The Most Important Sonographic Sections of the Abdomen: (UA = upper abdomen; LA = lower abdomen; RUQ ight upper quadrant of the abdomen; LQ = left lower quadrant of the abdomen; MCL = medioclavicular line) IN 8 UA, longitudinal (sagittal) ase ae LLQ, para-iliac oblique Ne Ge UA, transverse section ‘section ‘section \ Y | RUG, oblique section ( extended intercostal orientation) 7 RUQ, oblique section Y RUG, sagittal section along the MCL SX Y Right intercostal flank section in left lateral decubitus position TA i Left intercostal flank section in right lateral decubitus position fay / Left high flank section in right lateral decubitus position Par ara LUQ, transverse section DANG A LA, suprapubic transverse ee ¢ LA, suprapubic Try to think which organs appear in which sonographic sections. The solutions can be found overleaf.Sect Bee eee The most important organs and vessels that are various standard sonographic sections are listed dition to remembering the corresponding body landmarks, should be closely scrutinized using sweey the names of the sonographic sections should be ns with Corresponi fireman seen in the (UA = upper abdomen; MA = mid-abdomen; MCL = mid: here. In ad- _clavicular line; LA = lower abdomen). Each imaging plane ing motions of the memorized transducer. Sagittal section of the UA (median). Aorta (left paramedian), inferior vena cava (right), liver (left hepatic lobe and caudate lobe), stomach, body of the pancreas, portal vein (confluens), celiac axis, superior mesenteric artery (SMA) and vein, linea alba and liga- ‘mentum teres (median), rectus muscle and rectus sheath (paramedian), vertebral body and intervertebral disks (dorsal). 2. Oblique section of the LA (par ‘Small intestine, iliac vessels, sig ies, urinary bladder. 101d colon, iliopsoas muscle, possibly ovar- 3 Transverse section of the UA. Aorta, inferior vena cava, celiac axis liver, stomach, duodenum, pancreas (entire length), linea alba and ligamentum teres (median), splenic artery and vein, portal vein, hepatic artery, superior and inferior mesenteric ar- teries and veins, renal arteries and veins, bile duct, lesser sac (between stomach and pancreas). 4. Right oblique section of the UA (extended intercostal section Porta hepatis with hepatic artery, bile duct and portal vein, liver, gallblad- der, duodenum, pancreatic head, possibly stomach (antral and pyloric re- ion), inferior vena cava, aorta, vertebral column, 5 Right subcostal section. Hepatic vein confluence, inferior vena cava, li vertebral column, diaphragm. cr, gallbladder, duodenum, 6 Sagittal section along right MCL. Liver (for measurements), gallbladder, duodenum, diaphragm (possible pleural effusion, ascites), right colonic flexure, small intestine, portion of, the kidneys.0 u 2 Intercostal section of the right flank in the left lateral decubitus position. Right kidney, right adrenal gland, right renal hilum, liver (inferior por- tion), ascending colon, diaphragm, lung: right costophrenic angle. Intercostal section of the left flank in the right lateral decubitus position. Lett kidney, let adrenal gland, left renal hilum, spleen (inferior portion) descending colon, diaphragm, lung: left costophrenic angle. High intercostal section of the left flank in the right lateral decubitus pos tion, Spleen (for measurements), left hepatic flexure, pancreatic tail and splenic hilum, diaphragm, left adrenal gland, lung: left costophrenic angle. ‘Transverse section of the MA left. Jejunum, aorta, vertebral column, transverse and descending colon, upper portion of the left kidney, left adrenal gland. ‘Transverse suprapubic section of the LA (tilted inferiorly). Rectus muscles, urinary bladder; if the urinary bladder is filed: iac vessels, uterus, ovaries, prostate gland, ileum, rectum. Sagittal suprapubic section (tilted inferiorly). Linea alba, urinary bladder; if the bladder is filled: iliac vessels, uterus, ovaries, prostate gland, ileum, rectum.Ultrasound Teaching Manual The Basics of Performing and Interpreting Ultrasound Scans Matthias Hofer, M.D. With the collaboration of Tatjana Reihs, M.D Translated by Peter F. Winter, M.D. 486 Illustrations Thieme Stuttgart - New York 1999Matthias Hofer, M.D. Institute for Diagnostic Radiology (Chairman; Prof. U. Médder, M.D.) H, Heine University Dusseldorf, Germany Tatjana Reis, M.D, Department of Obstetrics and Gynecology H, Heine University Diisseldor, Germany ‘Translated by Peter F. Winter, M.D. CChlinical Professor of Radiology Boston University School of Medicine, Clinical Assistant Professor University of Illinois College of Medicine at Peoria USA Library of Congress Cataloging-in-Publication Data Hofer, Matthias, [Sono Grundkurs English) Ultrasound Teaching Manual, The Basics of Performing and In- terpreting Ultrasound Scans / Matthias Hofer: translated by Peter E, Winter, pom, Rev, translation of: Sono Grundkurs. 1997, Includes bibliographical references and index. ISBN 3-13-11 1041-4, — ISBN 0-86577-725-X (TNY) 1. Diagnosis. Ultrasonic. 1. Tite [DNLM: 1. Ultrasonography, WN 208 H697s 1999] RC78.7.U4H6413 1999 616.07°543—de2! DNLMIDLC {or Library of Congress 9845748, cP ‘Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary ‘names even though specific reference to this fact is mot always made in the text. Therefore, the appearance of a name without designa tion as proprietary isnot to be construed as a representation by the publisher that it isin the public domain, ‘This book, including all parts thereof, is legally protected by copy right. Any use, exploitation or commercialization outside the nar- ow limits set by copyright legislation, without the publisher's con- sent, illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage © 1999 Georg Thieme Verlag. RudigerstraBe 14, D-70469 Stuttgart, Germany ‘Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA, ‘Typesetting by primustype R. Hurler GmbH, D-73274 Notzingen typeset on Textline/HerenlesPro Printed in Germany by Druckhaus Gotz, Ludwigsburg ISBN 3-13-111041-4 (GTV) ISBN 0-86577-725-X (TNY) 123456 List of Abbreviations AC Abdominal circumference ASD Atrial septal defect BPD _Biparietal diameter RL Crown-rump length CT Computed tomography do Diameter of the aorta dye Diameter of the inferior vena cava EFW Estimated fetal weight EP Ectopic pregnancy ERCP Endoscopic retrograde i ESWL Extracorporeal shock wave lithotripsy FHVI Frontal horn ventricular index FL Femoral length : ENH Focal nodular hyperplasia GI Gastrointestinal tract GSD_ Gestational sac (= chorionic cavity) diameter HC Head circumference HCG Human chorionic gonadotropin IUD Intrauterine device IVE In vitro fertilization MCL Midclavicular line MRI Magnetic resonance imaging NPO Nothing by mouth ‘Nuchal translucency Occipitofrontal diameter (Occipital horn ventricular index Polycystic ovarian syndrome Pulsed wave Doppler RI Resistance index Systemic lupus erythematosus Superior mesenteric artery Status post ‘Transposition of the great arteries ‘Volume of the urinary bladder Ventricular septal defect Yolk sac diameter orp. OHV SMA sip TGA Vols sD Important Note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and dmug therapy, Insofar as this book mentions any dosage or application, readers may rest assured that the authors, ‘editors, and publishers have made every effort to ensure that ‘such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any uarantee or responsibility on the part of the publishers in re spect of any dosage instructions and forms of application stated in the book, Eyery user is requested to examine carefully the ‘manufacturer's leaflets accompanying each drug and to check. if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindieations stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly re- leased on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsi bility. The authors and publishers request every user to report t0 the publishers any discrepancies or inaccuracies noticed.Lee hiceakst ‘The increasing role that imaging procedures have assumed in the clinical routine must be considered at an early stage in the education of medical students. The vast use and non- invasive character of sonography make it prudent to famili- arize tomorrow's physicians today with this comparatively low-risk technology. ‘The pilot project on medical didactics that began in Dls- seldorf in 1992 consisted of preliminary lessons in sonogra- phy for a few medical students particularly interested in sonography and endoscopy. Soon, the hands-on instructions in small groups became more and more accepted and this teaching concept could be enlarged and improved, Under the guidance of residents and lecturers, student in- structors relate the sonographic diagnostic to their junior stu- dents. The participants examine each other and systemati- cally learn the anatomic relationship of the abdominal organs as seen in the standard sonographic sections. Step by step, they learn how to use and handle the transducer. These hhands-on instructions are accompanied by complementary lectures, which address the subject of differential diagnosis of the pathologic changes by means of videos, slides, and live demonstrations. ‘The workbook presented here is largely based on the cur- riculum of this introductory sonography course for begin- ners. The approach selected here considers in particular the difficulties generally encountered by the novice. By relying ‘on the step-by-step process of the workbook, the novice will soon realize that initial frustration (“I only see a snow storm”) will soon give way to increasing enthusiasm for this elegant modality. It should be pointed out, however, that each sonographic diagnosis can only be as good as the examiner. False diag- noses can only be avoided through profound anatomic and sonomorphologic knowledge, unrelenting thoroughness, and, where appropriate, comparison with other imaging pro. cedures. Initial successes (“T now recognize all parenchymal organs”) should not lead to overconfidence during the learn- ing phase; a truly profound knowledge can only be gained through long exposure in the clinical setting and the resultant practical experience that leads to the familiarization of the diverse anatomic variations and pathologie changes. This workbook, of course, cannot encompass all aspects of diagnostic sonography and this is not its goal. Instead, it should offer the reader an optimal introduction to sonogra- phy, The spectrum of the information presented and the pathologic examples are especially targeted at the beginner. ‘The carefully prepared didactic presentation, which reflects the author's teaching experience over many years, will hope- fully motivate or perhaps even excite many students. Disseldorf Ulrich Modder, M.D. Direcior, Institute of Diagnostic Radiology Heinrich-Heine-University, Dusseldort GermanyPitan reek nee This workbook is primarily for medical students, technicians, and residents that have had no or little exposure to sonogra: phy and wish to learn this technique systematically. The first step is recognizing the normal anatomic structures. Each section therefore begins with the anatomic orienta- tion of the respective body region (where is the top of the image?) before presenting and commenting on a selection of the most common diseases Before reading the individual sections, the mat pages 6 to 10 should be studied to learn the basics before the hands-on practice. Thereafter, it is advisable to make a draw. ing of the body planes as seen in typical longitudinal (sagit- tal) as well as in typical cross (transverse) sections, for ample on a cone coffee filter. The shape of the cone cofiee fil ter corresponds to the shape of the sonographic image for the examination of the abdomen. [At this stage the reader can already experience the grati- faction of successful learning. The correct answer should not be passively copied from page 78. Instead, the anterior and dorsal structures as well as the superior and inferior struc tures, as seen on the Sagittal section and viewed from the patient’s right side, should be deduced. The cone coffee filter should be placed on the abdomen and oriented along the plane of the sonographic beam of a transducer (convex border of the cone coffee filter) placed on the epi gastric region along the midline (linea alba, between both rectus muscles) (Fig. 4.1 a). Next, anterior and dorsal structures as well as right and left structures should be marked on the reverse of the cone coffee filter as seen on the cross-sectional (transverse) sono- graphic image viewed from below (!) (Fig. 4.1b). Only after mastering the spatial orientation is the reader prepared for studying the normal findings as seen in the standard planes and, thereafter, the diffuse and focal abnormalities of the in- dividual organs. An explanatory diagram, intentionally annotated with numbers only, is placed adjacent to cach sonographic image, facilitating the interpretation of the sonographic image with the help of numbers incorporated in the accompanying text. To confirm the interpretation after the text has been studied, the back cover can be opened to use the key found on the un folded cover page. By blocking the labels, itis easy to check whether all structures have been correctly identified. The ‘numbers of the labels apply to all the diagrams in this work- book If the thirst for knowledge has not yet been quenched, the quiz found at the end of each section can be tackled. The im- in the quiz should be identified as to sectional orienta- tion and visualized structures, and, if possible, a differential diagnosis provided. Only afterwards should the answers on pages 76 and 77 be consulted since the suspense is prema- turely lost otherwise. The quiz may possibly arouse diagnos. tic inquisitiveness and lead to a first feeling of achievement through an imaging procedure, Whenever these practical ap- plications do not readily lend a mental concept of the imag: ing plane in question or the reader is confronted with other discouraging events, help may be found on pages 78 and 79.Image Formation and Echogenicity ‘Operating Sonographic Equipment Sonographic Equipment and Selection of the Appropriate Transducer Artifacts Sagittal Ov Upper Retroperitoneu Lower Retroperitoneum in Oblique Sections: Normal Findings Aortic Ectasia and Aneurysms Retroperitoneum: Lymph Nodes Retroperitoneum: Other Clinical Cases Upper Abdomen: Basic Anatomy Upper Abdomen: Normal Findings Upper Abdomen: Pancreatitis Pancreas: Additional Cases Upper Abdomen: Lymph Nodes Quiz for Self-Assessment TG Porta Hepatis: Normal Findings Portal Hypertension: Lymph Nodes Hepatic Vein Confluence and Hepatic Congestion Hepatic Size, Gallbladder, Normal Findings Normal Variants, Fatty Liver Focal Fatty Infiltration Other Focal Changes Infections, Parasite Cirrhosis and Hepatocellular Carcinoma Hepatic Metastases Quiz for Self-Assessment 4 Gallbladder and Biliary Ducts Cholestasis Gallstones and Polys Cholecystitis and Quiz for Self-Assessment SENET Normal Findings Normal Variants and Cysts Atrophy and Inflammation Urinary Obstruction Differential Diagnosis of Urinary Obstruction Renal Stones and infarcts Renal Tumors : Renal Transplant: Normal Findings Renal Transplant Quiz for Self-Assessment 12 13 14 15, 7 18 19 20 22 