotherapy,
regressive changes such as scarring, hyperechoic fibro-
sis or calcification (Fig. 60.2), or central necrosis (57)
can also occur (Fig. 60.3).

1 2 2
2 4
4 4 74 47 5
74 4
46 46
47 5
14 9
10
9 11
80
56 57

56 45 45 45 56
56 56 9 16
13 10
57 9
45 9 11 13
70
47 45
13 13 47

Fig. 60.1 b Typical halo Fig. 60.2 b Signs of regression Fig. 60.3 b Central necrosis

The decisive finding for excluding the differential diagno- focal lesions of the liver is not so much their echogenicity
ses of parasites (see p. 55), focal nodular hyperplasia (see as their pattern of enhancement with a contrast agent on
p. 57), or cirrhotic changes (see p. 58) when evaluating contrast-enhanced ultrasound (CEUS).

Hypervascularized Metastases
The primary tumors are often neuroendocrine tumors
such as thyroid carcinomas or carcinoids. In the arterial
perfusion phase of the contrast agent (about 15–45 se-
conds after injection, see p. 14), these show increased
perfusion proceeding from the periphery of the metas-
tasis (56) in comparison with the adjacent normal hepatic
parenchyma (Fig. 60.4a). In the portal venous phase
(approximately 45–120 seconds after contrast injection),
the hyperperfused zone expands into the center of the
lesion, sparing only central areas of necrosis (Fig. 60.4b),
and often shows early washout. The distinguishing feature
of malignant metastases occurs particularly in the late
venous phase (approximately 2–5 minutes after injec-
tion) in the form of an early washout phenomenon which
makes the lesion appear more hypoechoic than the
normal hepatic parenchyma in the vicinity (Fig. 60.4c).

Fig. 60.4 a Arterial phase b Portal venous phase c Late venous phase
Lesson 4 Liver 61

Hypovascularized Liver Metastases

Primary tumors that produce hypovascularized liver
metastases primarily include colorectal carcinomas.
The early washout phenomenon in the late venous 9
phase of contrast perfusion is due to the tendency of
malignant tissue to develop increased quantities of
pathologic arteriovenous shunts. These shunts circum-
56 14
vent the time-consuming passage through the capil-
lary system that occurs in normal liver tissue (9) with
the result that the contrast agent leaves the metastatic
tissue (56) early and appears in the hepatic veins (10) 56
after only 20–30 seconds.
Fig. 61.1 Plain scan
The noncontrasted images of the case shown here
demonstrated several hyperechoic lesions (56) with
ill defined hypoechoic halos (Fig. 61.1). In the end of
the arterial phase (about 15–45 seconds after contrast
injection, but also later in heart failure), the obviously
hypovascularized metastases here were already more
hypoechoic than the adjacent hepatic tissue (Fig. 61.2).

Fig. 61.2 End of the arterial phase

In the further course of the study in the portal venous

phase (about 45–120 seconds), the echogenicity can
partially equalize or remain hypoechoic (Fig. 61.3).
Focal and multifocal areas of increased or reduced
fatty infiltration (see p. 54), which a differential diagnosis
must consider, do not exhibit any differences in perfusion
to normal hepatic tissue.

Fig. 61.3 Portal venous phase

The difference in echogenicity between benign and

malignant lesions becomes particularly noticeable in
the late venous drainage phase, in which the metastases
enhance particularly markedly ( ), setting
them apart from the adjacent hepatic parenchyma
(Fig. 61.4). Here, too, the difference in echogenicity
results from the increased number of arteriovenous
shunts in the malignant tissue, leading to an early
washout phenomenon.

Fig. 61.4 Late venous phase

62 Quiz Lesson 4

Please take this quiz to test your command of the material check the answers only after you have worked through
presented in Lessons 3 and 4. You will find the answers all questions. Getting the answers too early ruins the
to the questions on the preceding pages. You will find suspense and defeats the purpose of the quiz.
the answers to the image quiz on page 156. It is best to

1. Repeat the drawing exercise for the standard
imaging plane of the porta hepatis. Where are
hepatic artery and bile duct in relation to the
portal vein and inferior vena cava? Please compare
your drawing with Fig. 41.2c.
2. What is the name of the imaging plane that visual-
izes the hepatic venous star? How do you hold the
transducer to obtain this plane? Draw the corres-
ponding body markers and sketch the appearance
of the hepatic venous star. What measurements can
you make at which locations? For what purpose?

3. Write down six characteristics of portal hyper-
tension and eight criteria of cirrhosis of the liver.
Compare your answers with the checklists on
pages 42 and 85, and repeat this exercise over the
next few days until you remember every finding
(leave time to rest in between!).
4. Do you remember the sites of predilection for focal
fatty infiltration and focal areas of reduced fatty
infiltration of the liver? How can you distinguish
these processes from hepatic malignancies?

5. What is the maximum diameter of the common 6. Write down several differential diagnoses for Fig.
bile duct? Above what diameter in mm would you 62.4. The solution is on page 156.
suspect obstructive cholestasis?

7. Review the following three ultrasound images. Write

down the imaging planes, the organs and vessels
visualized, and your differential diagnosis. Include
all changes and your interpretation as some images
include several pathologic processes.

Fig. 62.4

Fig. 62.1 Fig. 62.2 Fig. 62.3

Imaging plane:
Organs:
Vessels:
Differential diagnosis:
 Lesson 5 Kidneys and Adrenal Glands:
Anatomy 64
Kidneys, Normal Findings 65
Adrenal Glands, Normal Variants, Renal Cysts 66
Renal Transplants,
Kidney Degeneration, Nephritis 67
Spleen
Urinary Obstruction 68
Differential Diagnosis of Urinary Obstruction 69
Kidney Stones, Renal Infarcts 70
Tumors 71
Renal Transplants 72
Spleen:
Anatomy, Examination Technique 74
Spleen Size, Curtain Trick, Splenomegaly 75
Splenomegaly, Splenic Infarcts 76
Focal Splenic Lesions 77
Quiz 78
64 Kidney Lesson 5

Anatomy of the Kidneys and Adrenal

Glands
The right kidney (29) lies in the retroperitoneal 16
space posterior to the hepatorenal recess
13
(pouch of Morison) and the right hepatic lobe.
It lies immediately lateral to the spinal column 27 155 32
so that the right renal vein (25a) only needs to
cover a short distance to reach the inferior vena 18
cava (16) (Fig. 64.1). 24a
The right renal artery (24a) typically but not 29 17
25a
invariably courses posterior to the vena cava. Its
anatomy is highly variable; it can branch early or
there can be accessory renal arteries which arise
either from the aorta or even from the common 15
iliac artery in the form of an inferior polar artery.
28 16
Lying like a cap on the upper pole of the kidney
44
(27), the right adrenal gland (155) is very well
supplied by several arteries and is often the site
Fig. 64.1 Right kidney in the retroperitoneum
of metastases of bronchial and other carcinomas.
Normally both kidneys are highly mobile with re-
spiration and displace along the bed of the psoas
major muscle (44), which courses posteriorly. 27
The examiner can exploit this mobility to avoid 30
30
acoustic shadows of the ribs or intestinal air. 30
30
Within the kidney, the renal pelvis (31) located 29 149
in the center is differentiated from the outer 149
parenchyma (29) and the medullary pyramids 31
24b
(30) located outside the parenchyma/pelvis (PP)
border, ( – – – in Fig. 64.2).
These medullary pyramids contain tubules that
drain into the calices (149) at the tip of the
respective papilla. In adults the length of the 150
kidney from the upper pole (27) to the lower
29
pole (28) measures between 10 and 12 cm
depending on the person's height.
28
83
The left kidney lies posterior to the tail of the Fig. 64.2 Structure of the kidney
pancreas (33c) and has a shorter left renal artery
(24b) and a longer left renal vein (25b)
compared with the right kidney (Fig. 64.3).
Lying on the upper pole of the left kidney (27) 47
34 13 2
in an anterocranial position is the left adrenal 16
19
gland (155). The first regional nodal groups of 13
the kidney lie at the renal hilum in the vicinity of 15 155 27 109
the aorta (15) and celiac trunk (32). 11 32 20
The key to the other numbers may be found in
the legend on the back cover flap. 18 19
33c
23 20 24 b
25b
17 29
33b
15
33a
23 28
46 150
44
(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs,
3rd ed. Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)
Fig. 64.3 Topography of the left kidney
Lesson 5 Kidney 65

Normal Findings
The right kidney can be well visualized in a longitudinal
section through the liver from the anterior axillary line
with the patient positioned supine after deep inspiration
(Fig. 65.2a). Alternatively, the transducer can be placed
parallel to the intercostal spaces with the patient in the
left lateral decubitus position (Fig. 65.1a). Scan each
kidney thoroughly in two planes. The left kidney can
be visualized in the transverse and longitudinal planes
with the patient supine or in the right lateral decubitus
position (see Video clips 5.1a–c).
Deep inspiration should displace the kidney to the le-
vel of the psoas major muscle (44), that is caudally 3–7
cm. This displacement can be exploited to place the
kidneys in a better acoustic window between the ribs
and intestinal air.
Normally, the parenchyma of the right kidney is
isoechoic to hepatic parenchyma (Fig. 65.3). It should
be at least 1.3 cm thick in adults. A "string of pearls"
visualized along the border between the outer paren-
chyma (29) and the hyperechoic central renal caliceal
system (31) in the typical longitudinal plane (Fig. 65.2)
represents the hypoechoic medullary pyramids (30).
They should not be mistaken for anechoic cysts or renal
calices. The central region of the kidney appears hype-
rechoic because of the many impedance mismatches
between the walls of vascular structures, connective
tissue, and fat.
The right renal hilum is well visualized in the transverse
plane (Fig. 65.3) as is the course of the renal vein (25)
extending to the inferior vena cava (16) (see Video
clips 5.2a, b). Be alert to hypoechoic masses within the
hyperechoic suprarenal fat capsule at the upper pole
of the kidney (27) as these suggest adrenal tumors. An
important measure of chronic kidney damage is the
ratio of the thickness of the hypoechoic peripheral
parenchyma to the hyperechoic renal pelvis in the
center. This parenchyma to pelvis (PP) index decreases
with age (see Table 65.4):

Checklist of Normal Renal Values

Kidney length: 10–12 cm
Kidney width: 4–6 cm
Respiratory mobility: 3–7 cm
Width of parenchyma: 1.3–2.5 cm
PP index:
Age < 30 years > 1.6 : 1
Age 30–60 years 1.2–1.6 : 1
Age > 60 years 1.1 : 1

Fig. 65.1 a b Table 65.4

4 5

9 43

30

31 29
45
13
27 44

47

Fig. 65.2 a b Longitudinal section c

of the kidney
1
2

4
5

10 10
9

14
30

29
31 25 16

Fig. 65.3 a b Transverse section of the kidney c

66 Kidney Lesson 5

Normal Variants Renal Cysts

The normal shape of the kidney (Fig. 65.2) can exhibit
several developmental variants. Hyperplastic columns
of Bertin can protrude from the parenchyma (29) into
the central renal pelvis (31). However, these columns
are isoechoic to the rest of the renal parenchyma. An
isoechoic parenchymal bridge can completely divide the
renal pelvis, or partial or complete duplex kidneys (Fig.
66.1) may be present with separate ureters and blood
supply for each moiety.
A horseshoe kidney with prevertebral bridges can at
first glance be misinterpreted as a preaortic lymphoma
or thrombosed aortic aneurysm. An undulating kidney
surface due to persisting fetal lobulation is occasionally
observed in children and young adults. Although slightly
domed, the surface of the kidney itself is smooth. There
may be fine indentations between the medullary pyra-
mids. These indentations must be differentiated from
the more triangular scars occurring secondary to renal
infarcts (see Fig. 70.3), which are most often found in
older patients with renal artery stenosis or suprarenal
aortic aneurysm.
About 10% of all patients show localized parenchymal
thickening along the lateral border of the left kidney,
usually caudal to the adjacent lower pole of the spleen.
This "dromedary hump" is a normal bulge that can be
difficult to differentiate from an actual renal tumor.
Dysontogenetic cysts (64) are usually anechoic as in
the liver (see p. 55). Above a certain size as in Fig. 66.2
they show distal acoustic enhancement (70). Do you
remember the other criteria for differentiating cysts
from hypoechoic renal tumors in obese patients? If not,
see the checklist on p. 55.
Peripheral cysts lying on the renal capsule and projecting
outward are distinguished from parenchymal cysts (Fig.
66.2), and parapelvic and pelvic cysts. These latter cysts
can be mistaken for a urinary obstruction in the renal pel-
vis (31) because of their location (see pp. 68 and 73). The
examiner should note the diameter of the cyst and its
location (upper or lower pole; or upper, middle, or lower
third of the kidney) and carefully examine its immediate
vicinity for any signs of a tumorous mass. Some malig-
nant renal tumors contain cystic components that may
be significantly more conspicuous than the actual solid
component of the tumor.
Isolated renal cysts are of no clinical significance and
require only long-term follow-up. In contrast, the adult
form of familial polycystic kidneys (Fig. 66.3) can pro-
duce multiple cysts (64) with progressive growth in
middle age. These cysts can reach a considerable size.
Polycystic degeneration leads to kidney failure in ear-
ly adulthood as a result of displacement and thinning
of the renal parenchyma. These patients eventually
require dialysis.

1 1
2 4 2
4
1
4 2
5 74
46 3/5
9 11
29 13 9
29
9 43
64 64 5
29 64
64 45
31 30 29
31 64
31 31
64
70 47 70 44
70 2
27 5

Fig. 66.1 b Partial duplex kidney Fig. 66.2 b Renal cyst Fig. 66.3 b Polycystic kidneys
Lesson 5
Kidney Degeneration
Slowly progressive narrowing of the outer parenchyma
with increasing age is physiologic (see p. 65). Increased
parenchymal atrophy (Fig. 67.1) also occurs secondary
to repeated inflammation or in the setting of high-grade
renal artery stenosis. Reduced perfusion can involve the
entire kidney or circumscribed infarcts can occur, as is
often the case in embolic disorders (see Fig. 70.3). In
end-stage disease, narrowing of the parenchyma (29)
can be so pronounced that it is barely visualized on
ultrasound (Fig. 67.2). This imaging example of a shrun-
ken kidney shows the most common associated findings
of degenerative calcifications (53) or calculi (49) that are
visualized indirectly because of their acoustic shadows
(45). Shrunken kidneys can be so small that ultrasound
scans fail to detect them. Loss of function in a kidney can
be fully compensated by the contralateral kidney, which
shows compensatory hypertrophy. When a shrunken kid-
ney is detected on one side, one should first determine
the parenchyma to pelvis (PP) index (see p. 65). A normal
index suggests congenital renal hypoplasia. Usually the
combination of examination of the contralateral kidney
and color duplex ultrasound evaluation of renal perfusion
can establish a diagnosis.
Nephritis
The kidney reacts to various causes of inflammation with
a relatively uniform morphologic picture on ultrasound.
The kidney can appear normal in acute pyelonephritis or
where inflammation is limited to the glomeruli. How-
ever, it later increases in size due to edema. Interstitial
infiltration also increases the echogenicity of the pa-
2 1
4 2
74
46
9 46
31 30
49
29
45
29 49/53
27 31
13
45
47 45
Fig. 67.1 b Kidney stones Fig. 67.2
Kidney 67
renchyma (29). This increases its contrast against the
hypoechoic medullary pyramids (30 in Fig. 67.3). This
results in what are known as "punched out" medullary
pyramids. Compared with the adjacent spleen or liver
tissue (9), the parenchyma of the inflamed, infiltrated
kidney appears significantly more hyperechoic (Fig.
67.3) than it normally does (see Fig. 66.2).
Unfortunately, the increased echogenicity of the renal
parenchyma does not allow any conclusions as to the
cause of the inflammation. The same phenomenon
occurs with interstitial nephritis, chronic glomeru-
lonephritis, diabetic nephropathy, renal amyloidosis
(autoimmune infiltration), and urate nephropathy. This
latter form results from an elevated serum uric acid
concentration in gout or increased tissue destruction.
Ultrasound does not make any significant contribution
to a differential diagnosis among the various causes
of inflammation. However, it is useful for following up
nephritis during therapy and for excluding additional
complications. Using Doppler ultrasound to determine
the resistance index (a measure of renal perfusion)
can provide valuable information about the course of
infiltration or the onset of acute rejection in transplanted
kidneys. When in doubt, ultrasound-guided needle
biopsy can obtain renal tissue for histologic evaluation.
In acute nephritis, the parenchyma can be diffusely
hypoechoic and widened, and the border between
the parenchyma and renal pelvis can appear indistinct
or blurred. In normal kidneys this border is invariably
sharply demarcated.
2 1
4
4
74
9
9 46
46 11
74 10
29
29
74
45 30
31 45
25 a 29
35
45
45
13
27
b Shrunken kidney Fig. 67.3 b Nephritis
68 Kidney Lesson 5

Urinary Obstruction
The many impedance mismatches exhibited by the renal caliceal system
and the walls of the numerous vascular structures make the normal central
pelvic complex appear very hyperechoic (see Figs. 65.2 and 67.1). In the
absence of urinary obstruction, the pelvic complex is traversed only by
narrow hypoechoic lines corresponding to small blood vessels or parts of
the collecting system.
As diuresis increases after intake of a large amount of fluid or under diuretics,
the secretion effect can cause the collecting system (87) within the pelvic
complex (31) to appear more pronounced than usual (Fig. 68.1).

1
Checklist of Urinary Obstruction 5 2
43 4
46
First degree: only renal pelvis is dilated
29 45
30
Second degree: calices are also dilated 30
45
31 31
Third degree: additional parenchymal narrowing 87 29
28

Fourth degree: hydronephrosis

70 44
(residual parenchyma barely visible) 45

Table 68.1 Checklist for degrees of urinary obstruction in adults Fig. 68.1 Normal diuresis effect

Four degrees of urinary obstruction are distinguis-
hed in adults, up to and including hydronephrosis. In
first-degree obstruction, the renal sinus (87) is dilated
but the dilation does not involve the caliceal necks (Fig.
68.2). The thickness of the parenchyma is normal. In
second-degree urinary obstruction, the caliceal necks
and calices are dilated as well (Fig. 68.3).
Third-degree urinary obstruction is characterized by
pressure atrophy and narrowing of the outer renal paren-
chyma (29) as well (Fig. 68.4):

1 1
2
9 43 2
4 4
74 4 2 5
30
2 45 9
29 149 29 30 29
9 30 46 5

24 31 5 45
5 5
149 31
29 31 45
30
30 44 45
44 45
29 45
5
70

Fig. 68.2 b First-degree urinary Fig. 68.3 b Second-degree urinary Fig. 68.4 b Third-degree urinary
obstruction obstruction obstruction
 Lesson 5 Kidney 69

Urinary Obstruction
Chronic urinary obstruction finally leads to destruction
of the parenchyma of the affected kidney so that fourth-
degree urinary obstruction in adults corresponds to
the full picture of hydronephrosis (Fig. 69.1). Where
both kidneys are affected, the result is near total loss of
function so that dialysis is indicated. You will find the
classification of urinary obstruction in children on pages
138 and 139. The most common causes aside from
prostatic hypertrophy in men (see p. 101) include
gynecologic tumors (see p. 105) and calculi (49) lodged
in the ureter (150) causing retrograde urinary stasis (Fig.
69.2). Common sites for lodged ureter calculi are circled
in Fig. 69.3: At the origin of the ureter, at the crossing of
testicular vessels in the male and ovarian vessels in the
female and/or the iliac vessels, and at the distal insertion
of the ureter into the bladder wall.

13
16 32a
27 155
24a 18 19
25b
29 25a
17

28 15
16
150

21
2 44
1 5 22
4 5 4
150
9 21a 22b
149 43/46
149 46 21b
149 74 22a
46
149 49 43
5 150
31 83
44 45
38
31

44 35 45
155 / 5 45
13 45
35

Fig. 69.1 b Fourth-degree urinary Fig. 69.2 b Ureter calculus Fig. 69.3 Narrow points in the ureter
obstruction (Schuenke M, et al: THIEME Atlas of Anatomy–
Internal Organs, 3rd ed. Stuttgart: Thieme, 2020.
Illustrations by M. Voll, K. Wesker.)
Differential Diagnosis of
Urinary Obstruction
Patients with an ampullary type of
renal pelvis or slightly more promi-
nent hilum vessels (25) can also show
a sparse hypoechoic renal pelvis
(Fig. 69.4) that is of no clinical
significance. However, here the renal
vessels usually appear finer than
the typical thickening seen in
first-degree urinary obstruction
(see Fig. 68.2).
When in doubt, the differential
diagnosis may be resolved by color 1 1

duplex sonography. There, the more 2 2 4

4 43/46 43/46
rapidly flowing blood is color-coded
5
whereas the static or slowly flowing
5
urine remains anechoic (= black). 29 30 37 74
It is more difficult to distinguish 25 45 29
45
urinary obstruction from multiple 25 30
64
pelvic cysts (64) because these cysts 31 35 87
87
lack any flow and thus are not color- 27
31
35
coded by color duplex sonography
(Fig. 69.5). In order to make this 35 35
distinction, you can look for direct, 35
black (filled with fluid) connections Fig. 69.4 b Ampullary renal pelvis or Fig. 69.5 b Distinguishing pelvic cysts
to the renal pelvis and ureter. prominent hilum vessels from urinary obstruction
70 Kidney Lesson 5

Kidney Stones
Detecting stones in the kidney (nephrolithiasis) is more during their passage. They can also become lodged in the
difficult than detecting stones in the gallbladder (see p. ureter and cause acute urinary obstruction. In addition
46) because the hyperechoic stones (49) often lie wit- to detecting urinary obstruction, the value of ultrasound
hin the equally hyperechoic renal pelvis (31 in Fig. 70.1) lies in excluding other causes of pain such as pancreatitis
and therefore are not contrasted against the relatively or colitis as well as excluding free fluid in the pouch of
hypoechoic fluid in the vicinity of the stone. Stones in an Douglas (see p. 100).
obstructed renal sinus are a notable exception as the con-
trast is greater here. The examiner must be particularly
alert to acoustic shadows (45) caused by kidney stones Renal Infarcts
or calcifications. Fig. 70.2 shows an example of extensive
Circumscribed renal infarcts (71) have been observed as
renal calcifications (49) in a patient with hyperparathy-
a result of a renal embolus from an aortic aneurysm (see
roidism and a markedly elevated serum calcium level.
p. 27) or renal artery stenosis. These infarcts conform to
renal arterial territories and are broadbased at the renal
Depending on its composition, a kidney stone (49) can
surface and tapered toward the renal hilum. The result is
be completely transparent to sound waves (Fig. 70.1) or
a triangular defect (Fig. 70.3) in the renal parenchyma
be so reflective that only its proximal surface is visualized
(29), which in the late stage progresses to a hyperechoic
as a hyperechoic dome (Fig. 70.2). The differential
scar. The location and typical shape of these hyperechoic
diagnosis includes the arcuate arteries between the
scars should prevent them from being confused with
renal cortex and the medullary pyramids (bright echoes
kidney stones or renal tumors.
without acoustic shadows), vascular calcifications in
diabetic patients, and calcified scarring secondary to
In addition to digital subtraction angiography (DSA),
renal tuberculosis. Papillary calcifications secondary to
noninvasive color duplex sonography is useful for
phenacetin abuse are a less common cause. Large staghorn
detecting renal artery stenosis. Visualizing and evalua-
calculi are difficult to diagnose if there is only weak distal
ting small accessory renal arteries is especially diffi-
acoustic shadowing because the large calculus can easily
cult. They can arise from the aorta in the immediate
be mistaken for the hyperechoic renal pelvis.
vicinity of the main renal artery, or they can arise
from the aorta farther from it as upper or lower "polar
Renal concrements can dislodge and migrate into the
arteries." In rare cases, they can also arise from the
ureter (Fig. 68.4). Depending on their size, they can
common iliac artery.
pass into the bladder unnoticed or produce colicky pain

a 1 a a
2 4 2
2 4 2 4
4 74
43/46 46
9 5
37 46
45 9 9
49 71
29 45 71
31 45
30 49
49 31 29 31
29 29 31
31
29 44 29 25
27 45 35
44
13 13
35
35
45 45 47 47
35 45 45
45

Fig. 70.1 b Kidney stone Fig. 70.2 b Nephrocalcinosis Fig. 70.3 b Renal infarct
Lesson 5 Renal and Adrenal Tumors 71

Benign Renal Tumors Adrenal Tumors

Solid benign renal tumors (fibromas, adenomas, and
hemangiomas) are altogether rare and show an inhomo-
geneous morphology on ultrasound images. Their internal
echoes and lack of distal acoustic enhancement distinguish
them from fluid-filled cysts. Only the angiomyolipoma – a
benign mixed tumor comprising vessels, muscular tissue,
and fat – has a characteristic appearance in its early stage
that clearly distinguishes it from a malignant process. A
small angiomyolipoma (72) is similarly hyperechoic and
sharply demarcated as the renal pelvis (31) (Fig. 71.1).
Its ultrasound morphology resembles that of a hepatic
hemangioma (see p. 56). Angiomyolipomas only become
inhomogeneous as their size increases; they then become
difficult to differentiate from other types of tumors.
Malignant Renal Tumors
Small renal cell carcinomas (54) are often isoechoic to the
rest of the renal parenchyma (29). Only as their growth
progresses do they become more inhomogeneous and
can create a bulge in the contour of the kidney depen-
ding on their location (Fig. 71.2). If a carcinoma has been
detected, both renal veins and the inferior vena cava
must be carefully examined for tumor tissue to exclude
vascular invasion. Renal carcinomas occasionally develop
tumorous extensions into these vessels and occur bila-
terally in up to 5% of all cases. If the tumor penetrates
the renal capsule and infiltrates the surrounding tissue,
the kidney can lose its physiologic mobility with respira-
tion (see p. 65). Some malignant renal tumors can also
contain cystic components. Therefore it is important to
look for solid masses in the vicinity of what appear to be
benign renal cysts.
The left adrenal gland lies anteromedial (not cranial)
to the upper pole of the left kidney. The right adrenal
gland usually lies slightly cranial to the upper pole of
the right kidney and posterior to the inferior vena cava.
In adults, both adrenal glands are largely obscured by
the hyperechoic perirenal and suprarenal fat capsule.
This is not the case with the adrenal glands in new-
borns (see p. 140).
Hormone-producing adrenal tumors such as adeno-
mas in aldosteronism (Conn syndrome) or hyperplasia
in the setting of Cushing's syndrome are generally too
small to be detectable on ultrasound. Clinically appa-
rent pheochromocytomas are the only such lesions
that can usually be detected on ultrasound. By the
time symptoms appear, these lesions will often have
attained a size of several centimeters so that 90% of them
are detectable on ultrasound. When in doubt, order a
supplementary CT scan.
Ultrasound is more helpful in detecting adrenal metas-
tases (54), which usually appear as hypoechoic masses
(Fig. 71.3) between the upper pole of the kidney and the
spleen (37) or caudal margin of the liver, respectively.
These lesions must be differentiated from superficial
renal cysts. Because the adrenal glands are richly vascu-
larized, hematogenous spread of metastases from car-
cinomas of the bronchus, breast, or kidney is common.
The echogenicity of a suprarenal mass neither allows a
conclusion as to whether it is benign or malignant, nor
does it differentiate the mass from a neurinoma arising
from a sympathetic ganglion.

a a 1 a 2
1
2 4 74
2 47 46
4 4 13
47 4 5
74 74
46 37 29
5
43 5
54 31
30 45
72 30
29 45
54
31 49 44
31
45
29
29
45 45 45 44 47 35
13
45 44

Fig. 71.1 b Angiomyolipoma Fig. 71.2 b Renal cell carcinoma Fig. 71.3 b Adrenal metastasis
72 Renal Transplants Lesson 5

Normal Findings
Renal transplants are placed in the right or
left renal fossa and connected to the iliac
vessels. Like normal kidneys, they are
systematically examined in two planes
( and in Fig. 72.1), the difference being
that the transducer must be positioned over
the lateral lower abdomen with patient
supine. Because of the superficial position of
the renal transplant not far beneath the skin,
there is typically no interposed intestinal
gas. This position greatly facilitates the
ultrasound follow-up examination. Fig. 72.1 a Scanning b ... of renal transplants
procedure ...
A normal transplanted kidney can show a usually permanent volume increase of up to 20% postoperatively. The paren-
chyma (29) appears wider (Fig. 72.2) than in native kidneys. It is normal for the echogenicity of the parenchyma to be
slightly greater than in native kidneys, increasing the contrast to the medullary pyramids (30). Ultrasound follow-up
studies at close intervals are initially indicated to exclude progressive inflammatory infiltration. A prominent fluid-
filled renal pelvis or slight first-degree urinary obstruction (see Figs. 68.1 and 68.2) is often observed, but without
a functional impairment of the transplant that would justify intervention. The obstruction is best documented on
the transverse image (Fig. 72.3) and carefully measured to avoid missing progressive obstruction that may require
therapeutic intervention.

Early Detection of Rejection

The renal transplant should be further evaluated for sharp demarcation against surrounding tissues and for a sharply
demarcated border between the parenchyma (29) and renal pelvis (31). Blurring of the border between parenchyma
and renal pelvis or an increase in volume since the previous examination can be warning signs of beginning rejection.
Therefore, the longitudinal and transverse diameters are measured and documented to allow a valid comparison with
subsequent studies (see p. 73).
Doppler sonography is then used to determine the resistance index (RI) of the vessels in the transplant. This is an
important indicator of the onset of rejection. In the ongoing absence of rejection, both the dosage of immunosup-
pressives and the frequency of ultrasound follow-up examinations can usually be reduced over time.

2 4
74
46
45
29

31
28

30 29

Fig. 72.2 a b Renal transplant c

in sagittal plane

2 1

46 4

29
25
31

30 29
45

Fig. 72.3 a b Renal transplant c

in transverse plane
Lesson 5 Renal Transplants 73

Determining the Size of a Renal Transplant Lymphoceles

To obtain an accurate size measurement, first scan the
transplant longitudinally ( Fig. 73.1b) until you have
visualized its maximum length. The diagram in Fig. 73.1a
illustrates how choosing an imaging plane too far lateral
(black dotted line) would falsify the length measurement
by making the kidney appear too short. The transducer
must be tilted as indicated by the straight arrows ( ) to
obtain the actual maximum length (dL). Then the trans-
ducer is rotated slightly (Fig. 73.1c) to make sure that
the kidney has not been mistakenly visualized obliquely
as indicated by the red dashed line ( in Fig. 73.1a).
If necessary, the angle should be corrected as indica-
ted by the curved arrow ( ) by rotating the transducer
( ). The purpose of this two-step manipulation of
the transducer is to avoid errors that might cause you to
document a foreshortened length. Such a measurement
error could lead to subsequent misdiagnosis because the
seemingly increased volume on follow-up images could
suggest a rejection reaction.
A postoperative lymphocele (73) can develop as a com-
plication of renal transplantation (Fig. 73.2). Lympho-
celes usually occur between the lower pole of the renal
transplant (29) and the bladder (38), although they are
also observed elsewhere in the vicinity of the transplant.
Not every lymphocele is an indication for intervention;
small lymphoceles often resolve spontaneously. Large
lymphoceles can occasionally be initially mistaken for the
bladder at first glance.
Urinary Obstruction
Urinary obstruction (87) is an equally common postope-
rative complication that can result from reimplantation
of the ureter. Depending on its severity, it can require
temporary placement of a catheter (59) to ensure drain-
age (Figs. 73.3 and 73.4) so as to prevent damage to the
parenchyma (29) of the transplant.

29
31
29

30
dL

Fig. 73.1 a b c

a a a
2 2 1
4
74 2
4 5
46 46 4 5 74
77 46 46
74
29
45 29 45
29 38
73 31 59 59
87 59
45 87
30

70 45 29
31 44
29 45

Fig. 73.2 b Lymphocele Fig. 73.3 b Urinary obstruction Fig. 73.4 b ... Drainage catheter
with ...
74 Spleen Lesson 5

Anatomy
The spleen is loosely attached to the diaphragm (13) by
the splenorenal ligament and lies in its bed relatively far
posterior and lateral within the peritoneum; depending
on its size, it may be in contact with the left lobe of the
liver (9). It is supplied by the splenic artery (19), which
arises from the celiac trunk (32) and follows a retrope-
ritoneal course along the cranioposterior margin of the
pancreas (33) to the hilum of the spleen (Fig. 74.1). The
splenic vein (20) also follows a medial retroperitoneal
course posterior to the pancreas and (here obscured by
the head of the pancreas) joins the superior mesenteric
vein (23) to form the portal vein (11).
The stomach, air-filled small bowel loops (removed in
this view), and the left colic flexure (43) all lie anterior
and caudal to the spleen. The acoustic shadow of this
gastrointestinal air effectively prevents anterior or
anterolateral visualization of the spleen on ultrasound. The
only option is to visualize the organ from a posterolateral
position or between two ribs (109) through an intercostal
window as shown below.
The spleen (37) also acts as an acoustic window to the
tail of the pancreas (33c), which is often difficult to
visualize in its entire extention from an anterior position
because of overlying gastric air. The distal splenic artery
(19) often branches into several individual arteries before
entering the spleen. The same applies to the main bran-
ches of the splenic vein, which only merge into the main
trunk of the splenic vein (20) at the hilum.

13
13 9 47 109
10 34
47
16 37 2
37
11 32a 34 19
27
32 19
155
66 33c 19
18
33b
29 46 20
33c

33a
43
46
43b
43c
17
23

Fig. 74.1 View of the retroperitoneum Fig. 74.2 Intraperitoneal bed of the spleen
(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3 ed. Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)
rd

The key to the other numbers may be found in the legend on the back cover flap.

Examination Technique
The spleen is primarily visualized with the patient supine. It is best to have
the responsive patient lie close to the left edge of the examining table and
place the left arm behind the head (Fig. 74.3). This widens the intercostal
spaces and facilitates applying the transducer parallel to one of them from
a posterolateral position (see Video clip 5.3b). The examiner should stand
up or sit on the right edge of the examining table to be able to reach the
patient's posterior axillary line. The examination is performed in expiration
(see Video clip 5.3c) to prevent the lung (47) from expanding caudally and
obscuring the spleen (37) with an acoustic shadow (45) (see Figs. 75.1b and
c). Alternatively, one can perform the examination with the patient in the
right lateral decubitus position (see Fig. 75.1a). However, especially in older
patients this is more time consuming, and gravity causes the spleen to lie at
an unfavorable distance from the posterolateral chest wall. Fig. 74.3 Posterolaterally from the
posterior axillary line
Lesson 5 Spleen 75

Spleen Size
The normal adult spleen measures about 4 cm x 7 cm
x 11 cm (the "4711 rule"), whereby the longitudinal di-
mension (L) can be as much as 13 cm (instead of 11 cm)
without any clinical significance, for instance in patients
who have had infectious mononucleosis. The thickness or
diameter (D, measured from the hilum to the diaphrag-
matic capsule of the spleen) provides more information:
If it exceeds 6 cm (instead of 4 or 5 cm), additional tests
are indicated to exclude a lymphatic disorder, unless
venous congestion is present due to portal hypertension.

4
47 x
x
L
D 43

37 x 20 45
45

74
19 33
13

26
47 x

Fig. 75.1 a Lateral visualization b Normal findings c Measuring spleen size

of the spleen
Curtain Trick
In some patients, the cranial spleen
(37) is obscured by acoustic shadows
(45), either spontaneously or after
deep inspiration where the lung
(47) extends too far into the costo-
diaphragmatic recess (Fig. 75.2).
In such cases, one can take advan-
tage of the fact that the spleen will
often return to its cranial position
more slowly than the lung during
a a
1/2 4 slow expiration following maximum
2
47 43 inspiration. This relative motion
47 5 43
makes the acoustic shadow recede
37 20 like a "curtain" (see Video clip 5.3c).
37 The examiner must wait for the right
20 74
moment and then tell the patient to
5
immediately hold his or her breath.
45
26
20 45 This maneuver often succeeds in
45
45 visualizing the regions of the spleen
26
47 13 immediately beneath the diaphragm
45
13 74 (along the left edge of the image
in Fig. 75.3). The lower pole of the
Fig. 75.2 b Without curtain trick Fig. 75.3 b With curtain trick
spleen is occasionally obscured by
acoustic shadows behind bowel
loops (43).
Splenomegaly
Acute viral infections are the most common 5 2
4
cause of diffuse, homogeneous enlargement 47
46
of the spleen. In the case of infection with 37
Epstein-Barr virus (infectious mononucleosis),
20
the disease can resolve and leave behind 45 46
slight to moderate splenomegaly with 20 33
20
rounded poles. This often persists for life but 45
has no clinical significance. An important
differential diagnosis to consider is portal 26 74
hypertension in which the branches of the 45
13
splenic vein (20) are dilated (Fig. 75.4).
Fig. 75.4 a Splenomegaly ... b ... in portal hypertension
76 Spleen
Splenomegaly in Leukemia
Splenomegaly typically accompanies systemic hemato-
logic diseases, such as acute or chronic lymphatic leu-
kemia (CLL). Fig. 76.1 shows a spleen in a leukemia
patient with an adjacent accessory spleen (86) and the
tail of the pancreas (33c) close to the splenic hilum. In
principle, any disorder involving increased turnover of
erythrocytes, such as a hemolytic anemia or polycythe-
mia vera, can cause splenomegaly. In such cases the
spleen may be grossly enlarged, even extending into
the pelvis (Fig. 76.2), and may exhibit focal infarcts
(Fig. 76.3). The "kissing phenomenon" may also be ob-
served, in which the massively enlarged spleen displaces
the stomach and extends as far as the left lobe of the
liver. When evaluating the spleen, it is important to be
alert to any signs of thickening. The original crescentic
or half moon shape with tapered poles is lost, and the
poles appear rounded or thickened (Fig. 76.1). Ectopic
splenic tissue in the vicinity of the bed of the spleen,
which is occasionally present as a remnant of embryo-
nic development, can also become hypertrophic when
stimulated. Consequently, "accessory spleens" (86)
at the hilum (Fig. 76.1) or lower splenic pole are not
uncommon in diffuse splenomegaly. They have the
same echogenicity as the rest of the splenic parenchy-
ma (37) and are sharply demarcated. However, they can
be difficult to differentiate from enlarged lymph nodes
(55) as illustrated in Fig. 76.2.
2 2
47 4 4
43
37
86
33 c
37
45 55 / 86
47
13
13
47 45
Fig. 76.1 b Accessory spleen Fig. 76.2 b Splenomegaly
Lesson 5
Splenic Infarcts
Focal infarcts (71) are especially likely to occur in the
setting of rapidly progressive splenomegaly. Early-stage
infarcts appear as hypoechoic areas within perfused
hyperechoic areas (Fig. 76.3). Supplemental color duplex
sonography can establish the status of splenic perfusion
quickly and noninvasively.
Practical Suggestion
Neither size nor echogenicity of the enlarged spleen
reveals the nature of the underlying disease. If you
unexpectedly detect splenomegaly, you should examine
all accessible nodal groups (para-aortic, portal, para-
iliac, and cervical nodes) for enlargement suggestive of a
systemic hematologic disorder. You should also exclude
portal hypertension by measuring the diameter of the
splenic vein (normal value < 12 mm), portal vein (< 15
mm), and superior mesenteric vein, and by searching for
portocaval anastomoses at the porta hepatis.
Spleen size should be documented as accurately as
possible to allow follow-up examinations to determine
whether size has increased or decreased, such as can
occur after resolution of a viral infection or secondary to
chemotherapy in the interim, depending on the under-
lying disease. Keep this in mind when you perform the
initial examination.
1 1/5
2
4
5
37
71 71
20
55 /
86
37
37 20
45
45
Fig. 76.3 b Splenic Infarcts
Lesson 5 Spleen 77

Lymphomatous Infiltration Hyperechoic Lesions

Non-Hodgkin lymphoma can present with an isolated
hypoechoic splenic lesion or there may be inhomoge-
neous involvement of the entire spleen. An enlarged
spleen that appears homogeneous on conventional
ultrasound scans can nevertheless contain lympho-
matous focal lesions that escape detection. The detec-
tion rate has increased markedly with the introduction
of contrast agents used in combination with harmonic
imaging (see p. 14).
Splenic Hematomas
Definitive exclusion of splenic hematomas is of utmost
importance in trauma patients as an acute hemorrhage
may initially be contained within the splenic capsule (in-
tracapsular or subcapsular injury). The splenic capsule
may rupture only after some delay (in about 50% of
all cases within the first week), precipitating a life-
threatening hemorrhage into the abdominal cavity
(delayed splenic rupture). Therefore, one must carefully
exclude a hypoechoic lesion or delicate hypoechoic
double contour of the splenic capsule. Some splenic
hematomas (50) are also inhomogeneous (Fig. 77.1) or
isoechoic to the surrounding splenic parenchyma (37).
The two ( ) in Fig. 77.1 indicate the sites where you
should search for anechoic intraabdominal fluid (indica-
tive of hemorrhage). These sites are along the abdomi-
nal aspect of the diaphragm (13) posterior to the upper
pole of the spleen and in the vicinity of the lower pole
of the spleen (Fig. 77.2).
Spherical and homogeneous hyperechoic lesions that
are sharply demarcated from the splenic parenchyma
generally represent benign splenic hemangiomas, with
features identical to those of hepatic hemangiomas (see
p. 56). Such findings may also represent hyperechoic cal-
cifications secondary to tuberculosis infection or cirrhosis
of the liver. Multiple hyperechoic focal lesions (53) give the
spleen the appearance of a "starry sky" (Fig. 77.3). Such
lesions also occur as postinfectious scarring. Splenic
abscesses and the less common splenic metastases can
exhibit a rather varied ultrasound morphology, depending
on age and immune status. Unfortunately there are no
simple, reliable ultrasound criteria for differential diagnosis.
Splenic Cysts
Congenital sple-
nic cysts are an-
echoic and less
common than
hepatic cysts.
Their ultrasound
morphology does
not differ from
hepatic cysts (see
p. 55). Acquired Fig. 77.4 Echinococcus
splenic cysts develop secondary to trauma or infarction, or
in the setting of parasitic infestation. Fig.77.4 shows a CT
scan with cysts containing obvious radial septa ( ) in the
setting of echinococcosis of the liver and spleen.

68
37

29

1 1
2 116
47 47 2
5 43
13 47 5
43
37 37

50 68
37 45
50 45 37
20 45
45 46
20 20
37 29

13
45 37
45 47
13

Fig. 77.1 b Contained splenic Fig. 77.2 b Bleeding into Fig. 77.3 b "Starry sky" spleen
hematoma abdominal cavity
78 Quiz Lesson 5

These study questions are intended to help you to test Pursued with a little determination, you will find the
your knowledge so you can clear up any comprehension quiz rather enjoyable. You will find the answers on the
problems or close any gaps before you move on to the preceding pages (questions 1-4 and 7-8) or on page 157
next organ system. (images 5, 6, and 10).

1. From memory, draw a typical longitudinal section
of the right kidney, paying attention to the position
of the medullary pyramids relative to the border
between the parenchyma and renal pelvis (maxi-
mum 2 minutes). Repeat this task for a transverse
section of the right kidney at the level of its hilum,
and consider its position relative to the liver and the
inferior vena cava. Repeat both tasks (important: at
intervals of more than 2 hours) until you are able to
complete them without any errors.
7. Write down the normal size measurements of the
spleen in adults, and put the significance of spleno-
megaly in perspective.
8. What trick do you know to visualize the subdiaphrag-
matic portions of the spleen when you encounter
superimposed pulmonary air? How does it work?
9. You unexpectedly discover splenomegaly. How do
you proceed?

2. Make a rough sketch showing the different forms
of the normal kidney compared with the respective
findings in first through third-degree urinary ob-
struction. Discuss the differentiating criteria with a
fellow student. Validate your sketches by comparing
them with the images on pages 68-69.
10. Systematically evaluate the image in Fig. 78.4.
Proceed in the order recommended in the primer
on ultrasound on page 144 to give your thoughts
proper direction.

3. How do you recognize nephrolithiasis?

List a few possible underlying disorders that can
cause kidney stones. With the help of other sources
from the literature, provide a differential diagnosis
of hematuria (evidence of blood in the urine).

4. Do you remember the normal values for kidney

size, the parenchyma to pelvis (PP) index, and the
degrees of urinary obstruction in adults? Write
down your values and compare them with those
Fig. 78.4
listed on pages 65 and 68.

5. Carefully examine the two

ultrasound images in 78.1
and 78.2 and write down the
imaging planes; all visualized
organs, vessels, and muscles;
and of course your working
diagnosis and your reasoning
behind it.

Fig. 78.1 Fig. 78.2

6. This image (Fig. 78.3) shows a transverse section of the upper abdomen
at the level of the renal vessels. Describe the organs and vessels you can
recognize. Which vessel is atypical in its course and what conclusion do
you draw from that?

Fig. 78.3
 Lesson 6 Thyroid Gland:
Anatomy 80
Thyroid Gland, Normal Findings 81
Lymph Nodes, Goiter 82
Gastrointestinal Tract
Focal Solid Nodules, Thyroiditis 83
Lymph Nodes:
Cervical Lymph Nodes 84
Differential Diagnosis riteria, 85
Perfusion Parameters

Enlargement, Metastases 86
Retroperitoneal Lymph Nodes 87
Gastrointestinal Tract:
Anatomy 88
Gastric Tumors 89
Crohn's disease 90
Intestinal Intussusception, Hernias 91
Differential Diagnosis of ural ic ening, 92
Diarrhea, Appendicitis

Fecal Impaction, Colitis, Colon Carcinoma 93

With gastrointestinal images Diverticulitis 94

from Matthias Hofer and Quiz 95
Alexis Müller-Marbach
80 Thyroid Gland Lesson 6

Anatomy of the Thyroid Gland

The isthmus of the thyroid (81a) lies directly posterior to
the sternohyoid muscle (89) and sternothyroid muscle
(90), anterior and lateral to the trachea (84). The
common carotid artery (83) courses posterolateral to
the lateral lobes of the thyroid (81) and the internal
jugular vein (83) is further lateral. The vagus nerve
(169) courses between these two vessels (Figs. 80.1
and 80.2).
The esophagus (34) lies posterior to the trachea,
often slightly offset in a left paramedian location,
anterior to the anterior and middle scalene muscles
(88) and the cervical vertebrae (35). The sternoclei-
domastoid muscle (85) forms an anterolateral shield
overlying the cervical neurovascular bundle. The key to
the other numbers may be found in the legend on the
back cover flap.

82b
169 83
1
2
89 Platysma
81a
90
85
88 84 85
81 81
81a 83
82 83
82 123 34
84 88 88 35 88
83

169
16a

83
Fig. 80.1 Anterior view of the neck Fig. 80.2 Transverse section at the level of the thyroid
(Schuenke M, et al: THIEME Atlas of Anatomy–Head, Neck, and Neuroanatomy, 3rd ed. Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)

Volumetric Measurements
To determine the volume of the thyroid gland, the
maximum transverse and sagittal (anteroposterior)
diameters of each lobe are measured on transverse
sections. The respective values are multiplied by the cra-
niocaudal length as measured on the sagittal section and
the product is multiplied by 0.5. The result corresponds
to the volume of each lateral lobe (in mL), with a margin
of error of approximately 10%. The volume of both lobes
should be < 25 mL in men and < 18 mL in women.
When evaluating the volume of the thyroid, one should
take into account that Germany, in contrast to most of
its European neighbors, does not iodize drinking water
and is thus among the few remaining iodine-deficient
regions. Whereas the statistical average values of the
German population are "normal" values in the statistical
sense, they do not reflect the normal physiologic case.

Normal Thyroid Volume Values

The volume of the thyroid gland in girls younger than 15 years old is slightly higher than the volume in boys. To
properly answer the question of whether iodine prophylaxis is indicated, the upper threshold values in milliliters are
specified here for both iodine deficiency (black numbers)
and for iodine sufficiency (white numbers in Table 80.3). Age Female Male
The white numbers in parentheses specify the normal
values for children in Europe who do not live under Newborns < 2.3 (1.5) < 3.5 (2.0)
conditions of iodine deficiency. The respective highest 1– 4 years < 4.7 (3.0) < 3.8 (2.9)
volume of both thyroid lobes together that is still
5–10 years < 6.5 (5.0) < 6.0 (5.4)
regarded as normal is specified here as determined by
the volume formula 0.5 x A x B x C. The average volumes 11–12 years < 1.6 (14.1) < 13.9 (13.2)
are often considerably lower. Adults < 18.0 < 25.0

Table 80.3
Lesson 6 Thyroid Gland 81

Normal Findings
The patient's head is placed in slight hyperextension
and thyroid gland is examined using a linear trans-
ducer with 7.5 or more MHz (Fig. 81.1a). The organ
is scanned in successive transverse planes beginning
cranially and moving caudally (see Video clips 6.1a–c).
Next, sagittal images are obtained through each
thyroid lobe (Fig. 81.1b).
The midline acoustic shadow of the trachea (84) and,
farther laterally, the anechoic cross sections of the ca-
rotid artery (82) and jugular vein (83) provide anatomic
landmarks. The thyroid parenchyma (81) lies between
these vessels and the trachea (Fig. 81.1c). A thin paren-
chymal band (isthmus) anterior to the trachea connects
the two lobes of the thyroid (Fig. 81.2). The carotid
artery (82) usually lies in a posteromedial location, and
is round and incompressible in the transverse plane. The
jugular vein (83) is farther anterolateral. It exhibits a
typical biphasic venous pulse and is compressible when
gentle pressure is applied to the transducer.
When in doubt about the identity of any of the vascular
structures, the examiner can ask the patient to briefly
press with the mouth closed. The resulting venous con-
gestion distends the jugular vein, which usually provides
a clear anatomic landmark. The normal thyroid paren-
chyma is slightly more hyperechoic (brighter) than the
sternohyoid (89) and sternothyroid (90) muscles anterior
to it and the sternocleidomastoid (85) muscle farther
lateral (Fig. 81.2).

81

Fig. 81.1 a b c

2 5
90 /89 89/90
85

81 51 81

82 84 82
83
34
88 88
35 45
35
Fig. 81.2 a b c

Small cysts (64) in the thyroid gland (81) may not cause be differentiated from hypoechoic nodules and obliquely
any distal acoustic enhancement (Fig. 81.3b) and must visualized vessels.

1/2
5
85
81 64

35 35 35 35

45 45 45 45

Fig. 81.3 a b c
82 Thyroid Gland: Pathologic Examples Lesson 6

Goiter
In regions with insufficient dietary intake of iodine,
the most common diffuse thyroid disorder is iodine
deficiency goiter, i.e., diffuse enlargement of the thy-
roid gland. Compared with their normal appearance
(Fig. 82.1), both lobes of the thyroid are enlarged and
thickened (Fig. 82.2), often with a thickened isthmus as
well. The iodine deficiency frequently leads to isoechoic
nodules ( ) within the goiter. Where they occur peri-
pherally, they can cause protrusion of the organ surface
(Fig. 82.4). In chronic iodine deficiency, these nodules
(54) will often develop regressive calcifications or cysts
(64 in Fig. 82.3). With progressive degeneration, these
anechoic cysts can reach a considerable size (Fig. 82.5)
and can also show central hyperechoic hemorrhages
( ) (Fig. 82.6).
Malignant degeneration of hyperechoic or isoechoic
nodules is so rare (less than 1%) that it lies below the
normal malignancy rate of the German population.
Hypoechoic thyroid nodules behave differently (see
next page).

1/5
2 5 90 85
90
90 90
85 51
64
81 54 83
84 81 82
81 51 81 81 81 84

82
82 84 82
88
83 88
34 82
45
88 88 34 45
35
88 35
88 45
35 45 35 35 45

Fig. 82.1 b Normal findings Fig. 82.2 b Goiter Fig. 82.3 b Thyroid nodules

Fig. 82.4 Thyroid nodules Fig. 82.5 Cyst ... Fig. 82.6 ... with hemorrhage
Lesson 6 Thyroid Gland: Pathologic Examples 83

Focal Solid Nodules

The differential diagnosis of hypo-
echoic focal thyroid lesions includes
degenerative nodules with small
cysts and benign adenoma, but
also thyroid carcinoma. Hypoechoic
nodules therefore require supple-
mentary scintigraphy.
"Hot" nodules on a scintigram are
hormone-producing adenomas (72)
and frequently appear on ultrasound
scans with a hypoechoic rim within a a
normal thyroid parenchyma (81 in
Fig. 83.1). In contrast to the typical
5
ultrasound morphology of hepatic 90
85 5
metastases (see p. 60), a hypoechoic 72 54
rim (halo) in the thyroid gland does 72
not suggest malignancy. 81
"Cold" nodules on a scintigram that 82 81
are hypoechoic (54) require further
84
evaluation (needle aspiration for 45 45
cytology or biopsy) to exclude
malignancy (Fig. 83.2).
Fig. 83.1 b Fig. 83.2 b

Thyroiditis
In florid Graves' disease diffuse hypervascularization is
nearly pathognomonic (Fig. 83.3). The systolic peak
speeds exceed 100 cm/sec on average with flow vol-
umes per minute over 150 mL/min. The hyperperfusi-
on will initially persist for some time even after medical
therapy with normal thyroid metabolism; it only decrea-
ses later in the course of the disorder. Although hyper-
perfusion in Hashimoto thyroiditis (Fig. 83.4) shows a
similar picture, it is less pronounced than in florid Gra-
ves' disease. Chronic lymphocytic infiltration typically
produces a permanent diffuse hypoechoic appearance
in the otherwise hyperechoic thyroid parenchyma. In
de Quervain's thyroiditis the inflammation does not
usually involve the entire thyroid gland diffusely but in-
filtrates the organ unevenly, creating inhomogeneous
hypoechoic areas of edema (Fig. 83.5).

85 85 85
89 / 90
83
81 81
82
81
82

a a a

Fig. 83.3 b Graves' disease Fig. 83.4 b Hashimoto thyroiditis Fig. 83.5 b de quervain's thyroiditis
84 Lymph Nodes Lesson 6

Cervical Lymph Nodes

Enlarged lymph nodes (55) appear as oval hypoechoic
masses and are often located in vicinity of the cervical
neurovascular bundle (Fig. 84.1) along the internal
jugular vein (83) and carotid artery (82), but also in the
submental region. Physiologic lymph nodes that show
reactive enlargement in the setting of viral or bacterial
infection are usually elongated, with a ratio of maxi-
mum longitudinal diameter to maximum transverse
diameter (L/T ratio) of over 2.0. They can also appear in
groups (Fig. 84.2).
A lymph node exhibiting an L/T ratio over 2 with a central
hyperechoic hilum ( in Fig. 84.3) and a prominent
hilar vascular pattern (see pp. 85-86) can be evaluated as
benign [6.1].

85 5
85 85
55 81
89
83 84 55 55
55
82
55 55 55
55
35
45 45 45 83 55
35

Fig. 84.1 b Fig. 84.2 b Fig. 84.3 b

In contrast, thickened, spherical lymph nodes with an L/T ratio around 1.0
without a hilum sign are suspicious for pathologic enlargement due to a
process such as lymphoma or metastasis, which can occasionally show cen-
tral necrosis ( in Fig. 84.4). Infants tend to develop more severe nodal
swelling than adults even in the setting of secondary inflammatory reac-
tions. Occasionally they even develop abscesses with liquefaction in the
affected lymph nodes, which can also appear as anechoic areas. Infracla-
vicular lymph nodes can also be readily demonstrated on ultrasound, for
example in sarcoidosis as shown in Fig. 84.5.

When in doubt, additional criteria for differential diagnosis can be applied.

Fig. 84.4
These include visualizing the branching pattern of the intranodal blood
vessels on color duplex sonography, determining the pulsatility index (PI)
or resistance index (RI) at that site, and quantifying tissue elasticity, "elasto-
graphy." You will find examples of each on the next few pages.

Criteria Benign Malignant

Ratio length / width > 2.0 ~ 1.0
Hilum sign Positive Negative
Vascularization Centered in Diffuse or branch
the hilum
Table 84.1 Benign vs. malignant lymph nodes Fig. 84.5
Lesson 6 Lymph Nodes 85

Differential Diagnostic Criteria

The L/T ratio described on the previous page can only be
correctly calculated when you rotate the transducer 180°
around the axis of its cord over the center of the lymph
node. A lymph node that appears to have a low L/T ratio
(Fig. 85.1) may then show an oval L/T ratio of 3.0 as the
visualization more closely approaches as its "true" diameter
(Fig. 85.2). Although its hilar architecture is preserved
( ) there may indeed be metastatic infiltration ( ) in
such an elongated lymph node (Fig. 85.2). Especially
when higher center frequencies over 10 MHz are used,
it is occasionally possible to demonstrate multiple
metastases in a single lymph node ( in Fig. 85.3).
As the metastasis grows, the L/T ratio approaches the
value for a sphere (1.0) (Fig. 85.4). However, lympho-
mas in particular usually respect the capsule and tend to
grow and displace tissue only within the affected lymph
node (Fig. 85.5). In contrast, advanced metastases
later infiltrate the capsule ( ) and can then spread to
surrounding tissue (Fig. 85.6).

Fig. 85.1 Cross section of Fig. 85.2 Lymph node with a Fig. 85.3 Two metastases in
lymph node small metastasis one node

Fig. 85.4 Spherical shape of Fig. 85.5 Lymphomas with intact Fig. 85.6 Metastasis infiltrating
lymph node metastasis capsule capsule

Perfusion Parameters
Where perfusing vessels can be
measured within the lymph node,
PI values < 1.6–1.8 and RI values
< 0.8–0.9 suggest a benign process
(Fig. 85.7), whereas PI and RI values
above this gray area are more typical
of malignancy (Fig. 85.8). However,
these are not absolute threshold
values but approximate values.
Fig. 85.7 Reactive inflammatory Fig. 85.8 Malignant lymph node
lymph node with with PI = 2.27, RI = 0.92
PI = 1.37, RI = 0.73
86 Lymph Nodes Lesson 6

Differential Diagnostic Criteria

The fact that a lymph node is primarily sharply demar-
cated is no guarantee that it is benign. Nor does the
echogenicity of a lymph node reliably identify it as
malignant or benign, even though lymphomas often
appear homogeneously hypoechoic (relative to
adjacent muscle) and exhibit an L/T ratio of about 1
(spherical) (Fig. 86.1). In contrast, the metastases of a
malignant melanoma are almost invariably highly hypo-
echoic (Fig. 86.2). The intranodal perfusion pattern on
color duplex sonography [6.1] is another differentiating
criterion. An node infiltrated by lymphoma typically
exhibits a tree-like perfusion pattern (Fig. 86.3) that
can often be traced into the periphery.

Abb. 86.1 Homogeneously Abb. 86.2 Hypoechoic metastasis Abb. 86.3 Tree-like perfusion in
hypoechoic lymphoma of a melanoma lymphomas

Reactive Inflammatory
Lymph Node Enlargement
In contrast, benign lymph nodes
usually exhibit intact hilar architec-
ture ( in Fig. 86.4) and a central
pattern of perfusion that cannot be
traced into the periphery (Fig. 86.5).

Fig. 86.4 Positive hilum sign Fig. 86.5 Central perfusion in a

lymph node

Lymph Node Metastases

Lymph node metastases on the other hand typically exhibit an irregular perfusion pattern that can be traced into the
periphery of the node (Fig. 86.6). Findings may also include central liquefaction as in Fig. 86.7.
On elastography the malignant lymph nodes usually show stiffer (higher) values (here encoded in red) > 2
(Fig. 86.8) compared with the reactive inflammatory lymph nodes, although the accuracy of this method is still limited
(depending on the examiner's experience, sensitivity is only about 62% and specificity is about 84% [6.1]).

Abb. 86.6 Malignant nodal Abb. 86.7 Nodal metastasis with Abb. 86.8 Elastography with nodal
metastasis central necrosis metastasis
Lesson 6 Lymph Nodes 87

Retroperitoneal Lymph Nodes

On the last few pages, the shape of the lymph node (ratio of maximum
longitudinal diameter to maximum transverse diameter or L/T ratio) and
the hilum sign (see p. 84) have been described as evaluation criteria as have
a few supplementary criteria on color duplex sonography (pulsatility index
or PI, perfusion pattern, and elastography) (see pp. 85–86). Retroperitoneal
lymph nodes (55) often lie at a greater depth and adjacent to numerous
other neurovascular structures. The decreased spatial resolution at center
frequencies around 3.5 MHz makes it easier to miss them or mistake them
for obliquely visualized blood vessels.

At the hilum of the liver, for example, overlying intestinal gas or obesity can
create local conditions not conducive to ultrasound. In such cases there is
1
a risk of confusing sections of the hepatic artery (18) with preportal lymph
nodes (55) anterior to the portal vein (11) as in Fig. 87.1. A proven technique 2
3
in such cases is to carefully and systematically scan the porta hepatis, 5
5
continuously sweeping in only one direction. With this manual technique,
9 11
local blood vessels will either continuously decrease in caliber or increase as 55 33
they merge with other vessels, whereas lymph nodes will suddenly appear 11 53
55
and equally suddenly disappear.
18 11
5
8
This helpful diagnostic distinction will be lost if the examiner simply sweeps
the transducer back and forth more or less randomly. When examining lymph 45
9
nodes at the root of the mesentery, distinguishing isolated enlarged lymph
nodes (55) from obliquely visualized small bowel loops (46) can require the
examiner's full concentration as the bowel loops can also be hypoechoic and Fig. 87.1 b Periportal lymph nodes
exhibit a similar oval shape (Fig. 87.2). Where numerous lymph nodes (55)
form a conglomerate as in Fig. 87.3, it helps to be a little patient so that
peristalsis in the bowel loops can be used as an additional differentiating
criterion. The same applies to differentiating bowel loops from lymph nodes
in the vicinity of the iliac vessels (21) in the lower abdomen (Fig. 87.4).

1 1 1
3 3 2
2 3 2 4
74 4 5
55 55 74
55 55 55 46 46
55 74 55 55 55
46 74
46 46
74 55 55
55 55 55
55 45 55 55
55 46 46 21
46 55
16 45 45 46
15 74
45 16
45 35 55 45
35
45 45
45 45

Fig. 87.2 b Mesenteric Fig. 87.3 b Lymph node Fig. 87.4 b Para-iliac lymph nodes
lymph nodes conglomerate
88 Gastrointestinal Tract Lesson 6

Anatomy of the Gastrointestinal Tract

The anterior wall of the stomach (26) lies against the 9
posterior wall of the left lobe of the liver (9), and its pos- 9
37
terior wall is in contact with the body (33b) and tail of 14 26
18
the pancreas. The spleen (37) lies to the left of and lateral
to the stomach, and the transverse colon (43b) with the 11 32a
greater omentum lies caudal to it. 15
16 32 19
Along its lesser curvature courses the left gastric artery 66 33b
(32a) arising from the celiac trunk (32), and the splenic
43
artery (19) courses posterior to the stomach along the
43 46
cranial margin of the pancreas. Just caudal to the lesser 33a
omentum with the hepatic artery (18), portal vein (11),
and common bile duct (66), the antrum of the stomach
joins the duodenum (46), which surrounds the head of 43b
the pancreas (33a) in the shape of a C. The other num-
bers may be found on the back cover flap of this book.
Fig. 88.1
(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3rd ed.
Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)

Layers of the Stomach Wall

The normal wall structure of the gastrointestinal (GI)
tract consists of five layers, which appear alternatively
hyperechoic and hypoechoic (Fig. 88.3). From the inside
out, these are the hyperechoic margin of the mucosa
(74a), the very thin hypoechoic muscularis mucosae
(74b), the hyperechoic submucosa (74c), the thicker
hypoechoic tunica muscularis (74d), and the hyper-
echoic serosa (74e). However, this outermost layer
appears to merge with the hyperechoic capsule of the
liver (Fig. 88.2) on ultrasound. The posterior serosa
cannot always be clearly distinguished from the adjacent
pancreas (33) in the presence of lipomatosis (see p. 34).
Depending on its degree of contraction, the entire
thickness of the stomach wall varies between 5 and
7 mm. The hypoechoic tunica muscularis (74d) alone
should be under 5 mm unless it is visualized in the
middle of a peristaltic wave (Fig. 88.4).
Occasionally gastric air (47) creates acoustic shadows
(45) that obscure the view of the posterior wall of the
stomach.