37 38 39) 40 41 42 43 45 46 Normal Findings Diffuse Splenomegaly Focal Splenic Changes, Quiz for Self-Assessment Stomach Colon ‘Small Bowel 8 Urinary Bladder Normal Findings, Volume Measurements Indwelling Catheter, Cystitis, Sediment EEX En Prostate Gland, Testicles and Scrotum Undescended Testicle, Orchitis/Epididymitis Sern Normal Findings Uterus ‘Tumors of the Uterus Ovaries Diagnosis of Early Pregnancy Biometry in the First Trimester Biometry in the Second and Third Trimester Placental Location and Fetal Gender Diagnosis of Fetal Malformations Quiz for Self-Assessment ERIKS Normal Findings, Diffuse and Focal Changes, Solutions to the Quiz Tips and Tricks for the Beginner Acknowledgement On the fold-out covers: Front: Standard Sonographic Sections Rear Index Key to Diagrams Normal Measurements a7 43, 49 50 51 52 54 55 56 57 58 60 61 63 ea 6 67 B 74, 75 76 78Image Formation and Echogenicity ‘The sonographic image begins with mechanical oscillations of a crystal that has been excited by electrical pulses (piezoelectric effect). ‘These oscillations are emitted as sound waves from the crystals (dark blue arrows) just as sound waves are emitted from a loudspeaker membrane 1), though the frequencies used in sonography are not audible to the human ear. Depending on the desired applica- the sonographic frequencies range from 2.0 to approxi- mately 15.0 MHz. Several crystals are assembled to form a transducer from which sound waves propagate through the tissues, tobe reflected and returned as echoes (ight blue a. A A cy aa Tans Trans: vid Soest skin | —} cat — w 2 . K | Interface _|| ‘ i A 2 Intertace to 8 2 | tntetaca e Fig. 61a b An echo reflected repeatedly back and forth (Fig. 6.2) before it returns to the transducer has a travel time that is no longer proportionate to the distance of its origin. The proces- sor incorrectly assigns these reverberation echoes ($1) to a deeper level (Fig. 10-1), Additional distortion occurs through propa errors introduced by programn the assumption that the prop: jon speed the processor based on ation speed of sound in tissue is constant, whereas in actual fact itis different for each type of tissue. While sound travels through the liver with a speed sen cal | tnrtaco © rows) to the transducer. The returning echoes are, in reverse, converted by the crystals into electrical pulses that are then used to compute the sonographic image. ‘The sound waves are reflected at the interfaces (A, B, C) between media of different acoustic density (ic., different sound propagation). The reflection of the sound waves is Proportionate to the difference in acoustic density: mod- crate difference (interface A in Fig. 6.1 a) will reflect and re- tum a portion of the sound beam to the transducer, with the remaining sound waves to be transmitted and propagated further into deeper tissue layers. If the difference in acoustic density increases (interface B in Fig.6.1b), the intensity of the reflected sound also in- ‘teases, and that of the transmitted sound decreases propor: tionately. If the acoustic densities are vastly different (inter- c B in Fig. 6.1), the sound beam is completely reflected and total acoustic shadowing (48) results (total reflection) Acoustic shadowing is observed behind bone (ribs), stones (in kidneys or the gallbladder), and air (intestinal gas) Figure 6.3 illustrates acoustic shadowing (48) behind an air-containing bowel loop (46). Echoes are not elicited if no differences in acoustic density are encountered: homo= ‘geneous fluids (blood, bile, urine, and eyst content, but also ascites and pleural effusion) are seen as echo-free (black) structures, €,, the gallbladder (14) and hepatic vessels (10, 11) in Figure 6.3 ‘The processor computes the depth from which the echo originated from the registered temporal difference between ‘mission of the sound beam pulse and reception of the echo. Echoes from tissues close to the transducer (A) arrive earlier (ty) than echoes from deeper tissues (tgs te) (Fig. 6.1). of about 1570 misc, it travels through fat with a lower speed of 1476 msec. The assumed medium speed stored in the pro- cessor leads to small differences but no major distortion, If the propagation speed of adjacent tissue is vastly dffer- ent (bone: 3360 m/sec vs. air: 331 misee), total reflection takes place (Fig. 6.1b along interface 1) and acoustic shadowing ensues (45). For this reason a coupling gel is, needed to assure direct contact between transducer and sk with no air trapped in between.rene ees rt ‘The steps relevant for operating a sonographic unit are intro- duced here by means of a medium-sized unit (Toshiba). First, the patient's name has to be entered correctly (A, B) for proper identification. The keys for changing the program (C) or transducer (D) are found on the upper half of the control panel. (On most panels the freeze button (B) is in the right lower ‘comer. When activated, this will prevent the real-time im- ages from changing. We recommend having one finger of the Jeft hand always resting on this button, thus minimizing any delay in freezing the desired image for measuring, annotat- ing, or printing. The overall amplification of the received echoes is controlled by the gain knob (F). A Begin with a new patient B Enter name (ID) C Menu selection, ¢.g., abdomen, thyroid gland D Change of transducer E Freeze F Gain G Depth gain compensation (DGC) H Image depth/field of view 1. Trackball for positioning the dot or range markers J. Measurements K Annotation L. Body marker M Image recording Notes Depth gain compensation: For selective enhancement of echoes received from different depths, the amplication can also be selectively adjusted with slide-pots (G) to compen- sate for depth-related losses in signal. Moving the image depth up or down, usually in small increments, increases or deceases the field of view (I). A “trackball” (I) places the dot ‘or range markers (calipers) anywhere on the display. In general, this must be preceded by activating the measure- ment mode or annotation mode. To facilitate the review by ‘others, the appropriate body marker (L.) should be selected and the position of the transducer marked by the trackball (I) before the image is printed (M). The remaining functions are less relevant and can he learned by working with the unit. rater 5) =) 3) IPie ds eee ee mee een Sonographic units used today can be operated with different types of transducers (see below) and are mobile for use in the sonography suite as well as in the intensive care unit or emer- gency room (Fig. 8.1). The transducers are generally stored ‘on the storage shelf on the right side of the unit. Precautions should be taken when moving the sonographic unit. Avoid having a dangling transducer cable being caught ‘on a door knob, stretcher, ete., and do not drop a transducer ‘on the floor. Replacing a damaged transducer can be quite expensive! For the same reason, the transducer should never be left unattended on the patient's abdomen when the exami- nation is interrupted, for instance by a phone call. Further- more, the transducer should be placed upside down to hang. with the cable straightened and not pinched or kinked where it enters the transducer (danger of breaking the wites in the cable). Selection of the appropriate transducer: Of the many types of transducers only the appli three most important ones will be described here, jons of the The linear array transducer emits sound waves parallel to each other and produces a rectangular image. The width of the image and the number of scan lines are constant at all tissue levels (Fig. 8.2, center). An advantage of the linear array transducers is good near-field resolution. They are pri- marily used with high frequencies (5.0-7.5 MHz) for evaluat ing soft tissues and the thyroid gland. The disadvantage of these transducers is their large contact surface, leading to ar- tifacts when applied to a curved body contour due to air gaps between the skin and transducer. Furthermore, acoustic Fig. 8.1 Sector (phased array) shadowing (45) as caused by ribs can deteriorate the image (Fig. 8.2). In general, linear array transducers are not sui- table for visualizing organs in the thorax or upper abdomen. A Sector transducer produces a fan-like image that is nar- row near the transducer and increases in width with deeper penetration (Fig. 8.2, left). This diverging propagation of sound can be achieved by moving the piezo elements me- chanically. This is the less expensive solution but has the in- herent risk of wear and tear. The electronic version (phased array) is more expensive but has become established pri- marily in cardiology with frequencies of 2.0-3.0 MH. The in- terference of the sound-reflecting ribs can be avoided by ap- plying the transducer to the intercostal space and by taking. advantage of the beam’s divergency to a 60"- or 90°-sector with increasing depth (Fig, 8.2). The disadvantages of these lypes of transducer are poor near-field resolution, a decreas- ing number of scan lines with depth (spatial resolution), and handling difficulties (Curved or convex array transducers are predominantly used in abdominal sonography with frequencies from 2.5 MHz (obese patients) to 5.0 MHz (slim patients), with the ‘mean value around 3.5-3.75 MHz. AS a compromise of both preceding types, it offers a wide near and far zone and is, handled easier than a sector scan, However, the density of the scan lines decreases with increasing distance from the transducer (Fig. 82, right). When scanning the upper abdom- inal organs, the transducer has to be carefully manipulated to avoid acoustic shadowing (45) of the lower ribs. Linear Convex (curved array) 7.5 MHz |tees Cognizance of the physical properties of sound that can mimic pathologic findings is mandatory for the correct inter- pretation of a sonographic image. The most important arti- facts include so-called distal shadowing. An acoustic shadow (AS) appears as a zone of reduced echogenicity (hypoechoic black) and is found behind a strongly reflecting ning bone. Thus 's in the upper impeded by overlying ribs, and those of the lower pelvis by or anechoic structure, such as calcium-cont he visual zation of softtisue structa abdomen is the pubic symphysis. Ths effect, however, can be exploited to reveal calcific gallstones (49) (Fig, 9.2), renal stones (49) . 42.1, 42.2), and atherosclerotic plaques (49) (Fig. 9.3). Similar shadowing can be caused by ar in the lungs or in nal tract, Evaluating structures behind aircontaining bowel loops (46) is often precluded by acoustic shadowing (48) or echogenic comet-tal artifacts (Figs. 9.2-9.4), esti The ‘air artifacts interfere primarily with the evaluation of retroperitoneal organs (pancreas, kidneys, and lymph nodes) behind air-containing stomach or bowel, Adequate visualiza- is still possible by following scribed on page 79, he approach de- Another characteristic finding is the so-called edge shadowing (48) behind cysts (64), principally occurring be hind all round cavities that are tangentially hit by sound 1.1), Edge shadowing is caused by scattering and refraction and can be seen behind the gallbladder (14). Figure 9.4 requires careful analysis to attribute the acoustic shadow (48) to edge shadowing caused by the gallbladder rather than falsely attribute it to focal sparing tion (62) in the liver (9). atty infiltra Relative whi mogencous fluid. Because of decre distal acoustie ‘Enhancement (70) is found fever sound waves travel for some distance through ho: .ed reflection in fluid, the sound waves attenuate less and are of higher amplitude distally in comparison with adjacent sound waves. This pro. duces increased echogenicity that is scen as a bright band (70) behind the gallbladder (14) (Fig. 9.4), behind the urinary bladder (38) (Figs. 10.1-10.3), or even behind major vessels such as the sorta (15) (Fig. 9.3), This Transducer physical phe ated to the true characteristics of the underly issue. The acoustic enhancement, however, can be applied to dis: inguish renal or from hypoechoic Fig. 9.2, b Fig. 9.3, b 9.4a,b10 Not all echoes that originate at an acoustic interface return to the transducer without further reflection. If several strongly eflecting boundaries are encountered, the sound waves can be reflected back and forth before they eventually return as echo to the transducer. The resultant delay in registering these echoes leads to reverberation echoes (51). These re- verberation echoes project as several parallel lines in the anterior aspect (near the transducer) of the urinary bladder (Figs. 10.1 and 10.2) or gallbladder (Fig. 34.3), since the pro- cessor calculates the site of the reflection solely from the r istered time that has elapsed between emission and recording of the sound pulse by the transducer. Seetion-thickness artifacts (51) (Fig. 10.2) are caused when the boundary between the wall of a cyst, gallbladder, or urinary bladder (77) and the containing fluid is not perpen: dicular to the interrogating sound beam. The echoes within the returning beam include echoes from liquid as well as from solid structures and are averaged by the processor. Consequently, the boundary between solid tissue and fluid is seen as a low echogenic and indistinct structure. Sectior thickness artifacts can occasionally mimic sludge or layered ‘material (concrements, blood clots) ($2) in the urinary blad der (38) (Fig. 10.3), Strongly reflecting interfaces can cause a scattered reflee- tion of the echoes, spuriously displacing the acoustic inter laterally as a so-called afch artifact. For instance, the duodenal wall occasionally projects in the lumen of the face neighboring gallbladder, or an air-containing bowel loop can be seen within the urinary bladder (Fig. 57.4). Finally, mirror artifacts are primarily produced by the diaphragm and visceral pleura, causing intrahepatic structures to be seen as a mirage on the (Fig. 27.2). pulmonary side of the diaphragm Fig. 10.3a Sagittal Overview Did you already mark a cone coffee filter with the location of the Structures visualized on sagittal sections, as described on page 4? If not, please do so and compare your drawings with the results on page 78. Only thereafter should you proceed, The transducer should be perpendicularly placed on the epigastric region along the linea alba and the sound beam swept through the upper abdomen in a fan-like fashion 11.1), For the time being, it should suffice to memorize the appearance of the normal anatomy. With the transducer inclined to the patient's right side (Fig. 11.2), aorta (15), celiac axis (32), and superior mesenteric artery (SMA) (17) are found paravertebrally on the left and dorsal to the liver (9), Normally, all major vessels are hypoechoic (dark) or echoic (black) Fig. 1.2a Fig. 11.36 Upper Retroperitoneum The image displays the superiorly located diaphragm (13) on the left and the more inferiorly located panereas (33) and confluens (12) of the portal vein (11) on the right. The hypo. echoic extensions of the diaphragm (the crura) (13) and the gastroesophageal junction (34) are shown anterior to the aorta and immediately below the diaphragm. It is important to note where the left renal vein (25) crosses the aorta to reach the right-sided inferior vena cava. It travels