3 2 3

9 74d 9 74e
8 47
74b 74c 45
26
46 33c
33a 20 17
74
45 16 15
35
Fig. 88.2 a Transducer position for b Layers of the stomach wall c
the stomach

1
2
3 3
74
a 7
46
b 9
5
26 c
d
e 74d 74

16 45
9

Fig. 88.3 a Alternating Fig. 88.4 a Cross section of b ... in a peristaltic wave
echogenicity the pylorus ...
 Lesson 6 Gastrointestinal Tract 89

Gastric Tumors
A gastric carcinoma (54) initially develops as a focal
lesion at one location on the stomach wall (74), where
it can cause circumscribed thickening of the wall (Fig.
89.1) and obliterate the normal layering of the sto-
mach wall (see previous page). A dilated lumen (26)
can be an indirect sign of a tumor-induced delay in
gastric emptying (Fig. 89.2). In the example shown
here, the delayed gastric emptying was caused by a
large mural tumor (54) that had obliterated the normal
layers of the stomach wall ( ) over a distance of
several centimeters ( ) and expanded from the wall
into the lumen like a polyp.

74

Fig. 89.3 CT in lymphoma

3 2

2 5
3
9 3 74 26
13 54/
74 46/5
74a 26

9
54
29
45 45
45 31
47 70

Fig. 89.1 b Antral carcinoma Fig. 89.2
Since gastric air often prevents complete visualization
of the posterior wall of the stomach on ultrasound
images, modalities such as endoscopic ultrasound or
diagnostic CT are frequently applied. Here, the transmural
thickening of the wall involving the entire circumference
of the stomach that typically occurs in lymphomatous
infiltration is more clearly visualized (Fig. 89.3). CT also
allows precise evaluation of whether the tumor has
infiltrated adjacent organs and regional lymph nodes
regardless of the gas content of the gastrointestinal tract.
However, histologic determination of the type of tumor
requires gastroscopy. Finally, a radiologic double contrast
transit study is indicated. This study allows the examiner
b Delayed gastric Fig. 89.4 Normal transit study
emptying
to search the mucosal folds for atypical lesions, rigid seg-
ments, and ulcer craters (Fig. 89.4). Quiz: Can you tell
how this patient with normal findings was positioned?
Supine, left or right lateral decubitus, or head-down
position? (Answer: see p. 158).
As in lymphoma, portal hypertension (see p.42) can
be accompanied by circumferential thickening of the
entire wall of the stomach (74). Color duplex sonography
often shows a radial pattern of increased vascularity
(Fig. 89.5) and the other signs of cirrhosis of the liver
(see p. 58).

1 2
3
3 5 74
43 b
9

74 26

45
45

Fig 89.5 a Wall thickening ... b ... in portal hypertension c Radial vessels on color duplex
sonography
90 Gastrointestinal Tract Lesson 6

Crohn's disease
Normally the bowel walls are so thin that they are barely
visualized. However, in inflammatory bowel disorders,
the layers of the bowel wall (74) are markedly thickened
and the lumen is constricted as can occur in patients
with Crohn's disease (Fig. 90.1). A vanced cases can show
such massive mural thickening (Fig. 90.2) that the
process can be misinterpreted as a tumor (see p. 93) or
intussusception of the bowel (see p. 91) . Where the mural
thickening is due to inflammation (Fig. 90.3a), using
color coding in the affected segments can demonstrate
significant hyperperfusion of the wall (Fig. 90.3b)
as in this patient with sigmoiditis in the setting of
Crohn's disease.

Fig. 90.3 Plain scan

2 1
3 1 3 2 4
4
74 5
74 5 46 46
74
46
74
46 45
45 74
45
70 35

45
45

Fig. 90.1 b Mural thickening in Fig. 90.2 b Bull's-eye sign in Fig. 90.3 b Hyperperfusion in
crohn's disease crohn's disease sigmoiditis

One of the most common complications in this clinical
picture is the development of fistulas, abnormal
passages through which the inflammatory bowel
segment communicates either with other adjacent
organs (such as the bladder or adjacent bowel loops)
or with the skin as in Fig. 90.4. Here, in the left lower
abdomen a bowel segment (43) in the vicinity has
become inflamed, leading to development of a colo-
cutaneous fistula and thickening of the bowel wall (74).
The lumen of the fistula ( ) was precisely visualized on
contrast-enhanced ultrasound (Fig. 90.4b).

1/2
3
3
43
46

74 74

43 43
43
74
45

Fig. 90.4 a Noncontrasted image of b Lumen of the fistula on c d

colocutaneous fistula contrast-enhanced ultrasound
Lesson 6 Gastrointestinal Tract 91

Intestinal Intussusception
Intussusception most commonly occurs in infants be-
tween the ages of 6 and 9 months. Boys are affected
more often than girls. The rule of thumb is that intussus-
ception very rarely occurs before the age of 3 months
and after the age of 3 years and thus is rather unlikely.
Typical symptoms include episodic pain of sudden onset
interspersed with asymptomatic or minimally sympto-
matic intervals. Usually the terminal ileum at the cecal
pole displaces into the colon through the ileocecal valve,
creating a ring-like intestinal wall within the lumen of
the colon (Figs. 91.1 and 91.2). Less often, intussus-
ception occurs in the jejunum as well. The result is an
outer hypoechoic muscular layer (74d) separated from the
inner invaginated muscularis by the hyperechoic mucosa
(74b). Visualized end on, this produces what is known as
a "target sign" or "bull's-eye sign". Occasionally two hyper-
echoic mucosa layers (74b) of both bowel segments
are detectable (Fig. 91.2). Fig. 91.3 shows the appear-
ance of intussusception (74) on CT, seen here next to
fluid-filled colonic segments (43).

a a a
74 1/2
16 15
46 74
4
9 74d 74 43
43
74
74 46 74
46
74 74 43
74b 74 9 35
43
29
43
29
45 45
46 45
45
46

Fig. 91.1 b "Target sign" in ... Fig. 91.2 b ... intestinal Fig. 91.3 b Intussusception on CT
intussusception
Hernias
Protrusion of a bowel loop (46) through the anterior abdominal fascia (6) is observed particularly around the um-
bilicus (Fig. 91.4) and along the linea alba. The width of the hernia ( ) is of particular importance to the risk
of incarceration; where the hernia is wider,
there is less of a risk of impingement of the
blood vessels supplying the herniated bowel 46 / 120
74
segment (120). One should be alert to any
ischemic thickening of the herniated bowel 6
74
wall (74) as it is an indirect sign of hypoper- 45 6
fusion (not present in the example shown).
Fig. 91.4 a Umbilical hernia b

Contrast Enema
Where intussusception has been confirmed by one of the two methods
mentioned, an immediate attempt should be made to reduce the intussuscepted
bowel segment ( ) by means of a retrograde contrast enema (Fig. 91.5). This is
necessary in order to promptly prevent or resolve compression of the vessels of
the involved mesenteric root. In this example, the small bowel was intussuscep-
ted as far as the mid and transverse colon. Ideally, the hydrostatic pressure of
the retrograde injection of contrast medium completely pushes back the intus-
suscepted intestinal segment, so the child is spared a surgical intervention. The
ultrasound follow-up examination after reduction is important. There should be
no evidence of a target sign. Fig. 91.5 Contrast enema
92 Gastrointestinal Tract Lesson 6

Differential Diagnosis of Mural Thickening

The differential diagnosis of Crohn's disease must also
consider ischemic wall thickening such as can occur
secondary to mesenteric ebolism, high-dose catechol-
amine therapy (Fig. 92.1), and gluten enteropathy
(sprue). Patients generally exhibit increased fluid
in the bowel and, in the late stage, loss of the folds
of Kerckring. In the acute stage they also exhibit
thickening of the mucosa and submucosa (Fig. 92.2),
but this does not affect the entire bowel wall as in
Crohn's disease(see p. 90).

2
3
74 a

46

74 a
74 d74
/e
c
68
Fig. 92.1 Ischemia of the Fig. 92.2 Mucosal thickening b
bowel wall in sprue

Diarrhea 3
74 46
In watery diarrhea, the bowel loops 46 74
contain a large amount of anechoic
fluid (46 in Fig. 92.3). These intralu- 46
minal fluid accumulations should 46
46
not be mistaken for extraluminal 46
ascites. In fecal impaction (see Fig. 46
46 46
93.1) or Hirschsprung's disease (see
45 45
p. 142), the bowel contents are 74
more echogenic. Fig. 92.3 b Fluid-filled bowel loops in diarrhea

Appendix, Normal Values Normal Inflammatory

Wall thickness ≤ 2 mm ≥ 3 mm
a imum e ternal diameter ≤ 6 mm ≥ 7 mm

Table 92.4
Appendicitis
A normal vermiform appendix has an inner hyperechoic
layer surrounded by an outer hypoechoic layer (Fig.
92.5). The maximum diameter of a normal appendix
should not measure more than 6 mm and the wall should
be no more than 2 mm thick. External diameters of
7 mm or more and/or wall thickness of 3 mm or more
are pathologic. Additionally, acute appendicitis typically
causes edematous wall thickening, which appears as a
thick hypoechoic ring with a hyperechoic center (mucosa
and narrowed lumen) in the transverse plane (Fig. 92.6a).
In the longitudinal plane (Fig. 92.6b), the thickened
appendix can be distinguished from other bowel
segments by its lack of peristalsis and its dead end. One
can also test for local tenderness by gently applying
pressure with the transducer. The perifocal bowel loops
can show a reactive reduction in peristalsis. Presence
of abscess presents as an increasingly inhomogeneous
and hyperechoic conglomerate with an ill-defined
border which in its late stage makes the appendix
difficult to identify.

Fig. 92.5 Normal findings Fig. 92.6 Acute appendicitis b

(without peristalsis)
Lesson 6 Gastrointestinal Tract: Colon 93

Fecal Impaction
Normally, only the wall of the colon 1
3 3
near the transducer can be evaluated 2
74
because the colon contains so much 5 6
gas that the lumen or opposite wall 5

cannot be evaluated. However, fecal 43

43
material is occasionally retained,
especially in older patients (fecal im-
paction, Fig. 93.1). Here it is seen 15
in the transverse colon (43) without 16
gas, allowing good evaluation of
35
both walls of the colon.
Fig. 93.1 Fecal impaction b
Colitis
In inflammatory thickening of the 1
4 4
colonic wall (74) in the setting of 2
colitis, the edematous semilunar 5
74 46
folds can become much more promi-
nent than usual, as seen here in the 43
sigmoid colon (Fig. 93.2). Alterna- 43
43
tively, thickening of the colonic wall 74
74
45
can be ischemic, as is seen in mesen-
teric infarction or mesenteric venous
thrombosis. The differential diagnosis
is made by measuring perfusion on
color duplex sonography. Fig. 93.2 Wall thickening in b
colitis

Colon Carcinoma
In normal colonic segments the wall is so thin that it is
barely visible at the margin of the haustra (43 in Fig.
93.3). In carcinoma of the colon (Fig. 93.4) there is
circumscribed solid tumorous mural thickening (54).
Depending on the stage there can be higher-grade
constriction of the lumen (Fig. 93.5) by the tumor (54),
which in combination with melena can lead to impaired
passage of feces.

4 1 4 1
1 2
2 74
3 5 5 74 5 48
5 5
43
43 43
43 43 54
43 54
77
38 45
74
45
46
45 45 45 45
43
70 70
45

Fig. 93.3 b Normal findings Fig. 93.4 b Longitudinal section of Fig. 93.5 b Transverse section of
colon carcinomat colon carcinoma
94 Gastrointestinal Tract Lesson 6

Diverticulitis
Colonic diverticula are not rare but often occur in older
patients in the absence of inflammation. Fig. 94.1
shows a diverticulum (54) that communicates via its
narrow neck ( ) with the lumen of the adjacent colon
(43). However, here the colonic wall (74) appears suspi-
ciously thickened, a finding also seen on a CT scan of
the same patient (Fig. 94.2). Whereas the central recto-
sigmoid junction is still sharply demarcated from its
pericolic fat ( ), the pericolic tissue in the vicinity of the
diverticulum ( ) is ill-defined and shows edematous
thickening ( ) consistent with inflammation. Fig.
94.3 shows a hyperechoic air bubble (47) in a small
diverticulum with beginning thickening of the bowel
wall (74) in the immediate vicinity of the diverticulum
in an early stage diverticulitis.

2 4
4 2 2
74 1
5 4 3 4
46 3
46 74 46 3 6
54
43
45 22
74 45
43 21 22 46
64
54
74
2
47
70 45
2

Fig. 94.1 b Neck of diverticulum Fig. 94.2 b Diverticulitis on CT ... Fig. 94.3 b … in the early stage

When in doubt, the examiner enlists the help of the
patient, who can often identify the point of maxi-
mum pain with great precision, and then visualizes the
respective colonic segment in the transverse (Fig.
94.4a) and longitudinal planes (Fig. 94.4b) to evaluate
whether localized wall thickening ( ) is present in the
vicinity of the diverticulum ( ). Advanced stages
will also show significant thickening of the pericolic
connective tissue (5) as an accompanying hyperechoic
reaction as in Fig. 94.5.

1
2
4

5 74
74f
5

43
43
47 47
45 74
a b 45 47
45
Fig. 94.4 Colonic diverticulum Fig. 94.5 Advanced b
diverticulitis
Lesson 6 Quiz 95

Here again are a few quiz tasks from the chapter you have
just finished. You will find the answers on the preceding
pages. The solution to the image is on page 157.

1. What distinguishing features do you know for Criteria for a benign Criteria for
evaluating the malignancy status of lymph nodes? process malignancy
List at least three criteria for physiologic and malig-
nant nodal enlargement, respectively.

2. What do benign adenomas of the thyroid typically

(but not invariably) look like? Which criteria taken
together suggest a thyroid malignancy?

3. Please write down the normal values for the maxi-

mum diameter of the vermiform appendix and its
wall thickness.

4. Can you draw the layers of the stomach wall here

and label their respective echogenicity?

5. Do you remember how a diverticulum of the bowel

differs from diverticulitis? Please write your differen-
tial diagnostic criteria here.

6. Please specify five conceivable causes for the

phenomenon shown in Fig. 95.1.

Fig. 95.1
 Lesson 7 Bladder:
Anatomy 98
Bladder and Examination Technique, Bladder Volume 99
Reproductive Organs Indwelling Catheter, 100
Differential Diagnosis of ystitis

Reproductive Organs:
ale Reproducti e Organs

rostate land, estes 101

Undescended estis, Orc itis, 102
pididymitis, ydrocele, Inguinal ernia

emale Reproducti e Organs

ndo aginal Ultrasound 103

Uterus ormal indings, 104
Intrauterine Device (IUD)

Uterine umors 105

O aries olume, enstrual ycle ases 106
O aries ysts and umors, 107
Infertility erapy

regnancy esting, ctopic regnancy 108

lacenta osition, ender Determination 109
Quiz 110
98 Bladder and Reproductive Organs Lesson 7

Anatomy 155 34
16
Urinary Tract: 13
13 18
The two ureters (150) course from the kidneys 24a 27 155
17
(29) through the retroperitoneum anterior to 29 19
the psoas major muscle (44) after crossing the 25a 150 25b
iliac vessels (21 and 22) to the posterior margin 28 15
of the bladder (38), which lies in a subperitone- 150
al location (Fig. 98.1). Immediately posterior to
the bladder is the rectum (43d) and between the 21 22 21
44
two lies the pouch of Douglas (122), a common
b a
site of free abdominal fluid (blood, ascites, peri-
toneal dialysis fluid) at the far caudal end of the
peritoneal cavity (Fig. 98.2).
43 d
22a
22b 38

83
Fig. 98.1
Female Reproductive Organs:
The cervical region (40) of the uterus (39) lies
posterior to the bladder at the cranial end of the 6
vagina (41). Depending on how full the bladder 2
(38) is, the uterus usually lies anteflexed on the
roof of the bladder as shown in Fig. 98.2 or 77 48
assumes a more vertical position as the bladder 152
fills. Only rarely is the uterus retroflexed, and in
38
these cases it is significantly more difficult to
39
visualize in a transabdominal view due to inter- 41
posed intestinal gas. In the center of the uterus
78
one will find an endometrium (78) of varying 40 43d
122
height and echogenicity depending on the
phase of the cycle (see p. 104). 43d

Male Reproductive Organs:

In men the prostate (42) is located on the floor of
the bladder (38). The urethra (152) passes
through it. The normally air-filled rectum (43d)
lies directly posterior to the prostate. The seminal Fig. 98.2
vesicles (42a) lie immediately cranial to it in the
median plane. They typically appear hypoechoic
on ultrasound images. In men the retrovesical 2
pouch (122) is located cranial to these struc- 6
tures. It is the lowest point in the peritoneal cavity.
Except in the case of an undescended testis 48
77 98 / 100
(see p. 102), the testis (98) lies within the
scrotum (100). 38
152
The pubic symphysis (48) presents a barrier to
direct transabdominal visualization of the bladder 42a
42
and reproductive organs that must be circum-
122
vented by appropriate transducer positioning (see 43d
p. 99 and Video clip 7.1).

The key to the numbers not mentioned here may

be found on the back cover flap.

(Schuenke M, et al: THIEME Atlas of Anatomy–Internal Organs, 3rd ed.

Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.) Fig. 98.3

© 2021 Thieme. All rights reserved.

Lesson 7 Bladder: Normal Findings 99

Examination Technique
The bladder is systematically scanned in a
suprapubic transverse plane (Fig. 99.1a) and in
the sagittal plane (Fig. 99.1b). The examiner
must perform the scan slowly enough to
detect any suspicious wall thickening or
intraluminal masses (see Video clip 7.1c).
Including the adjacent lateral perivesical tissue
in the scan has proven effective. Wherever
possible, the examination should be performed
with the patient’s bladder maximally filled Fig. 99.1
a b

after drinking a large amount of clear liquid and before voiding or, in catheterized patients, after clamping the
indwelling catheter. This will better visualize the bladder wall. Examining the empty bladder after the patient has
voided has no diagnostic value.
The normal bladder (38) on a typical transverse image (Fig. 99.2) lies posterior to the two rectus muscles (3) and
cranial and anterior to the rectum (43). When full it exhibits the shape of a rectangle with rounded corners. In the
sagittal plane (Fig. 99.3) the bladder appears more triangular. The prostate in males (42) or the vagina in females (see
Figs. 101.2 and 103.1) can be visualized caudal to the bladder.

Determining Postvoiding Residual Bladder Volume

Where neurogenic dysfunction or obstruction due to hypertrophy of the prostate gland (see p. 101) is suspected, the
bladder volume should be calculated to determine the postvoiding residual bladder volume. The maximum trans-
verse diameter (Fig. 99.2b) is determined on the transverse image and the maximum craniocaudal diameter on the
sagittal image (the horizontal dotted line in Fig. 99.3b). To obtain a suitable sagittal scan, it will often be necessary
to tilt the transducer caudally as indicated by the arrow (Fig. 99.3a) to prevent the acoustic shadow (45) of the pubic
bone (48) from obscuring your view. The maximum anteroposterior diameter (vertically dotted line on both images)
must then be determined in one of the two planes. The postvoiding residual bladder volume is then calculated in
milliliters according to the simplified volume formula as the product of the three diameters multiplied by 0.5. Even
though a postvoiding residual bladder volume up to 100 mL has been described as physiologic in the literature, one
should consider an outlet obstruction wherever the postvoiding residual bladder volume exceeds 50 mL.

Determining Bladder Volume: Bladder volume= A x B x C x 0.5

2 1 5
3 3

46 46
6

38
45
45

77
70 70
42 a 70
43 42 a

Fig. 99.2 a b Bladder in the transverse plane c

1 2
3 5
74 3
48
46 77

38 45

45 46
42
42 a
43 d
46 74 45

Fig. 99.3 a b Bladder in the sagittal plane c

100 Bladder Lesson 7

Indwelling Catheter and Differential
Diagnosis of Cystitis
In patients with an indwelling catheter (76) the bladder
(38) is usually collapsed, effectively preventing reliable
evaluation (Fig. 100.1). Therefore the catheter should
be clamped some time prior to the examination
(remember to do this!) to allow the bladder to fill. Only
in the presence of an advanced edema of the bladder
wall (77) is it possible to diagnose cystitis (Fig. 100.2)
without first allowing the bladder to fill. Wall thickness
in a distended (filled) bladder should not exceed 4 mm.
After voiding, even the normal bladder wall is irregular
and up to 8 mm thick, potentially masking mural polyps
or circumscribed tumors.
Wall Thickening
Diffuse wall thickening involving the entire circumference
is usually due to edema in the setting of cystitis. A
circumscribed area of wall thickening is more suggestive
of a mural tumor. The differential diagnosis in males
must consider a trabeculated bladder, which can occur
in response to a bladder outlet obstruction in prostatic
hypertrophy. When in doubt, transrectal or (in females)
vaginal endoscopic ultrasound at higher frequencies or
CT studies can provide more information.
to the sound beam and can mimic intraluminal matter
(see p. 18). These artifacts must be differentiated from
actual sediments of crystals, small blood clots (52), or
calculi (49) along the bladder floor (Fig. 100.3).
Sediment can be mobilized by rapidly varying the
pressure applied to the transducer (be careful with a full
bladder). This maneuver will naturally fail to separate an
actual mural tumor from the bladder wall.
Ureteral Peristalsis
Incidental findings occasionally include signs of inflow
into the bladder from the ureteral ostia due to propulsive
ureteral peristalsis. In infants one must also exclude urete
roceles (see p. 141). Free fluid: In any abdominal trauma,
it is essential to confirm or exclude free fluid (68) in
the abdomen. Fig. 100.4 shows free fluid in its typical
location in the pouch of Douglas posterior to the uterus
(39), such as can occur in acute intraabdominal bleeding
or ascites.
2
1
3
5

Internal Echoes and Sedimentation 77 51a

41
38
Even the healthy bladder is never entirely anechoic 45
74
39
(= black). Reverberation artifacts (51a) induced by the 43 d
40
anterior abdominal wall (Fig. 100.3) are usually projected 74 45
into the lumen of the bladder (38) near the transducer. 68
Section thickness artifacts (51b) are often observed in 46 74
the posterior bladder distal to the transducer. These are
Fig. 100.4 a Ascites ... b ... in the pouch of Douglas
caused by the oblique course of the bladder wall relative

a a a
1 1
1 2
5 3 2 3 2
3 74 74 74
5 3
46 5 46
46 77 5
74 46
38 77 51a
43/47
43 38 38
76 45 38 76
45
45
45
77
45 45 70
45 70 70 77 / 51b
74 43 49 / 52
39

Fig. 100.1 b Blocked balloon ... Fig. 100.2 b ... of an indwelling Fig. 100.3 b Sediment on the floor
catheter of the bladder
Lesson 7 Male Reproductive Organs 101

Prostate Gland
Transabdominal ultrasound examination of the repro-
ductive organs requires a full bladder (38) to displace
gas-filled bowel loops (46) cranially and laterally and
prevent their acoustic shadows (45) from interfering
with visualization. The prostate gland (42) is at the
bladder floor anterior to the rectum (43) and is visua-
lized and measured in the suprapubic transverse and
sagittal planes (Fig. 101.1).
Prostatic Hypertrophy
The normal prostate gland should not measure more than
5 cm x 3 cm x 3 cm and its calculated volume should not
exceed about 25 mL (A x B x C x 0.5). However, a high
percentage of older men have prostatic hypertrophy
(Fig. 101.2), which can cause voiding difficulties and
trabeculation of the bladder (see Fig. 100.2). An enlarged
prostate gland (42) elevates and indents the floor of
the bladder (38). The bladder wall (77) is usually well
demarcated and appears as a smooth, hyperechoic line
(Fig. 101.2).
Prostate cancer (54) frequently arises in the periphery
of the gland. It can invade the bladder wall and even-
tually protrude into the bladder lumen (Fig. 101.3).
Increasing urethral compression can lead to diffuse
hypertrophy of the bladder wall (77), which then appears
thickened (Fig. 101.3).

48 1 3
2 2 5
5 2
3 6 46 77
46 3 48
5
46
38 38 51
38 51
45
45 77
38
54 45 38 45
77 70
42 / 54
45
42 77
42 42
70 70
43 70 70
43
77 74
70

Fig. 101.1 b Prostate size Fig. 101.2 b Prostatic hypertrophy Fig. 101.3 b Prostate carcinoma

Testes and Scrotum

The adult testis (98) is normally
homogeneously hypoechoic and
clearly demarcated from the layers 100
of the scrotum (100). It measures
about 3 cm x 4 cm in the longitudinal 98
99
plane (Fig. 101.4).
The upper pole of the testis is co-
vered by the epididymis (99), which
extends along the margin of the 47
testis. In children, an undescended
testis should be excluded on the 45 45
transverse image (see p. 102), which
must show both testes next to each
other in the scrotum. Fig. 101.4 a Testis: b
normal findings
102 Male Reproductive Organs Lesson 7

Undescended Testis
If both testes are not found in the scrotum at 3 months, the undescended or ectopic testis must be located. The
testis (98) is frequently found in the inguinal canal near the abdominal wall (2/5) as shown in Fig. 102.1. If the testis
cannot be located on ultrasound, a supplementary MRI scan is indicated as malignant degeneration can occur in an
undescended or ectopic testis.

2
5
99 98
47
47
47
74
46

Fig. 102.1 a Testis in the inguinal b Fig. 102.2 Perfusion of the testis
canal

Orchitis and Epididymitis
The differential diagnosis of sudden severe scrotal pain
radiating into the inguinal region must consider an incar-
cerated inguinal hernia, testicular or epididymal inflam-
mation, and testicular torsion. Testicular tissue can tole-
rate ischemia for only about 6 hours before irreversible
necrosis sets in. Where "only" inflammation is present,
Doppler ultrasound will demonstrate perfusion with
arterial pulses in the flow profile ( in Fig. 102.2). The
affected side may even show hyperperfusion. Torsion
leads to considerably reduced or absent testicular
perfusion in comparison with the contralateral testis.
Orchitis or epididymitis typically shows edematous
enlargement of the testis (98) or epididymis (99) as
well as thickening of multiple layers of the scrotal wall
(100), as shown in Fig. 102.3. Equivocal findings can be
resolved by comparison of contralateral size.
Hydrocele and Inguinal Hernia
A homogeneous anechoic fluid accumulation (Fig. 102.4)
is either a hydrocele (64) or a varicocele. A varicocele en-
larges with the Valsalva maneuver and shows detectable
perfusion on color duplex sonography. Occasionally, a
herniated bowel loop (46) is seen in the inguinal canal or
scrotum together with a hydrocele (64) next to the normal
testis (98, Fig. 102.5). A malignant testicular tumor
usually produces inhomogeneous changes in the testicular
parenchyma. Malignant but still well-differentiated
seminomas can be homogeneous with mostly unre-
markable ultrasound morphology.

a a a

47
99 98 98
64 64
99
47 46
98 45
99

100 100

Fig. 102.3 b Epididymitis Fig. 102.4 b Hydrocele Fig. 102.5 b Differential diagnosis
of varicocele
Lesson 7 Female Reproductive Organs 103

The transabdominal visualization (Fig. 103.1) of the lower frequencies around 3.5 MHz are used with corres-
uterus (39) including the ovaries (91), vagina (41), and pondingly limited resolution. Gynecologists often prefer
rectum (43) requires a full bladder (38) as an acoustic endoscopic ultrasound as an alternative because of its
window. Because of the depth of penetration required, higher spatial resolution (see below).

51a 38

39 41
51c
43 d
51b

45 40
122 45
45

Fig. 103.1 a b c

Endovaginal Ultrasound
Because of the proximity to the target
organs, transvaginal transducers
(Fig. 103.2) can be operated at cranial
higher frequencies (8–12 MHz or
more) with correspondingly higher
spatial resolution (see p. 11). Another anterior posterior
advantage of endovaginal ultrasound
is that the bladder need not be full. caudal
An assortment of electronic and
mechanical transducers with variable
imaging sectors (70–180°) is available.
sagittal view
Transducers that emit an eccentric
sound beam must be rotated 180°
to visualize the contralateral ovary. In
contrast to transabdominal imaging,
the caudocranial endovaginal scan
Fig. 103.2 a b
visualizes findings "upside down."
The sound waves propagate from
the bottom to the top of the image
(Fig. 103.3). This orientation visuali-
Image Orientation
zes intestinal loops (43) with acoustic
shadows (45) in the upper half of the Many gynecologists prefer sagittal planes viewed from the patient’s left side,
image, whereas the uterus (39) and the opposite of the convention used by internists. The bladder (38) and other
cervical region (40) are visualized in anterior anatomic structures are on the left side of the image (Fig. 103.3)
the lower half near the transducer. whereas the cervix (40) and other posterior structures are on the right side.

35
45
45
39 78

2 45
43 39
48
77 78
38

40
38

Fig. 103.3 a Normal anteflexed uterus b c

on an endovaginal image
104 Female Reproductive Organs Lesson 7

Uterus: Normal Findings

The thickness of the endometrium (78) varies with the
menstrual cycle. Immediately after menstruation, only
a thin hyperechoic central line is observed (Fig. 104.1).
Later, around the time of ovulation, the endometrium
(78) is demarcated by a thin hyperechoic rim ( ) from
the myometrium (39) (Fig. 104.2). After ovulation, the
secretory endometrium increasingly loses its central
echo ( in Fig. 104.3) until the endometrium becomes
entirely hyperechoic.

a a a

45 45
43 / 46 45
43 / 46

47 47 46
78
39
78 H 39
39
78
40
38
Fig. 104.1 b Fig. 104.2 b Fig. 104.3 b

The normally homogeneous hyperechoic myometrium can be traversed by vessels appearing as anechoic areas. The
body (39) and cervix (40) of the uterus do not differ in echogenicity. In premenopausal women, 2 times the height
(H) of the endometrium (78) should
be less than 15 mm ( in Fig. 104.3).
In postmenopausal women, that
measurement should be less than
6 mm, unless the patient is under-
going hormone replacement therapy.
To avoid exaggerating size due to
oblique sectioning, the measure-
ments should be obtained exclusively
on longitudinal sections of the uterus.

Intrauterine Device (IUD)

a a
An IUD (92) is easily recognized by
its high echogenicity with acoustic
45
shadowing (45) and should be located
at the fundus in the uterine cavity.
45
The distance between the IUD (d) and
46/45 47
d 39 the fundal extension of the endome-
trium should be less than 5 mm, and
D the distance to the end of the fundus
78 (D) less than 20 mm (Fig. 104.4).
92 40 78
92 Longer distances (Fig. 104.5) sug-
41 39 gest the IUD is displaced toward the
40
cervix (40) and is no longer providing
Fig. 104.4 b Correctly seated IUD Fig. 104.5 b Displaced IUD sufficient contraceptive protection.
Lesson 7 Female Reproductive Organs 105

Uterine Tumors
The normal uterus is demarcated by hyperechoic serosa
and shows a homogeneous hypoechoic myometrium
(39). Myomas (54) are the most common benign ute-
rine tumors. They arise from the smooth musculature
and usually occur in the uterine body. For preoperative
planning of a myomectomy, myomas are categorized as
intramural or transmural (Fig. 105.1), submucosal (Fig.
105.2), or subserosal projecting from the outer uterine
surface (Fig. 105.3). A submucosal myoma can easily be
mistaken for endometrial polyps (65 in Fig. 105.2).
Myomas exhibit a homogeneous or concentric crescentic
echo pattern and are sharply demarcated with a smooth
surface. However, they can also contain calcifications
with acoustic shadowing or central necroses.
The size of myomas should be accurately measured and
documented on follow-up to exclude rapid progression
indicative of rare sarcomatous degeneration. Note that
sudden enlargement of a myoma in early pregnancy
can be benign in nature.

a 1 a a
2
45
74
39
47 45 46
78
65 / 54
45
54 46 54
41 43

47 46
40 78 39
45 39
45 122 40
46
Fig. 105.1 b Uterine myoma Fig. 105.2 b Submucosal myoma Fig. 105.3 b Subserosal myoma

Postmenopausal endometrial hyperplasia (Fig. 105.4) can be induced by

administration of estrogens, by estrogen-secreting ovarian tumors, or
persistent follicles. Persistently high estrogen levels increase the risk of the
endometrial hyperplasia degenerating into an adenocarcinoma (54 in Fig.
105.6). Malignancy criteria include an endometrium that measures more
than 6 mm after or 15 mm before menopause, exhibits an inhomogeneous
echo pattern, and is irregularly demarcated as in Fig. 105.6.
A hypoechoic accumulation of blood ( ) in the uterine cavity (hematometra)
can be caused by postinflammatory adhesions in the cervical canal following
conization or by a cervical tumor (Fig. 105.5).
a

23
21
39

54

40

Fig. 105.4 Endometrial hyperplasia Fig. 105.5 Hematometra Fig. 105.6 b Uterine carcinoma
106 Female Reproductive Organs Lesson 7

Volumetric Measurements of the Ovaries

The ovaries (91) are visualized in a craniolateral sagittal
plane (Fig. 106.1) and are usually located in the imme-
diate vicinity of the iliac vessels (21 and 22). To measure
their volume, the ovaries are also visualized in a transverse
plane. The product of the three diameters multiplied by
0.5 provides an adequate estimate of ovarian volume. In
adults, the values range from 5.5 to 10 cm3, with a mean
of 8 cm3. Ovarian volume is not affected by pregnancies,
but continuously decreases in postmenopausal women
from about 3.5 to 2.5 cm3, depending on the length of
time since menopause.

a a a

21
22

45 43
21 b 91
91 45
22 74
93 74 22 68
21 64
43 93 46
43 39
91
38
Fig. 106.1 b Normal Findings Fig. 106.2 b Graafian follicle Fig. 106.3 b Corpus luteum cyst

Menstrual Cycle Phases

In the first days of a new mestrual cycle, several follicles (93) are normally visible as small 4–6 mm anechoic cysts
within the ovary. Beginning with the 10th day of the cycle (Fig. 106.2), a dominant follicle (Graafian follicle) measuring
about 10 mm in diameter begins to mature. It shows linear growth of about 2 mm per day, reaching a preovulatory
diameter of 1.8 cm to 2.5 cm. This process is accompanied by regression of the remaining follicles.

For infertility treatment and in vitro fertilization (IVF), ultrasound follow-up examinations performed at close intervals
are important in that they can trace follicular maturation and occasionally even demonstrate the time of ovulation.
Follicle size exceeding 2 cm, demonstration of a small mural ovarian cumulus, and digitations within the follicular
wall are regarded as signs of imminent ovulation. Following the ovulation, the Graafian follicle disappears or at least
markedly decreases in size. At the same time, free fluid may be detectable in the pouch of Douglas.

Vascular proliferation into the ruptured follicle transforms it into the progesterone-producing yellow body (corpus
luteum), which remains visible for only a few days as a hyperechoic area at the site of the former follicle. If nidation
occurs, the corpus luteum persists
and can remain visible as a corpus
luteum cyst (64) up to the 14th week 45
of pregnancy (Fig. 106.3). Abnorma-
lities of follicular development include
premature follicular luteinization 45 47 45
leading to missed ovulation and
formation of a follicular cyst (64 in Fig.
64
106.4). A follicular cyst that remains 46
larger than 3 mm for more than one 91
menstrual cycle may represent a
persistent follicle (see next page). Fig. 106.4 a Follicular cyst b
Lesson 7 Female Reproductive Organs 107

Ovaries: Cysts and Tumors

An ovarian cyst exceeding 5 cm in diameter (see p.
106) is suspicious for tumor. Malignancy must be
suspected especially where a cyst exhibits septa and/
or solid internal echoes ( ) or increased wall thickness
(Fig. 107.1). Similar features are found in dermoid
cysts (Fig. 107.2), which account for 15% of unilateral
ovarian tumors. Their internal echoes ( ) correspond
to sebum, hair, and other tissue components. They
should initially be regarded as benign and only rarely
degenerate into malignancies.
These findings must be distinguished from hemorrhagic
or endometriotic cysts, which either contain fluid levels
( ) within their lumens (Fig. 107.3) or can be complete-
ly filled with homogeneous blood products (50 in Fig.
107.4). Do you know why the fluid level in Fig. 107.3 is
almost vertical on the image? The answer is on page 158.

Fig. 107.1 Ovarian carcinoma Fig. 107.2 Dermoid cyste Fig. 107.3 Hemorrhagic cyst

Infertility Therapy
Simply measuring the hormone levels of an externally
stimulated cycle neither allows one to definitively exclude
hyperstimulated ovaries (Fig. 107.5) nor does it provide
reliable information about the number of stimulated
follicles (93). Ultrasound monitoring of the number of
growing Graafian follicles is indicated so that disconti-
nuation of the hormone therapy can be considered where
there are more than two stimulated follicles and the
patient can take contraceptive measures if necessary.
About 5% of women have polycystic ovaries syndrome
(PCO), characterized by lack of typical follicular matura-
tion. This is usually attributable to adrenal hyperan-
drogenism. The typical features of PCO are multiple
small cysts (64) arranged like a string of pearls primarily
along the periphery of the ovary around a hyperechoic
stroma (91 in Fig. 107.6). Homone therapy can help
resolve undesired infertility in such cases.

45
46 45
45 43 / 46 45
68 47 45
45 45
22 b 74
93 47
64
21 22 64
50 74
93 93 64 91
21 b 46
91

Fig. 107.4 b Endometriotic cysts Fig. 107.5 b Hyperstimulated Fig. 107.6 b Polycystic ovaries
ovaries
108 Female Reproductive Organs Lesson 7

Pregnancy Testing Threshold Discussion

regnancy testing is not limited to measuring h in
the maternal blood or urine. The ultrasound examination
should not only confirm the pregnancy, it can also exclude
an ectopic pregnancy and detect a multiple pregnancy
that hormone testing is unable to confirm (Figs. 109.3,
109.4). Intravaginal ultrasound can detect an early intrau-
terine pregnancy, here our first daughter Lea Céline, once
the chorionic cavity has reached a diameter of about 2–3
mm. If you look very closely, you will discover a tiny hyper-
echoic point (Fig. 108.1). This size is generally reached
14 days after conception, or 4 weeks and 3 days after the
last menstruation. The original vesicle in the body of the
uterus (39), which is surrounded by hyperechoic endome-
trium (78), grows at a rate of about 1.1 mm per day and
develops into the gestational sac (170), within which the
embryo (95) can later be detected (Fig. 108.2).
Embryonic cardiac activities begin at a gestational age
of 6 weeks with a heart rate of 80–90 beats per minute.
In later stages, ultrasound can also verify the proper
number of fingers and toes or exclude pathology such as
fetal diaphragmatic defects or heart defects. Our second
daughter Joana was very cooperative in this regard
(Fig. 108.3).
Ultrasound waves have been known to awaken fetuses
in the third trimester, which then show spontaneous-
ly the movements of a child. Contrary to the opini-
on of many midwives, this phenomenon is absolutely
harmless. According to the guidelines of the American
Institute of Ultrasound in Medicine (AIUM), sound
energies below 100 mW/cm2 or 50 J/cm are safe.
Because the energies delivered with B-scan ultrasound
(black and white) are far lower than the threshold values,
current knowledge indicates that neither relevant
thermal injury to tissue nor mutagenic effects are to
be expected. It is only in color Doppler ultrasound and
pulsed wave Doppler studies that the threshold values
mentioned can be reached and exceeded during longer
examinations. Therefore, any unnecessary color Doppler
studies should be avoided during the sensitive phase
of organogenesis in the first trimester despite the
fact that there has been no evidence to date of any
damaging effect of ultrasound waves [7.1].

Ectopic Pregnancy 51a

In an ectopic pregnancy (Fig. 38
108.4), the embryo (95) is outside
51c
the uterus (39). Because of the 41
consequences it entails (including 170
78
risk of hemorrhage), it is important 39
45 40
not to overlook this pathologic
condition. 122 43 / 45

Fig. 108.1 a Early pregnancy b

2
23 170
43 / 45 97 39
21 38
95
96 91 45
95 47
78 78
170 35 95
170 39
39 39 45

Fig. 108.2 b Embryo Fig. 108.3 b Fetal development Fig. 108.4 b Ectopic pregnancy
Lesson 7 Female Reproductive Organs 109

Placenta Position
The normal location of the placenta
is near the fundus along the anterior
or posterior uterine wall. In about 20%
of cases, the placenta (94) will show
one or more unilocular or multilocular
cysts or lacunae (64), which usually
have no functional significance Fig.
109.1). However, an association
with maternal diabetes or rhesus
incompatibility has been suggested.
However, the location of the placenta
2
should only be definitively deter-
3
mined at about the end of the second
trimester. This is because the increas- 39 39 95
ing expansion of the lower uterus
can change what began as a placenta
39 94 109
previa in early pregnancy to a normal
64
or low-lying placenta (distance to 96 94
internal os of the cervix < 5 cm). 95 40
97
Three types of placenta previa are 97
distinguished: total placenta previa, 45
45 38
which totally covers the internal os
of the cervix (40); partial placenta Fig. 109.1 b Placental cyst Fig. 109.2 b Placenta previa
previa, which partially covers the
internal os (Fig. 109.2); and marginal
placenta previa, which encroaches on the internal os. The evaluation of placental structure has become less important
as placental and fetal perfusion can be evaluated with Doppler ultrasound.

Multiple Pregnancies
In multiple pregnancy, it must be determined whether the embryos (95)
share a common placenta ( in Fig. 109.4) or each embryo is supplied
separately. For parents-to-be (and their obstetrician) it is not only important
to know whether to expect twins (Fig. 109.3) or even triplets (Fig. 109.4).
Some also want to know whether they are expecting a daughter (Fig. 109.5)
or son (Fig. 109.6).

Gender Determination
Remember to reveal the gender of the fetus to the parents only when asked
or if it has been previously requested. Above all, you should be certain of this
determination. Early in pregnancy, it is possible to mistake (?) the umbilical
Fig. 109.3 Twins
cord ( ) for a clitoris or penis ( ), and the female labia for the scrotum ( )
(Figs. 109.5, 109.6).

95

Fig. 109.4 Triplets Fig. 109.5 Umbilical cord ... Fig. 109.6 ... a boy!
110 Quiz Lesson 7

To complete this chapter, we again offer you the oppor- questions 1 through 6 can be found on the preceding
tunity to test which details you have remembered and pages, while the answer to the image question (no. 4) is
where your knowledge is still patchy. The answers to quiz on page 157 at the end of the book.

1. On page 107, you were asked why a fluid level in

a hemorrhagic endometrial cyst was vertical on the
ultrasound image. Do you know the answer? If not,
please review the description of the sagittal imaging
planes on endovaginal ultrasound on p. 103.

2. An 18-year-old male patient presents with severe

pain in the left scrotum, which began about three
hours earlier and radiates into the left groin. What
are the main causes you must consider in a diffe-
rential diagnosis? How much time do you have to
establish the diagnosis? Which ultrasound methods
do you plan to use?

3. How do you recognize imminent ovulation on an

ultrasound scan? What should change after the
ovulation? How many days after the last
menstruation or conception it is possible to
document nidation on endovaginal ultrasound?

4. A 58-year-old female patient is referred to you for

a routine gynecologic examination. The patient
had undergun menopause at age 52 years and has
not taken any hormone medications within the last
5 years. You perform an endovaginal ultrasound
examination and detect the findings shown in
Fig. 110.1. The transverse thickness of the endo-
metrium is 18 mm. What is your tentative diagnosis
and what further steps would you take?

Fig. 110.1
 Lesson 8 FAST 112
eFAST, M-mode 114
FAST, eFAST, Lung
Seashore Sign, Barcode Sign 115
Pleural Mobility, Pulmonary Pulse 116
Lung Point in Pneumothorax 117
Pleura:
uantifying Pleural Effusions 118
Pleuritis, Empyema, Mesothelioma 119
Ribs:
Costal Fractures and Metastases 120
Lungs:
Pneumonia 120
Bronchial Carcinoma, Pulmonary Infarct, 121
Pulmonary Metastases, Pulmonary Edema

Quiz 122

With images from

Matthias Hofer and
Georg Groß
112 FAST Lesson 8

FAST
The FAST method (Focused Assessment with Sonogra-
phy for Trauma) represents a technique for quickly and
reliably excluding or confirming life-threatening bleeding
into the serous cavities of the chest and abdomen in
trauma patients. This standardized method [8.1–8.3]
is also suitable for diagnosing parenchymal tears in the
spleen or liver.
Trauma patients are usually supine in the ambulance,
emergency room, or shock room. Therefore, the exa-
miner must consider where gravity will cause relevant
hemorrhages to collect. From a lateral view of the torso
of a supine patient (Fig. 112.1) it quickly becomes appa-
rent that free fluid will primarily collect in the pouch of
Douglas in the lesser pelvis ( ) and in the cranial portion
of the peritoneal cavity ( ). This pattern of distribution
(anatomic predilection) is essentially attributable to the
lumbar lordosis ( ).
Free fluid in the pleural cavities (in this case hemothorax)
also drains posteriorly into the costodiaphragmatic recess
( ) unless prevented from doing so by the presence of
extensive pleural adhesions from previous pleuritis (see
Fig. 117.3).

3
1
33
17
46 16 2
15

29 29 4

Fig. 112.1 Fig. 112.2 Fig. 112.3

The hematoma is also lateralized on both sides within the abdominal cavity. This is because the spine causes anterior
protrusion of the overlying median peritoneum relative to its lateral periphery (Fig. 112.2). As a result, one rarely finds
larger accumulations of blood close to the midline because the intraperitoneal hematoma follows gravity and drains
laterally and posteriorly ( ). Accordingly, the transducer positions shown in Fig. 112.3 are now internationally
accepted for rapid evaluation. First transducer position: The transducer is initially placed on the epigastrium in the
transverse plane and tilted caudally (Fig. 112.4a) to evaluate the heart and pericardium for possible hemopericar-
dium. Such a hemorrhage will be detectable as an anechoic rim of fluid (79) in the circular marginal spaces around
the cardiac cavities (114 in Fig. 112.4b). Be sure to adjust the unit for sufficient penetration depth and a small zoom
factor to visualize the posterior borderline of the pericardial sac ( ).

83 1
2
3
79
79
114
13 114 115
115 114

114
47
79
47

47
Fig. 112.4 a Transducer position for ... b ... visualizing the pericardium ... c ... from beneath the xiphoid

69 9
68
29

Fig. 112.5 a Transducer position for ... b ... right hemothorax and ... c ... pouch of Morison
Lesson 8 FAST 113

The second transducer position on the right anterior

axillary line (Fig. 112.5a) also detects a right anechoic
hemothorax (69 in Fig. 112.5b) and possible bleeding
(68) into the hepatorenal recess (pouch of Morison)
between the liver (9) and the right kidney (29) (Fig.
112.5c).

The third transducer position on the left posterior

axillary line (Fig. 113.2a) is used to exclude left
hemothorax, which can lie cranial to the diaphragm
(13) either laterally ( ) close to the transducer or
medially at the lower edge of the image ( ). This
transducer position can also detect splenic hematomas
(50) in rupture of the spleen (Fig. 113.2b) as well as
Fig. 113.1 The transducer is angled anteriorly to
hemorrhage (68) into the abdominal cavity, here into visualize the posterior pouch of Koller.
the pouch of Koller, the recess between the spleen
(37) and left kidney (29) (Fig. 113.3).
The transducer must be angled anteriorly so that the
sweep also includes the posterior costodiaphragmatic
recess and perisplenic space (Fig. 113.1).

2
47
5
37
68
50
50

45
20 37

37 29

45
13

Fig. 113.2 a Third transducer b Splenic hematoma Fig. 113.3 perisplenic hemorrhage
position

Fourth transducer position: Finally, the transducer is placed on the median suprapubic region in the sagittal
plane and angled caudally (Fig. 113.4a) to evaluate the pouch of Douglas (122) between bowel loops (46), bladder
(38), and rectum (43) to detect any blood (68) that might be present there (Fig. 113.4b). In larger hematomas,
hemorrhage may also be detectable on the roof of the bladder and anterior to the bladder (if full).
An experienced examiner can perform the entire FAST examination without photo documentation in as little as 20–30
seconds (hence the acronym). This dynamic procedure is convincingly illustrated in Video clip 8.1a–c.
1
5
3 74
46
77 51a

38
39
45 40 45
43 d
68
122
46

Fig. 113.4 a Transducer position b ... sagittal suprapubic plane c ... and the pouch of Douglas
for the ...
114 eFAST Lesson 8

eFAST
The so-called "extended FAST algorithm" is intended
to quickly exclude pneumothorax in trauma patients
or, if present, to estimate its size in order to identify
tension pneumothorax requiring aspiration and drainage.
Each hemithorax is divided into four quadrants and
systematically examined for a pneumothorax space. The
transducer is positioned sequentially in a sagittal plane
at each of the four positions marked in Fig. 114.1.
Close to the transducer, the resulting ultrasound image
shows the anterior or lateral chest wall with the skin
(1), subcutaneous tissue (2), pectoralis muscles (117),
intercostal muscles (116) between the hypoechoic
ribs (109), and, on the posterior aspect of the ribs, the
pleural border (101) before the lung (47), which is
visualized at a greater depth (Fig. 114.2).

109 117
116
109
101

45 45

47

PSL AAL PAL

Fig. 114.1 Transducer position Fig. 114.2 a Sagittal thoracic b
for eFAST plane

M-mode
To evaluate the respiratory mobility and size of the
lung, one line of the image in a M-mode is defined
as the Y axis (vertical yellow line in Fig. 114.3) and
positioned in one of the intercostal spaces (ICS) to
preclude any acoustic shadowing from the ribs (109).
The change in echo behavior from this single line of
the image is then plotted
against time (= X axis).

In the superficial layers of

Chest wall

the chest wall, nearly hori-

zontal lines will form over
109 the time axis because the
109 skin, subcutaneous tissue,
and musculature remain in
101 a nearly constant position:
No change in the location of
the echo => horizontal lines.
Lung

47

sec 1 2 3 4 5 6 7

Fig. 114.3 a Line of the image b M-mode image

in an ICS

However, this changes beginning at the depth of the in the location of the origin of the echoes. As a result,
pleural border (101). Within the lung tissue (47) the instead of horizontal lines indicative of constant position,
motion of physiologic or artificial respiration and arterial there is a finely granulated snowstorm here that resembles
pulsation over time will create small regular changes a random pattern of grains of sand.
Lesson 8
Seashore Sign
Where the lung is fully expanded and extends in the
imaged area as far as the parietal pleural border (101),
the upper (proximal) portion of the resulting M-mode
image resembles a row of waves parallel to the seacoast,
while the lower (distal) portion of the image resembles
a sandy beach (Fig. 115.1). This has given rise to the
Chest wall
101 101
Lung
Fig. 115.1 a Seashore sign b In M-mode in ...
Barcode Sign
However, if the lung is not fully expanded and does not
extend as far as the chest wall in the imaged area, the
air in the interpleural space will cause total reflection
of the sound waves directly at the pleural border (101).
You will then see echoes against the hypoechoic back-
ground that have been reflected back and forth several
times between the layers of the chest wall. Because
they arrive back at the transducer late, the image
processor incorrectly projects them deep within the
lung (see reverberation artifacts, p. 18). However, as the
101
Fig. 115.3 a Barcode sign b In M-mode in ...
eFAST 115
name "seashore sign," which suggests physiologic expan-
sion of the lung without pneumothorax at this location
(Fig. 115.2). A small pneumothorax with formation of
a circumscribed space may nonetheless be present at
another location, For this reason, all four quadrants of
both halves of the lung are examined.
c Fig. 115.2 ... a fully
expanded lung
layers of the chest wall remain in a constant position,
the reverberation echoes do not change their depth or
position over time.
Therefore the resulting M-mode image shows only
horizontal lines in a constant position which because of
their varying thickness resemble a barcode on a product
label (Fig. 115.3). Such a "barcode sign" is found at those
locations on the chest wall where there is air in the
interpleural space and thus pneumothorax ( ) is
present at this location (Fig. 115.4).
c Fig. 115.4 ... pneumothorax
116 eFAST Lesson 8

Pleural Mobility
Where the lung is fully expanded and extends in the
imaged area as far as the parietal pleural border (101),
the respiratory excursion of the lung will produce
observable left-right displacement ( ) of pulmonary
tissue on the normal B-mode image (Fig. 116.1). This
respiratory mobility is more readily discernible in the
dynamic image sequence in Video clip 8.2.

101

101 47

Fig. 116.1 Lung mobility Fig. 116.2 a Pulmonary b ... in M-mode c ... during respiratory
pulse ... standstill

Pulmonary Pulse During Respiratory Standstill

When another intercostal image line is recorded over
time and patients are asked to hold their breath or
artificial respiration of unconscious patients is briefly
interrupted, the pleural border (101) will show
vertical lines ( ) or blurred stripes in the otherwise
homogeneously granular pattern of the lung (47) as in
Fig. 116.2. These vertical lines correspond to shifts in
the proximal portions of the lung occurring as a result
of perfusion with the arrival of the arterial pulse wave.
They are synchronous with the pulse, vary with the
heart rate, and are evidence of a fully expanded lung at the
site being examined (Video clip 8.3). In pneumothorax
neither pleural mobility nor a pulmonary pulse can be
demonstrated during respiratory standstill.
A small pneumothorax with only a small amount of air
in the interpleural space will not cause the affected lobe
of the lung with its elastic fibers to completely contract
toward the hilum of the lung. In such cases ultrasound
can detect the border up to which the lung is still
expanded and lies against the chest wall (Fig. 116.3)
or, respectively, the area beyond which a pneumothorax
(102) is present during physiologic or artificial
respiration (Fig. 116.4). Determining this so-called
"lung point" makes it possible to estimate the size of a
pneumothorax (see next page).

102

114 114
16 16

109 109
15 15
35 35

34 34

Fig. 116.3 Pneumothorax on inspiration: Fig. 116.4 Pneumothorax on expiration

lung extends up to the chest wall between chest wall and lung
Lesson 8 eFAST 117

Lung Point
While systematically evaluating all four quadrants of the
chest (see p. 114) the examiner may conceivably place
the transducer directly on the border between the
expanded lung and the pneumothorax (Fig. 116.4).
If this is the case, the M-mode image at that location
will show a picture alternating between the seashore
sign and the barcode sign, depending on how the lung
expands and contracts during respiration (Fig. 117.1).
This limit to pulmonary expansion is known as the "lung
point." Detection of this phenomenon ( ) is regarded as
sufficient evidence of partial or complete pneumothorax.

Inspiration Expiration

Fig. 117.1 a Lung point ... b ... on the M-mode image demonstrating the limit c
to pulmonary expansion

Diagnostic Accuracy in Excluding Pneumothorax

The particular advantage of the eFAST algorithm is that
it can be applied in the prehospital phase of emergency
treatment, for example in the ambulance, and that it can
be performed quickly in the event a chest radiograph
cannot be quickly obtained.
Add to this the fact that not every pneumothorax ( ) In Fig. 117.4 the right lung has completely collapsed
is as easy to diagnose as the one shown in Fig. 117.2,
in which both the lung and the pneumothorax (102) are
readily identifiable. Many patients exhibit postpleuritic
adhesions ( ) between the two pleural membranes.
These adhesions tether parts of the lung to the chest
wall and can lead to incomplete collapse of the lung with
residual expansion, findings that can be difficult for the
inexperienced diagnostician to recognize (Fig. 117.3).
The strength of the radiograph is that it can demonstrate
an acute threat to the patient's life from tension pneu-
mothorax (Fig. 117.4), which because of the severely
reduced venous return flow to the heart can lead to
acute heart failure before the reduced area of gas
exchange reaches a critical level.
toward the hilum. The high pressure in the right pleural
cavity has caused it to herniate into the contralateral
left side ( ), displacing the heart and mediastinum
laterally to the left. This has created a kink at the junction
of the inferior vena cava with the right atrium, severely
reducing the venous return flow to the heart.
Such cases require prompt aspiration of the overpressu-
rized pleural cavity and placement of a pleural suction
drain to reexpand the lung.

102 102

Fig. 117.2 "Classic" mantle Fig. 117.3 Partial pneumothorax Fig. 117.4 Tension pneumothorax
pneumothorax with postpleuritic adhesions with midline shift
118 Lung Lesson 8

Quantifying Pleural Effusions on Chest Radiographs

On conventional PA radiographs of the lung, pleural
effusions are usually only detectable as lateral basal shor-
tening of the costophrenic angle ( ) once the volume
of the effusion has exceeded about 200–500 mL. On AP
radiographs of a supine patient, the detection limit is
even higher, at 500–1000 mL. Smaller volumes are only
detectable on lateral films or radiographs obtained with
the patient in the right lateral decubitus position (Fig.
118.1). The crescentic opacity ( ) suggests that the
effusion at the lateral chest wall extends farther cranially
(Fig. 118.2).
In fact, the fluid is nearly horizontal in the chest cavity
( ) of a sitting or standing patient and in the la-
teral area only leads to greater cumulative absorption
of X-rays (Fig. 118.3). The opacity on the radiograph
obscures compressive atelectasis of the lateral basal
segments of the lung, which is detectable on the ul-
trasound image.

RLD Lateral Posterior

Effusion
surrounds lung
47
in a horseshoe
pattern

Lateral
PA AP
69

Summation of
absorption of
effusions

Anterior

Fig 118.1 Detection limits on Fig. 118.2 Effusion in the Fig. 118.3 Summation effect
radiographs costophrenic angle
on a PA radiograph

Quantifying Pleural Effusions on Ultrasound

On ultrasound images pleural effusions are detectable
without comparable artifacts. Images are best obtained
with the patient sitting (or standing if possible). Even
significantly smaller effusion volumes (69) are clearly
detectable as anechoic (black) areas between the
dome of the diaphragm (13) and the lung (47), which
depending on the size of the effusion can exhibit
compressive atelectasis (118 in Fig. 118.5).
The semiquantitative estimation of the effusion volume
is performed on ultrasound with the patient sitting and
the transducer in a posterior or lateral position. The
maximum craniocaudal extent ( H ) of the anechoic
fluid is measured and then the shortest distance (D )
between the caudal margin of the lung and the dome of
the diaphragm (13 in Fig. 118.6). The sum of these two
values (in cm) is multiplied by a factor of 70 to estimate
the effusion volume in milliliters (Table 118.4).
Volml = (H + D [cm]) x 70
Table 118.4 Calculation of pleural eddusions

1 Lateral chest wall

2 H
117
D
116 109 116 69
13 118
118
47
74 29
47 69
45 13
26

Fig. 118.5 a Basal pleural effusion ... b … in a sitting patient Fig. 118.6 Calculating the
effusion volume
Lesson 8 Pleura 119

Other Pleural Changes

Larger pleural effusions (69) usually lead to accompa-
nying compressive atelectasis (118) in the adjacent basal
segments of the lung. Fig. 119.1 also shows signs of
pneumonia (119) in the form of hyperechoic air inclusi-
ons resembling rice kernels and exhibiting a branching
pattern in the consolidated and otherwise barely venti-
lated lung tissue. If internal echoes from sedimentation
( ) in the pleural fluid are detected, they may represent
either sedimented corpuscular blood components in
hemothorax or an accumulation of pus in the pleural
cavity (pleural empyema, 58 in Fig. 119.2).
After chronic recurrent pleuritis, adhesions develop
between the visceral and parietal pleura with decreased
respiratory mobility and diffuse widening of the pleural
border (101) with fibrous and partially calcified
components consistent with pleural fibrosis (Fig. 119.3).

1 1
2 2 2
117
116 5
117
101
69 69
69
13 118
13
118 51a
26
119 9
58
58
47
47

Fig. 119.1 b Large pleural effusion Fig. 119.2 b Pleural empyema Fig. 119.3 b Dry pleuritis

This must be distinguished from malignant changes in the
setting of bronchial or mammary tumors such as pleural
carcinosis which can cause nodular irregular pleural
thickening ( ) (Fig. 119.4) but which shows increased
perfusion ( ) on power Doppler (Fig. 119.4b).
Mesotheliomas show a similar picture with extensive
irregular pleural thickening ( ) as in Fig. 119.5. The
lesions cover the chest cavity like a carpet and invade
the diaphragm (13) with footlike tumor extensions.

13

9
69
9

69

Fig. 119.4 a Pleural carcinosis b Perfusion image Fig. 119.5 Mesothelioma

on a noncontrastet scan
120 Ribs and Lung Lesson 8

Ribs
One may suspect a rib fracture in a patient with a history
of trauma or even after a spontaneous event such as a
severe coughing attack. In the presence of an acute
fracture, a step-off ( ) will be detectable in the cortex
of the rib (109) with a fracture line (168) at the clinical-
ly suspicious site (Fig. 120.1). Chronic rib fractures are
characterized by formation of a callus which typically
produces a convex but smoothly demarcated protrusion
( ) of the contour of the rib that lacks a visible fracture
line (Fig. 120.2). However, where ultrasound findings
include an irregular bulbous and inhomogeneous
hypoechoic distension of the rib, then one must consider
the differential diagnosis of a costal metastasis (56) of a
malignant process ( in Fig. 120.3).

1 1 1 2
2 2
5 117
117
117
117
109
56
168
109 109
45
45 / 47

Fig. 120.1 Acute fracture Fig. 120.2 Chronic fracture Fig. 120.3 Costal metastasis

Pneumonia
In lobar pneumonia the inflammatory edema and reten-
tion of secretions and mucus leads to consolidation of the
inflammatory lung tissue (119) with only greatly reduced
residual ventilation of the alveoli (Fig. 120.4). Typical
findings include a positive air bronchogram ( in Fig.
120.5) of the branching pattern of air-filled and therefore
hyperechoic bronchi against the fluid-filled adjacent lung
tissue, often with parapneumonic effusion. This must be
distinguished from two forms of hypoechoic pulmonary
atelectasis: compressive atelectasis in large pleural
effusions which partially expands in deep inspiration (see
Video clip 8.4) and postobstructive atelectasis (which
develops distal to a plug of mucus or a centrally stenosing
bronchial carcinoma) which shows fluid-filled bronchi
referred to as a "fluid bronchogram" ( in Fig. 120.6).
Especially in immunocompromised patients, complica-
tions of pneumonia can include a pulmonary abscess
(58) with central liquefaction (57 in Fig. 120.7a).
Doppler ultrasound will often show marginally
pronounced hyperperfusion (Fig. 120.7c).

1 2 2 2 116
69 69
119 119

118
47 47 47
45 45 13

Fig. 120.4 Lobar pneumonia Fig. 120.5 Air bronchogram Fig. 120.6 Fluid bronchogram
1
116
2

58

57

47
47
58 45
45

Fig. 120.7 a Pulmonary abscess ... b ... with signs of marginal ... c ... hyperperfusion on power Doppler
Lesson 8 Lung 121

Bronchial Carcinoma
A pulmonary tumor (54) that lies in the periphery of the
lung and not in a central location or near the hilum will
be detectable on an ultrasound scan (Fig. 121.1a). In
order to distinguish such a hypoechoic focal lesion from
2
a peripheral pulmonary infarct (Fig. 121.2), a power
Doppler or color duplex scan is performed to determine
whether perfusion ( ) is detectable in the changed area
(Fig. 121.1c).
1

117
116

54
47
45
47
45
Fig. 121.1 a Bronchial carcinoma b c ... Perfusion image

Pulmonary Infarct
Like renal infarcts (see p. 70) pulmonary infarcts (71)
also exhibit a conical shape in the periphery and appear
as hypoechoic biconvex zones or triangles on the pleural
border (101) like shown in Fig. 121.2.
Possible complications include infarct pneumonia (Fig.
121.3) and, in the presence of fulminant pulmonary
embolisms, dilation ( ) of the retrosternal right ventricle
(114) consistent with the acute right heart strain in cor
pulmonale (Fig. 121.4).