through the narrow space between aorta and SMA, immedi ately caudal to the aortic origin of the SMA. If not well de- ‘monstrated, the uninitiated examiner might mistake this ves. sel for a hypoechoic lymph node. Comparison with the trans. verse section at the same level clarifies this finding further (Fig. 18.3). diaphragmatic Now the transducer is inclined to the patient's left side (Fig. 11.3) for the visualization of the right paravertebrally situated inferior vena cava (16), including its continuation into the right atrium, At the same level, the hepatic veins (10) can be distinguished from intrahepatic branches of the portal vein (11) The presence of air prevents evaluation of the lungs (47). The diameter of the inferior vena cava should not exceed 2.0 em or, in young athletes, 2.5 em. The maximum diameter of 2.5 em also applies to the aortic lumen at this level. The luminal diameter is always measured perpendicular to the al axis. The dao = 1.8 em and dye = 2.3 em im the cases illustrated here (Figs. 11.2, 11.3) are within the normal range 2ci | Sagittal Overview After the upper retroperitoneum has been scanned, the transducer is moved inferiorly (arrow) along the aorta and inferior vena cava (Fig. 12.1). While the transducer is being moved, the vascular lumina should be visualized and eval- uated and the perivascular spaces searched for space-occupy ing lesions. Preferably, the examination should be biplanar by adding transverse sections (see pp. 17 and 18). Enlarged a Fig. 12.1 The confluence of the external (22) and internal (23) iliac veins is a frequent site for regional nodal enlargement (Fig, 12.2), The iliac artery (21) is anterior (ic the im .e) to the vein, In unclear cases, the compression test can differentiate these structures, with the vein as a low pres: Lower Peritoneum in Oblique Sections: Normal Findings lymph nodes a eristically visualized as ovoid to lobulated space-occupying lesions with a hypoechoic pattern (see pp. 14 and 21). Distal to the aortic bifurcation, the branching iliac vessels are delineated and evaluated in two planes by sweeping the sound beam parallel (Fig. 12.1b) and perpendicular (Fig. 12.1¢) to the longitudinal vascular axis. Fig. 12.1¢ sure system showing easy compressibility. On transverse sec- tion (Fig. 12.3), the iliac vessels can be easily distinguished from hypoechoic fluid-filled intestinal loops (46) by the peri stalsis of the intestinal wall Fig. 12.2a Fig. 12.2b Fig. 12.3 Fig. 12.2¢ Fig. 12.3¢| Sagittal Overview Localized dilatations of the vascular lumen are generally caused by atherosclerotic lesions and local weakening of the arterial wall, They are rarely posttraumatic, A dilatation of upto ed to as /estasia and can be found in addi- tion to an aneurysm (Fig. 13.1) The dilatation can be fusiform or saccular. It can be com: plicated by dissection of the arterial wall (disseeting aneurysm) or circumferential intraluminal clot formation (52) with possible peripheral emboli, Risk factors for rupture of an aortic aneurysm are a diameter of greater than 6 em, an excentric lumen, and diverticulum-like bulging of the aortic wall. As general rule, the risk of a rupture increases with the Checklist Aortic Aneurysm: Normal lumen: suprarenal <2.5 em ¢ Ectasia: 2.5-3.0.em Aneurysm: > 3em Risk of rupture increased by: progressing dilatation diameter > 6cm excentric lumen saccular dilatation (instead of fusiform dilatation) Fig. 13.34 Fig. 13.3b Aortic Ectasia and Aneurysms size of the aneurysm and patients with an aortic aneurysm ex ceeding Sem in diameter should be assessed clinically for surgical repair. If an aneurysm is detected, the sonographic examination should report its maximal length (Fig. 13.2) (Fig. 13.3) as well as any detected thrombi (52) and possible involvement of the re aorticanéurysmis are infrarenal, their exact extent should be established before surgical intervention. bleeding primarily occurs into the retroperitoneum but can extend into the and iliac arteries. Though most Any aneurysmal ritoneal cavity in the presence of high pres.| sagittal Overview Lymph nodes (85) are generally hypoechoic and must be differentiated from fluid-filled bowel loops (46) by absent peristalsis and from veins by lack of compressibility. Comput erized tomography (CT) is superior in evaluating throm boxed veins (non-compressible) or markedly obese patients, but sonography is advantageous in very thin or cachectic patients. Enlarged lymph nodes can be found with inflamma- tion, malignant lymphoma (Hodgkin disease or non-Hodg. kin Iymphoma), and metastatic deposits The normal size of abdominal lymph nodes is given as 7-10 mm. Larger and still normal Iymph nodes measuring up to 20 mm in longitudinal diameter can be found in the ingui: region and along the distal external iliac artery (21) 14.3). Important for all enlarged lymph nodes are fol- any possible progression « low-up examinations to determin or regression—for instance, for the evalu apy. Furthermore, any possible hepatomegaly or sple megaly should be documented and quantified. on of chemother: Lymph nodes with inflammatory changes maintain their ovoid shape, have a distinct border, and exhibit two layers with a centrally increased echogenicity at the hilum (hilar fat sign) and peripheral liver-like echogenicity. Inflammatory Retroperitoneum: Lymph Nodes lymph nodes can often be encountered along the hepato: duodenal liga 24.3) accompanying viral hepatitis, cholangitis, or pancreatitis (Fig. 19.3). In contrast, metastatic lymph nodes are more round than oval, frequently of heterogeneous echogenicity, and indis. tinct in outline. They also have the-tendency to form aggre. gates. The site of the primary tumor can be deduced from the known Iymphatic pathways; para-aortic lymphadenopathy in young men, for instance, suggests a testicular tumor, Enlarged lymph nodes as manifestation of malignant lym- phoma generally exhibit an ovoid form, smooth margins, and more pronounced hypocchogenicity than found in in- flammatory or metastatic lymph nodes, In one third of cases, the spleen shows concomitant focal or diffuse involvement (Fig. 48.1). Predominant involvement of the mesenteric lymph nodes (55) (Figs. 14.1, 14.2) suggests a non-Hodgkin lymphoma and not Hodgkin disease, which has a predilection for thoracic and retroperitoneal Iymph nodes. Malignant lymphomas indent or displace adjacent vessels (Fig. 14.2) but respect the vascular wall and do not invade adjacent organs (ee also p. 21). Fig. 14.2b‘| Sagittal Overview The systematic evaluation of the (Fetfopéritonétim should delineate and document all abnormalities of the major ves sels. Atherosclerotic plaques (49) along the aorta can be seen directly by their echogenicity or indirectly by their acoustic shadowing (45) (Fig. 15.1) The linferior vena eava (16) should be evaluated for a di latation exceeding 2 em (or 2.5 em in young athletes), which would suggest a venous congestion as manifestation of a right cardiac insufficiency (Fig. 15.2). The measurements are ob: tained perpendicular to the longitudinal vascular axis (!) and should not accidentally encompass the hepatic veins (10), which enter the inferior vena cava subdiaphragmatically (Fig. 15.2). In questionable cases, the luminal diameter of the inferior vena cava is observed during forced maximal inspiri tion, which can be achieved by asking the patient to take deep breath with the mouth open, The transmitted sudden increase in intrapleural negative pressure cause lapse of gmatic portion of the normal inferior vena cava, with the lumen being reduced to a third or less of its diameter during quiet respiration. With fluid overload of the right cardiac atrium, the cava does not collapse during forced inspiration, During the thoracic movement of this maneuver, it can be difficult to stay with the same sono graphic section of the inferior vena cava. For further clarifi cation, the luminal diameter of the hepatic vein should be assessed in the right subcostal oblique section (see p. 25). Do you remember why in Figure 15.2 the hepatic parenchyma appears more echogenic dorsal to the distended inferior vena cava than anterior to it? Ifnot, return to page 9 and name this phenomenon, a brief col: fhe subdiaph Fig. 15.14 Retroperitoneum: Other Clinical Cases When visualizing the distal iia Vessels (Fig. 15.3) follow ing an inguinal vascular puncture, a hematoma (80) can oc casionally be encountered adjacent to the iliac artery (21) or vein (22). If blood flows into this perivascular space through a connection with the arterial lumen, a false ancurysm (aneurysma spurium) is present. This’ type of aneurysm differs from a true aneurysm (aneurysma verum), which rep. resents luminal widening of all mural layers and is not caused by a complete mural tear (Fig. 15.3). Old inguinal hema tomas must be differentiated from psoas abscesses and syn ovial cysts arising from the hip joint, and, when extending into the lower pelvis, from lymphoceles, large ovarian cysts, and metastatic lymph nodes with central necrosis ($7), Checklist Right cardiac Insufficiency: © Dilatation of the to > 2.0 cm (2.5 em in inferor vena cava trained athletes) © Dilated hepatic veins > 6mm in the hepatic periphery © Absent caval collapse with forced inspiration © Possible pleural effusion, initially almost always on the right Fig. 15.2b| Sagittal Overview Quiz for Self-Assessment section, the swers to the figure of question 7 can be looked up on page 76 Before turning to the material of the following following questions should be answered to test whether the after the individual questions listed in the text have b pal of the first lesson has been achieved. The answers to addressed. {questions | to 6 can be found on the preceding pages. The an- IB Which side of the body corresponds to the left side of the image? Superior or inferior? Where is anterior in the image, and where are the posterior structures? BB What is the luminal diameter of the inferior vena cava and abdominal aorta (upper limits of normal) in cm? How is vortic ectasia defined and from what luminal width in em ‘What procedure can be added when the luminal diameter of the inferior vena cava is borderline and a right cardiac insufficiency must be excluded? What vessel crosses between the aorta and SMA to the contralateral side on the sagittal image and can mimic a hypoechoic lymphoma? At what level is this vascular BH What isthe maximum longitudinal diameter of retroper- ‘oneal Iymph nodes that can still be called normal? What s the value of follow-up examinations for the evaluation of visualized lymph nodes? GB Look at the three transducers shown. Which transducer is used for which body region? What is the rationale? What frequency (in MHz) belongs to each transducer? Write the answer below each transducer. Fig. 16.1 HH Review this image step by step. What is the imagi plane? Which or possible. How does the image differ from a normal image? Try to give a differential diagnosis. ans are shown? Name all structures, if Fig. 16.2Axial Overview Working through the following pages should be preceded by a review of the sonographic sections obtained in the {ansverse plane. Where isthe liver on a correctly oriented sonographic transverse section? Right or left? If you cannot answer this with certainty you should consult page 4 and re capitulate the intricate anatomic relationship of the organs as seen on transverse images by means of a cone coffee filter (the solution is found on p. 78), The transducer is turned 90° and placed horizontally on the upper abdomen, With the patient taking a deep breath and holding it, the upper abdomen is systematically reviewed while the transducer is moved slowly and steadily in eranio- caudal direction (Fig. 17.1). By following the course of the vessels, they can be easily identified. On these transverse sections, the examiner is confronted with a multitude of arteries, veins, biliary ducts, and lymph ‘nodes, all confined to a small space and demanding differen tiation from each other (all vessels are hypoechoic, but so are lymph nodes), Do you remember where the left renal vein crosses to the contralateral right side, or whether the right renal artery is anterior or posterior to the inferior vena cava to the right kidney? Refresh your basic anatomic knowledge Upper Abdomen: Basic Anatomy Fig. 17.1 by writing the names of all the “numbered! 'StrUCtuFeS in Figure 17.2 and 17.3 below both figures and thereafter unfold the back cover page to compare your list with the key. Re- view again the topography of pancreas, duodenum, and spleen in relation to the major abdominal vessels as il- lustrated in Figure 17.3, To make the review easy, the three ‘most important transverse sections of the upper abdomen are described and illustrated on the next page. Fig. 17.3i: 2| Axial Overview First, the patient has to take a deep breath and hold it, so that the inferiorly displaced liver can serve as an (acoustic ‘window for the pancreas and lesser sac, including the major vessels traversing it (see p. 79). Skin (1), subcutaneous fat (2) and both rectus muscles (3) are directly beneath the trans- ducer, The ligamentum teres (7) with the obliterated umbil cal vein can be delineated posterior to the linea alba (6), par- ticularly in obese patients. The lesser sae is seen as a small cleft posterior to the liver (9) and, further posterior to it, the pancreas (33), The tail of the pancreas is often obscured by air shadows (45) arising from the stomach (26). The splenic vein (20) always runs directly along the posterior border of the pancreas. The renal vein (28), however, is more posterior between the SMA (17) and aorta (15), and is only imaged on — Fig. 18.1b Fig. 18.34 Upper Abdomen: Normal Findings audal sections (Fig. 18.3). A more cranial transverse section (Fig. 18.1) visualizes the celiac axis (32) together with the hepatic (18) and splenic (19) arteries. The gastric artery is jenerally not visualized. The origin of the SMA (17) is more caudal by about 1-2 em (Fig, 18.2), as clearly illustrated on the sagittal images (Fig. 11.2). I should be noted that the dis- play inverts the position of the organs (which are shown as if viewed from the patient’s feet). The inferior vena cava (16), seen as an ovoid structure, is on the left side of the image, and the aorta (15), seen as a round structure, is on the right side anterior to the spine (35). The head of the pancreas (33) characteristically surrounds the confluens (12) of the portal vein (I1), which is frequently obscured by duodenal air (46) in the region of the lesser omentum. Fig. 18.3¢2| Axial Overview The echogenicity of the (panereas changes with increasing ge. In young and slim patients, the parenchyma is hypo. echoie in comparison with the surrounding tissue, including the hepatic parenchyma. The deposition of fat in the pan creas (pancreatic lipomatosis) can be found in older or obese Patients and causes the parenchy its echogen- ity, leading to a hyperechoic, ie., brighter, appearance of the pancreas. The normal anteroposterior diameters of the are somewhat variable and should be less than 3m «land less than 2.5 em for its body and tail. The uses of pancreatitis include biliary obstruction (cholesta- sis) secondary to a stone lodged