1 2 2
118 1
2
117 117 115
116
71
116 71 101 114
119
47 47
47 45
45 45
45

Fig. 121.2 Peripheral infarct Fig. 121.3 Infarct pneumonia Fig. 121.4 Acute dilation of the
right ventricle

Pulmonary Metastases
When a bronchial carcinoma creates a bronchial obstruction, the lung segments ventilated by this bronchus develop
atelectasis (118). Ipsilateral or contralateral pulmonary metastases (56) that may be present within this area can then
be identified as spherical or oval zones or triangles with a hyperechoic halo (Fig. 121.5), some of which may exhibit
central necrosis and liquefaction.

1 2
Pulmonary Edema
In pulmonary congestion or edema
13
due to left heart failure, the ultrasound 9 10
image will show an increased number 56
of what are known as B lines particu- 47
larly in the peripheral lower lung fields. 118 45
These lead to long "comet tail" artifacts
56
( ) that move back and forth with
respiration (flashlight phenomenon,
Fig. 121.6, Video clip 8.5).
Fig. 121.5 Pulmonary metastases Fig. 121.6 B lines in
pulmonary edema
122 Quiz Lesson 8

To complete this lesson, the study questions below give any remaining gaps. The answers can be found on the
you the opportunity to test your knowledge and close preceding pages or in the appendix on page 158.

1. Which three hemorrhages can you simultaneously FAST position 2

confirm or exclude in FAST positions 2 and 3?
•
•
•

FAST position 3
•
•
•

2. Please briefly repeat in keywords what causes the

seashore sign and the barcode sign. What do each
of them suggest?

3. What three conditions must be met so that the 1.

pulmonary pulse phenomenon can be observed on
M-mode images? 2.

3.

4. Look at Fig. 122.1 on this page. It shows the lung

visualized through an intercostal window. Identify
the image details shown and formulate your diffe-
rential diagnosis and tentative diagnosis.

Fig. 122.1

5. This image was obtained from an anterolateral

position above the right pectoralis muscles. Please
formulate your tentative diagnosis and differential
diagnoses.

Fig. 122.2
 Lesson 9 Skull and Central Nervous System (CNS):
Anatomy of the CSF Spaces 124
Pediatrics Normal Findings in the Sagittal Plane 125
Normal Variants 126
Normal Findings in the Coronal Plane 127
Cerebral Hemorrhage 129
Hydrocephalus, Cerebral Atrophy 130
Shunt in Hydrocephalus, Spinal Canal 131

Hip:
Preparation and Positioning 132
Normal Findings 133
Setup and Measurement Errors 134
Graf`s Classification of Infant Hips 135

Kidneys, Bladder, Spleen:

Kidneys and Typical Variants in Newborns 136
Diffusely Increased Echogenicity, 137
Nephrocalcinosis
Urinary Obstruction and Reflux 138
Renal and Adrenal Tumors 140
Patent Urachus, Hematoma and Cystitis, 141
Ureterocele, Spleen Size in Pediatrics

With images from Gastrointestinal Tract:

Matthias Hofer and Pyloric Hypertrophy, Reflux, 142
Jasmin D. Busch Hirschsprung's disease
124 Skull and Central Nervous System Lesson 9

Anatomy of the CSF Spaces

The external CSF spaces and other superficial structures
are visualized with a linear transducer at 5.0–7.5 MHz CSF spaces in newborns [9.3]
in order to achieve sufficient resolution (Fig. 124.1). SCW (sinocortical width) < 3 mm
The normal width of the anterior horns (103) measured
CCW (craniocortical width) < 4 mm
from the midline falx cerebri (106) is no more than 13
mm ( ) in newborns. The measurement is made at IHW (interhemispheric width) < 6 mm
the junction with the foramina of Monro (144) or with SVW (lateral ventricle width,
the third ventricle (124), which itself should be no wider anterior horn) < 13 mm
than 10 mm. 3rd VW (width of third ventricle) < 10 mm
The interhemispheric fissure (146), which is defined
as the shortest distance between the superior frontal gyri ( ), has a maximum width of 6 mm in the neonate
(Fig. 124.1c). Sinocortical width (147, < 3 mm) and craniocortical width (148, < 4 mm) are determined to exclude
cerebral atrophy (with expansion of the subarachnoid space) or obstructive hydrocephalus (with narrowing of the
subarachnoid space).

140
136
148 147
146

126

103 131

128
Fig. 124.1 a b Coronal section c

103c
124 144

124 103a

103b
144
103c
103a

125 110
103b

125

Fig. 124.2 Lateral view of ventricle Fig. 124.3 Top view of ventricle
(Schuenke M, et al: THIEME Atlas of Anatomy–Head, Neck, and Neuroanatomy, 3 ed. Stuttgart: Thieme, 2020. Illustrations by M. Voll, K. Wesker.)
rd

Optimal conditions for examining newborns and infants
include not only a quiet environment free of any hectic
activity, a prewarmed gel, and a heat lamp over the
examination table, but also the presence of a person
emotionally close to the child. The examination is
performed through the anterior fontanel (Fig. 124.1)
until it closes at the age of about 9 to 18 months. The
size of the acoustic window steadily decreases with age,
making it increasingly difficult to visualize lateral and
peripheral cerebral structures, even with maximal tilting
of the transducer.
Lesson 9 Skull and Central Nervous System 125

Normal Findings in the Sagittal Plane

The transducer is placed on the fontanel and the skull is
systematically scanned in the sagittal plane with a slow
and continuous sweep from right to left (Fig. 125.1a).
The individual examiner should best stick to a unchan-
ging examination sequence. This reduces the chances of
confusing the two sides.
For example, one can begin in the median plane
(Fig. 125.2), adjusting the zoom factor so that the
hyperechoic margin of the occipital bone ( ) is barely
visible. Then one scans first the left and then the right
hemisphere systematically for pathologic changes
(Fig. 125.3).
It is important to verify normal morphology of the
corpus callosum (126) and the overlying cingulate
gyrus (130). The cerebellum (110) is visualized as a
hyperechoic structure posterior to the pons (145) in
the posterior cranial fossa (see Fig. 125.2).

126
128 132
130
132
124
134
144 129
145
124 103
125 110 Fig. 125.3
Fig. 126.1
141
Fig. 125.2

Fig. 125.1 a b c

The thalamus (129) lies at the center of the laterally
oblique imaging planes (Figs. 125.2 and 125.3). The
anechoic CSF in the lateral ventricle (103) is above the
thalamus and contains the hyperechoic choroid plexus
(104), whose contour should appear smooth without
local bulging. This must be distinguished from a choroid
plexus hemorrhage (see p. 129). Where the corpus callo-
sum (126) is normally developed, the cerebral sulci (133)
of the parietal and occipital lobes do not extend to the
lateral ventricles, but are interrupted by the cingulate
gyrus (130). A midline section including the pons (145),
hyperechoic cerebellum (110), and fourth ventricle (125)
is shown in Fig. 125.2, whereas Fig. 125.3 shows an
oblique sagittal section through the left lateral ventricle.

130 133
126
128
124
145
127
105
45 110 125 5
10
45
Fig. 125.2 a b c

133
103
105
138
129 130

45
104 105
105

Fig. 125.3 a b c
126 Central Nervous System: Normal Variants
Choroid plexus cysts: Occasionally small unilateral
choroid plexus cysts (64) can occur (Fig. 126.1). Small
perinatal hemorrhages or viral infections have been dis-
cussed as possible causes. If the cyst is small and does
Fig. 126.1 a b
Preterm newborns: The normal cerebral sulci can be
totally absent in preterm newborns delivered around the
28th week of gestation or, depending on gestational age,
they can be less well developed than in term newborns.
However, this is not necessarily indicative of a genuine
maturation disturbance. Accordingly, the CSF spaces in a
preterm newborns are more capacious and occasionally
asymmetric (Fig. 126.3). The corpus callosum is often
incompletely developed in preterm newborns as well.
It then appears as a thin hypoechoic line in the coronal
plane, usually just above the cavum of the septum
pellucidum. These physiologic signs of immaturity will
have to be monitored on follow-up studies to distinguish
them from impaired CSF flow or genuine hypoplasia or
agenesis of the corpus callosum (Fig. 126.4).
Cavum of the septum pellucidum: Incomplete fusion of
the septum pellucidum between the anterior horns leads
to a CSF-filled cavum of the septum pellucidum (128).
This is usually obliterated within the first few months of
life but in rare cases persists into adulthood (Fig. 126.2).
Slight asymmetry of the lateral ventricles (103) is another
a a
a
105 140 136
164 132
138
131
103 128 129
Fig. 126.2 b Fig. 126.3 b Fig. 126.4
Lesson 9
not impair the CSF circulation, it generally has no clinical
consequence. Only larger parenchymal defects that
are isoechoic to CSF (porencephaly) suggest areas of
hemorrhage resorption or cerebral malformations.
140
121 133
103
126
129 64
104
105
45
c
normal variant that is not necessarily indicative of
impaired CSF flow. Fig. 126.3 shows a wide anechoic
CSF space lateral to the choroid plexus (104) on the left,
but not on the right.
Agenesis of the corpus callosum: Many developmental
disorders, syndromes, and metabolic disorders involve
the corpus callosum, and involvement may also be
secondary to hypoxia or infection. The spectrum of callosal
abnormalities ranges from partial to complete absence
(agenesis) of the corpus callosum. In the coronal plane
(Fig. 126.4a), agenesis of the corpus callosum leads to
a "steer horn" appearance of both anterior horns ( ),
which are farther apart and farther lateral than normal.
In the sagittal plane (Fig. 126.4b), the cingulate gyrus
is also absent in the area of agenesis (see Fig. 125.2) so
that the gyri of the cerebral hemispheres extend to the
lateral ventricles ( ). This makes it easy to detect even
partial agenesis of the corpus callosum. This example
(Fig. 126.4) shows not only prominent lateral ventricles
but also a prominent subarachnoid space ( ) consistent
with diffuse cerebral atrophy (compared to Fig. 124.1).
140
105
103
104
b
Lesson 9 Pediatrics: Skull and Central Nervous System 127

Normal Findings in the Coronal Plane

After scanning in the sagittal plane, the transducer is
rotated 90 degrees to scan in the coronal planes.
The transducers that have proven most useful are multi-
frequency sector transducers (Fig. 127.1c) with a
small contact coupling area and a center frequency
of about 3.0 MHz for infants, 5.0 MHz for ages 6–8
months, or 7.5 MHz for preterm and term newborns.
Mixed type transducers are now available that combine
the good near-field resolution of linear transducers
with a beam that diverges in the deeper layers. This
makes it possible to visualize a wider segment of the
brain (Fig. 127.1c).
The skull is scanned in the coronal and sagittal planes
with a slow and continuous sweep of the transducer
(Figs. 127.1a, b). The examination passes through and
documents five standard coronal planes. The examiner
begins anteriorly (Fig. 127.2) and inspects the peri-
ventricular white matter (131), which is physiologically
more hyperechoic than the adjacent cortex (132). The
transducer rests on the superior sagittal sinus (136).

135

132
132
103

131
124
104 110 Fig. 128.3
Fig. 126.2
Fig. 126.3 Fig. 128.1 Fig. 128.2 Linear Sector Mixed type

Fig. 127.1 a b c

136

140
131
131

132
105
45

Fig. 127.2 a b c

The plane immediately posterior to the first one (Fig. can still be physiologic or can be due to oblique sectioning.
127.3) intersects the anterior horns of both lateral The shape of the hyperechoic Sylvian fissure (134)
ventricles (103), which in this plane should not contain any resembles a Y rotated 90° (see Fig. 128.1).
hyperechoic choroid plexus. Slight ventricular asymmetry

140

103
133
129

105
132

Fig. 127.3 a b c
128 Pediatrics: Skull and Central Nervous System Lesson 9

Normal Findings in the Coronal Plane

The transducer is now moved posteriorly to the next
imaging plane to document the communication
between the lateral ventricles (103) and the third
ventricle (124) through the interventricular foramen
of Monro (144 in Fig. 128.1). In addition to anechoic
cerebrospinal fluid, the hyperechoic choroid plexus
(104) is visualized in the lumen of this ventricular
communication. This hyperechoic choroid plexus must
not be mistaken for an intraventricular hemorrhage,
which would be equally hyperechoic.

140

103

104
144
134 124
105
132

Fig. 128.1 a b c

Tilting the transducer further anteriorly (Fig. 128.2a)
causes the sound waves to propagate further occipi-
tally. This visualizes the curved bodies of both lateral
ventricles, which merge with the temporal horns (Fig.
128.2b). Here it is also easy to determine the width of
the lateral ventricles (103) and thickness of the choroid
plexus (104), which is normally smoothly demarcated.
The thalamus, internal capsule, and putamen are located
medially.

135 140

132
131
103
133 104

105 45
110

Fig. 128.2 a b c

Placing the transducer at an extreme angle (Fig. 128.3a) fly. Note the many sulci (133) that traverse the cortex
visualizes the somewhat ill-defined and hyperechoic as hyperechoic lines because of their rich vascularity and
occipital white matter (131 in Fig. 128.3b), which connective tissue. The normal widths of the CSF spaces
surrounds the ventricle in a pattern resembling a butter- are shown on page 124.

133 132

131 131

105
45

Fig. 128.3 a b c
Lesson 9 Pediatrics: Skull and Central Nervous System 129

Cerebral Hemorrhage
Cerebral hemorrhages occur according to the following
pathophysiologic mechanism:
The ventricles are lined by an epithelium known as
the ependyma. The subependymal tissue layer lies
beneath it. This tissue layer proliferates between the
24th and 32nd weeks of gestation and becomes richly
vascularized. During this time, this germinal matrix is
very sensitive to fluctuations in blood pressure as the
mechanism for regulating intracerebral blood flow is
not yet fully developed.
Cerebral hemorrhage: Grading
Grade 1 Isolated subependymal hemorrhage
Grade 2 With additional ventricular extension
without ventricular dilation
(involving more than 50% of the lumen
Grade 3 With additional ventricular dilation
(involving more than 50% of the lumen)
+ Additional extension into the cerebral
parenchyma

As a result, fetal cerebral hemorrhages (50) very often Table 129.1

occur in the subependymal region or in the region of the
choroid plexus. In newborns, bleeding commonly occurs
140
in the caudothalamic groove (121) between the head 133
of the caudate nucleus (138) and the thalamus (129 in
Fig. 129.2). Three grades of cerebral hemorrhage are 126
distinguished according to severity (Table 129.1); all 121
can occur with or without parenchymal hemorrhage.
138 129
50 104

Fig. 129.2

140 140

133 105 133

133
105 132 126 103
131 105 130
71
129 50 129
50/ 132
105 129 104 105
103 104
104
105
45 45

Fig. 129.3 b Fig. 129.4 b Fig. 129.5 b

Ultrasound Morphology
Acute hemorrhage (50) is hyperechoic compared with the
adjacent cerebral parenchyma (132) and for the reasons
outlined above is usually located in the vicinity of the
ventricular system (Fig. 129.3). An irregularly shaped
or bulging choroid plexus (104) suggests a hemorrhage
(50) into the plexus (Fig. 129.4). An earlier intrauterine
hemorrhage that has been resorbed leaves behind
CSF-filled parenchymal defects (71) that can be mistaken
for dilation of a lateral ventricle (103 in Fig. 129.5).
The differential diagnosis between a periventricular
parenchymal defect and genuine hydrocephalus is
discussed on the next page.
130 Pediatrics: Skull and Central Nervous System Lesson 9

Hydrocephalus
Obstructive (noncommunicating) hydrocephalus (Fig.
130.1) is usually caused by posthemorrhagic adhesions
that obstruct the free flow of cerebrospinal fluid out
of the ventricular system. Less frequent causes include
compression of CSF channels by an aneurysm of the vein
of Galen, a biconvex (!) cyst of the septum pellucidum
(see cavum of the septum pellucidum, Fig. 126.2)
obstructing the foramen of Monro, or aqueduct stenosis.
Isolated dilation of the fourth ventricle occurs where
aqueduct stenosis is accompanied by obstruction of the
foramina of Luschka and Magendie.
The resulting increase in pressure in the lateral
ventricles initially produces rounded and distended
temporal horns because here the pressure of the
surrounding cerebral parenchyma is lowest. Thickening
and dilation of the entire lateral ventricles only occurs
later (Fig. 130.1) and is accompanied by distension and
dilation of the entire lateral ventricle and simultaneous
narrowing of the subarachnoid space. The resulting
increase in pressure must be slowly relieved by a
diversionary CSF shunt ( in Fig. 130.2). In chronic
hydrocephalus, excessively rapid decompression could
place excessive strain on the external cerebral vessels
(with risk of hemorrhage). After a CSF shunt has been
placed, follow-up examinations are indicated to monitor
the position of the shunt and exclude malfunction.

Fig. 130.1 136

148 140
147 147 136 148
132 132
146
146

71 71
138
103 103

Fig. 130.2 Fig. 130.3 b Fig. 130.4 b

Cerebral Atrophy
The width of the subarachnoid space can differentiate defects (71) result in widening of the ipsilateral
obstructive hydrocephalus from an enlarged ventricular subarachnoid space (148) in comparison with the
system due to cerebral atrophy. Here, a linear transducer contralateral side (Fig. 130.4).
is used because of its better near-field resolution. Fig.
130.3 shows significant widening of all CSF spaces ( ) Additionally, the superficial cerebral sulci are more
in diffuse cerebral atrophy involving both hemispheres prominent in cerebral atrophy, whereas they tend to be
(see Fig. 124.1). Note the unusually good visualization of effaced in obstructive hydrocephalus.
the superior sagittal sinus (136). Unilateral parenchymal
Lesson 9 Pediatrics: Skull and Central Nervous System 131

Monitoring the Shunt in Hydrocephalus

Where ultrasound findings such as progressive ventricular enlargement suggest malfunction of the CSF shunt, the
examiner should evaluate not only the intraventricular position of the shunt tip (Fig. 130.2) but also the entire
length of the shunt catheter.

The adjacent radiographs

show a disconnected
( ) shunt (Fig. 131.1a)
and a follow-up image
after shunt revision (Fig.
131.1b) in a child with
a ventriculoperitoneal
shunt.
On the second
radiograph, the catheter
has been reconnected
to the coupling. Shunts
occasionally need to be
replaced or revised after
several years as the child
grows taller.

Fig. 131.1 a Valve dislocation b after correction

Spinal Canal
In infants, the conus medullaris (142) of the spinal cord (141) is visualized on a posteroanterior scan of the prone
patient preferably using a high-frequency (10-18 MHz) linear transducer (Fig. 131.2). The spinal cord is demarcated
from the anechoic spinal CSF space (140) by the delicate hyperechoic line of the pia mater. The hyperechoic double
line in the center of the cord is not the central canal but the interface between the white commissure and the anterior
median fissure.
The fibers of the cauda equina (143) extend caudally and are visualized as a hyperechoic structure around the conus
medullaris ( ), which should not extend below the L2-L3 disk space in the newborn.
Anatomic landmarks: The beginning of the sacrum can be identified by its fused S1 vertebra, which is the first
structure to protrude posteriorly (toward the transducer ) from the straight line of the vertebrae. Occasionally, a cyst
( ) can be found in the filum terminale, which usually does not have any clinical significance.

140

141 142 143

36 35 36 36 35
35 36 35 36

L1 S1

Fig. 131.2 a Prone position b Conus medullaris c

The progressive ossification of the vertebral arches makes visualization of the spinal cord increasingly difficult on
ultrasound images, and gradually requires the use of magnetic resonance imaging (MRI). It is important to verify
unrestricted mobility of the spinal cord with respiration and pulse. This can be documented on M-mode studies.
Absent pulsation, distortion, or a low conus medullaris and fixation of the cord to the posterior wall of the spinal canal
suggest a tethered cord syndrome, which is often caused by an intraspinal lipoma or epidermoid cyst. A tethered cord
can also occur from fixation of neural structures as a result of postsurgical scarring.
132 Pediatrics: Hip
Preparation for Hip Examination
Early exclusion of hip dysplasia in a newborn requires
precision. It is also crucial to perform the various steps
of the examination quickly before the newborn becomes
restless. A changing table with tray is placed in the
examining room or adjoining room to allow the mother
or the person accompanying the child to remove the
diaper without stress and clean the newborn if necessary.
A heat lamp over the examination table will prevent the
newborn from becoming cold (Fig. 132.1).
Positioning the Newborn
The examiner places the newborn in a special cradle in a
precise 90° lateral position. Then the mother can place her
Changing
table
Mother
Free
floor space
Foot switch
Examiner
Ultrasound unit
Fig.132.1 Setting in the ultrasound Fig. 132.2 Positioning the newborn
suite
Ultrasound Documentation
The German Quality Assurance Agreement on the Infant
Hip requires that each hip be photographed twice and
measured once at a minimum of 1.7 power magnification
in the standard plane defined by Graf without any tilt.
The following structures must be clearly identifiable: the
osteochondral junction (line of the growth plate between
the ossified femoral shaft and the cartilaginous femoral
head and greater trochanter), the femoral head (153), the
fold of the transition from the joint capsule to the peri-
chondrium of the femoral neck, the joint capsule itself,
Fig. 132.4 Transducer position Fig. 132.5 a Standard plane
Lesson 9
left hand beneath the newborn's head and her right hand
on the upper shoulder. Most term infants exhibit strong
flexion and react to unexpected extension of their legs
with resistance and restlessness. Experienced examiners
take care not to extend the upper leg more than necessary.
The edge of the examiner's left hand gently presses the
infant's thigh to prevent anteversion of the femoral neck.
The goal is to obtain moderate extension in slight internal
rotation (Fig. 132.2), without allowing the knee to move
forward ( ) past the edge of the positioning cushion into
external rotation as shown in Fig. 132.3. A foot switch is
used to freeze the image so that the examiner has both
hands free for positioning the newborn if necessary and
guiding the transducer.
Fig. 132.3 Positioning errors
the acetabular labrum (158), the cartilaginous acetabular
roof, the ilium (112) including its inferior margin, and the
bony promontory of the acetabular rim (159), right next
to the transition point ( , see p. 133). Once the inferior
margin of the ilium has been clearly visualized, the usabil-
ity test is performed: The imaging plane is centered on
the inferior margin of the ilium by rotating the transducer
around the axis of the cord (Fig. 133.6) and corrected to
obtain the median imaging plane. The acetabular labrum
can then be visualized without having to search for it.
157
162
156
158
112 153
159
45 160 165 45
161
b Anatomic diagram
Lesson 9 Pediatrics: Hip 133

Graf favors an image in which the ilium is visualized
perpendicular to the upper margin of the image. Yet
many radiologists, internists, and pediatricians prefer
the orientation they are more familiar with: Here, cranial
structures are visualized along the left margin of the image
and the lateral structures close to the transducer appear
along the upper margin of the image. However, Graf
maintains that there is evidence that this manner of visual-
ization may be associated with a higher error rate [9.3].
First the baseline is drawn: This line originates at the
"Z point" (the insertion of the rectus femoris tendon on
the ilium) and extends distally, tangential and parallel
to the sharply demarcated ilium with the hip extended
(Fig. 133.1). Then the inferior margin of the ilium
( in Fig. 133.2) and the center of the lateral aceta-
bular labrum ( in Fig. 133.3) are identified.
To determine the angle alpha of the bony roof, this
inferior margin of the ilium ( in Fig. 133.2) is identi-
fied and using that as a center of rotation, a tangential
line is drawn along the bony acetabulum (Fig. 133.5).

Fig. 133.1 Baseline at the ilium Fig. 133.2 Inferior margin Fig. 133.3 Acetabular labrum
of the ilium

To construct the line for the cartilage roof angle beta
( ) one irst determines the transition point according
to the concave-convex rule by moving laterally along the
concavity of the acetabulum from the inferior margin of
the ilium. After an acoustic interruption, the convex curve
extends cranially along the ilium. The transition point
lies at that point where the acetabular concavity joins
the convexity. It can be readily identified by the acoustic
interruption ( in Fig. 133.4).
The correct imaging plane is found by having the exami-
ner rotate the transducer around the axis of its cord or,
respectively, counterclockwise ( in Fig. 133.6): If he
or she rotates the cranial part of the transducer too far
anteriorly, the line of the ilium will also course obliquely
to the transducer as in Fig. 134.2.
The farther the acoustic shadow extends medial to the
bony promontory, the more the hip is ossified. In a type I
hip with an angular promontory, the transition point
lies directly in the bony acetabular promontory. A line is
now drawn laterally from this transition point through
the center of the acetabular labrum (Fig. 133.5). The
rule for identifying a type IIc unstable but still centered
hip and differentiating it from a type D decentering hip
(critical range hip) is as ollo s: The value determines
the hip type where it is more than 77° [9.2].

Fig. 133.4 Bony convexity Fig. 133.5 Alpha and beta lines Fig. 133.6 Rotating the transducer
134 Pediatrics: Hip Lesson 9

Measurement Errors
Especially in a restless newborn, it is easy for the
examiner to lose the correct imaging plane. Where
the transducer tilts posteriorly ( in Fig. 134.1a) this
usually produces a medially convex, curved course
( ) of the ilium (Fig. 134.1b) away from the transducer.
However, where the transducer is tilted anteriorly
(Fig. 134.2a) or rotated, the echo of the ilium ap-
proaches the transducer obliquely ( in Fig. 134.2b).
Angling the transducer too far cranially (Fig. 134.3a)
also visualizes the course of the ilium obliquely (Fig.
134.3b) and often makes it impossible to clearly
visualize its inferior margin.

Posterior tilt Anterior tilt Cranial angulation

Fig. 134.1 b Posterior error plane Fig. 134.2 b Anterior error plane Fig. 134.3 b Cranial error plane

If the examiner angles the trans-

ducer too far caudally (Fig. 134.4a),
the line of the ilium also courses
obliquely and the osteochondral
junction is often more blurred ( )
or no longer identifiable ( in
Fig. 134.4b).
Because of the many sources
of error and the great clinical
significance of this screening exa-
mination, it is best performed by
experienced examiners. Fig. 134.4 a Caudal angulation b Caudal error plane
Lesson 9 Pediatrics: Hip 135

Classification of infant hips according to Graf

In hip dysplasia, the femoral head ( ) increasingly
migrates craniolaterally. On the radiograph (Fig. 135.2), Classification of Infant Hips According to Graf [9.2]
the bony acetabular roof is no longer close to the Alpha Beta Femoral
horizontal line ( ) but courses laterally at a steeper head
cranial angle ( ). The MR image (Fig. 135.3) shows the I (normal) > 60° < 55° centered
extreme case of a dislocated femoral head ( ) and an II a+ 56–59° 55–70° centered
empty acetabulum ( ) that is obvious in comparison with II a– 50–55° 55–70° centered
the contralateral side. The alpha angle measured on ul- II c 44–49° 55–77° centered
trasound decreases with increasing severity of the dysplasia.
II d 44–49° > 77° centered
s a rule o thum rapid gro th should cause the angle
to expand from a minimum postpartum value of 50° to III (eccentric) < 44° > 77° eccentric
an angle of at least 60° by the beginning of the fourth IV (dislocated) < 44° undeter-
month of life. Statistically, the optimum angle is 64°. mined dislocated
The maturation curve shows a very strong, exponential
increase only in the first few weeks of life, after which securely center it within the acetabulum. For example,
it continues at a plateau. Therefore, it is important to a type IIa-hip (Fig. 135.1) persisting after the age of
make the diagnosis as early as possible so that adequate 6 weeks represents defective maturation. For further
therapy appropriate to the stage of the disorder can detailed information, consult the extensive monograph
be promptly initiated to stabilize the femoral head and by Reinhard Graf ([9.3] see p. 133 below).

Fig. 135.1 Fig. 135.2 Fig. 135.3

Transient synovitis of the hip: Thickened synovia and joint develops in the setting of viral infection and appears as
effusion are typical findings of acquired hip disorders. anechoic widening ( ) of the joint space (Fig. 135.5).
The child is positioned supine and examined with a high- Where an anechoic joint effusion persists longer than two
frequency linear transducer placed on the anterior hip weeks or internal echoes are detected within the effusion,
(Fig. 135.4a). The normal joint space (168) appears as a clinical and
thin anechoic space between the hyperechoic joint capsule laboratory tests
(163) and the anterior contour of the femoral epiphysis or supplemen-
(166) and metaphysis (167 in Fig. 135.4b). The indentation tary MRI studies
of the femoral growth plate (107) between them is easily are indicated to
identified. Measurements of the height of the epiphysis rule out Legg–
( ) obtained on follow-up examinations can easily Calvé–Perthes
establish a loss of height such as can occur in necrosis of disease or septic
the femoral head. A transient joint effusion frequently arthritis. Fig. 135.5

163
168

107
166 167

Fig. 135.4 a b c
136 Pediatrics: Kidneys Lesson 9

The next two pages present the crucial morphologic
characteristics in newborns and children that play an
important role and differ from findings in adults.
Kidneys in Newborns
Before examining the kidneys in the prone newborn (Fig.
136.1a), one should first examine the bladder with the
patient supine as it can only be evaluated when full and
newborns often void during the examination. After this,
the newborn is positioned prone and posteroanterior
scans of both kidneys are performed with a high-
frequency 10–18 MHz linear transducer in the longitudinal
plane (Fig. 136.1) and transverse plane (Fig. 136.2).
Anteroposterior transhepatic scanning (see p. 65) or
lateroposterior examination with the patient in the lateral
decubitus position is more suitable only in older infants.
Lower center frequencies of 3.5–5 MHz are preferred
in older children. Reference values of childrens’ kidneys
are defined in percentiles depending on childrens’ body
height. A summary can be found on the following page.
Typical Variants in Newborns
Compared with adults, the kidney in newborns shows
a more diffusely hyperechoic outer parenchyma (29)
with sharper contrast to the hypoechoic medullary
pyramids (30). The triangular shape of the medullary
pyramids is therefore more sharply defined in newborns
than in adults, whose pyramids appear more rounded.
Many neonatal kidneys also show residual fetal lobula-
tion and gradually assume an increasingly smooth oval
contour only later in infancy. The hyperechoic central
renal caliceal system (31) initially appears as a thin
line in newborns and only increases gradually in width
during infancy.
This is due to the increasing deposition of fat between
blood vessels and calices. As a result the anechoic renal
pelvis is more conspicuous in a newborn. It can mea-
sure up to 5 mm in width in the absence of any urinary
obstruction (see p. 138).
The "dromedary hump," a bulge in the left lateral renal
cortex opposite the lower pole of the spleen, is also
typical of the shape of the kidney in younger children
and usually disappears as the organ grows. Hyperplastic
columns of Bertin can traverse the hyperechoic pelvic
region as hypoechoic parenchymal bridges, mimicking
renal duplication (see Fig. 66.1). Neither finding has
a mass effect, and neither should be confused with a
renal tumor.

109
29

30
45 31
30

74
46
46 46
74
Fig. 136.1 a b Lumbar longitudinal section c
of the kidney

154

150 31
25
29
46

35
Fig. 136.2 a b Lumbar transverse section c
of the kidney
Lesson 9 Pediatrics: Kidneys 137

Diffusely Increased Echogenicity Height (cm) m – 2 SD m m + 2 SD

Diffusely increased echogenicity in the renal parenchyma Newborns 3.40 4.16 4.92
in newborns is regarded as normal (see previous page). < 55 3.00 4.35 5.70
Yet even in later infancy it is a sign of parenchymal dam- 55–70 3.60 5.00 6.40
age (Fig. 137.1). Findings then include renal parenchyma 71–85 4.50 5.90 7.30
(29) that appears isoechoic or hyperechoic to the liver (9) 86–100 5.30 6.60 7.90
and particularly to the medullary pyramids (30). Aside 101–110 5.85 7.10 8.35
from glomerulonephritis, possible causes include diffuse 111–120 6.35 7.65 8.95
leukemic infiltration and medication-induced damage 121–130 6.90 8.20 9.50
such as can occur secondary to multiple chemotherapy 131–140 7.40 8.70 10.00
(Fig. 137.2), shown here with nascent obstruction in the 141–150 7.90 9.25 10.60
renal pelvis (31). >150 8.60 9.95 11.30
Diffusely increased echogenicity in the kidney should Table 137.1 Table of normal kidney sizes in children
invariably prompt the examiner to search for pleural [9.3]
effusion (see Fig. 55.3) and ascites in the true pelvis
(Fig. 137.3). In the presence of proteinuria and
apices or diffusely throughout the pyramids. This inverts
hypoproteinemia, such findings suggest nephrotic
the contrast between these structures, with hyper-
syndrome. The example in Fig. 137.3 was intentionally
echoic medullary pyramids and a relatively hypoechoic
selected to emphasize the risk of misinterpretation
parenchymal rim. The calcifications initially show no
when the examination is performed after voiding. The
acoustic shadowing.
bladder (38) is nearly empty after voiding, so that the
Possible causes include tubular acidosis, urate nephrop-
ascites (68) adjacent to the small uterus (39) could
athy with massive cell destruction in the setting of
easily be mistaken for the bladder.
chemotherapy, vitamin D overdose, and therapy with
ACTH or furosemide. The picture of diffusely hyper-
Nephrocalcinosis
echoic medullary pyramids resembles that in a
The deposition of crystals that occurs in nephrocal- dehydrated newborn with protein precipitation. These
cinosis initially creates a hyperechoic rim around the deposits of Tamm–Horsfall protein are reversible within
medullary pyramids, later extending to the caliceal a few days when the newborn is rehydrated.

4 4
3

9 30
29 30 30 68
39
30 30 30
30 30
31 31 150 68 38
77 74
9 30 30 41
47 40
29 43 d
29
30 47
45 47 45
47 45

Fig. 137.1 b Fig. 137.2 b Fig. 137.3 b

138 Pediatrics Lesson 9

Urinary Obstruction and Reflux

When the initial ultrasound screening examination of a Only a renal pelvis exceeding 10 mm in width with clubbed
newborn is performed, it is crucial to detect any stenosis calices (149) or a dilated ureter (150) are indications for
of the ureteropelvic or ureterovesical junction or any an immediate diagnostic workup (Fig. 138.3). A voiding
vesicoureteral reflux with secondary obstruction so as to cystourethrogram is generally obtained (see next page).
avoid any subsequent damage to the kidneys.
Remember that the delicate anechoic renal pelvis (31)
in newborns may be up to 5 mm wide (Fig. 138.1) in Width of the renal pelvis in newborns [9.3]
the absence of any urinary obstruction. Where the renal Normal < 5 mm
pelvis measures between 5 and 10 mm in width (Fig.
138.2), follow-up examinations at short intervals are in- Follow-up indicated 5–10 mm
dicated to clarify whether findings represent a congenital Suspected pathologic dilation > 10 mm
ampullary pelvis or a pathologic progressive dilation of
the collecting system. Table 138.4

4
154

30 29
30 30
30 30 149
29 30
31
31 31
30
30 29 30 150
46 29
74

Fig. 138.1 b Fig. 138.2 b Fig. 138.3 b

Where there is continuous dilation of the ureter (150) as
in Fig. 138.3 and the renal pelvis (31), a ureteropelvic
stenosis can be reliably excluded as the cause of the
urinary obstruction. However, isolated dilation of the
renal pelvis with or without caliceal clubbing should be
further evaluated with a voiding cystourethrogram or
intravenous urogram to exclude vesicoureteral reflux
or stenosis of the ureteropelvic junction. The example
in Fig. 138.3 shows a thinned parenchyma 29) due to
urinary obstruction. Here, immediate diagnostic workup
is indicated and possibly decompression as well.
Lesson 9 Pediatrics 139

Possible Sequelae of Urinary Obstruction

When urinary obstruction is not detected early, it can
lead to thinning of the parenchyma (29 in Fig. 139.2) Grades of reflux in children
and gradually progress to a shrunken kidney (see Fig. Grade I Reflux into ureter only
67.3) with corresponding loss of renal function. Grade II Reflux into pelvicaliceal system
Grade III Additional beginning ureteral dilation
Chronic urinary tract infections or metabolic disorders and caliceal clubbing
can also induce crystalline deposits ( ) in the dilated Grade IV Increasing ureteral dilation
calices of the caliceal system (Fig. 139.3). and caliceal clubbing
Grade V Pronounced ureteral dilation and
beginning parenchymal thinning
Table 139.1

29

31

150

47
45 45

Fig. 139.2 a b Fig. 139.3

Voiding Cystourethrogram
A voiding cystourethrogram excludes or confirms
vesicoureteral reflux and should be performed in patients
with recurrent urinary tract infections or urinary obstruc-
tion in the infection-free interval after antibiotic therapy.
Normally (Fig. 139.4), even during voiding through the
urethra ( ), the full bladder shows no retrograde reflux
into the ureters ( ). The images are obtained in a
slightly oblique projection to avoid misinterpreting the
adjacent cortex of the ilium (imaged end on) as grade I
reflux (into distal ureter only). Reflux into the caliceal
system ( ) is referred to as grade II reflux (Fig. 139.5).
Grade III is reached where there is extensive dilation of
the ureter and beginning clubbing of the calices.
Grade IV reflux in children is characterized by increas-
ing caliceal clubbing and ureteral dilation; grade V refers
to cases where parenchymal thinning is also present
(Table 139.1). The chronic end stage is characterized by
tortuosity of the entire dilated ureter as seen in Fig. 139.6.
Benign Renal Tumors
Aside from fibromas in neurofibromatosis (Reckling-
hausen's disease), benign masses in the pediatric kidney
include angiomyolipomas, which occur in combination
with Bourneville–Pringle disease (tuberous sclerosis) and
resemble adult angiomyolipomas (see Fig. 71.1).

Fig. 139.4 Fig. 139.5 Fig. 139.6

140 Pediatrics Lesson 9

Nephroblastoma
Nephroblastoma (54) is the second most common malignant mass encountered in children (Figs. 140.1 and 140.2).
Also known as Wilms' tumor, it leads to complete destruction of the normal renal anatomy and frequently exhibits an
inhomogeneous hyperechoic internal structure and impairs urinary drainage from the remaining parenchyma (29) as
in Fig. 140.3. It is important to examine the contralateral kidney to exclude bilateral involvement, which is observed
in up to 10% of all cases.

a a a 5
4
29 47
30

54 13 29
29 13 54
44 54 29
57
57 149
45 45 45
45 44
29 45 35
Fig. 140.1 b Fig. 140.2 b Fig. 140.3 b

Lymphomatous Infiltration and Metastases

Malignant infiltration of the kidneys from lymphomas
or metastatic disease is less common. The difference in
echogenicity between involved areas and normal renal
parenchyma (29) may not be very conspicuous (Fig.
140.3), and some such lesions are identifiable only by
central necrosis (57) or associated urinary obstruction in
adjacent caliceal groups (149).
Adrenal Gland
In newborns and preterm neonates, the hypoechoic
adrenal cortex can invariably be distinguished from
the hyperechoic medulla (155 in Fig. 140.4). On a
posteroanterior scan, the adrenal gland typically
appears as a Y shape craniomedial to the upper pole
of the kidney. However, this difference in echogenicity
disappears during infancy and adult adrenal glands
are barely distinguishable from perirenal fat (see Fig.
67.1). In newborns, bleeding in the adrenal glands
is usually visualized as a hypoechoic area ( ) at the
upper pole of the kidney (Fig. 140.5). If this finding is
indeed a hematoma, it should measurably decrease in
size within a month. If its size is unchanged, laboratory
tests or MRI must be performed to exclude a cystic
neuroblastoma. Adenomas of the adrenal gland are
less common. Because of their small size they are often
detectable only on noncontrasted high-resolution CT
densitometry studies.

109

47
30

29
30 31
29
30
155
13

Fig. 140.4 a b Fig. 140.5

Lesson 9 Pediatrics 141

Patent Urachus
In the newborn, the bladder is best
examined in longitudinal and
transverse suprapubic planes (Fig.
141.1a) as long as it is still filled
(this means at the beginning of the
examination!). Particular attention
should be paid to the roof of the
bladder (Fig. 141.1b) to avoid mis-
sing a patent urachus. This will
appear as a hypoechoic channel ( )
along the anterior abdominal wall
between the umbilicus ( ) and the
roof of the bladder (Fig. 141.2). Fig. 141.1 a b

Hematoma and Cystitis Ureterocele

In children, the most common masses in the bladder (38)
are blood clots (52), which usually occur in the setting
of hemorrhagic cystitis (Fig. 141.3). This child received
chemotherapy in preparation for a bone marrow trans-
plant. As in adults (Fig. 100.2), cystitis manifests itself as
circular wall thickening (77).
In infants presenting with urinary obstruction, one must
exclude a uterocele (151) in addition to stenosis at the
ureteropelvic or ureterovesical junction. An ureterocele
can project into the bladder lumen as a thin membranous
structure (Fig. 141.4) that can change size and shape
depending on the level of filling. This image also shows a
dilated distal ureter (150).

a a 1 a 1
2 3 2
3
47
51
74 38
46 77 38
74 74
45 151
52 77
150
45 43
43 47

Fig. 141.2 b Fig. 141.3 b Fig. 141.4 b

Height [cm] Length of spleen [cm] Spleen Size in Pediatrics

m – 2 SD m m + 2 SD While the "4711 rule" applies to
Newborns 2.90 4.07 5.24 adults with the caveats discussed
< 55 2.13 2.91 3.69 above, the size of the spleen in
55–70 2.44 3.46 4.48 children is measured craniocaudally
71– 85 2.23 3.71 5.19
86–100 2.61 4.69 6.77 along the midaxillary line (not
101–110 3.02 4.88 6.74 parallel to the intercostal space),
111–120 3.38 5.26 7.14 and is specified relative to height
121–130 3.37 5.31 7.25 (according to Weitzel, D.: Sonogra-
131–140 4.10 5.96 7.82 phic Organometrics in Childhood,
141–150 4.61 5.81 7.01
> 150 4.36 6.18 8.00 Mainz).

Table 141.1 Normal values for spleen size according to height [9.4]
142 Pediatrics: Gastrointestinal Tract Lesson 9

Pyloric Hypertrophy
In pediatrics, the hypoechoic muscular layer of a term
newborn up to 2 months old should not exceed 4 mm.
The entire diameter of the pylorus should measure less
than 15 mm. Pyloric hypertrophy is present whenever
the transverse diameter (Fig. 142.1) exceeds these
values or the pylorus measures more than 16 mm in
length in the longitudinal plane (Fig. 142.2). Failure
to detect gastroduodenal passage of gastric contents
substantiates the diagnosis.

Gastroesophageal Reflux
To confirm an insufficient lower esophageal sphincter
with esophageal reflux in children, the child should be
examined after drinking a small amount of fluid or, if it is
a newborn, with the stomach filled after nursing. In either
case, the swallowed fluid invariably contains air bubbles
(47) and will be visualized as hyperechoic motion within
the stomach (26), often with comet tail artifacts or
acoustic shadows (45 in Fig. 142.3). After the esophageal
hiatus of the diaphragm is identified in the proper sagittal
plane (see Fig. 25.2), one observes the esophagus for
some time with head-dependent table positioning to
watch for retrograde passage of gastric contents through
the cardia and into the esophagus. In adults, it is preferable
to perform pulsed fluoroscopy after ingestion of an oral
contrast medium.

3 1
2/5
3 3
9 5 m
22 m
7

74 5 mm
9
47
26
26
10 33 74 45
26 33 b
12 74
11
5
9 74 5 9

Fig. 142.1 b Pyloric hypertrophy on Fig. 142.2 b ... and on a Fig. 142.3 b
a transverse section ... longitudinal section

Hirschsprung`s Disease
The distinguishing feature of Hirschsprung's disease is the aganglionic and therefore narrowed colonic segment with
massive dilation of the colonic segment proximal to it (43), whose luminal width differs significantly from adjacent
bowel loops (46 in Fig. 142.4). 74
74
Familial clustering involves boys in 46
46
about 80% of all cases. A typical funnel 74
-shaped junction is observed between
the narrowed segment and the
megacolon. Often the dilated lumen 45 43
contains only a little intestinal gas (47)
with distal acoustic shadowing (45), 47 46
allowing good sound transmission
45
through the retained fecal matter.
Fig. 142.4 a b
Appendices Primer of Ultrasound Findings 144
Index 148
Template for Report of Normal Findings 149
Diagram Templates for Standard Planes 150
Answers to Quizzes 155
Thanks to Contributors 159
Hands-on Ultrasound Courses

List of Abbreviations 160

Examination Algorithms 161
References 166
Space for Your Notes and Drawing Exercises 167
144 Primer of Ultrasound Findings

When communicating with experienced colleagues, brief review is intended as a guide to use until you have
novices are occasionally confused about which terms become more familiar with the common terms.
to use to describe findings clearly and concisely. This

A General Description of the Ultrasound Morphology of a Finding:

Imaging plane?
Name the imaging plane (see front cover flap). Is the lesion visualized in the
longitudinal or transverse plane?

Location, side, position within an organ or relative to other organs and ves-
Where?
sels, i.e., central, hilar peripheral, subcapsular, adherent to the wall.

Number? Lesions may be focal or unifocal, multiple, or diffusely distributed.

Specify in mm or cm. Important for follow-up examinations:
How large?
Estimate progression or regression, such as can occur under therapy.
Round, oval, spherical stellate, wedge-shaped, geographic, irregular,
Shape?
thickened.
Sharp (likely benign) ill-defined (= sign of infiltration, as in
Demarcation?
inflammation or malignancy).
Anechoic (= homogeneous fluid), hypoechoic, or hyperechoic
Echogenicity?
(possibly relative to surroundings).
Homogeneous inhomogeneous, finely granular coarse, septated.
Echo texture? Recently introduced categories also include elastic deformation
(using special scanning technique).
Acoustic shadow, edge shadow, total reflection, acoustic enhancement,
Acoustic phenomena?
section thickness, mirror image, side lobe, reverberation artifacts.

Displacement or infiltration of adjacent structures or vessels? Caution:

Expansion? Mass effects can also occur with benign cysts and are therefore not
necessarily a sign of malignancy.

B Useful Terms (in alphabetical order)

Ampullary Developmental variant of the renal pelvis
( can mimic obstruction)
Anechoic Black ( homogeneous fluids: blood, urine,
bile, cyst contents, pericardial or pleural
effusion)
Artifacts Visual findings lacking physical correlates
Biliary air Air inclusions in bile ducts ( secondary
to papillotomy or abscess)
Bull's-eye Concentric circles of alternating echo-
sign genicity ( intussusception; differential
diagnosis: bowel wall inflammation)
Caliber Abrupt changes in caliber (diameter) of the
change branches of the portal vein ( cirrhosis of
the liver)
Capsule line Thin hyperechoic border of an organ
( absent in cirrhosis of the liver)
Comet tail Resonance artifact deep to
pulmonary air or bowel gas
Concentric At a pericentral location in a vessel
( thrombus or calcification)
Curtain trick Respiratory maneuver ( improves
visualization of the spleen)
Delayed
( application, possible meaning)
Late splenic hemorrhage can occur
after trauma
Density Term is occasionally used incorrectly.
The echogenicity of a tissue on an ultra-
sound image has little to do with its
physical density.
Depth Adjustment of gain) to sound
compensation penetration depth
Diffuse Distribution pattern, as in increased
echogenicity
Dissection Complication ( aortic aneurysm)
Double-barrel Immediate adjacency of two anechoic
shotgun sign ductal structures in the hepatic parenchyma
( dilation of intrahepatic ducts parallel to
portal venous branches)
Eccentric Adherent to the wall
( location of thrombus in blood vessels)
Echogenicity "Brightness" of the pixels (increases with
the number of impedance mismatches)
Ectasia Dilation of the lumen of the abdominal
aorta > 2.5–3.0 cm
Edge shadows Acoustic phenomenon occurring deep to
the edge of the gallbladder and cysts
 Primer of Ultrasound Findings 145

Fluke of Typical appearance of the celiac trunk Perifocal Marginal zone around a lesion
a whale in the transverse plane Plaque Hyperechoic calcified zone in blood
vessels
FNH Focal nodular hyperplasia of the liver Polycyclic Tuberous or resembling cauliflower
( structure of tumor in the stomach
Focal Circumscribed lesion (focus) or bladder)
Focal zone Part of the image with the highest PP index Parenchyma to pelvis index
vertical resolution ( kidney findings)
Forced Respiratory maneuver Predilection Typical location of a lesion or
inspiration ( vena cava collapse test) abnormality
Gain Overall amplification of ultrasound signal Pseudocysts ( Complication of pancreatitis)
Halo Hypoechoic rim of a lesion Pulsation Simple ( arteries such as aorta), double
( typical of hepatic metastases) ( veins such as inferior vena cava)
Haustration Convex pouching ( typical of colon) Rarefaction Decreased vascularity
( cirrhosis of the liver)
Hilum fat sign Benignity criterion for lymph nodes
Respecting Failure to invade vascular structures is
Hyperechoic Bright ( as in fatty degeneration inconsistent with infiltrative growth
of parenchymal organs) ( benignity criterion)
Hypoechoic Dark, few echoes ( muscle, Reverberation Repetitive echoes (artifact)
subcutaneous fat, parenchyma)
Section thickness Apparently ill-defined border of an
Ill-defined Demarcation ( criterion of infiltration artifact obliquely sectioned wall of a hollow
in malignancy and inflammation) organ ( important to consider in
Impedance Interface between tissue layers with differential diagnosis of gallbladder
mismatch differing velocity of sound propagation sludge or bladder sediment)
that produces echoes Septate, Anechoic hollow spaces are divided by
Indentation Blunt, convex protrusion with displace- septated hyperechoic lines ( cysts, cystic
ment of adjacent structures ( tumors) ovarian tumors, aortic dissection)
Infiltration Spread into adjacent structures Sharp Demarcation ( benignity criterion)
( malignancy criterion) Side-Lobe occurs in anechoic structures
Inhomogeneous Irregular pattern of distribution Artifact next to strong reflectors
or echogenicity Sludge Hyperechoic sediment in the gallbladder
Iris sign Typical progression of enhancement Spoke-wheel Pattern of echogenicity ( focal nodular
in a liver hemangioma on spiral CT pattern shyperplasia of the liver, septation in
and contrast-enhanced ultrasound echinococcal cysts)
Jet sign Inflow from the ureter into the bladder on Starry sky Multiple hyperechoic focal lesions
color duplex sonography (intrastenotic ( in tuberculosis of the spleen)
and poststenotic acceleration of flow)
Stenosis Narrowing of a vessel or hollow organ
Kinking Tortuous, angular course
( aortic aneurysm) Stent Tube implanted to maintain patency of
vascular stenosis
L/T ratio Longitudinal diameter divided by
transverse diameter ( malignancy String of Configuration of the medullary pyr-
status of lymph node) pearls amids along the border between the paren-
chyma and renal pelvis, pattern of dilation
Liquefaction Usually anechoic ( as in the of the pancreatic duct in pancreatitis
center of abscesses, metastases)
Target sign Concentric circles of alternating
LN Lymph node echogenicity ( bowel intussusception)
Lobe of sound The acoustic wave front has a Thickening Variation in shape ( margins of the
beam finite thickness section thickness the liver in hepatic disorders)
artifact
Total reflection A black shadow occurs deep
Mass Mass to bone and air
Trackball Important control device on the
Metastasis Spread of a malignancy from ultrasound unit
one part of the body to another
Triangular Typical three-sided configuration
Multifocal Having several foci in a single organ ( organ infarcts)
Narrowing of ( Typical finding in renal degeneration)
renal Vena cava Examination maneuver in
parenchyma collapse test forced inspiration ( in
suspected right heart failure)
Necrosis Hypoechoic, usually central area of lique-
faction ( abscess or central metastasis) Wall thickness Diagnostic criterion ( in hollow organs,
vascular structures)
Nodular Multifocal distribution pattern of lesions
Wedge-shaped Pattern of increased parenchymal
Nutcracker Compression of the left renal vein by the echogenicity ( typical pattern in
aorta and superior mesenteric artery infarct)
Oscillating Back and forth motion of bowel contents
peristalsis
Pennate Exhibiting parallel stripes
( pattern typical of muscles such as
the psoas major)
146 Primer of Ultrasound Findings
The following list contains terms
that are applicable to certain or-
gan systems. For each organ, terms
for spatial orientation are listed,
followed by typical ultrasound
changes that may provide informa-
tion about the underlying disor-
der. Then any features and consid-
erations specific to the organ are
listed. This section is intended as a
concise, time-saving review.
Liver
Spatial terms
• Subdiaphragmatic, subcapsular
perihilar, central; specify seg-
ment (not only lobe), periportal,
parahepatic, focal, diffuse
Typical morphology
Possible diagnosis
• Diffuse increase in echogenicity
Fatty liver
• Diffuse loss of sound
penetration with depth
Fatty liver
• Geographic, sharply demar-
cated differences in echogenicity
around the gallbladder bed or
near the portal bifurcation
Focal fatty infiltration or focal
sparing in fatty infiltration
• Spherical anechoic and sharply
demarcated lesions with edge
shadows and distal acoustic
enhancement
Benign cysts
• Septated cysts
Echinococcosis
(spleen involved?)
• Singular or multiple lesions with
hypoechoic rim (= halo)
Metastases
• Spherical hyperechoic and
sharply demarcated lesion
without halo
Hemangioma
• Double-barrel shotgun sign
along portal vein branches
Dilated intrahepatic
bile ducts
• Intraductal hyperechoic, oval
lesions with acoustic shadowing
Gallstones or air in the bile
ducts
• Absent capsule line, peripherally
rarefied vessels, thickened organ
edges and "pruned portal tree"
Cirrhosis (shrunken liver only
in late-stage disease)
Specific considerations
• Differential diagnosis may
require contrast harmonic
imaging and elastographic
techniques
• Spiral CT or contrast-enhanced
ultrasound: multiphase study
with typical contrast enhance-
ment pattern diagnostic of
hemangioma: "iris sign"
Gallbladder
Spatial terms
• Endoluminal, adherent to the
wall, infundibular, fundal
Typical morphology
Possible diagnosis
• Hypoechoic, multilayered,
edematous wall thickening,
possibly with perifocal ascites
Acute cholecystitis
• Hyperechoic intraluminal
sedimentation
Sludge (differential diagnosis:
section thickness, reverbera-
tion, and side-lobe artifacts)
• Hyperechoic, spherical to oval
intraluminal lesion with distal
acoustic shadowing
Cholecystolithiasis
• Focal wall thickening or hyper-
echoic lesion adherent to the
wall without acoustic shadow
Polyp
Spleen
Spatial terms
• Subdiaphragmatic, subcapsular,
central, perihilar, perisplenic,
parasplenic
Typical morphology
Possible diagnosis
• Thickened organ shape
Splenomegaly in viral
infection, lymphoma, or
portal hypertension
• Triangular or wedge-shaped
area of decreased echogenicity
Suggests infarct => color
duplex sonography
• Inhomogeneous patchy
parenchyma
Suggests lymphomatous
infiltration
• Parasplenic round mass
isoechoic to spleen
Accessory spleen, lymph node
• Hypoechoic, bandlike dis-
continuity in the parenchyma,
possibly with subcapsular
hypoechoic fluid
Suggests splenic rupture
(free abdominal fluid?)
Pancreas
Spatial terms
• Head, uncinate process, body,
tail, disseminated, peripancreatic,
omental bursa (lesser sac)
Typical morphology
Possible diagnosis
• Diffuse increase in echogenicity
Lipomatosis
• Hypoechoic edematous
enlargement, applying pressure to
transducer is painful, anechoic
peripancreatic fluid may be present
Acute pancreatitis
• Organ atrophy with focal
hyperechoic calcifications with
acoustic shadowing, possibly
with irregular dilation of the
pancreatic duct
Chronic pancreatitis
• Anechoic, cystic cavity in the
pancreatic region
Pseudocyst (differential
diagnosis: bowel loop)
Specific considerations
• Endoscopic ultrasound allows
intraluminal visualization through
the stomach
Adrenal Glands
Typical morphology
Possible diagnosis
• Unilateral or bilateral hypoechoic
thickening
Adenoma (differential
diagnosis: metastasis)
Specific considerations
• Differential diagnostic modalities
include dynamic densitometry using
spiral CT (contrast washout curve)
Kidneys
Spatial terms
• Parapelvic, pelvic, perihilar, sub-
capsular, parenchymal, cortical,
pericapsular, polar, perirenal, at
the pelvic–parenchymal border,
unilateral, bilateral; do not forget
to specify the side (body markers)
Typical morphology
Possible diagnosis
• Homogeneous, anechoic, round
to oval, sharply demarcated lesion
with distal acoustic enhancement
Cyst
• Homogenous, hyperechoic, sharply
demarcated, spherical lesion
Angiolipoma
• Row of round hypoechoic lesions
without distal acoustic enhance-
ment along the border between
the parenchyma and renal pelvis
resembling a string of pearls

Physiologic medullary pyramids
• Hypoechoic pelvic thickening or
prominent pelvis
Urinary obstruction (differ-
ential diagnosis: pelvic cyst,
ampullary renal pelvis)
• Parenchymal thinning with PP
index < normal and kidney size
< 10 cm
Renal atrophy
• Inhomogeneous mass with ex-
pansion Suggests malignancy
• Inhomogeneous patchy paren-
chyma Suggests infarct
Specific considerations
• Differential diagnostic modalities
include densitometry on spiral
CT and perfusion pattern on
color duplex sonography
• Ectopic kidney, horseshoe kidney
• Accessory renal arteries
Gastrointestinal Tract
Spatial terms
• Intraluminal, adherent to the
wall; also specify abdominal
quadrant for bowel
Typical morphology
Possible diagnosis
• Bull's-eye or target sign (con-
centric structure of alternating
echogenicity)
Intussusception
• Focal hypoechoic wall thickening
with discontinuity of the layers of
the wall
Suggests malignancy
(differential diagnosis:
lymphoma, more likely
disseminated than focal)
Specific considerations
• Hypotonic visualization of the
gastric wall is possible using
water as an anechoic intraluminal
medium
• Endoscopic ultrasound (of gastric
and rectal wall) is an option
• Peristalsis can be provoked by
rapidly alternating pressure on
the transducer
Bladder
Spatial terms
• Intraluminal, adherent to the wall,
intravesical, extravesical, perivesi-
cal, bladder floor, bladder roof
Typical morphology
Possible diagnosis
• Hyperechoic material with gravita-
tional sedimentation pattern
Sludge, hematoma
• Diffuse, hypoechoic wall
thickening
Cystitis
Primer of Ultrasound Findings 147
• Focal wall thickening, possibly
extending into lumen as
polypoid projection
Suggests malignancy
• Spherical, anechoic, sharply
demarcated perivesical structure
Bladder diverticulum
• Hyperechoic intraluminal circle
Balloon of indwelling catheter
(rare differential diagnosis:
ureterocele in children)
• Suddenly appearing linear
intraluminal inhomogeneity
Jet sign from ureteral
peristalsis and differing
concentration of urine
Specific considerations
• Remember to clamp an indwel-
ling catheter prior to examination
so the bladder will be full and
allow adequate evaluation of the
bladder wall
Vessels and Retroperitoneum
Spatial terms
• Paraaortic, retro-aortic,
preaortic, paracaval, retrocaval,
precaval, aortocaval, preverte-
bral, retrocrural, mesenteric,
para-iliac, inguinal, cervical
Typical morphology
Possible diagnosis
• Endoluminal material of varying
echogenicity
Thrombus
• Diameter of thrombosed vein
more than twice that of the
accompanying artery
Sign of acute thrombosis
(< 10 days)
• Dilated aortic lumen containing
a hyperechoic membrane
Dissected aortic aneurysm
• Hypoechoic oval structure adja-
cent to a vessel
Typical lymph node
• Oval lymph node (L/T ratio > 2)
with hilum fat sign
Benignity criterion for
lymph nodes
• Homogeneously hypoechoic
spherical lymph node (L/T
ratio ~ 1) without hilum fat sign
Typical of lymphoma (deter-
mine perfusion pattern on
color duplex sonography)
Specific considerations
• Color duplex sonography
often provides additional
information
Thyroid Gland
Spatial terms
• Isthmus, lobes (specify side), sub-
capsular, at upper or lower pole
Typical morphology
Possible diagnosis
• Isoechoic nodular lesions with
hypoechoic rim
Typical of adenoma
• Cystic anechoic lesions, often
multifocal
Nodular transformation
induced by iodine deficiency
• Hypoechoic nodular lesions
Suggest malignancy if scin-
tigram shows cold (inactive)
lesions
• Normally hyperechoic
parenchyma appears diffusely
hypoechoic
Hashimoto's thyroiditis
• Thyroid enlargement with ill-
defined hypoechoic areas within
otherwise normal echogenicity
Subacute de Quervain's
thyroiditis
Specific considerations
• Findings are often best inter-
preted together with scintigraphy
and color duplex sonography
c
Checklists
The third part of this review compri-
ses the checklists and tables of stan-
dard values which are not repeated
here to save space. They are listed on
the pocket-sized cards and/or on the
following pages:
Subject Page
Aortic aneurysm 27
Right heart failure 29
Acute and chronic pancreatitis 35
Normal values for the porta hepatis 41
Portal hypertension 42
Acute cholecystitis 45
Cyst criteria 55
Liver cirrhosis criteria 58
Normal renal values, PP index 65
Benign vs. malignant lymph nodes 84
Appendix, normal values 92
CSF spaces in newborns 124
Cerebral hemorrhage 129
Classification of infant hips
according to Graf 135
Width of the renal pelvis in
newborns 138
Grades of reflux in children 139
148 Index
A Delayed splenic rupture 77
Abscess 59, 120
Accessory spleen 76
Acoustic enhancement 18
Acoustic shadow 19
AcuNav 17
Acute transient synovitis of
the hip 135
Adamkiewicz 27
Agenesis of the corpus
callosum 126
Air bronchogram 120
Anatomy 24, 32, 40, 50, 64,
74, 80, 88, 98, 124
Aneurysm 27–28
Angiomyolipoma 71
Aorta 24–28
Appendicitis 92
Applying pressure 21
Artifacts 18–20
Ascites 12, 95
Atelectasis 118, 119, 121
B Edge shadows 19, 46
B lines in pulmonary
edema 121
Bandwidth 9, 13
Barcode sign 115
Bile ducts 40, 41, 48
Blood clots 100, 141
Breathing instructions 20
Bronchial carcinoma 121
C Legg–Calvé–Perthes
Carotid plaque 17
Catheter 73, 100
Cavum of the septum
pellucidum 126
Center frequency 9
Cerebral atrophy 124–126
Cerebral hemorrhage 129
Cervix 103
Cholecystitis 44–45
Cholestasis 47
Chorionic cavity 108
Choroid plexus 124
Cine loop 10
Cirrhosis of the liver 58
Clarity of detail 12
Colitis 93–94
Collapse test
(inferior vena cava) 29, 52
Columns of Bertin 66
Common bile duct 40, 48
Compound imaging 15
Concretion 46, 70
Congested liver 51
Conn syndrome 71
Contrast agent 14, 58, 61
Contrast enema 91
Contrast harmonic 14
Costophrenic angle 51
Cruveilhier-Barmgarten
disease 42, 43
CSF shunt 130
CSF spaces 124
Curtain trick (spleen) 75
Cystitis 100
Cysts 55, 66, 81–82
D Newborns 136–141
De Quervain's thyroiditis 83
Density 9
Dermoid cyst 107
Diagram templates for
standard planes 150–154
Diarrhea 92
Dilation 27, 139
Dissection 27, 28
Diverticulitis 94
Doppler ultrasound
10, 13, 19
Double-barrel shotgun
sign 47
Drainage catheter 48
Dromedary hump 66
Duodenum 33, 88
E Parasites 55
Echinococcus 55, 77
Echo 8
Echogenicity 9
Ectasia 27
Ectopic pregnancy 108
eFAST 114–117
Elastography 86
Embankment 51, 54
Endometriosis 107
Endometrium 104
Endoscopic ultrasound 35,
103
Epididymitis 102
ERCP 48
F disease 132
FAST 112–113
Fatty infiltration (liver) 54
Fatty liver 9, 53–54
Fecal impaction 93
Focal nodular hyperplasia
(FNH) 57
Follicle 106
Foramen of Monro 124, 127
Freeze 10
Frequencies 8, 11
G Pulmonary edema 121
Gain 10
Gallbladder 40, 44–47
Gallstones 47
Gel quantity 22
Gender determination 109
Goiter 82
Graafian follicle 106
Graves' disease 83
H Morison Pouch 112
Halo sign 60, 83
Harmonic imaging 13
Hashimoto's 83
Hemangioma 56, 77
Hematometra 105
Hepatic steatosis 54
Hepatic veins 52
Hepatitis 58
Hepatocellular
carcinoma 59
Hernia 91
Hilum sign,
hilum fat sign 84
Hip dysplasia 132–135 Non-Hodgkin
Hirschsprung's 142 lymphoma 77, 87
Hodgkin 87
Hydrocele 102
Hydrocephalus 130 O
Operation 10
Orchitis 102
I
Orientation 21, 32
Iliac vessels 26 Ormond 68
Image generation 8 Ovulation 106
Impedance 8
Indwelling catheter 100
Inferior vena cava P
24–26, 29
Pancreas 32-36
Infertility 106
Pancreatic carcinoma 36
Intercostal spaces 114–115
Pancreatitis 35
Intestinal
Panorama image 12, 15
intussusception 91
Intrauterine device
Partial loss of volume 118
(IUD) 104
Penetration depth 10–11
Intussusception 91
Pericardial effusion 112
Iodine deficiency 82
Peristalsis 87, 92
Iris sign 56
Peritoneal carcinosis 35
IUD 104 Phase inversion 13
Piezoelectric effect 9
Placenta position 109
K
Plaque 15
Kidney failure 66 Pleural effusion 12, 118–119
Kidney stones 70 Pleural empyema 119
Koller pouch 113 Pleuritis 119
Plexus cysts 126
Pneumonia 120
L Pneumothorax 114–117
Polyps 46
L/T ratio 84 Porta hepatis 40–41
Portal hypertension 42–43
Portal vein 40–43
Lesser sac 33
Portal vein thrombosis 43
Leukemia 37, 84–87 Position of lumen 27–28
Light adaptation 12
Postvoid residual bladder
Liver 49–62 volume 99
Liver abscess 59
Pouch of Douglas 100, 106, 112
Liver cirrhosis Pouch of Morison 112
criteria 58
Precision up-sampling 16
Liver hemangioma 56 Pregnancy testing 108
Liver metastases 60, 61
Primer of ultrasound
Lung mobility 116 findings 144–147
Lung point 117
Prostate carcinoma 101
Lymph nodes 37, 84–87 Pulmonary abscess 120
Lymphocele 73
Lymphoma 87 Pulmonary metastases 121
Pulmonary pulse 116
Pulsatility index (PI) 85
M Pulse compression 16
Medullary pyramids 65, Pyloric hypertrophy 142
136–137
Megahertz 9, 11
Mesothelioma 119 Q
Metastases 60–61, 121 Quantifying pleural
Midline shift 117 effusions 118
Mirro-image artifact 19 Quizzes for assessing progress
30, 62, 78, 95, 110, 122
Myoma 105
R
N
Rarefaction 58
Near-field resolution 11 Reflux 138–139, 142
Nephritis 67 Rejection reaction 73
Nephroblastoma 140 Renal atrophy 67
Nephrocalcinosis 70 Renal carcinoma 71
Nephrolithiasis 70 Renal cyst 66
Neurinoma 71 Renal duplication 66, 136
Renal infarct 67, 70
Renal transplant 72–73