in the distal common bile duct (biliary pancreatitis), increased viscosity of the bile sec ondary to parenteral nutrition and, above all, alcoholism (al- cohol pancreatitis), which is, among others, related to protein plugs obstructing the small pancreatic duct, rma to incr ‘A@ite pancreatitis of the first degree can initially be devoid of any sonomorphologie changes The edema found in more advanced stages causes marked hypoechogenicity. in- creased thickness, and indistinctness of the pancreas (33). ‘Chronic pancreatitis is characterized by a heterogeneous fi- brosis (Fig. 19.1) calcific deposits (83), and an undulated, ir regular outline of the pancreas (Figs 1.1, 19.2), Moreov bbeuded or irregular dilatation of the pancreatic duct (7S) can occur (Fig. 19.2). The normal pancreatic duct is smoothly outlined and measures up to 2mm in diameter. Inflam- matory Iymph nodes (Fig. 19.3) in the vicinity of the pan- Fig. 19.14 Upper Abdomen: Pancreatitis eas, for instance anterior to the portal vein (11), can accom pany pancreatitis. The real contribution of sonography is not the early diag: nosis of acute pancreatitis This can be better achieved by laboratory tests or CT, particularly in view of the markedly increased bowel gas encountered with an acutely inflamed pancreas and interfering with sonographic imaging. Sono phy has the role of exeluding other diagnostic possibilities, such as cholecystitis, choledocholithiasis, and aortic aneurysm. Furthermore, sonography can be used to follow the pancreatitis and to detect its complications, such as in- flammatory infiltration of the neighboring duodenal or gastric wail (46, 26) and thrombophlebitis of the adjacent splenic vein (20). It might be necessary to add color Doppler sonography of the splenic vein if the conventional sono- graphic evaluation of the spleen is normal. Moreover, necrotic paths in the retroperitoneum (grade II acute pan- cteatitis) and the development of pseudocysts should be dis- covered early, so that surgical intervention or puncture under sonographic or CT guidance can be carried out, if indicated, without undue delay. The inflammation does not always in: volve the entire pancreas, and segmental and “channel” pan- creatitis confined to certain ts of the pancreas or along its duodenal surface can be encountered. These ‘manifestations cannot always be reliably differentiated from other localized space-occupying processes, such as a carci- Fig. 19.3a Fig. 19.262| Axial Overview Looking at the normal echogenicity of the pancreas (33) on longitudinal (Fig, 11.2) or transverse sections (Fig. 18.3) re veals no appreciable difference in comparison with the echo. genicity of the liver. With increasing age or obesity, the echo- genicity increases as a manifestation of panereatie lipomato- sis (F 0.1). This accentuates the contrast between pan- creas and hypoechoic splenic vein (20) Tumors of the pancreas ($4) are generally more hypo: echoic than the remaining pancreas and are sometimes not casily differentiated from adjacent bowel loops (by peristal sis) or space-occupying lesions arising from peripancreatic lymph nodes (see p. 21). Pancreatic carcinomas have a poor prognosis and remain clinically silent for a long time. They are often only detected after they have metastasized, when they compress the common bile duct, or after they have led to an otherwise unexplained weight loss. Early retroperi toneal extension, nodal or hepatic metastases, and/or peri- Fig. 20.2a Pancreas: Additional Cases toneal carcinomatosis are responsible for the poor 5-year survival rate, which is far below 10%. Endocrine pancreatic tumors are generally small at the ime of diagnosis because of their systemic hormonal effects and, as all small pancreatic tumors, are best visualized by endosonography (Fig. 20.3). An dnnular transducer at the tip of an endoscope is positioned into the stomach or through the pylorus into the duodenum, surrounded by a water-filled balloon for acoustic coupling with the gastric or duodenal wall Because of the short penetration needed to reach the tar get structure, a high frequency (5-10 MHz) can be selected, resulting in improved resolution. The same principle is used in transesophageal echocardiography that also has, because of the use of high-frequency transducers, a markedly im proved image quality in comparison with transthoracic echo. cardiography Fig. 20.34 Fig. 20.1b Fig. 20.2b Fig. 20.3b2| Axial Overview The riteria distinguishing inflammatory lymph nodes from ‘metastatic and Iymphomatous lymph nodes were already dis cussed on page 14. Depending on the incidence angle, the upper abdominal vessels (15, structures on transverse sections and must be distinguished from pathologic lymph nodes (Figs. 21.1, 21.2). Familiarity with the normal vascular anatomy is therefore fundamental. Very hypoechoic Iymph nodes that lack an echogenic hilus and displace, but do not invade, adjacent veins are suggestive of the presence of a lymphoma, such as chronic lymphatic leukemia (Fig. 21.2). The pathologic lymph node shown here is situated directly anterior and to the right ofthe bifur- cation of the celiac axis (32) into the common hepatic artery 48) and splenic artery (19). The resultant space-occupying effect obliterates the characteristic fluke-like configuration of the celiac axis. Occasionally, large ‘nodal ABETeBAEES (Fig. 21.1) can be seen around and virtually “encasing” the retroperitoneal or ) can be visualized as ovoid Upper Abdomen: Lymph Nodes mesenteric vessels. In such cases, representative lymph nodes are identified and measured to assess any interval growth on subsequent studies. If intra-abdominal or retroperitoneal lymph nodes are encountered, the examination should proceed to measuring the size of the liver and spleen. Both organs must also be searched for heterogeneous infiltrations, Diffuse lymphomatous involvement of the splenic parenchyma does not always translate into sonomorphologic changes, and the infiltrated spleen can appear normal or show only diffuse enlargement (Fig. 48.1). Additional lym phadenopathy must be searched for in the inguinal, axillary and cervical regions, Paralytic fluid-filled intestinal loops are rarely mistaken for lymph nodes. An intestinal diverticulum (64) can mimic a tumor or enlarged lymph node, as shown in Fig. 21.3. Fliciting peristaltic ac nal loop by applying graded compression can clarify the differential diagnosis. ivity from a paralytic intesti- Fig. 21.1b Fig. 21.2b. 2 | Axial Overview After this session the standard sagittal and transverse sec tions are supplemented by oblique sections, clarifying the spatial orientation of individual structures. Answering the [i Draw the approximate course of the relevant upper dominal vessels on a piece of paper, naturally just from memory without the help of this workbook. This drawing should include the biliary ducts. Test your knowledge by comparing your drawing with the one shown in Figure 17.2 and with the key on the unfolded back cover. Repeat this exercise until you succeed without making any mis- takes. BI How does the echogenicity of the pancreas parenchyma inerease with advancing age? How is acute pancreatitis, recognized’? What other imaging modalities are available if sonography fails to delineate the pancreas because of increased bowel gas? Bi Ty, without consulting this workbook and entirely from memory, to draw the three standard planes of the upper abdomen. Pay attention to the correct depth dimension of the individual vessels and to accurate annotation! Do not forget the structures of the anterior abdominal wall. Com- pare your finished sketches with the drawings shown in Figures 18.1 e-18.3¢. Repeat these exercises until you get them right—only then will you have mastered the topo- graphic anatomy of the most important sonographic planes and have laid the foundation for understanding the subsequent oblique sections. On this image, name every vessel and all other structures. Which vessel appears distended/congested? What can be the cause? Is this finding pathologic? Quiz for Self-Assessment subsequent questions correctly is a prerequisite for the next session. The answer to question 4 is found on page 76, Notesme This session leaves the transverse plane and moves to a sono: graphic plane that visualizes the major structures in the ‘esser Omentu. Again, the patient has to be asked to take a deep breath and hold it so that liver and porta hepatis move inferiorly from under the acoustic shadow of the lung and ribs. The transducer is turned from the previous transverse orientation until the sound beam is parallel to the portal vein (roughly parallel to left costal arch) (Fig. 23.1 a). Sometimes, the transducer has to be angled craniad (Fig. 23.1) to follow the course of the portal vein (11) from the porta hepatis to the confluens of the splenic vein and superior mesenteric vein (12) (Fig. 23.2) ‘Three hypoechoic layers can be delineated in the minor ‘omentum. The normal position of the portal vein (11) is im: mediately anterior to the obliquely sectioned inferior vena cava (16), with the common bile duct (not visualized in Fig. 23.2) and hepatic artery proper (18) situated more ante rior. Good visualization without intervening duodenal air also allows delineation of the pancreatic head, aorta (15), and SMA (17) on the right side of the display (ie., on the patient’s left side) “The (iiajOR bFaHCHESTOM tH EpAtIE AMERY (18) divide at the porta hepatis, with one branch seen in cross-section on the sonographic orientation under discussion here. This cross-section should not be mistaken for preaortic Iymph- adenopathy (Fig. 23.2b), Porta Hepatis: Normal Findings ‘The (GOmMGOR|BIIE GEL can be so narrow that it might be barely visible along the adjacent artery. Its normal diameter should be less than 6 mm. After cholecystectomy it assun some reservoir function and can dilate up to 9mm without pathologic significance. A borderline dilated common bile duct (obstructive cholestasis) can no longer be differentiated from adjacent vessels by its luminal diameter but only by its location anterior to the portal vein. Visualizing the duct’s en tire length is important to exclude intraductal gallstones (see p. 35). By moving the transducer, an attempt should be made to follow all three tubular structures upward to the porta he: patis. Distally, the common bile duct should be followed to the duodenal ampulla at the pancreatic head, the hepatic artery to the celiac axis, and the portal vein to the porto splenic confluence or the splenic vein The normal \ltiminall Width OF the portalVein is less than 13. mm when its main branch is measured perpendicular to its longitudinal axis. Dilatation should only be suspected with measurements exceeding 15 mm. A dilated portal vein alone is an uncertain criterion for the presence of portal hyperten sion. The highest accuracy is achieved by the definitive de- monstration of portocaval collaterals, which are described on the next page. Fig. 23.2a Fig. 23.2ba 3} Liver The most common cause of increased pressure in the portal vcin is impaired drainage secondary to citthosis, Direct com- pression of the portal vein by adjacent tumor is found less frequently or superior mesenteric vein, without affecting the portal vein. Dilatation of the portal vein (11) to more than 13 mm should be considered suspicious for portal hypertension (Fig. 24.1). ‘The luminal diameter of the portal vein is measured perpendicular to the vessel's longitudinal axis, which is usually obliquely oriented in relation to the sono’ graphic image. The vascular wall is not included in th measurement. It should be kept in mind that splenomegaly of any other cause can lead to an increased luminal diameter of the splenie vein or portal vein, without the presence of portal A pancreatic tumor can involve the splenic vein hypertension. A dilated portal vein with a diameter of more than 13 mm is by itself no certain criterion for portal hypertension. Addi tional splenomegaly (Fig. 48.2), ascites (Fig. 31.1), and |portoeaval collaterals. With progressing cir rhosis, collateral channels develop to the superior or inferior vena cava. Blood can drain from the portal system via a di criteria are lated coronary vein of the stomach and a dilated esophageal venous complex into the (hemi-)azygos vein and from there into the superior vena cava, This can lead to the severe clini cal complication of bleeding esophageal varicose veins. Occasionally, small venous connections between the splenic hilum and left renal vein open up, with resultant portosystemic drainage directly into the inferior vena cava shunt). Less frequently, the umbilical vein, which passes through the faleiform ligament (spontaneous splenorenal Portal Hypertension: Lymph Nodes and ligamentum teres from the porta hepatis to the umbilical advanced stage, this collateral circulation (Fig. 24.2) can produce dilated and markedly tortuous subcutaneous peri ‘umbilical veins referred to as caput medusae. In questionable cases, color Doppler sonography can be used to detect a decreased or reversed (hepatofugal) portal blood flow ccanalizes (Cruveilhier-Baumgarten syndrome). In its Evaluation of the lesser omentum should not only assess the luminal diameter of the portal vein but also exclude enlarged periportal Iymph nodes ($5) (Fig. 24.3), which frequently accompany viral hepatitis, cholecystitis, or pan creatitis. They are caused by inflammatory changes and should be repeatedly checked for resolution and exclusion of malignant lymphoma. Checklist Portal Hypertension: ‘¢ Demonstration of portocaval collaterals at the porta hepatis ‘© Diameter of the portal vein at the porta hepatis > 15 mm Dilatation of the splenic vein > 1.2 em Splenomegaly Demonstration of ascites Recanalized umbilical vein (Cruveilhier-Baumgarten syndrome) ‘© Esophageal varices (by endoscopy) Fig. 24.26 Fig. 24.3b3) Liver After the porta hepatis has been evaluated, the liver itself is methodically visualized on transverse images and ‘sibeostal ‘Oblique images parallel to the right costal arch, What is wrong with the position of the transducer shown in F The answer can be found in the left lower corner of this pag The right subcostal oblique image (Fig. 25.2.) is particu larly suitable for visualizing the hepatic veins lengthy (10) and their confluence with the obliquely visualized infe rior vena cava (16). Fig. 25.2a Normal values: Hepatic veins (peripheral): < 6mm Angwer to quiz, Fi (svouse jews 298) Ajfeqpour 9x0ur pur your [PIs09 24 spreno} paxow! ag isnt 1] “uorysod ut oUDFUIOINTE] 18} OO} St A9NpSUEN IHL Fig. 25.34 Hepatic Vein Confluence and Hepatic Congestion If the inferior vena cava is borderline in diameter and the maneuver to test the caval collapse with forced inspiration is, unsuccessful (see p. 15) or inconclusive, the luminal diameter of the hepatic veins is best measured at this level. The maxi mal diameter of a peripheral hepatic vein should not exceed 6mm (Fig. 25.2). Measuring the hepatic veins at the con fluence with the inferior vena cava has the disadvantage of wide anatomic variations and corresponding false measure the hepatic veins of the patient with no cardiac problems shown in F ments, For instan 2 measure 10 mm directly anterior to the vena