Retroperitoneum 23–38
Reverberation 18
Reverberation artifact 18, 115
RI (resistance index) 85
Rib fracture 120
Ribs 114, 120
Right heart failure 29, 52
Risk of rupture 27
S individual case requires.
Seashore sign 115
Section thickness artifact 18
Segments of the liver 50
Shrunken liver 58
Side lobe 20
Side-lobe artifact 20
SieScape 12
Sludge 46
SonoCT 15
Sonovue 14
Sound waves 8
Spatial orientation 21, 98
Spinal canal 131
Spleen size 142
Splenic infarct 76–77
Splenic rupture 77, 113
Splenic vein thrombosis 35
Splenomegaly 76
Starry sky spleen 77
T is homogeneous without evidence of focal masses. Echogenicity is normal. Intrahepatic
Tables of normal values: aorta
27, inferior vena cava 28,
portal vein 41, kidney 65,
spleen 141, appendix 92,
CSF spaces 124, thyroid
gland 80, Hip 135
Target sign 90–91
Target sign 91
Tension pneumothorax 117
Testis 101–102
Tethered cord syndrome 131
Thyroid carcinoma 83
Thyroiditis 83
Total gain 10
Total reflection 8
Trabeculated bladder 100
Trackball 10
Transducer pressure 21
Transit study 89
Types of transducers 11
U
Ultrasound of the
skull 124–130
Umbilical hernia 91
Undescended testis 102
Upper GI study 89
Urachus 141
Ureter dilation 139
Ureterocele 141
Urinary obstruction 68,
138–139
Uterine carcinoma 105
V cm. No evidence of focal masses or calcifications. The seminal vesicles are unremarkable.
Varicocele 102
Vascular rarefaction 58
Venous star (liver) 52
Volume formula 99
Template for Report of Normal Findings 149
The Ultrasound Agreements valid since 1 April 2017 pursuant to § 135, paragraph 2, of
the German Social Code, Vol. V, stipulate that at minimum the medical documentation
must mention the patient's identity (name and age), the examiner's identification, the
date of the examination, the line of inquiry, in applicable cases limited visualization, and
a description of findings specific to the organ (except in the case of normal findings).
Additionally, the diagnosis or tentative diagnosis and the diagnostic and/or therapeutic
consequences deduced from that diagnosis must be stated. Below you will find a template
for report of normal findings which should be adapted and/or supplemented as the
Template for report of normal findings for patient ______________________________
Date of birth _________________
The examination was performed with/without contrast agents with a _______ MHz trans-
ducer/with the following additional technology: THI / CHI / SonoCT/ CEUS ___________
Retroperitoneum: The retroperitoneum is well visualized without evidence of lymph
node enlargement or other pathologic masses. Aorta and inferior vena cava are
unremarkable.
Pancreas: The parenchyma is homogeneous without evidence of focal lesions or
inflammation. The size of the pancreas is within the normal range/ ______, with the head
measuring _______ cm, the body ____________ cm, and the tail _______ cm. The pan-
creatic duct is normal/cannot be visualized / ____________ and measures ______ (Delete
inapplicable text.)
Liver: The liver is of normal size and shape and exhibits a smooth border. The parenchyma
biliary ducts and vessels appear normal.
Gallbladder and bile ducts: The gallbladder is of normal size and ductal diameter with-
out evidence of inflammatory wall thickening, stones, or sludge. The common bile duct
is completely visualized / visualized as far as _____________. The beds of both adrenal
glands are unremarkable without evidence of a mass.
Kidneys: Both kidneys are well visualized, show normal respiratory mobility, and are of
normal longitudinal size, with the right kidney measuring _____ cm and the left kidney
_____ cm in length. The parenchyma is homogeneous and of normal width in both kid-
neys. The PP index of the right kidney is 1:_____ and of the left kidney 1:_____. No evi-
dence of calculi, congestion, or pathologic masses.
Spleen: The spleen is normal in size for the patient’s age, measuring _____ cm in length
and _____ cm in width, and exhibits a homogeneous parenchyma. No evidence of focal
lesions on the plain ultrasound scan / application of __________reveals_______________.
Abdominal Cavity: No evidence of free fluid.
Gastrointestinal Tract: The thickness of the gastric wall is within the normal range, mea-
suring _____ mm. No evidence of focal thickening of the wall of the stomach, small
bowel, or colon. Normal peristalsis was observed.
Bladder: The wall has a smooth contour and normal thickness, measuring _____ mm.
Normal postvoid residual bladder volume of _____ mL. No evidence of calculi, diverticula,
or ureterocele.
Reproductive Organs: The uterus is of normal size for the patient’s age, measuring _____
x _____ cm. The thickness of the endometrium multiplied by 2 is _____ mm. No evidence
of retained secretion or focal masses. No evidence of free fluid in the pouch of Douglas. The
ovaries are well visualized / not visualized on the (right / left) and are of normal size; the right
ovary measures _____ x _____ cm and the left ovary _____ x _____ cm.
The prostate gland is homogeneous and of normal size, measuring _____ x _____ x _____
Conclusion: Unremarkable normal findings in the abdomen and retroperitoneum.
(Don’t forget to address the clinical line of inquiry. Delete inapplicable text.)
Remarks: _______________________________________________________________
150 Diagram Templates for Standard Planes

On the pages with the quiz questions, I suggested the
approach of using drawing exercises to help you memorize
tomographic anatomy. How is this supposed to work?
It works with surprisingly little effort: The idea is to draw
and label specific standard planes from memory (in the
cafeteria on a napkin during a coffee break, or at night
on any piece of paper) with long intervals in between.
Do not spend more than two minutes on this exercise!
Then fill in your gaps using the diagram templates
copied from this page. You just have to keep these copies
with you (in your lab coat pocket). Only begin a new
attempt after this exercise has left your short-term
memory (> 2–4 hours). You will be surprised how few
attempts it takes to master the tomographic anatomy
if you pursue these tasks with a little determination.
Have fun with it . . .

1. 2.
,45°

Sagittal upper abdomen, left paramedian plane (AO) Sagittal upper abdomen, right paramedian plane (IVC)

3. 4.

Oblique lower abdomen, para-iliac plane Transverse upper abdomen (celiac trunk)

5. 6.

Transverse upper abdomen (renal vein crossing) Oblique right upper abdomen (porta hepatis)

Please label the vessels and organs yourself when doing these exercises so that you can better memorize them.
The solutions, which structure corresponds to which organ or vessel, can be found on page 151.
 Diagram Templates for Standard Planes 151

To help you memorize topographic anatomy as effec-
tively as possible, you can compare the figures shown
here to the diagram templates on page 150. If in doubt,
you can use the legend on the back cover flap to quickly
check the numbers and see which structure corres-
ponds to which respective organ, muscle, or vessel.
Your retention of this material depends heavily on the
number of times you do these active drawing exercises
and the time intervals between repetitions. Good luck!

1. 1 2. 2
3 < 45°
2
3 13
26
9 11 18 66
9 26 47 33
13
10
23 24 a
32 33 9a
32 a 17
12
34
13
46 35
16
25 b 114
47 15
35
35 47 45

Sagittal upper abdomen, left paramedian plane (AO) Sagittal upper abdomen, right paramedian plane (IVC)

3. 1 4. 2
1
2
3
3
7
21 21 a 8 26
46 18 32
22 a
22 9
33
11 19
22 b

21 b 16
35 15 20
13
13
35

Oblique lower abdomen, para-iliac plane Transverse upper abdomen (celiac trunk)

5. 2
1 6. 2
1

3 3
74 7
7
8
10
9 26
26 11 18 33
33 b 66 17
33 a 46 20
12 11
17 33 c 25 b
46 11
16 15
15 20 9
13 16
25 b 13
35 35
24 a 24 b 24 a

Transverse upper abdomen (renal vein crossing) Oblique right upper abdomen (porta hepatis)
152 Diagram Templates for Standard Planes

These diagrams naturally represent idealized situations,
and the structures they show are not always visualized
in the same plane in every patient. Yet this is not impor-
tant. What matters is that you know where to look for,
say, the pancreas or the origins of the renal arteries in
obese patients with limited sonographic visibility. Most
physicians are visual learners, and you are most likely one
as well. With time, you will develop a "visual template" of
the normal findings in every standard plane, and you will
immediately notice any deviation ("something doesn’t
look right here"). That is the goal. You can even go one
step further and write in the normal values where you
find double-headed arrows ( ). This will help you to
memorize these values as well.

We have included a minor mistake for the advanced reader on this page. Can you find it?

7. 8.

Right oblique subcostal plane (hepatic veins) Longitudinal transhepatic plane (right kidney)

9. 10.

Transverse plane (right kidney and IVC) High plane of the left flank (spleen)

11. 12.

Median sagittal suprapubic plane Transverse suprapubic plane

(bladder and uterus) (bladder and prostate gland)
The solutions, where to find which organ or vessel, can be found on the next page.
 Diagram Templates for Standard Planes 153

Here you will find the solution to which structure on page vessel. If anything is unclear, you can check the numbers
152 corresponds to which respective muscle, organ, or in the legend on the back cover flap.

7. 2 1 8. 2 1
3 4

9
43

29 45
9
10 13 30 31
13
9 44
45
16
47 5
35
47 13

Right oblique subcostal plane (hepatic veins) Longitudinal transhepatic plane (right kidney)

9. 2
1 10. 2 1
116
3
43/46
9 80
10 17 26 13
46 14
33
33 37
29 12 15 25 b 45
16
30 24 b 47 33
74
13 35 26
24 a
44 20

Transverse plane (right kidney and IVC) High plane of the left flank (spleen)

1
11. 12. 2
1 6
2 48
3 3
46 46
77

38
51 a 51 a
39 38

41
78 43 d 77 45
45 45
46 40 70 42
46
122
43 d

Median sagittal suprapubic plane Transverse suprapubic plane

(bladder and uterus) (bladder and prostate gland)
154 Diagram Templates for Standard Planes

Here you find three additional standard planes for your solutions, which area corresponds to which vessel or
drawing exercises from the transverse plane of the thy- muscle, etc., are shown directly opposite in four-color
roid, the subxiphoid plane of the four chambers of the figures. The key to the respective numbers can be found
heart, and sagittal parasternal sections of the lung. The in the legend on the back cover flap.

13a. 13b.
1

2
89
a 2
90
85 84 5 85
81 81

83 169 169
82 34 83
82

88 88 35 88
88

Transverse section at the level of the thyroid

14a. 14b.
1
2
3 79
79
114
13
114 115
115 114

114
47
79
47

47
Transverse subxiphoid section of the heart

15a. 15b. 1
2

109 117
116
109

101
45 45

47

Sagittal thoracic plane

 Answers to Quizzes 155

Answer to Fig. 20.4 2 1

5/6

The image shows a longitudinal section of the aorta (15). Its wall contains 9
9
hyperechoic calcifications (arteriosclerotic plaques, 49), with posterior 64 49
15
46
acoustic shadows (45). The larger plaque could have been easily overlooked
without the acoustic shadow because it is located immediately adjacent to
hyperechoic (= bright) bowel gas (46), which also creates an acoustic shadow. 70 70
Below (= posterior to) the aorta (15) we also see the phenomenon of distal
acoustic enhancement (70). 45
45
45

Fig. 155.1
Answer to Fig. 21.1
Prior to beginning the practical sessions, you should become familiar with spatial orientation in a three-dimensional
space. To make the first step easy, we will initially consider only two planes perpendicular to each other: the vertical (sagittal)
plane (Fig. 155.2) and the horizontal
(transverse) plane (Fig. 155.3).
Sagittal planes
On page 21 you were asked to use a
Anterior
coffee filter to help picture how the
sound waves propagate through the
body when the transducer is placed
on the anterior abdominal wall. Both
Cranial Caudal
planes display the anterior abdomi-
nal wall at the upper edge of the
image (up = anterior). As the con-
vention is to view all sagittal images Posterior
from the patient’s right side (Fig.
155.2a), the patient’s cranial struc- Fig. 155.2 a b

tures are displayed at the left edge

of the image (left = cranial) and the Transverse planes
caudal structures at the right edge.
Rotate the transducer 90° coun- Anterior
terclockwise to place it in the trans-
verse plane. As this plane is viewed
from below (caudal) all the structu-
res are reversed (left = right, Fig. Right Left
155.3b). The same imaging conven-
tion is used for transverse planes in
CT and MRI. It all makes good sense: Posterior
If you stand at the foot of the bed
before a supine patient, the patient’s Fig. 155.3 a b

liver (on the patient’s right side) will

be on the left in your field of view. Only neurosurgeons prefer to view CT images of the cranium from above as this
corresponds to their intraoperative perspective.

Answers to Figs. 22.4–22.6

When viewing these three images, it is apparent on the
left image that the structures on the whole are more
poorly visualized than usual. The image in Fig. 22.4
seems blurred and is diffusely obscured by scatter. This
is due to the typical beginner’s error of applying insuffi-
cient pressure to the transducer, not too little gel.
If the amount of gel is indeed inadequate or the exam-
iner breaks the skin coupling by tilting the transducer,
an image like that shown in Fig. 22.5 will result: A black
band appears along the margin of the lost coupling
(here on the right side of the image) beginning imme-
diately at the skin-transducer interface and not only in
a deeper plane.
This finding distinguishes lost skin coupling from acoustic
shadows behind ribs, bowel gas, gallstones, or renal cal-
culi. In Fig. 22.6 the same plane in the same patient was
imaged a few seconds later with better coupling and
sufficient pressure on the transducer. All structures are
visualized far more clearly.
156 Answers to Quizzes

Answer to Fig. 30.2 (Question 6) Answer to Fig. 38.1 (Question 4) Answer to Fig. 62.4 (Question 6)
3 1 1
2
3 2
3 2 6
3 9
9
8 26
13 33 9 7 46
11 33 a 33 b 11
10 9
5 11 12 20
79 17
45 80
45
16 15
16 25 9 80
33 c 45
13
24 a 24 b 29
35 13 31
13 13

Imaging plane: Imaging plane: Imaging plane:

Sagittal upper abdomen, paramedian Transverse section at the level of the Right oblique subcostal plane
plane over the inferior vena cava (16) renal vein crossing Organs:
Organs: Organs: Liver (9), stomach (26), Liver (9), gallbladder (80),
Liver (9), heart, and pancreas (33) and pancreas (33) kidney (29)
Structures: Vessels: Aorta (15), inferior vena Significant finding:
Diaphragm (13), hepatic vein (10), cava (16), renal artery (24), renal vein Inhomogeneous, poorly
portal branch (11), caudate lobe (9a) (25), superior mesenteric artery (17), demarcated area along the
Significant finding: confluence of the portal vein (12) caudal margin of the liver
Anechoic space (79) between Structures: Diagnosis:
myocardium/epicardium and Ligament (7, 8), rectus abdominis Cholecystitis with marked wall
diaphragm muscle (3), lumbar vertebra (35) thickening (80)
Diagnosis: Pericardial effusion (79) Significant finding: Prominent Differential diagnosis:
Differential diagnosis: lumen of the renal vein (25) Parasitic involvement of liver or
Epicardial fat Diagnosis: Still physiologic, no gallbladder, sludge, bowel content
pathologic dilation of the left renal
vein (due to nutcracker syndrome
between 15 and 17)

Answer to Fig. 62.1 (Question 7) Answer to Fig. 62.2 (Question 7) Answer to Fig. 62.3 (Question 7)
2 1 2
3/4 3
5 26 47
11 9
5
9
10
63 13 29
56 45
56
46 47 56 27

47 61
56 13
45 45
13
5 9
9 45 69 13
11 35

Imaging plane: Imaging plane: Imaging plane:

Right oblique subcostal plane Sagittal plane along the right Sagittal upper abdomen,
Organs: midclavicular line right paramedian plane
Liver (9), stomach (26), Organs: Organs:
small bowel (46) Liver (9), kidney (29), lung (47) Liver (9), lung (47), diaphragm (13)
Significant finding: Diagnosis: Significant finding:
Homogeneous, hyperechoic, sharply Subdiaphragmatic hepatic metas- Hyperechoic, partially
demarcated area (63), multiple tasis (56) with hypoechoic rim and inhomogeneous intrahepatic mass
round to oval intrahepatic lesions pleural effusion (69) Diagnosis:
with hypoechoic rim Differential diagnosis: Hemangioma (61) with
Diagnoses: Hyperechoic appearance draining vein (10)
Focal fatty infiltration (63) and mul- suggests hemangioma, but the Differential diagnosis:
tiple hepatic metastases (56) with halo is inconsistent with this Hyperechoic metastasis, hepatic
at least two episodes of metastatic tumors of other origin
spreading as new and older metas-
tases are visible next to each other
 Answers to Quizzes 157

Answer to Fig. 78.1 (Question 5) Answer to Fig. 78.2 (Question 5) Answer to Fig. 78.3 (Question 6)
1
2 4 2 5
2
3
46 26
4
9 9
46 29 28
9 45 33
31
24
29 54 17
13 31
29 45 45 16 15 45
64 54
47 27 55
45
35
70
Imaging plane: Imaging plane: Imaging plane:
Intercostal plane of the right flank Intercostal plane of the right flank in Transverse upper abdomen in
Organs: left lateral decubitus position an infant
Liver (9), kidney (29), lung (47), Organs: Liver (9), bowel (46) with Organs: Liver (9), pancreas (33)
bowel (46) acoustic shadow (45), kidney (29) Significant finding:
Structures: Structures: Poorly demarcated organs and large,
Diaphragm (13), renal pelvis (31) External and internal oblique mus- inhomogeneous tumor (54) in the
Significant finding: cles (4), upper and lower poles of right paravertebral region. The tumor
Anechoic, spherical, sharply de- the kidney (27 and 28) displaces the right renal artery (24)
marcated lesion (64) at the upper Significant finding: Ill-defined anteriorly over a long segment.
pole of the right kidney, with distal hypoechoic lesion (54) in the renal Suspected lymph node metastasis (55)
acoustic enhancement (70) parenchyma (29) with mass effect between the aorta (15) and lumbar
Diagnosis: Diagnosis: vertebra (35)
Renal cyst (64) Renal cell carcinoma Diagnosis:
Differential diagnosis: Differential diagnosis: Metastatic nephroblastoma
Adrenal tumor with cystic Renal lymphoma, metastasis, Differential diagnosis:
components hypertrophied column of Bertin, Neuroblastoma of the right
hemorrhagic renal cyst sympathetic chain

Answer to Fig. 78.4 (Question 10) Answer to Fig. 95.1 (Question 6) Answer to Fig. 110.1 (Question 4)
2
4 1 45 45
43 4 2 45 45
5
47 46
45 46
54 78
74
74
54 37
45 18 mm
45 43c
74

13 37 5 39
5
47 46 46 9
74 43d

Imaging plane: Imaging plane: Imaging plane:

High plane of the left flank in the Sagittal plane of the left flank Endovaginal view of the uterus
right lateral decubitus position Organs: Organ:
Organs: Colon (43), small bowel (46) Uterus (39)
Spleen (37), lung (47), colon (43), oblique muscles (4) Significant finding:
diaphragm (13) Significant finding: Inhomogeneously hyperechoic en-
Significant finding: Thickening of the colonic wall (74) dometrium (78), widened to about
Several sharply demarcated homo- Diagnosis: 18 mm in a menopausal woman
geneously hyperechoic lesions (54) Ischemia of the bowel wall without hormonal therapy
in the splenic parenchyma without a Differential diagnosis: (see question).
hypoechoic rim Colitis, colon carcinoma Diagnosis:
Diagnosis (rare finding): Suspected endometrial carcinoma
Multiple splenic hemangiomas Work-up:
Differential diagnosis: Fractionated dilation and curettage
Hyperechoic metastases, vasculitis for histologic evaluation
in systemic lupus erythematosus,
histiocytosis X
158 Answers to Quizzes

Answer to question on 4
2
page 56: 5
68
Fig. 56.3a shows two pathologic 9
fluids: 68 = Ascites caudal to the 47
diaphragm 69 = Pleural effusion 61 10
13
cranial to the diaphragm has led to
compressive atelectasis of the basal 45 68 9
segments of the lung (47) 61 = He-
mangioma with draining veins (10)
47
69 13

Fig. 158.1 a b

Answer to Question on the Upper GI Series on Page 89

Gravity causes the contrast medium (white) to collect
in the more posterior fundus and in the pylorus and du-
odenum. The more anterior body of the stomach is
easily evaluated on a double-contrast study. The patient
is therefore supine. If the examiner wants to evaluate the
gastric fundus, the table must be adjusted to bring the
patient into a more upright position or the patient must
be placed in the right lateral decubitus position to cause
the contrast medium to flow out of the fundus.
To visualize the duodenal bulb on the right side, the
patient must be placed in a left lateral position. Plea-
se remember to register your patients only for an early
morning upper GI series (in a fasting patient) and note
that gastric peristalsis may need to be suppressed by
medication (beware of the side effects of intravenous
scopolamine methylbromide!) to achieve a reliable
result. It is advisable to tell patients beforehand to try not
to belch and release the air produced by the effervescent
powder. How else will they know?

Answer to Question on Page 107 Answer to Question 1 on Page 122

Fig. 103.2b illustrates the anatomic orientation on endo-
vaginal images. The right edge of the image is posterior.
The blood clot in the supine patient therefore appears
on the right edge of the image in Fig. 107.3 as gravity
brings it to rest in a posterior location.
FAST position 2 allows one to exclude liver lacerations,
hemorrhage into the pouch of Morison, and right hem-
othorax. FAST position 3 covers ruptures of the spleen,
hemorrhage into the pouch of Koller, and left hemothorax.

Answer to Question 3 on Answer to Fig. 122.1 Answer to Fig. 122.2

Page 122 (Question 4) (Question 5)
The three conditions for demonstrat- 1 1
ing the pulmonary pulse are a ful- 2 116
2
ly expanded lung (on the side being
117
scanned), the presence of an arterial
118
pulse (cardiac output), and respira-
116 56
tory standstill or briefly interrupted
artificial respiration, for example with 69
71
the "inspiration hold" key pressed.
47 47
45 45

Imaging plane: Imaging plane:

Thoracic intercostal plane
Organ: Lung (47)
Structures:
Chest wall (1, 2, 116, 117)
Significant finding: Hypoechoic
region (71) near the pleura
Diagnosis:
Peripheral pulmonary infarct
Differential diagnosis:
Peripheral bronchial carcinoma;
therefore perfusion imaging with
color duplex sonography is indicated
Thoracic intercostal plane
Organ: Lung (47)
Structures:
Chest wall (1, 2, 116)
Significant finding:
Hypoechoic, solid visualization of
large areas of the lung (118) with
even less hypoechoic focal lesions
(56)
Diagnosis (rare finding):
Postobstructive atelectasis with
liquefied metastases
 Thanks to Contributors / Hands-on Ultrasound Courses 159
This revised and expanded edition could not have been real-
ized without the support of numerous helpers. Since 1991,
more than 15,000 course participants and 300 ultrasound
instructors have contributed to the continuing optimization
of this book in systematic evaluations with their feedback
and constructive criticism. I wish to thank them all.
I would specifically like to mention the following persons
and institutions: I am indebted to Ramona Sprenger
for the excellent graphic production including the inte-
gration of colored diagrams by Willi Kuhn and for the
entire layout of the book, based on the previous drafts
by Inger Wollziefer. Jochen Neuberger and Michael Zepf
of Georg Thieme Verlag have contributed decisively to
ensuring that the production and combination with the
new media server have gone smoothly and efficiently.
We cordially thank Samsung and Marburger Bund Foun-
dation for their continuous support of our ultrasound
courses for our physician colleagues (see below).
Alexis Müller-Marbach, MD has contributed many new
exemplary images from gastroenterology, Georg Groß,
MD several pulmonary ultrasound images, Prof. C.F.
Dietrich Fig. 57.2, Christoph Sproll, MD several images
on the differential diagnosis of lymph nodes. I thank my
colleagues Jörg Schaper, MD, H.D. Matthiessen, MD and
Information on hands-on ultrasound courses
Even comprehensive textbooks will never be able to pro-
vide the necessary opportunity to practice how to handle
the transducer or to convey how best to deal with patients
in an ultrasound examination. We therefore recommend
combining this book with the included video clips and with
ultrasound courses in which one can acquire sound and
systematic knowledge of this elegant diagnostic method
under qualified supervision. In cooperation with Marburger
Bund Foundation, the editor offers ultrasound courses for
physicians. This manual is also intended as introductory
reading for these ultrasound courses; it has gradually
developed from approximately 30 years of classroom
experience with students and physicians. These courses
are also offered in English and are characterized by a high
proportion of hands-on exercises and a favorable student
to teacher ratio: A maximum of five participants share an
ultrasound workplace under the supervision of a specially
trained instructor. These small groups are one of the key
factors contributing to a successful learning experience.
Information about dates, course content, registration for-
malities, and course fees are available from this web site:
www.medidak.de
Additional courses are available for those who would later
like to go one step further and enter the world of color
duplex sonography. Interdisciplinary elementary courses
providing an introduction to color duplex sonography
are designed according to the same quality criteria
with respect to teaching and method. They are held in
Düsseldorf (in German) and on request also at other
locations in English. A manual entitled "Teaching Manual
Jasmin D. Busch, MD for valuable information regarding
ultrasound examination of the infant hip. I cordially thank
my wife Stefanie Ole Martin, MD and Christian Weigel,
MD for their critical review and additional creative
suggestions.
Finally, I would like to thank the 38 current ultrasound
trainers of our Working Group Medical Didactics and
honor their willingness to provide ongoing, intensive,
video-supported continuing education: Bastian Benner,
Franca Bergfelder, Jonathan Brück, Klemens Freitag, Ira
Gabor, Arnd Giese, Fabian Girke, Stephanie Göller, Lisa
Haddad, Elisabetha Hahn, Tessa Hattenhauer, Annika
Hogrebe, Anna-Lena Hotze, Maike Hüssmann, Kai
Jannusch, Anne Jäckel, Marie Klar, Kathrin Klein, Shining
Liu, Nicole Majewski, Jean-Luc Niederst, Alice Martin,
Ole Martin, Felix Mohr, Sara Naisar, Johanna Noelle, Ralf
Rulands, Nora Schlecht, Stefan Schmidt, Thomas
Schmidt, Rene Stegemann, Isabell Stetter, Richard
Truse, Rebecca Voigt, Elena van Loon, Christian Weigel,
Daniel Weiss, Björn Wieland.
Bern, Summer 2020
Matthias Hofer, MD, Associate Professor, MPH, MME
(Director of Education at DIPR, University of Bern)
of Color Duplex Sonography, Stuttgart: Thieme; 2010" is
also available to accompany this course. Both courses sha-
re a common structure. Brief theory modules are integra-
ted intermittently into longer practice modules, and dra-
wing exercises consolidate the student's understanding of
tomographic anatomy and typical vascular flow patterns.
More specific literature on the subject may be found here:
Hofer M, Kamper L, Heussen N, Martin O, Heverhagen J.
Relevance of clinical expertise between clinician versus
student instructors on ultrasound course efficiency.
Ultraschall Med 2020 in press.
N. Nourkami-Tutdibi N, Tutdibi E, Schmidt S, Zemlin
M, Abdul-Khaliq H, Hofer M. Long-term knowledge
retention after peer-assisted abdominal ultrasound
teaching: Is PAL a successful model in obtaining know-
ledge retention? Ultraschall Med 2020; 41(1): 36-43
Hofer M, Kamper L, Miese F et al. Quality indicators
for the development and didactics of ultrasound courses
in continuing medical education. Ultraschall Med 2012;
33(1): 68–75
Hofer M, Kamper L, Sadlo M, Sievers K, Heussen N.
Evaluation of an OSCE-assessment tool for abdominal
ultrasound courses. Ultraschall Med 2010; 32: 1–8
Hofer M, Jansen M, Soboll S. Potential improvements in
medical education as retrospectively evaluated by can-
didates for specialist examinations. Dtsch. Med. Wschr.
2006; 131: 373–378
Hofer M, Schiebel B, Hartwig H-G et al. Didactic
training of ultrasound instructors. Ultraschall Med 2002;
23: 267–273
160 List of Abbreviations

AAL Anterior axillary line EFW Estimated fetal weight MRI Magnetic resonance
AC Abdominal circumference ERCP Endoscopic retrograde imaging
ACTH Adrenocorticotropic hormone cholangiopancreatography mW Milliwatt
AIUM American Institute of ESWL Extracorporeal shock NHL Non-Hodgkin lymphoma
Ultrasound in Medicine wave lithotripsy NT Nuchal translucency (fetal)
AO Aorta FAST Focused assessment with PA Posteroanterior
ASD Atrial septal defect sonography for trauma PAL Posterior axillary line
AP Anteroposterior FCC Fetal cranium circumference PCO Polycystic ovaries
AVHR Ratio of anterior horn FL Femur length (fetus) (syndrome)
with to width of ipsilateral FNH Focal nodular hyperplasia PI Pulsatility index
hemisphere FOD Fronto-occipital diameter PP Parenchyma to
B- Brightness mode (black (fetus) index pelvis index
mode and white) ultrasound FW Fetal weight PSL Parasternal line
BC Bronchial carcinoma GI Gastrointestinal tract PVHR Ratio of posterior
BPD Biparietal diameter of tract horn width to width of
the head GW Gestational week ipsilateral hemisphere
CBD Common bile duct HCG Human chorionic PW Pulsed wave (Doppler)
CCD Chorionic cavity diameter gonadotrophin RI Resistance index
CCE Cholecystectomy ICS Intercostal space RLD Right lateral decubitus
CCL Chronic lymphatic leukemia IHW Interhemispheric width (position)
CCW Craniocerebral width of IUD Intrauterine device SAS Subarachnoid space
the subarachnoid space IVC Inferior vena cava SCW Sinocortical width of the
CDS Color duplex sonography IVF In vitro fertilization subarachnoid space
CEUS Contrast-enhanced IVU Intravenous urogram SD Standard deviation
ultrasound LA Lower abdomen SLE Systemic lupus
CHI Contrast harmonic imaging LN Lymph node erythematosus
CNS Central nervous system L/Tratio Longitudinal diameter SMA Superior mesenteric artery
CRL Crown–rump length (fetus) divided by transverse THI Tissue harmonic imaging
CSF Cerebrospinal fluid diameter UA Upper abdomen
CT Computed tomography LVW Lateral ventricle width VE Vascular enhancement
CW Continuous wave (Doppler) m Mean VHR Ventriculohemispheric ratio
D Diameter or thickness MA Midabdomen VolB Volume of the bladder
dAO Aortic diameter MCL Midclavicular line VSD Ventricular septal defect
DSA Digital subtraction MHz Megahertz VW Ventricle width
angiography (unit of frequency) YS Yolk sac
dVC Diameter of the vena cava
 Examination Algorithms 161

How Do I Scan Which Organ Step by Step?

The following examination sequences do not represent a organs carefully and completely. These tabular sequences
dogmatic "only possible correct" approach. Instead they of steps are most easily learned when viewing the digital
provide a useful aid to inexperienced ultrasound exam- video clips which you can access online on MedOne (see
iners for how they can scan certain vascular regions or information and access code on page 3).

The following terms are used to describe these specific transducer motions:
Transducer tilt: Transducer rotation: Transducer angulation: Shift transducer to a parallel
Sweep left or right Clockwise or For example, cranial position: Along the longitu-
counterclockwise or caudal dinal axis of the transducer

Fig. 161.1 a Fig. 161.1 b Fig. 161.1 c Fig. 161.1 d

Lesson 1: Sagittal scan of the retroperitoneum (aorta, inferior vena cava, lymph nodes)
1 Place the transducer on the median epigastrium and break the skin coupling cranially.
2 The lost coupling creates a shadow along the left side of the image (left = cranial). Couple the transducer
(= press it posteriorly).
3 Instruct the patient to take a deep breath (pause briefly) and hold their breath.
4 Tilt the transducer to the right to send the sound waves into the left paraaortic region.
5 Adjust the magnification and then slowly and continuously tilt the transducer back to the median plane.
6 As you do this, exclude paraaortic lymph node- and verify the correct shape and diameter of the aorta.
7 Sweep through the aortocaval space. Are there enlarged lymph nodes? (= lymph node- ?).
8 Sweep through the inferior vena cava (IVC diameter? IVC thrombosis?)
9 Sweep to the right paracaval region (lymph node- ?) and increase pressure on the transducer EXACTLY when the
patient takes a breath.
10 As you pause to let the patient breathe, shift the transducer to a parallel position one transducer width caudally while
maintaining pressure on it.
11 Instruct the patient to again take a deep breath (and again maintain pressure on the transducer).
12 Make the same slow sweeping motion backwards from the right paracaval region to the left paraaortic region.
13 Let the patient take a few breaths. If you have not yet reached the aortic bifurcation:
14 Again shift the transducer one transducer width caudally and repeat steps 3–9.
15 Visualize the aorta and a long segment of its intimal/medial border in a central longitudial plane.
16 Freeze the image, let the patient breathe, measure the suprarenal and infrarenal aortic diameters.
17 Visualize the inferior vena cava in a central longitudial plane and verify sharp vascular contours.
18 Freeze the image, let the patient breathe, measure the diameter of the inferior vena cava and caudate lobe.

Lesson 1: Performing the vena cava collapse test

1 Place the transducer on the right paramedian epigastrium and break the skin coupling cranially.
2 The lost coupling creates a shadow along the left side of the image (left = cranial). Couple the transducer
(= press it posteriorly).
3 Demonstrate to the patient "live" forced inspiration through the nose with the mouth closed.
4 Optimize the zoom to visualize the inferior vena cava in the sagittal plane just below the diaphragm in a neutral
respiratory position.
5 Freeze the image and then switch to double image mode (second window is active).
6 Place your left hand on the freeze button, then instruct the patient to take a sudden deep breath as previously
demonstrated.
7 Once the minimal vena caval diameter has been reached, freeze the image and let the patient breathe again.
8 If necessary, go back through the digital memory (using the trackball) and select the appropriate image.
9 Measure the original diameter (first window) and the minimal diameter of the inferior vena cava in the second window.
10 When in doubt, determine the diameters of the peripheral hepatic veins (see p. 52).

Lesson 1: Scanning both iliac neurovascular bundles

1 Place the transducer obliquely on the left lower abdomen between the umbilicus and the anterior superior iliac spine
and press it posteriorly.
2 Break the skin coupling cranially; the lost coupling creates a shadow along the left side of the image (left = cranial).
3 As breathing commands are neither necessary nor effective in the lower abdomen, let the patient breathe normally.
4 Tilt the transducer medially to send the sound waves laterally toward the iliopsoas muscle.
5 Increase pressure on the transducer to displace intestinal gas from the imaging plane and allow visualization
of the retroperitoneum.
162 Examination Algorithms

6 Slowly shift the transducer medially to a parallel position or tilt it until the iliac bifurcation comes into the image.
7 Optimize the magnification and zoom factor so you can readily detect any venous thrombosis or arterial plaque.
8 Continuously sweep medially past the iliac vessels to the bladder (perivascular lymph node- ?).
9 Rotate the transducer 90° counterclockwise and perform the compression test on the cross-section of the vessel
to exclude thrombosis.
10 Repeat steps 1–10 on the contralateral side.

Lesson 2: Systematic scanning of the pancreas in the transverse upper abdominal plane
1 Place the transducer in the transverse plane in the epigastric angle and break the skin coupling on the patient's right side.
2 The lost coupling creates a shadow along the left side of the image (everything is reversed).
3 Tilt the transducer caudally to send the sound waves cranially toward the heart.
4 Place the transducer at an acute angle and press it posteriorly below the level of the ribs.
5 Instruct the patient to take a deep breath (pause briefly) and hold their breath.
6 Then slowly and continuously bring the transducer into an upright position, change your grip, and shift it caudally to a
parallel position.
7 Continuously scan first the tail of the pancreas and then its body and head.
8 Continue caudally past the caudal margin of the head of the pancreas and the uncinate process.
9 Let the patient take a few breaths and EXACTLY at that moment slightly increase posterior pressure on the transducer.
10 Instruct the patient to take a deep breath (pause briefly) and hold their breath.
11 On the way back, scan the head of the pancreas cranially until the body appears (stop!).
12 At this point, rotate the transducer 5–15° counterclockwise until the tail of the pancreas appears as well.
13 Freeze the image and immediately let the patient breathe normally.
14 Measure the three diameters of the organ (head, body, tail) perpendicular to the longitudinal axis of the
organ (width of the duct?).

Lesson 3: Systematic scanning of the porta hepatis in the oblique right upper abdominal plane
1 Place the transducer on the right epigastrium (parallel to the left costal arch) in the oblique right upper abdominal plane.
2 Break the skin coupling on the patient's right side; the lost coupling creates a shadow along the left side of the image
(everything is reversed).
3 Instruct the patient to take a deep breath (pause briefly) and hold their breath. Press the transducer posteriorly.
4 Tilt the transducer slightly laterally, caudally, and to the right to initially send the sound waves across the porta hepatis.
5 Optimize the magnification and zoom factor if applicable so as not to miss even small periportal lymph nodes.
6 Then slowly sweep caudally across the porta hepatis (periportal lymph node ? collaterals?) ...
7 ... past the portal vein. Then let the patient take a few breaths.
8 As you pause to let the patient breathe, increase the pressure slightly during the first expiration.
9 Have the patient inhale again and sweep back cranially until the portal vein appears.
10 Then rotate the transducer around the axis of its cord until a long segment of the course of the portal vein is visualized.
11 Freeze the image and immediately let the patient breathe normally.
12 Measure the diameter of the portal vein at the hilum (without the thickness of the wall) at a right angle to its longitudinal axis.

Lesson 3: Systematic scanning of the gallbladder in two planes

1 Place the transducer in the sagittal plane in the right midclavicular line just below the right costal arch,
then angle it cranially.
2 Break the skin coupling cranially; the lost coupling creates a shadow along the left side of the image (left = cranial).
3 Instruct the patient to take a deep breath (pause briefly) and hold their breath. Press the transducer posteriorly.
4 Tilt the transducer to the right (laterally) to send the sound waves into the perivesical region (medially).
5 Optimize the magnification and zoom factor if applicable so as not to miss even small lesions of the gallbladder wall.
6 Then slowly and continuously tilt the transducer back to the sagittal midclavicular line and scan the gallbladder ...
7 ... until you have passed the lateral margin of the gallbladder. Sweep the transducer back to the center of the gallbladder
and freeze the image.
8 Immediately let the patient breathe normally, and measure the thickness of the wall.
9 As you pause to let the patient breathe, rotate the transducer 90° counterclockwise.
10 Instruct the patient to again take a deep breath, place the transducer at an acute angle, and scan toward the liver
cranial to the gallbladder.
11 Slowly scan the gallbladder caudally (focal or diffuse wall thickening, gallstones?) ...
12 ... past its caudal margin (fluid around the gallbladder?). Then let the patient exhale.

Lesson 4: Scanning the left lobe of the liver in two planes

1 Place the transducer on the right paramedian epigastrium parallel to the inferior vena cava.
2 Break the skin coupling cranially; the lost coupling creates a shadow along the left side of the image (left = cranial).
3 Instruct the patient to take a deep breath (pause briefly) and hold their breath.
4 Angle the transducer slightly cranially so that the border of the diaphragm is just visible along the left side of the image.
5 Shift the transducer to the left to a parallel position, then tilt it and press it posteriorly, and ...
6 ... scan the subdiaphragmatic segments (at sufficient magnification) past the left lateral margin
(typical boomerang shape). Then let the patient take a few breaths.
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164 Examination Algorithms

7 As you pause to let the patient breathe, angle the transducer caudally and then again have the patient inhale.
8 On the way back, scan the caudal portions of the left hepatic lobe medially as far as the inferior vena cava.
9 As you pause to let the patient breathe, rotate the transducer 90° counterclockwise into the transverse plane.
10 Place the transducer at an acute angle, press it posteriorly, couple it cranially, and scan toward the heart.
11 After deep inspiration, slowly and continuously scan the left hepatic lobe craniocaudally, change your grip, and scan
past the caudal border of the liver (focal hepatic lesions?). Let the patient breathe normally.

Lesson 4: Scanning the right lobe of the liver in two planes

1 Coming from 4.1., reduce the magnification 2–3 steps (adjust for greater penetration depth).
2 Apply a thin oblique line of gel along the right costal arch.
3 Position the transducer in a right sagittal paramedian plane over the inferior vena cava and directly beneath the
right costal arch.
4 Shift the transducer to a parallel position 2–3 cm caudally, press it posteriorly, and angle it sharply cranially.
5 Have the patient breathe in deeply (a knee cushion will relax the anterior abdominal wall).
6 With the diaphragm visualized at the left edge of the image, slowly slide the transducer obliquely and laterally
along the right costal arch, ensuring good acoustic coupling at the cranial edge of the transducer (focal hepatic lesions?).
7 Adjust the zoom factor so that the hyperechoic border of the diaphragm is barely visible.
8 Shift the transducer to a parallel position as far as the right anterior axillary line. From here sweep laterally past
the border of the organ.
9 Let the patient take a few breaths. As you pause to let the patient breathe, take the transducer out of its cranial angulation.
10 After instructing the patient to breathe in, scan the caudal portions of the right hepatic lobe as far as the inferior
vena cava on the way back.
11 Finally, with the transducer now in the sagittal plane over the inferior vena cava, instruct the patient to continue breathing.
12 As you pause to let the patient breathe, place the transducer in an oblique subcostal plane parallel to the right costal arch.
13 Break the right (lateral) skin coupling; the lost coupling creates a shadow along the left side of the image
(everything is reversed).
14 Place the transducer at a very acute angle (shift your grip to withdraw the back of your hand), press it,
and direct the sound waves cranially.
15 After deep inspiration, slowly and continuously scan the right hepatic lobe craniocaudally, ...
16 ... scanning past the caudal border of the liver and back to the hepatic venous star.
17 There freeze the image, let the patient breathe, and measure the diameter of the peripheral hepatic veins distal
to the second venous confluence.
18 Then shift the transducer one transducer width laterally and caudally to a position parallel to the right costal arch.
19 Again press the transducer posteriorly, hold it at an acute angle, and, after the patient has inhaled deeply,
systematically scan the lateral portion of the right hepatic lobe for focal hepatic lesions.
20 Finally, let the patient breathe normally.

Lesson 5: Scanning of both kidneys in two planes

1 Place the transducer in the sagittal plane in the right midaxillary or anterior axillary line
(or left posterior axillary line) just below the right costal arch.
2 Break the skin coupling cranially; the lost coupling creates a shadow along the left side of the image (left = cranial).
3 Angle the transducer cranially so that the patient does not have to displace the kidney too far caudally by inhaling.
4 Instruct the patient to take a deep breath (pause briefly) and hold their breath.
5 Optimize the magnification and zoom factor to better detect focal kidney lesions.
6 Sweep the transducer lateromedially, possibly rotating it 5–15°clockwise until ...
7 ... the imaging plane is parallel to the longitudinal axis. Sweep past the borders of the organ.
8 As you pause to let the patient breathe, rotate the transducer 90° counterclockwise into the transverse plane.
9 After another deep breath, slowly and systematically scan the kidney craniocaudally past the lower pole
(note that medullary pyramids can be difficult to distinguish from focal kidney lesions).
10 As you pause to let the patient breathe, rotate the transducer 90° clockwise back into the longitudinal plane of the kidney.
11 After deep inspiration, sweep or rotate the transducer to visualize the true maximum longitudinal section of the kidney.
12 Freeze the image, let the patient breathe, and measure the kidney size and parenchyma to pelvis (PP) index.

Lesson 5: Complete scanning of the spleen

1 Place the transducer in the high plane of the left flank parallel to an intercostal space in the posterior axillary line.
2 Break the skin coupling cranially; the lost coupling creates a shadow along the left side of the image (left = cranial).
3 Use different intercostal windows and shift the transducer to different parallel positions until the spleen is
optimally visualized.
4 Optimize the zoom factor so that the immediate perisplenic region is barely visible.
5 To avoid interference from pulmonary air, have the patient inhale only slightly or perform the scan in expiration.
If necessary use the curtain trick with rapid expiration after inspiration.
6 It is possible to scan the entire spleen merely by sweeping through different intercostal windows.
7 As you do this, pay attention to the tail of the pancreas and possible accessory spleens.
8 Visualize the greatest diameter of the spleen with visible hilar vessels and freeze the image.
9 Let the patient breathe normally. Measure the craniocaudal size of the organ then measure the thickness at
the splenic hilum in a perpendicular plane.
 OBB-Querschnitte:
ExaminationPankreatitis
Algorithms 165
23

Lesson 6: Scanning of the entire thyroid gland using the thyroid preset with the patient's neck
slightly hyperextended
1 Instruct the patient to place the right hand on the left shoulder (to support the examiner's arm).
2 Place a linear transducer in the transverse left paramedian cervical plane, resting your forearm on the patient's forearm.
3 Break the medial skin coupling; the lost coupling creates a shadow along the left side of the image
(everything is reversed).
4 Set the magnification so that the thyroid gland appears as large as possible on the image without being truncated.
5 Use the Valsava maneuver to distend the internal jugular vein in order to clearly identify the vessels on the image.
6 Then slowly tilt the transducer cranial and, beginning to the thyroid gland, continuously scan it craniocaudally.
7 Visualize the greatest diameter of the left thyroid lobe by tilting or rotating the transducer and freeze the image.
8 Rotate the transducer 90° clockwise into the sagittal plane and break the skin coupling cranially (left = cranial?).
9 Slowly and continuously scan the thyroid lateromedially (focal thyroid lesions?).
10 Measure the longitudinal diameter and anteroposterior thickness of the left thyroid lobe and save the measurement image.
11 After saving the second image apply some acoustic gel to the transducer and spread it over the right cervical region.
12 In the right paramedian transverse plane now continuously scan the right thyroid lobe craniocaudally (focal lesions?).
Visualize the largest transverse diameter, freeze the image, and measure the diameter.
13 Repeat steps 8–11 for the right thyroid lobe and document all measured values.
14 In the median transverse plane slowly scan the thyroid isthmus craniocaudally (focal lesions?).

Lesson 7: Scanning of the urinary bladder in two planes

1 Place the transducer in the median sagittal suprapubic plane (breathing commands are not necessary
when scanning the lower abdomen).
2 Break the skin coupling cranially; the lost coupling creates a shadow along the left side of the image (left = cranial).
3 Angle the transducer caudally and ensure caudal acoustic coupling with the anterior abdominal skin.
4 Shift the transducer to a left lateral position and slowly scan the bladder, moving from a left perivesical
location through the median plane to a right perivesical location (focal or diffuse wall thickening? concretion?).
5 If only the cranial portions of the wall have been visualized in a full bladder, then scan the caudal portions on the
way back from right to left (Caution: pay attention to the zoom factor!).
6 In the median sagittal plane, visualize the maximum size of the bladder and then measure the craniocaudal
and anteroposterior diameter (not including the wall thickness). Document the measured image.
7 In female patients repeat the sagittal scan to visualize the uterus and cervix.
8 Rotate the transducer 90° counterclockwise into the suprapublic transverse plane.
9 Shift the transducer to a parallel position 3–5 cm cranially and scan the roof of the bladder craniocaudally, ...
10 ... scanning past the caudal border of the floor of the bladder (prostate, seminal vesicles, uterus?).
11 Sweep the transducer back to the largest diameter of the bladder and measure and document it.
12 In male patients scan and measure the prostate and seminal vesicles in two planes.

Lesson 8: FAST algorithm in emergency medicine

1 Position the transducer in the transverse plane in the epigastrium, place it at an acute cranial angle, and couple it.
2 On the respirator, press the "inspiration hold" key or ask the respirator operator to do so.
3 Reduce the magnification until the posterior wall of the pericardium is visualized at the lower edge of the image.
4 Scan the heart with a generous tilting motion and be alert to any epicardial rim of fluid.
5 Apply some acoustic gel to the transducer and spread it along the right anterior axillary line or midaxillary line
just beneath the ribs.
6 Place the transducer on the right anterior axillary line or midaxillary line and briefly break the skin
coupling cranially (for orientation).
7 Angle the transducer far cranially to visualize the pouch of Morison and costodiaphragmatic recess.
8 After adjusting the zoom, sweep lateromedially (free fluid or liver lacerations?).
9 Continue respiration, apply some acoustic gel, place the transducer on the left posterior axillary line
parallel to a caudal intercostal space, and couple it.
10 Break the skin coupling cranially; the lost coupling creates a shadow along the left side of the image (left = cranial).
11 Use different intercostal windows and shift the transducer to different parallel positions until the spleen
is optimally visualized.
12 Optimize the zoom factor so that the spleen, right kidney, and both pulmonary recesses are well visualized.
13 In expiration, scan the entire bed of the spleen (pouch of Koller, splenic rupture, hemothorax?).
14 Continue respirating the patient, apply acoustic gel, and place the transducer in the suprapubic median sagittal plane.
15 Briefly break the skin coupling cranially (orientation okay? left edge of image = cranial).
16 Angle the transducer caudally and then perform short bilateral paramedian sweeps (pouch of Douglas,
rectovesical pouch?).

Important note: These scanning algorithms merely represent an aid for systematic yet time-saving scanning of the re-
gions of interest mentioned. However, if you find any pathologic or focal lesions, they must be measured and documented
in two planes. Where indicated, additional examination steps must then be undertaken; for example, determination of the
perfusion pattern of a contrast agent over time (contrast-enhanced ultrasound) or similar methods.
166 References

[6.1] Bhatia CSS, Cho CCM, Yuen CYH et al. Realtime qualitative ultrasound elastography of cervical
lymph nodes in routine clinical practice: Interobserver agreement and correlation with
malignancy. Ultrasound in Med & Biol 2010 (36): 1990–1997

[7.1] Nyborg WL. Biological effects of ultrasound: Development of safety guidelines.

Part II: General review. Ultrasound in Med & Biol 2001 (27): 301–333

[8.1] Ligawi SS, Buckley AR. Focused abdominal US in patients with trauma.
Radiology. 2000 (217): 426–429

[8.2] Rose JS. Ultrasound in abdominal trauma.

Emerg Med Clin North AM. 2004 (22): 518–599

[8.3] Brooks A, Davies B, Smethhurst M, Connolly J. Prospective evaluation of

non-radiologist emergency abdominal ultrasound for haemoperitoneum.
Emerg Med J. 2004 (21): e5

[9.1] Libicher M, Tröger J: US measurement of the subarachnoid space in infants: normal values.
Radiology 1992 (184): 749–751

[9.2] Graf R. Sonografie der Säuglingshüfte und therapeutische Konsequenzen.

6th ed. Stuttgart: Thieme, 2010

[9.3] Dinkel E et al: Kidney size in childhood. Sonographical growth charts for kidney length and
volume. Pediatr Radiol 1985 (15): 38–43

[9.4] Weitzel D: Untersuchungen zur sonografischen Organometrie im Kindesalter, Mainz)

[9.5] Chudleigh P, Pearce JM: Obstetric ultrasound: how, why, and when.
Churchill Livingstone, Edinburgh 1992

[9.6] Hadlock FB et al: Sonographic estimation of fetal weight. The value of femur length
in addition to head and abdomen measurements. Radiology 1984 (150): 535–540
Legend of Numbered Structures

1 Skin 52 Blood clots, thrombus 108 Thigh

2 Fatty tissue 53 Fibrosis, partially calcified 109 Rib
(subcutaneous and peritoneal) 54 Mass (tumor or diverticulum) 110 Cerebellum
3 Rectus abdominis muscle 55 Lymph nodes or lymphoma 111 Arm and hand
4 Oblique muscles 56 Metastasis 112 Pelvis
5 Connective tissue, fascia, septa 57 Liquefaction (necrosis) 113 Spinal canal
6 Linea alba 58 Abscess, partially liquefied 114 Chambers of the heart
7 Ligamentum teres 59 Catheter, stent 115 Myocardium
8 Falciform ligament 60 Air inclusions in bile ducts 116 Intercostal muscles
9 Liver; 9a caudate lobe (biliary air) 117 Pectoralis and latissimus dorsi muscles
10 Hepatic vein 61 Hemangioma 118 Pulmonary atelectasis
11 Portal vein and its branches 62 Focal sparing in fatty infiltration (liver) 119 Pneumonia
11a Umbilical vein 63 Focal fatty infiltration (liver) 120 Hernia
12 Confluence of the portal vein 64 Cyst (fluid-filled) 121 Caudothalamic groove
(from 20 and 23) 65 Epithelial outgrowth (polyp) 122 Pouch of Douglas
13 Diaphragm 66 Common bile duct; 123 Subclavian artery
14 Gallbladder Hepatic duct a, cystic duct b 124 Third ventricle (CNS)
15 Abdominal aorta 67 Sludge (thickened bile) 125 Fourth ventricle (CNS)
16 Inferior vena cava 68 Free fluid in the abdomen (ascites) 126 Corpus callosum
16a Superior vena cava 69 Pleural effusion 127 Fornix
17 Superior mesenteric artery 70 Distal acoustic enhancement 128 Cavum of the septum pellucidum
18 Hepatic artery 71 Infarct 129 Thalamus
19 Splenic artery 72 Adenoma or angiomyolipoma 130 Cingulate gyrus
20 Splenic vein (benign thyroid and renal tumors) 131 White matter
21 Common iliac artery 21a external 73 Lymphocele 132 Gray matter (cortex)
iliac artery, 21b internal iliac artery. 74 Gastric and bowel wall: mucosa a 133 Cerebral sulci
22 Common iliac vein 22a external iliac muscularis mucosae b, submucosa c 134 Sylvian fissure
vein, 22b internal iliac vein tunica muscularis d, serosa e, 135 Anterior fontanel
23 Superior mesenteric vein diverticulum f 136 Superior sagittal sinus
24 a right, b left renal artery 75 Pancreatic duct 137 Internal capsule
25 a right, b left renal vein 76 Balloon of a urinary catheter 138 Caudate nucleus
26 Stomach (often contains air) 77 Bladder wall 139 Putamen and pallidum
27 Upper pole of kidney 78 Endometrium 140 Cerebrospinal fluid (CSF)
28 Lower pole of kidney 79 Pericardial effusion 141 Spinal cord
29 Renal parenchyma 80 Gallbladder wall 142 Conus medullaris
30 Medullary pyramids 81 Thyroid gland 81a Isthmus 143 Cauda equina
31 Renal caliceal system with pelvis 82 Carotid artery; internal 82a, 144 Foramen of Monro
32 Celiac trunk external 82b 145 Pons (CNS)
32a Left gastric artery 83 Internal jugular vein 146 Longitudinal fissure
33 Pancreas 84 Trachea 147 Sinocortical width of the
33a Head, 33b body, 33c tail 85 Sternocleidomastoid muscle subarachnoid space
34 Esophagus 86 Accessory spleen 148 Craniocortical width of
35 Vertebral body 87 Urinary obstruction the subarachnoid space
36 Intervertebral disk (in renal pelvis and calices) 149 Calices of the renal caliceal system
37 Spleen 88 Anterior scalene and longus 150 Ureter
38 Bladder colli muscles 151 Ureterocele
39 Uterus 89 Sternohyoid muscle 152 Urethra
40 Os of the cervix 90 Sternothyroid muscle 153 Femoral head
41 Vagina 91 Ovary 154 Autochtonous musculature
42 Prostate gland 92 Intrauterine device (IUD) of the back
42a Seminal vesicles 93 Follicle (in ovary) 155 Adrenal gland
43 Colon (often contains air) ascending a, 94 Placenta 156 Gluteus minimus muscle
transverse b, descending c, rectum d 95 Embryo or fetus 157 Gluteus medius muscle
44 Psoas major muscle 96 Umbilical cord with umbilical vessels 158 Acetabular labrum
45 Acoustic shadow behind air 97 Amniotic fluid 159 Cartilaginous convexity (hip)
(GI system, lung) 98 Testis 160 Bony acetabular roof
46 Small bowel 99 Epididymis 161 Ischium
(duodenum, jejunum, ileum) 100 Scrotum – layers of the wall 162 Ossification center of the femoral neck
47 Lung, air-filled or, 101 Pleural border 163 Joint capsule
see 45, intestinal gas 102 Pneumothorax 164 Triradiate cartilage of the acetabulum
48 Pubic bone 103 Lateral ventricle (CNS); 165 Capitis femoris ligament
49 Stone, concretion, calcific plaque temporal horn a, occipital b, central c 166 Capital femoral epiphysis
50 Hematoma 104 Choroid plexus 167 Femoral metaphysis
(solid and liquid components) 105 Skull 168 Joint cavity or fracture line
51 Artifacts: reverberation a 106 Central echo of the falx cerebri 169 Vagus nerve
section thickness b, side-lobe c 107 Femur 170 Gestational sac (amnion)
Table of Normal Values for Adults

The normal values specified on this page are subject to
variation within and among individuals and therefore re-
present only approximate values for adult patients from
a Caucasian population. These guideline values repre-
sent mean values from the literature and refer to mea-
surements in the standard planes discussed previously.
The values for the vascular structures are specified as the
respective inner diameters of the vascular lumens
without regard to the wall, whose thickness can vary
between individuals.
You will find the normal values for pediatrics on pages
124, 135, 137, 138, and 141 as well as on the pocket-
size cards.

Diameter of superior mesenteric artery < 0.5 cm Lymph node Longitudinal diameter divided by transverse
Abdominal aorta Diameter: diameter: > 2.0 (1.0 = round, suspicious)
< 2.5 cm (suprarenal) Hilum fat sign (Benignity criterion)
< 2.0 cm (infrarenal)
Spleen Organ size:
2.5–3.0 cm = ectasia
< 11.0 cm
> 3.0 cm = aneurysm (from upper to lower pole)
Angle between aorta and SMA < 30 ° < 4.0 cm
Distance between aorta and lumbar vertebra < 0.5 cm (thickness > 6 cm suggests lymphoma)

Appendix Transverse diameter: ≤ 6 mm Adrenal gland Maximum thickness:

Wall thickness: ≤ 2 mm < 1.0 cm

Gallbladder Wall thickness: Kidney Maximum size, respiratory mobility:

< 0.3 cm preprandial 10.0–12.0 cm longitudinal diameter
< 0.5 cm postprandial 4.0–6.0 cm transverse diameter
Maximum size of gallbladder: 3.0–7.0 cm respiratory mobility
< 11.0 x 4.0 cm (longitudinal x transverse) 1.3–2.5 cm width of parenchyma
Parenchyma to pelvis (PP) index:
Biliary tract Common bile duct: > 1.6 : 1 (under 30 years)
> 0.6 cm or 1.2–1.6 : 1 (31–60 years)
< 0.9 cm postcholecystectomy 1.1 : 1 (over 60 years)
Intrahepatic bile ducts:
Pancreas Maximum diameter:
< 0.4 cm
< 3.0 cm (head)
Gynecology Uterus (nulliparous): < 2.0 cm (body)
5.0–8.0 cm length < 2.5 cm (tail)
1.5–3.0 cm thickness < 0.2 cm (pancreatic duct)
Endometrium (double thickness):
Prostate gland Maximum size:
< 1.5 cm (premenopausal)
< 5.0 cm (transverse)
< 0.6 cm (postmenopausal)
IUD-fundus distance: < 3.0 cm (sagittal and craniocaudal)
< 2.0 cm (greater = dislodged) Thyroid gland Maximum size:
IUD-endometrium distance: 4.0–7.0 cm (craniocaudal)
< 0.5 cm 1.0–3.0 cm (transverse)
1.0–2.5 cm (sagittal)
Ovary Volume:
Volume (both lobes together):
5.5–10.0 cm3/ovary premenopausal
< 18 mL (women)
2.5–3.5 cm3/ovary postmenopausal
Yolk sac: 0.3–0.5 cm < 25 mL (men)
Fetal cervical subcutis thickness Inferior vena cava Diameter:
(between 10th and 14th weeks of < 2.0 (< 2.5 cm in young athletes)
pregnancy): < 1/3 of original lumen
< 0.3 cm (greater: neck edema) on forced inspiration
Bladder Wall thickness: Splenic vein Diameter:
< 0.4 cm (filled bladder) < 1.0 cm
< 0.8 cm (postvoiding) (> 1.2 cm c suggests portal hypertension)
Residual bladder volume:
< 50 ml Portal vein Diameter:
Volume: < 1.3 cm normal
< 550 ml (women) 1.3–1.5 cm gray area
< 750 ml (men) > 1.5 cm c suggests portal hypertension
Liver Sagittal size in right midclavicular line: Hepatic veins Diameter:
< 13.0–15.0 cm ≤ 0.6 cm (distal peripheral portions)
Lateral angle: ≥ 0.7 cm c suggests right heart failure
< 30° (left lateral margin) Volume formula 0.5 x A x B x C (simplified)
< 45° (right caudal lobe)