cava while the peripheral hepatic veins only 3-S mm, With venous congestion proximal to the right atrium secondary to right-sided heart failure, the he Patic veins are dilated (Fig. 25.3) and lack any respiratory changes, This image section also allows the exclusion of a igh pleural effusion. which appears as echo-free fluid between the diaphragm (13) and the acoustic shadow of the lung (47). Vascular rarefaction along the periphery of the liver can be a sign of advanced cirrhosis. Hepatie vein thrombosis (Budd= Chiari syiidrome) can be diagnosed on the oblique subcostal image with color Doppler sonography, which can determine velocity, profile, and direction of the intravascular blood flow Fig. 25.363) Liver Alter the liver (9) has been scrutinized on transverse and subcostal image sections, it is further evaluated Sagittally, also in deep inspiration (Fig. 26.1). It is important to keep the patient cooperative by allowing adequate time intervals for normal breathing. The best method seems to be a two- stage evaluation with a slow, continuous sweeping of the transducer. First, the left hepatic lobe is screened to the level of the inferior vena cava, followed by a break for normal breathing while the transducer is moved from the midline to the right MCL. The patient takes another deep breath and the right hepatie lobe is now methodically screened applying the same sweeping motion (Fig. 26.1) to the transducer, Fig. 26.1b Fig. 26.2a Fig. 26.34 Hepatic Size, Gallbladder, Normal Findings The [Sig6\Of thelliver is aSSENEM by measuring the antero- posterior (sagittal) and the superoinferior diameters in the right MCL (Fig. 26.2a, Fig. 26.3a). To encompass an en larged liver, the transducer has to be angled superiorly and inferiorly (Fig. 26.1). Measurements are taken in inspira- tion. ‘The normal craniocaudal diameter should be less than 13 or 15 em, depending on the patient's body habitus. Itis im- portant to watch for the acute angle formed by the inferior margin of the right hepatic lobe. In hepatic congestion oF patomegaly, this angle exceeds 45° and becomes blunted. The normal lateral margin of the left hepatic lobe also should form an acute angle measuring less than 30' The normal gallbladder wall (80), which should only be evaluated when the gallbladder (16) is not contracted (the patient must be NPO), c: up to 4mm in thickness The postprandial gallblad- erally too contracted to ex clude edematous wall thickening, stones, or a tumor with any degree of certainty, Fig. 26.3¢3) Liver In athletic persons, hyperechoic strue- tures (1) that appear to arise from the phragmatic surface (13) can indent the hepatic dome (9) (Fig. 27.1). These structures are only a few millimeters in width and are prints caused by ithickened muscular ‘bundles that run from the central tendon to the costal insertion of the diaphragm, They have no clinical sig nificance and should not be mistaken for pathologic processes. A similar dia phragmatic muscular bundle can also be seen as a mirror artifact along the pulmonary side of the diaphragm (Fig. 27.2) A. \fatiV"iveF or hepatic steatosis produces a diffuse increase in echogen icity of the liver (Fig. 27.3). This in- creased echogenicity is best appre- ciated in comparison with the renal echogenicity (29). In normal patients, liver and kidney exhibit about the same ‘echogenicity (Fig. 37.3). The reflection caused by severe hepatic fatty infitra tion results in sound attenuation (Fig. 27.4) that increases in the liver commensurate with the distance from the transducer. ‘The resultant decreased echogenicity in the more posterior regions of the liver might not be adequate for evaluation, Do you re member why the hepatic parenchyma appears more echogenic behind 1 gallbladder (70) If not, look it up on page 9 Fig. 27.14 Fig. 27.3b Normal Variants, Fatty Liver Fig. 27.43) Liver Fatty infiltration is not only diffuse throughout the liver, but may also be confined and regional. These fo€al fatty, changes (63) predominantly occur around the gallbladder fossa or anterior to the poral vein (Lt). The sharply demarcated and more echo genic than the surrounding hepatic parenchyma (9). They can assume raphic configuration (Fig. 28.1) and have no space-occupying effect. Adjacent hepatic veins (10) or the branches of the portal veins (11) are not displaced. The faleiform ligament (8), which is composed of connective tissue and sur rounded by fat, is. se as a similar echogenic structure that sharply inter rupts the adjacent normal hepatic parenchyma (Fig. 28.2). It must be dis Linguished from focal fatty infiltration, Diffuse fatty infiltration might not involve the entire liver, resulting in focal fatty sparing (62). These regions of relatively reduced fatty conten primarily found in the immediate viein ity of the portal vein or gallbladder (14) (Fig. 28.4). 4 space-occupying component, Adjacent 28.3); peripherally located areas of increased or relatively reduced fatty infiltration show no bulging hepatic border and do not project into the gallbladder, as is sometimes the case with tumors or in, this finding lacks a vessels are not displaced (Fi The branches of the portal vein (11) ‘can be distinguished from hepatic veins by their hyperechoic outline. This appearance is caused by the density difference between the portal vein wall, periportal connective tissue, and accompanying biliary duet and hepatic artery. This hyperreflectivity of the portal vein wall () becomes accen tuated in the vicinity of the porta he patis (Fig. 28.2) where it should not be mistaken for focal fatty. infiltration, Since the hepatic veins (10) traverse the parenchyma without concomitant vessels, they lack a density difference and do not show any wall hyperecho- genicity. Only a large hepatic vein per- pendicular to the sound beam can ex- hibit a hyperechogenie wall Focal Fatty Infiltration Fig. 28.3b Fig. 28.4b3) Liver Other Focal Changes Hepatic eysts (64) can be congenital (dysontogenetic) or acquired. In contrast to congenital biliary dilatations (Caroli syndrome), the congenital cysts contain no bile but serous fluid (Fig sociated with polycystic kidneys (Fi 29.1), They are of no clinical consequence unless as- 38.3) (risk of renal failure The Gtit@tid to distinguish a cyst from a lesion of low echogenicity are as follows echo-free content, spherical shape, smooth outline, distal acoustic enhancement (70), and e ital eysts can exhibit indentations oF delicate septa, and parasitic hepatic cysts must then be excluded (Fig. 30.3). Diagnostic dif ficulties can arise when internal echoes are found secondary to intracystic hemor hag ge effect (see p. 9). Con Hepatic hemangiomas (61) are homogeneously echogenic (bright) in compari son to the remaining hepatic tissue (9), have a smooth outline, and lack an echo genic rim. A draining, but not dilated, hepatic vein (10) can be characteristically found in their immediate vicinity (Fig. 29.3). Most hemangiomas are small nerally of rather heterogeneous echogenicity, making it difficult to establish a definitive diagnosis. The lesion ($4) shown in (Fig. 29.4) can represent a large hemangioma or malig: nant tumor, but actually is a foeal nodular hyperplasia (FNH), which is not always iso-echoic in relation to the surrounding hepatic parenchyma, Unclear cases can be further evaluated by a dynamic CT with serial images after bolus injection of con- trast medium. A hemangioma exhibits a characteristic enhancement and delayed washout. How would you interpret the echo-free areas (68, 69) seen in Figure 29.3h? The answer can be found in the key at the end of this workbook. 29.2), but they can reach considerable size a Fig. 29.4bAnother important group of focal hepatic changes comprises inflammatory and parasiticchanges. The primary causes of a focal inflammation are cholangitis, fungal disease, and he- matogenous seeding, particularly in immunosuppressed patients, Hepatic abscesses (58) can produce a rather variable sonomorphology, including an anechoic center due to lique- 0.2), heterogeneous foci surrounded by a rim ised echogenicity, and echogenic lesions (Fig. 30.1) The effectiveness of inserted drainage catheters (59) can be casily monitored by follow-up sonographic examinations (Fig. 30.1), If compression of adjacent biliary ducts has led to obstruction (cholestasis), bile can be drained by internal stents into the duodenum or percutaneous transhepatic catheters into a collection bag. Occasionally, an infectious process can introduce air bubbles (60) into the biliary ducts (Fig. 30.2). Intraduétal air without implying a hepatic (9) infection can be seen after endoscopic retrograde cholangiopancreatography (ERCP) as well as in patients with a papillotomy or biliary-enteric anastomosis, Infections, Parasites The most common parasitic involvement of the liver is cystic echinococeal disease (Echinococcus eysticus), which characteristically produces several daughter cysts within a cyst. Such hydatid cysts should not be aspirated since id to peritoneal seeding of the larvae. Echino. lisease can be treated medically with mebendazole or lly by excision. Alveolar (Echinococcus alveolaris) poses more sonographic difficul- ties. A lesion with a mixed solid, liquid, and eystic pattern, traversed by several septa, is typically found (S4) (Fig. 30.3) Differentiating this finding from a primary hepatocellular }oma, metastasis (compare F ), abscess, or old he: matoma is virtually impossible echinococcal disease Checklist of Criteria for Establishing a Cyst: ‘Spherical configuration Echo-free interior Smooth outline Distal acoustic enhancement Sharply defined distal wall Edge shadowing duc to critical angle phenomenon, Fig. 30.3b3) Liver In addition to chronic alcoholism, the possible cifrhosis include viral hepatitis, metabolic disorders, and exposure to toxic environmental substances. Latent cirrhosis with hepatic decompensation can be present without sono: graphically detectable changes, and sonography is not suit able for excluding a cirrhosis. More advanced st es of several sonographic changes that can serve as éfiteria for the presence of a cirrhosis While the normal liver (9) exhibits a thin echogenic cap. sule along its border (Fig. 26.3), the cirrhotic liver has an ir regular surface (small undulations and bumps), which causes increased sound scattering with loss of the normal capsular reflection. This results in absent or only patchy capsular visu alization. The absence of a capsular line is best appreciated when the liver is surrounded by ascites (68) (Fig. 31.1). Furthermore the peripheral vasculature becomes rarefied in citthosis. (Fig. 31 showing a variable diameter and an increased angle, at their confluence (> 45°). Normal hepatic veins (10) have a straight course, join each other at an acute angle and are visible to the hepatic periphery (Fig. 25.2). In cirrhosis, the portal vein branches close to the porta hepatis show thickening of their hyperreflective walls and sudden changes in caliber (“pruned portal tree”). Regenerating nodules are of normal echogen icity and recognized only indirectly by displaced adjacent vessels, Finally, a deformed and biconvex hepatic configura tion, decreased pliability (as revealed when pressing down ), with the remaining visualized vessels Fig. 31.2a Cirrhosis and Hepatocellular Carcinoma the transducer over the liver), and an enlarged and rounded left lobe or eaudate lobe suggest cirrhosis “THe CompLIGAHIGH ON GAAROE include portal hyperten: sion and its sequelae (sce p. 24), ascites (68), and hepato: cellular carcinomas (84) that arise from long standing cirrho- sis (Fig. 31.2), Therefore, a cirrhotic liver must be carefully and thoroughly (!) scrutinized for pathologic lesions. Only the late stage of cirrhosis produces a shrunken liver The hepatocellular carcinomas (§4) can be iso- echoic in relation to the remaining hepatic parenchyma (9) and might only be detectable by the convex displacement of adjacent hepatic veins (9) (Fig. 31.3) Checklist of Criteria for Establishing Hepatic Cirrhosis: ‘© Absence of thin, hyperechoic capsular line Paucity of peripheral hepatic vessels ‘Obtuse angulation of the hepatic veins > 45° Accentuated echogenic wall of the portal vein Abrupt caliber changes of the branches of the portal vein Regenerating nodules with displacement of adjacent vessels Nodular liver contour (advanced stage only) ¢ Contracted liver (advanced stage only) Signs of portal hypertension . . . . Fig. 31.16 Fig. 31.2 Fig. 31.3 31a 3) Liver Secondary neoplastic lesions (metastases) in the liver do not only arise from primary tumors of the intestinal tract, but also from primary tumors in the breast and lung. The sono- aphic polymorphic. Hepatic metastases 32.2) from colorectal carcinomas are often echogenic findings are (56), presumably related to neovascularity secondary to their relatively slow growth. The more rapidly growing metastases from bronchogenic or mammary carcinomas consist almost exclusively of tumor cells and have the tendency to be more hypoechoic. In view of their multifarious presentation, ‘metastases cannot be reliably assigned to any particular pri- mary tumor. Characteristically, meta: ases (56) exhibit a hypoechoic halo orrrim as seen in Fi and 32.2, This hypoechoic zone could represent proliferating tumor or perifocal edema. Central necrosis ($7) can frequently be seen as cystic areas caused by liquefaction (Fig. 32.3). Large metastases gener- ally exhibit a space-occupying feature as evidenced by dis- placement of adjacent vessels. They can compress biliary ducts, possibly leading to regional intrahepatic cholestasis (Fig. 34.2). If located peripherally, they frequently (but not Hepatic Metastases necessarily) expand the hepatic contour that is seen as a lo. calized convexity After chemotherapy, various signs of |EuimGr Regression can be encountered, such as heterogeneous sears, calcifica- tions, oF partial cystic liquefaction, depending on the ther: apeutic effect. Such regressively altered metastases or small metastatic nodules cannot be easily separated from areas of cirrhotic transformation. It is crucial to follow these findings sonographically to assess their growth potential. Alterna: tively, a percutaneous needle biopsy under sonographic or CT guidance can be obtained, Multiple metastases that vary in size and echogenicity suggest several episodes of hemato- genous spreads, Do you remember why the hypoechoic bands (48) seen in Figure 32.1 appear in the liver and why the region in between (10) is more echogenic (brighter) than the remaining hepatic parenchyma (9)? Just keep in mind that the gallbladder (14) lies between both findings and the transducer, with the gall- bladder wall (80) hit tangentially by the sound beam. If you are still puzzled, you should go back to page 9. Fig. 32.1b Fig. 32.3b3) Liver Before you proceed from the sonographic examination of the liver to the evaluation of the gallbladder, you should try to work through the following questions. The required drawings should be done on a piece of paper. The answers to the ques. tions 6a-c can be found on page 76, but check the answers Bh Try to draw from memory the body marker that shows the section of the porta hepatis. Then make a drawing in the shape of a cone coffee filter and systematically enter from front to back all lines, organs, and vessels that can be ex: pected to appear in this sonographic section. Compare your drawing (but only after completion) with the find: ings in Figures 23.2b and ¢, Did you place all major struc: tures in the lesser omentum at the correct depth? If not, repeat this exercise until you succeed without making any mistakes, BB What is the name of the sonographic section for measur- ing the luminal diameter of the hepatic vein? Name this section, draw the appropriate body marker, and then proceed as in question 1 Hl What sonographic section is used to measure the liver? What are the maximum diameter values and what are the terms given to them? Can you draw such an image from memory? You already know how to proceed (sce above). Write down the three characteristic findings of portal hy pertension and the five characteristic findings of citrhosis Compare your answers with the material on pages 24 and 31 EH Name the characteristic sites of focally decreased and fo- cally increased fatty infiltration of the liver. How can they be differentiated from malignant hepatic processes? Hi Review the following three sonographic images. Write down the imaging plane and ist your differential diagno sisof the findings Tnelude every abnormality since several pathologic procestes are presat Quiz for Self-Assessment only after all the questions have been answered so that the suspense does not disappear too early! (You would otherwise inadvertently read the answers to the second and third image questions, that are listed next to each other on page 76.)i az Gallbladder and Biliary Ducts Cholestasis The bile duct (66), comprising the common hepatic duet above the cystic duct in- sertion and the common bile duct below it, normally measures up to 6 mm at the level of the minor omentum, but luminal diameters between 7 and 9 mm ate still within the range of normal (Fig. 34.1), particularly after cholecystectomy. A dilated duct (exceeding 9 mm in diameter) invariably becomes visible anterolaterally to the portal vein (11) (compare p. 23). Even when the distal segment of the common bile duct is obscured by duodenal air (compare Fig. 17.3), a proximal intrahepatic obstruction (¢.g., hepatic metastasis) can be sonographically distinguished from a distal obstruction (c.g., stone lodged at the papilla, lymphadenopathy in the lesser ‘omentum, or carcinoma of the pancreas). The proximal obstruction distends neither gallbladder (14) nor common bile duct The small intrahepatic biliary duets are parallel to the portal vein branches (11) and are normally invisible. They become visible along the portal veins when biliary obstruction has dilated the ducts, resulting in the double-barreled shot-gun sign ty iphy is successful in up to 90% of cases in distinguishing be tween obstructive (ductal dilatation) and hepatocellular (no ductal dilatation) jaundice. Characteristically, a severe biliary obstruction (Fig. 34.2) produces a tortuous dilatation of the intrahepatic biliary ducts (66) that can assume the ap: pearance of a towering antler. Cholestasis can increase the viscosity of the bile that can lead to the precipitation of cholesterol or calcium crystals (Fig. 34.3). This so- called “sludge” (67) can also be seen after prolonged fasting without biliary ob- struction. Before diagnosing sludge, a thickness artifact (p. 10) should be excluded by obtaining additional sections and by turning and shaking the patient. The ERCP in drain a biliary obstruction by inserting a biliary stent (59). Alternatively, biliary ainage can be achieved with a percutaneous transhepatic catheter. Fig. 34.1b Fig. 34.2b4Q| Gallbladder and Biliary Ducts Stones are formed inthe gallbladder (gallstones) because of an altered composition of the excreted bile. Depending on their composition, gallstones (49) can transmit sound almost completely (Fig. 38.3), float within the gallbladder (cholesterol stones) or, if high in calcium content, reflect sound to the degree that only the surface is visualized g. 35.1). A stone is established if an echogenie structure can be dislodged from the gallbladder wall (80) by moving and turning the patient, in contradistinction to a polyp (65), (Fig. 382). Some stones remain fixed at the gallbladder wall be of inflammatory processes, or become lod dibulum, rendering the differentiation between stones and polyps difficult. Acoustic shadowing (45) distal to such a le sion (Figs, indicates a stone. An edge effect of the gallbladder wall ( 35.2) must be carefully di guished from stone-induced acoustic shadowing (compare Fig. 9.4) to avoid any misinterpretation. The polyp shown in Gallstones and Polyps this case (Fig, 35.2) should be followed for signs of growth to exclude any malignant process. Intrahepatic cholestasis (Fig. 3 festation of malignancy and can be caused by obstructing stones (49) in the intrahepatic ducts (66) (Fig. 35.3). The prev of cholelithiasis is about 15%, whereby older women are affected more often. Since 80% of the patients asymptomatic, detected gallstones are only consequential in context with their complications (cholecystitis, cholangitis, colics, biliary obstruction), If re moval is indicated, this can be achieved by percutaneous or open cholecystectomy or, alternatively, by ESWL (extracor poreal shock wave lithotripsy) or ERCP. Furthermore, the composition of the bile can be altered by medication and some stones regress following nutritional cha ) is not always a mani with gallstones are Note the thin, single-layered, echogenic wall (80) of both gallbladders (14) shown in Figures 35.1 and 35.2. There is no flammatory thickening of the gallbladder wall. Compare this finding (o the one on the images on the next page. Fig. 35.1. 4| Gallbladder and Biliary Ducts Cholecystitis is invariably caused by stones (49). Early cholecystitis only causes the gallbladder (14) to be tender. but inflammatory edema of the gallbladder wall (80) soon develops and the wall becomes thickened and multilayered (Fig. 36.1), The preprandial gallbladder wall normally measures less than 4mm. Thickening of the gallbladder wall does not have be found in many hypoalbu- to be a sign of inflammation since it c including ascites (68) (Fi minemia, or right-sided cardiac insuffiency. conditions, An additional finding indicative of an acute inflammation is pericholecystic accumulation of fluid (68), which in some ses can be confined to Morrison's pouch between the infe- jor hepatic border and right kidney. Finally, the gallbladder Cholecystitis and Quiz for Self-Assessment can become indistinct in outline where it abuts the hepatic parenchyma (9). An increased diameter of the gallbladder of more than 4 cm is a sign of hydrops, but even more charac- leristic for hydrops is the associated altered configuration from a pear-shaped to a more biconvex and spherical struc- ture. Recognizing air within the lumen of the gallbladder or in its wall (mural emphysema) is crucial since an infection with gas-forming organisms implies a poor prognosis and is as- sociated with a high risk of perforation. Chironie ehole= @¥stitis can lead to a contracted gallbladder or a porcelain gallbladder with mural caleifications, Both conditions cannot casily be differentiated by sonography and have to be eval: uuated together with the clinical findings the common down Bi Write age 76. Quiz for self-assessment: BB What is the maximum diameter of bile duct? diameter in mm arouses suspicion What of a biliary obstruction? diagnoses found in the sonographic image on the left, after careful review. Com- pare your result with the answer onHEY «neys ana Adrenal Glands ‘The kidneys are generally best shown in the lateral decubitus, position. The Jongitudinal section of the kidney is visualized by placing the transducer on the extended intercostal line of the flank. With deep inspiration, the kidney moves inferiorly away from the obscuring costal acoustic shadows and ap- pears in its longitudinal dimension (Fig, 37.1) for evalua- tion. As is essential for a complete evaluation of any organ, the kidney must also be delineated in a second plane, as dem- onstrated in Figure 37.1b for the ‘evaluation of the trans= ‘verse plane Of the left kidney (right lateral decubitus pos tion). Normal ‘renal! parenchyma (29) is slightly decreased or equal in echogenicity relative to the splenic or hepatic parenchyma (9). The width of the parenchyma should measurements in Fig. 37.2 between measure at least 1.3.em (thi LSem and 24cm, respectively). The ratio Fig. 37.20 Fig. 37.34 Normal Findings parenchymal width and pelvic width (= PP-index) decreases ‘with age (compare normal values below). In the typical longi- tudinal section (Fig. 37.2), the hypoechoic medullary py ramids (30) are seen like a string of pearls between the parenchymal cortex and the centrally situated echogenic col- lccting systemn(renal pelvis, 31). They should not be mistaken for tumors or cysts. An enlarged adrenal gland should be searched for within the perirenal fat above the upper pole of the kidney (27), where it can appear as a hypoechoic mass within the echogenic perirenal fat. The renal hilum, together with the renal vein (25), is generally well seen on the trans- verse section (Fig. 37.3). Bi ureter and renal artery are often identified only with great difficulty, Why is the position of the transducer depicted in Figure 37.3a not completely compatible with the images wres 37.3b and ¢? se of their thin diameter, the ‘Normal renal values: Renal length: 10-12 em Renal width: 4- 6em Respiratory mobility: 3- 7em » ee PP-index (depending on age): < 30 years: 16: < 60 years: 12-16: > 60 years Ltt38 5| Kidneys The normal configuration Of the kidney (Fiz. 37.2) can show several findings that can be traced to its embryologic lopment. Hyperplastic columns of Bertin can protrude from the parenchyma (29) into the renal pelvis (31) and do not differ in echogenicity from the remaining renal parenchyma. An equally iso-echogenic parenchymal bridge can completely divide the collecting system. A partial or complete parenchymal gap at the same location indicates renal duplication (Fig. 38.1) with separate ureters and blood supply for each moiety. The prevertebral parenchymal bridge ‘of horseshoe kidneys might even be mistaken at first sight for preaortic lymphadenopathy or a thrombosed aortic aneurysm. A lobulated renal contour can be seen in children and young adults as manifestation of persistent fetal lobuta tion, characterized by an otherwise smooth renal surface that is indented between the individual medullary pyramids These changes have to be differentiated from renal infarcts (Fig. 42.3) that can be found in old patients with athero- selerotie stenosis ofthe renal artery. Localized parenchymal thickening along the lateral border of the left kidney, usually just below the inferior pole of the spleen, is found in about 10% of patients. This is an anatomic variant, generally referred to as “dromedary hump,” and its Normal Variants and Cysts differentiation from a true renal tumor might occasionally be difficult Renal cysts (64) are echo-free and produce, as shown in Figure 38.2, distal acoustic enhancement (70). Additional cri- teria for the diagnosis of a cyst are the same as for the diagno- sis of hepatic cysts (see p. 29). Cysts can be separated into peripheral cysts along the renal surface, parenchymal cysts, or peripelvic cysts, with the latter to be differentiated from an obstructed and dilated renal pelvis (Fig. 41.2). The evalua tion of a cyst should include measuring its diameter as well as stating its approximate location (upper, middle, or lower third of the kidney), Finding a few renal cysts is clinically inconsequential, though re-evaluation at regular intervals is advisable. In con- trast, the adult form of polyeystic renal disease (Fig. 38.3) presents with innumerable cysts (64) that progressively in- nce the cysts can reach a considerable size, the paticnts can complain of fullness and pressure in the upper ab- domen. Furthermore, polyeystic renal disease leads to renal atrophy by displacing and thinning the renal parenchyma, re- sulting in renal insufficiency in early adulthood and eventu- ally requiring dialysis or a renal transplant. Other causes of, renal atrophy will be discussed on the next page. Fig. 38.3b5) Kidneys The kidney reacts to the 'Vatious inflammatory Conditions With similar sonographic changes. It can be entirely normal in early pyelonephritis or glomerulonephritis. Later, edema causes an enlargement and interstitial infiltration an in: creased parenchymal echogenicity with accentuated demar- cation of the parenchyma (28) relative to the hypoechoic py ramids (30) (Fig. 39.3). This is referred to as “punched-out medullary pyramids” In comparison with the adjacent he patic or splenic parenchyma (9), the renal parenchyma ap- pears more echogenic (Fig. 39.3) than the parenchyma of the normal kidney (Fig. 38.2). Interstitial nephritis can be caused by chronic glomerulonephritis, diabetic nephropathy, urate nephropathy (hyperuricemia as manifestation of gout or in creased nucleic acid turnover), amyloidosis or autoimmune disease, but the etiology cannot be deduced from the in creased parenchymal echogenicity. Another sign indicating an inflammation is the indistinet interface between parenchyma and collecting system. Atrophy and Inflammation In addition to causing peripheral infarcts ( artery stenosis can induce a generalized dé size (Fig. 39.1), which, however, can also be a manifestation of recurrent of chronic inflammation. The marked thinning of the parenchyma (29) found in end-stage chronic nephritis, leads to renal atrophy (Fig. 39.2), which is frequently accom- panied by degenerative calcifications (49) with their corresponding acoustic shadows (45). The atrophic kidney can be so small that it eludes sonographic de tection, The associated loss of excretory funetion can be made up by compensatory hypertrophy of the contralateral kidney. In a unilaterally small kidney, the PP index (see p. 37) should be determined. If this index is normal, a developmen. tally hypoplastic kidney might be present 3) or conerements, While sonography does not contribute to the differential diagnosis of inflammatory renal disease, it is of value in monitoring any renal inflammation during therapy, in ex cluding any complications (e.g., acute obstruction) and in guiding any percutaneous needle biopsy. Fig. 39.3bIneys The Golléeting system is seen as a central complex of strong echoes that are only traversed by small thin vascular struc With increased diuresis after fluid intake the renal pelvis (31) can distend and be visualized as a more echo-free structure (87) (Fig. 40.1). The same finding can represent the developmental variant of an extrarenal pelvis, In both conditions, the dilation does not involve the calices and infundibula It can be difficult to separate this finding from a first c (mild) (obstructive dilatation (Fig. 40.2), which also causes a dilated renal pelvis but without infundibular exten- sion and detectable parenchymal thinning. A second degree (moderate) obstructive dilatation causes increasing fullness of the infundibula and calices as well as the onset of parenchymal thinning (Fig. 40.3). The bright central echo complex G1) becomes rarefied and eventually disappears. The third degree (severe) obstructive dilatation is character- ized by severe pressure atrophy of the parenchyma (no case illustrated) Urinary Obstruction Sonography cannot reveal all the (GaUS@S of an ObStRCtIVE turopathy.. Since the midureter is obscured by overlyin, the majority of cases, a ureteral stone is g ized unless itis lodged at the ureteropelvic junction or in the prevesical ureter. Less frequent causes of ureteral obstruc tion are a tumor of the bladder of, uterus and aggregated lymph nodes as well as retroperitoneal fibrosis after radia- tion, or idiopathic as a manifestation of Ormond disease. A latent obstruction can develop during pregnancy, caused by ureteral atony, and during infection, Furthermore, distended bladder as manifestation of a neurogenic t or secondary to prostatic hypertrophy can cause ureteral ob- struction, and the sonographic evaluation must include the bladder and a search -d prostate gland in men (compare Figs. 56.1, $6.2). For assessing the postvoid residual see page 54. for an enlars The obstruction causing t dilatation of the collecting sys- tem can be relieved by eystoscopically placed ureteral stents (compare Figs. 45.3, 45.4) or by sonographically guided per- cutaneous nephrostomy,5| Kidneys Not every [dilated renal pelvis (31) is indicative of obstruc tive uropathy. pelvis was already mentioned on the preceding page The developmental variant of an extrarenal Furthermore, the renal hilum can show prominent vessels (25) (Fig. 41.1) that can be followed to the hypoechoic medul: lary pyramids (30) and might be mistaken for structures of the collecting system, These vessels generally appear rather delicate and lack the characteristic fullness found with an ob. structed and dilated collecting system (compare Fig. 40.2) I the findis inconclusive, ‘€6l6F Doppler Sonography can casily determine whether these structures Fig. 41.1b Fig. 41.2b Differential Diagnosis of Urinary Obstruction represent blood vessels containing rapidly flowing blood or the colle Blood vessels are seen as color-coded structures with the color depending on the direction and velocity of blood flow, while the barely moving urine in the collecting system re mains black. The same principle of difference in relative flow can be employed to differentiate pelvic or peripelvic cysts (64), which do not require any therapy, from an obstructively dilated renal pelvis (87), which has to be expectantly ob: served or treated. Both conditions ean, of course, concur (Fig. 41.2). ing system filled with essentially stationary urine. Notesineys Detecting conerements in the kidney |(nephrolithiasis) is more difficult than detecting stones in the gallbladder since the echogenic renal stones (49) are often located within the equally echogenic collecting system (31) (Fig. 42.1) and ‘might not elicit any echogenicity that is discernible from its surrounding structures. Concrements in a dilated collecting system are a notable exception since they are easily revealed as echogenic structures within the echo-free urine. In the ab- sence of any dilatation, it is of utmost importance to look for acoustic shadowing (45) caused by concrements or calcifica tions, such as is found in hyperparathyroidism, Depending on its composition, a renal stone (49) can be either completely sound transmitting (as seen in Fig. 42.1) oF so reflective that only its near surface is seen as echogenic cap (Fig. 42.2). The differential diagnosis includes the arcuate arteries between the renal cortex and medullary pyramids (right echoes without shadowing), vascular calcifications in diabetic patients, and calcified fibrotic residues following renal tuberculosis, Finally, papillary calcifications can oceur Renal Stones and Infarcts after phenacetin abuse. Large staghorn calculi are difficult to diagnose if the distal acoustic shadowing is weak and its echogenicity mistaken for the central echogenic complex. If renal concrements dislodge and migrate from the in- trarenal collecting system into the ureter, they can, depend ing on their size, pass into the bladder without symptoms or with colics, or become lodged and cause ureteral obstruction. In addition to detecting obstructive uropathy, sonography can exclude other causes of abdominal pain, such as pan creatitis, colitis, and free fluid in the cul-de-sac. Renal emboli or renal arterial stenosis can cause localized renal infarcts (71), which, conforming to the vascular distribution, are broad-based at the renal surface and apered toward the renal hilus, Sonographically, they are seen as triangular defects (Fig. 42.3) in the renal parenchyma (29). The resultant scars are as echogenic as renal calculi but should not be mistaken for concrements on the basis of their form and localization. Fig. 42.26 Fig. 42.35| Kidneys In contrast to fluid-filled cysts, Solid Fenal tumors exhibit in- ternal echoes and have only weak or no distal acoustic en- hancement. Benign renal tumors (fibromas, adenomas, hem- jomas) are altogether rare with no uniform sonomo phology. Only the angiomyolipoma, a benign mixed tumor comprising vessels, muscular tissue, and fat, has in its early stage a characteristic sonographic presentation that sepa- rates it from a malignant process. A small angiomyolipoma (72) is as echogenic as the central echo complex and clearly demarcated (Fig. 43.1). With increasing size lipomas become heterogeneous, rendering their differentia tion from malignant tumors more difficult. ‘angiomyo: Small renal cell carcinomas (hypernephromas) are often iso-echoic with the remaining renal parenchyma (29). Only with further growth do the hypernephromas (54) b heterogeneous and space-occupying with bulging of the renal contour (Fig. 43.2). If a hypernephroma has been detected, the renal vein, related lymph-node-bearing sites, and con- tralateral kidney have to be carefully scrutinized for neoplas- tic changes, About 5% of renal cell carcinomas are bilateral, and advanced carcinomas can have vascular invasion with in. travenous tumorous extension. If the tumor extends beyond the renal capsule and infiltrates the adjacent psoas muscle, the kidney loses its respiratory mobility. Renal Tumors ‘The left (adFehial/Bland lies anteromedial (not cranial) to the upper renal pole. The right adrenal gland extends posteri- orly to the inferior vena cava. In adults, neither of the adrenal glands is visible, or only barely visible, in the perirenal fat Hormone-producing adrenal tumors, such as an adenoma in Conn syndrome or hyperplasia in Cushing syndrome, are generally too small to be detectable sonographically. Only clinically manifest pheochromocytomas are often already several centimeters in size and can be sonographically de tected in 90% of cases Sonography plays a more important role in the detection of adrenal metastases (54) (Fig. 43.3). Metastases are usu- ally seen as hypoechoic lesions between the upper renal pole and spleen (37) or inferior hepatic surf must be differentiated from atypical renal cysts ( The hematogenous spread of metastases is attributed to the exquisite vascularity of the adrenal glands and can be found with bronchogenic carcinomas as well as with carcinomas of the breast and kidney. Whether or not a suprarenal space- ‘occupying lesion is malignant cannot be deduced from the le- sion’s echogenicity. Before proceeding to a needle biopsy, a pheochromocytoma must be excluded to avoid precipitating a hypertensive crisis. Fig. 43.2bi: 5| Kidneys Renal transplants can be in either of the iliac fossa and are connected to the iliac vessels. Like the orthotopic kid- neys, they are sonographically ex- amined in two projections (Fig. 44.1), but the transducer is placed over the lateral aspect of the lower abdomen, No interfering intestinal air is present because of the superficial position of the transplanted kidney just beneath the anterior abdominal wall aata It is crucial to detect a [rejection Or other complications carly (compare p. 45). It is normal for a renal transplant to show an often permanent increase in size by up to 20% after surgery. In comparison with the native kidneys, its cortex (29) appears wider (Fig. 44.2) and the par o that the medullary pyramids (30) become bet- ter demarcated. Progressive inflammatory infiltration must be excluded by serial sonographic studies, which should be obtained at short intervals during the immediate postopera- tive period. A prominent renal pelvis or a slightly distended (first degree) collecting system (compare Figs. 40.1, 40 1 be observed without requiring intervention because of functional impairment of the renal transplant. The urinary distention should be documented and measured in cross see ichymal echogenicity Renal Transplant: Normal Findings Fig. 44.1b tion (Fig. 44.3) to avoid missing on subsequent studies any progression that might require therapeu ntervention. The renal transplant should be further evaluated for the distinctness of its outline and its interface between the parenchyma (29) and collecting system (31). An indistinct PP-interface or a slight increase in volume can be warning signs of the onset of rejection. To allow a valid comparison, reproducible longitudinal and transverse diameters should be selected for measurements and documentation (compare p.45). After transplantation, the immunosuppressive medi- cations can gradually be reduced and the intervals between the sonographic studies extended.5| Kidneys For an (aceuirate assessment OF it818i7€, the renal transplant has to be visualized longitudinally first (Fig. 45.1b) and the position of the transducer then adjusted until the maximal length comes into view. The diagram (Fig. 45.1 a) illustrates a line too far lateral (dotted line) that would measure a spuriously short distance. To get to the “true” longitudinal di mension (d) the transducer has to be tilted along the straight Thereafter, the transducer is slightly turned (Fig. 45.1.6) ulation along the curved arrow uiding the trans. until there is no longer a (Fig. 45.1). This two-step approach to ducer should assure that the length documented is not too short, which could lead to a spurious inerease in the caleu- Renal Transplant lated volume (simplified volume formula: vol = A x Bx Cx 0.5) on follow-up examinations. A lymphocele (73) can develop as a (Géifipligation after Fenal transplant surgery (Fig. 45.2) and is usually found between the lower pole of the renal transplant and the uri: nary bladder (38), but can be anywhere adjacent to the trans- plant. Urinary obstruction (87) is an equally frequent compli cation and, depending on its severity, might require tem: inage (59) (Figs. 45.3, 45.4) to prevent dam age of the renal parenchyma (29). Measuring the RI of the supplying renal vessel by Doppler sonography provides addi. tional information concerning the condition of the renal transplant porary stent dr Fig. 45.2b Fig. 45.3b | Fig. 45.46Itis the goal of this workbook to provide factual knowledge and to facilitate memorization by means of most effective teaching strategies. This should facilitate immediate and rapid recall from memory whenever nei Empirically, it has been shown that beginners in sonography sary at a later time. IE From memory, draw a typical transverse section of the right kidney at the level of its hilum, including its position, relative to the liver and inferior vena cava, How would the corresponding body marker look? Compare your drawing with the diagram shown on page 37 (the body marker has been left out intentionally), Try, by means of a sketch, to characterize the different shapes of the normal kidney, the kidney with prominent vessels, and the kidney with mild to severe (grade I 10 grade Il) dilatation. Discuss with a fellow trainee the ct teria that differentiate these five possibilities. It is not the other trainee’s lack of comprehension but your fault if your he or she cannot reconstruct the findings you de- scribe. Compare your sketches afterwards with Figures 37.26, 41-1, 40.2b, and 40.3). EI How would you recognize a nephrolithiasis? What possible underlying conditions are there? By consulting a textbook, try to list the possible causes of hematuria (blood in the urine). List the sonographic criteria of a renal angiomyolipoma. Why can it be difficult to differentiate its findings from other renal tumors? FH Write down the normal values for the longitudinal and transverse diameters of the kidneys, for the width of the renal parenchyma, and for the respiratory mobility. Com 37 pare your values with those listed on p. Gi Review carefully the sonographic images provided and write down next to each image all visualized organs and muscles as well as your diagnosis, including your reasons. for arriving at this diagnosis, After you are done, compare your results with the answers given on page 77. Quiz for Self-Assessment become faster and better oriented with the three-dimen- sional abdominal space if they are able to sketch the few standard orientations from memory. Do not get annoyed at the following questions: there are no better teaching methods that relate new material in a shorter period of time.Fig. 47.2a Fig. 47.3b Normal Findings The (spleen is Visualized in the right lateral decubitus position with the p: taking a deep breath (Fig. 47.2). The costal space to avoid interfering acoustic shadows (45) that arise from the ribs. The spleen is carefully scrutinized from the diaphragmatic dome (13) to the level of its hilar vessels (20) (Fig. 47.1), ient sducer is placed parallel to the inter Frequently, visualization of the spleen is compromised by air in the left lung (47) or in an adjacent intestinal loop (43). Normal splenic measurements “are 4x7x 11 om ("4711” rule), whereby the maximum diameter measured in this visu alized plane between hilum and diaphragmatic surface of the spleen should be 4em Fig. 47.2b Fig. 47.2¢ Suggestion: If the inspiration is too deep, the lung (47) extends inferiorly into the diaphragmatic angle and ob. scures the subdiaphragmatic portion of the spleen (Fig. 47.3). In this situation the “eutain triek” should be tried by asking the patient to exhale slowly fol- lowing maximal inspiration until. the spleen becomes visible (Fig. 47.4). Like a curtain, the lung frequently recedes before the spleen (37) moves back up. ward. During this asynchronous rate of retraction, the moment has to be watched for when the acoustic shadows (45) from the lung no longer interfere with visualization of the spleen, A\ point, the patient has to be asked to hold his or her breath, Occasionally, the spleen is better seen in the supine than in the right lateral decubitus position. 6| Spleen Many conditions are associated with /@iffUse\enlargement of the spleen, and the differential diagnosis does not only in- clude portal hypertension (Fig. 48.2) secondary to hepatic cirrhosis but also viral infections, such as mononucleosis. Furthermore, all diseases causing an in erythrocytes, such as hemolytic anemia and polycythemia vera, can produce a splenomegaly (Fig. 48.3). ased turnover of Splenomegaly typically: aécompanies systemic hemato- logic diseases, such as acute or chronic leukemia (Fig. 48.1 in CLL), but can be found in rheumatic, immunologic storage diseases. Not every splenomegaly is of pathologie rel- evance since many diseases heal by leaving behind a mild to moderate splenomegaly, for instance mononucleosis. The en- largement of the spleen (37) begins with a rounding of its normal erescentic configuration (Fig. 47.2) and can progress to the so-called “giant spleen.” The massively enlarged spleen can touch the left hepatic lobe and this is referred to as kissing phenomenon.” Occasionally, an ageessory spleen can reach a considerable size. Accessory spleens (86) Diffuse Splenomegaly (Fig. 48.1) are generally located at the splenic hilum or adja. cent to the lower splenic pole and cannot always be differen- tiated from enlarged lymph nodes (55) (Fig. 48.3) Suggestions: If the sonographic examination of the abdo- men reveals a splenomegaly, a systemic hematologic condi tion must be considered and jal node-bearing areas of the abdomen should be explored for any lymphadenopathy (sce pp. 14 and 21). Furthermore, portal hypertension should be excluded by measuring the luminal diameter of the splenic vein (20), portal vein, and superior mesenteric vein and by searching for portocaval collaterals. The size of the spleen should be measured accurately. Only by having a baseline measurement of the splenic size can subsequent examina- tions determine any interval growth. Questions that sub- sequent examinations might address, such as possible inter- val growth during therapy, should already be kept in mind during the initial examination, Neither size nor echogenicity of the spleen allows any inference as to the nature of the un- derlying condition.6| Spleen Areas that are hypoechoic in relation to the remaining splenic parenchyma include as possible causes all foeal Iymiphomatous infiltrations. In non-Hodgkin lymphoma, these Ivmphomatous infiltrations ean be localized as well as diffuse throughout the spleen giving it a heterogeneous ap- pearance. Congenital (dysontogenetic) splenic cysts are rather uncommon and do not differ sonographically from he- patie cysts (64) (Fig. 29.1), thus they are not illustrated again he c. Acquired splenic cysts frequently develop after trauma or infarcts, est a parasitic origin (compare Fi As is true for hepatic cysts, internal septations 3). Recognizing a |splenie hematoma (Fig. 49.2) might be dif ficult since a fresh hemorrhage can be iso-echoie with the sur- rounding splenic parenchyma (37), In general, the echogen- icity of the extravasated blood decreases within a few days, and subacute or old hematomas (50) are usually well visual- ized as hypoechoic space-occupying lesions. A parenchymal laceration without a capsular tear can produce an initially un, recognized subcapsular hematoma, The risk of such a hema toma is a delayed tear of the splenic capsule, which releases the tamponaded hematoma and causes free bleeding into the abdominal cavity. More than 50% of splenic ruptures occur within 1 week after the these so-called ‘delayed’ Focal Splenic Changes trauma, and itis advisable during this interval at least to per form serial follow-up studies. Finally, the spleen can exhibit (GeHOZEHIC TOG. They could represent splenic hemangiomas, which are rare. or calcified granulomas, which are rather common and usually found with tuberculosis or histoplasmosis, Splenic calcifications can also accompany cirrhosis. A spleen harboring multiple echo: genic foci (53) has been called the ,starsky spleen’ (Fig. 49.3). Splenic abscesses and splenic metastases, which are rare, can have a rather varied sonomorphology, in part depending on their duration and underlying cause. There are no simple reliable differential diagnostic criteria, and consul tation of reference textbooks is recommended. Splenic in- farets (71) can be observed in splenomegaly with com: promised vascular supply (Fig. 49.1), Suggestion: Patients with acute abdominal and thoracic trauma should be searched for free fluid in the cul-de-sac and below the diaphragm (13) as well as around the spleen and liver, Carefully scrutinize the spleen for a double contour along its capsule (subcapsular hematoma?) and for a hetero: neous echo pattern of its parenchyma, to avoid overlook possible splenic rupture. Fig. 49.2b Fig. 49.3 49e 6| Spleen Quiz for Self-Assessment The material about the spleen presented in the preceding tained in the text, and the answer to question 5 is found on three pages should have prepared you to answer the follow- page 77. ing questions. The answers to questions 1 to 4 are con HB What are the diameters (maximal values) of a normal I What structure frequently superimposes air over the spleen and how can this be remedied? Bi What must the examiner search for in patients who have sustained a blunt abdominal trauma? How should the examination be extended if a splenomegaly is found? BB Examine this image of a clinical Wh aphic section is it? What organ is primarily shown? What other structures can be seen’ Is the parenchymal pattern normal? If the answer is negative, how can the changes be de- scribed? Try to give a differential diagnosis 1 step by step: Notes‘The endosonographic presentation of the mural layers ofthe Gl tact: Stomach The normal lili AV8HS of the GI tract can be seen in Figure $1.1. Abdominal sonography at best shows three (c,d, ) of the five mural layers. The transducer is placed over the left upper quadrant of the abdomen (Fig. S1.2a). In the NPO patient the mural layers (74) of the gastric antrum (26) can be seen behind the liver (9) and directly in front of the pancreas (33) (Figs. 512), e). Air shadowing (45) precludes a reliable evaluation in patients who have meteorism or are postprandial If the stomach is markedly distended (Fig. 51.3), wall-based tumors (S4) oF muscu- lar thickening ax manifestation of pyloric hypertrophy (Figs. 51. must be looked for. Depending on its state of contraction, the [i8tFEWAll should measure 5-7 mm and the hypoechoic lamina muscularis by itself not more than S mm, Any suspi- cious gastric lesions should be further evaluated by gastroscopy or radiography Fig. 51.2b Fig. 51.3b Fig. 51.5b7 | Gitract _= Colon Fig. 52.1 Fig. 52.1 The ascending Golon can be seen in the lateral sagittal see- 2.1.4). In most cases, air in the colon pr sualization of its lumen. Large amounts of retained fecal mat ler (coprostasis) can occasionally be found in the colon of ald patients. A transverse colon (43) without any evidence of in- Hlammatory mural thickening (transverse section of the Fig. 52.1¢ upper abdomen) is shown in Figures 52.1b and ¢. This con- trasts with the thickened wall (74) found in ulcerative colitis or ischemia (eg. due to mesenteric artery infarction or mesenteric vein thrombosis), as seen in a case of colitis (Fig. $2.2) in which the descending colon exhibits strikingly thickened haustral indentations, Fig. 52.2¢ Fig. 52.3¢ Diverticulitis is a complication of Wiverticul6sis €6li (sac-like mucosal projec- tions through the muscular layers of the colonic wall), The neck of the diverticulum, (®), as shown in Figures $2.3 and ¢, connects the normal colonic lumen (43) and the hypoechoic diverticulum (§4). The associated edema of the colonic wall (74) is demonstrated by the CT performed on the same patient (Figs. $2.3a, d). The recto- igmoid junction is still well demarcated from the hypodense fatty tissue (black). while the colonic wall is indistinct in outline in the immediate proximity of the diverticula ($4) due to inflammatory obliteration and thickening of the adjacent fatty tissue. Fig. 52.37 | Gitract Because of air in the intestinal lumen, the sonographic eval- tion of small bowel loops (46) is often limited or not possible at all. However, the intraluminal air frequently decreases when itis surrounded by inflammatory wall thick- ening or can be reduced by graded (!) compression applied to the transducer. (CFORA|WISEARE frequently presents as terminal ileitis, (Fig. 53.1). The edematous wall thickening (74) confined to this segment is easily separable from adjacent uninvolved loops (46). In more advanced stages (Fig, 53.2), the intestinal ‘wall (74) becomes massively thickened and can resemble the sonographic findings of intestinal invagination. On cross sec tions, the thickened, edematous walls of intestinal loops can be compared to a concentric lamellation of a “target.” The examiner should always look for adjacent fistular tracts or abscesses as well as for free abdominal fluid in the cul-de-sac The [ileSChtGFIE FOES of individual small bowel loops are normally not identified, but can be delineated in the preset of extensive lymphadenopathy or massive ascites (68). The small bowel loop seen in cross section (46) floats within Small Bowel ascitic fluid (Fig. 53.3) that is devoid of internal echoes ex: cept for reverberation artifacts from the anterior abdominal wall (2, 3) (compare p. 10). Lymphomatous infiltration of the small bowel often leads to long segments of hypoechoic wall thickening and is primarily observed in immunocom promised patients, High frequeniey transducers (> 5 M7) can add informa tion in selected cases if used. for instance, intraoperatively to exclude mesenteric lymphadenopathy: If a tender appendix shows no peristalsis, has reduced or no compressibility, and measures more than 6 mm in diameter, it fulfills the criteria of acute appendicitis. Sonography has the advantage of al- lowing real time evaluation of intestinal peristalsis, easily re vealing aperistalsis (atony) or prestenotic hyperperistalsis. Though it is often necessary to proceed with other imaging modalities (endoscopy, endosonography, conventional radi ology, CT) because of acoustic shadowing (48) by intestinal air that limits the sonographic evaluation of the small bowel sonography can still make a contribution if properly targeted in selected cases. 53i 5 Urinary Bladder The (tiFinaryblaWder is systematically sereened in suprapubie transverse ig. S4.1.a) and sagittal sections usually achieved after the intake of a large amount of fluid, A representative transverse section (Fig. 54.2) shows the normal bladder (38) in the shape of a rounded ree- tangle behind the rectus muscles (3) and in front of and above the rectum 43) The lor triangle (F respectively, seen below the bladder (compare {tudinal section delineates the bladder more as a 54.3), with the prostate gland (42) and vagina, 58.1), I voiding difficulties due to a neurogenie bladder or pros- latic hypertrophy (Figs. $6.2, 56.3) are suspected, the post void residual should be calculated by measuring the maxi mum transverse and sagit I diameters of the bladder after the patient has voided (Fig. 54.2b). Thereafter, the trans- ducer is turned 90° and angled inferiorly (Fig. 5434) to Normal Findings, Volume Measurements measure the craniocaudal diameter (horizontally displayed on the image) without interfering acoustic shadowing (45) of the pubic symphysis (48) (Fig. 54.3). Using the simplified volume formula (volyy = A x Bx Cx 0.5), the \postvoid residual (ml) can be calculated by dividing the product of the three diameters by two. Find out which diameter in the case shown in Figure $4.3b has been incidentally measured twice?8 | Urinary Bladder Thelwall (77) atid NaMeH (38) of the urinary bladder can only be adequately evaluated when the bladder is full. An indwelling catheter (76) usually results in an empty bladder (Fig. 58.1), precluding any reliable evaluation. The catheter therefore should be clamped for an extended period to achieve filling of the bladder (38). When the edema of the bladder wall (77) is rather advanced, cystitis (Pig. $5.2) can also be recognized with the bladder empty. The {Will thickHeSS/6P the distended bladde® should not exceed 4 mm. After voiding, the wall is irregularly thie! and measures up to 8mm in width, Wall-based tumors or polyps can no longer be detected, Wall thickening can be caused by inflammatory edema, increased trabeculations due to prostatic hypertrophy with bladder outlet obstruction, or a space-occupying lesion Even the (HGaIRYNBHGUGF is never entirely echo-free Often, reverberation artifacts (1) of the anterior abdominal Indwelling Catheter, Cystitis, Sediment wall (Fi in the bladder (38) anteriorly, or sec tion thickness artifacts posteriorly, simulating intraluminal matter (compare p. 10). These artifacts have to be differen tiated from the real sedimentations of blood clots ($2) or concrements (49) along the floor of the urinary bladder (Fig. 55.3), By rapidly changing the pressure applied to the transducer intraluminal matter can be mechanically dis- A section thick ness artifact or wall-based tumor lack any response (0 this turbed and made to float within the lumen. AAs an incidental finding, a forceful jet of urine can be pro pelled from the ureteral ostium into the bladder lumen. This jet phenomenon is physiologic. If transabdominal sonog raphy is inconclusive, transrectal or vaginal transducers should be used. These endocavitary transducers. generally have a better resolution because a higher frequency can be used due to the shorter distance to the target organ. These special examinations require additional expertise and train Fig. 55.34 Fig. 55.1b Fig. 55.3bIransabdominal sonography of the genital organs requires a filled urinary bladder (38), which displaces the air-contain ing intestinal loops (46) cranially and laterally to avoid their interfering shadows (45) and serves as an acoustic window. The prostate gland (42) is located on the floor of the bladder anterior to the rectum (43) and is visualized on the supra pubic transverse section and on the sagittal longitudinal sec tion (Fig. 56.1). ‘The ‘normal prostate gland should not exceed the approximate size of 3.x 3x5 em or the approxi mate volume of 25 ml. In older men, gland is frequently encountered ( an enlarged prostate ), which interferes 56 Prostate Gland, Testicles and Scrotum with voiding and can lead to a trabeculated bladder ( pare Fig. 55.2) The [enlarged prostate land (42) clevates the bladder floor (38), but the urinary bladder remains outlined by a wall that is seen as a smooth line (Fig. $6.2). Advanced pros- latic hypertrophy stenoses the urethra, causing hypertrophy of the bladder wall, that beomes visible as a thick rim (77) around the bladder (Fig. 56.3). The carcinoma of the pros- tate gland (54) usually arises in the periphery of the gland, can infiltrate the bladder wall and extend as a lobulated mass into the lumen of the bladder (Fig. $6.3), The normal ‘testicle (98) of the adult male is homogeneously hypo cchoic, sharply demarcated from the layers of the |serottum (100), and measures about 3x4em (Fig. 56.4) The epididymis (99) sits on top of the upper testicular pole like a cap and ex. jends along the posterior testicular wall, In children, both testicles should be visualized together in the scrotum on the transverse section to exclude an with certainty undescended_ testicle (refer to p. $7), Fig. 56.4 Fig. 56.4bI both testicles are not found in the scrotum after the age of 3 months, the question of localizing the (WHUeSeENUeU GF BCtOpIC cesticle (98) is found in the inguinal canal near the anterior abdominal wall (2, 5), raphic detection of an undescended or ectopic testicle, which is at risk of malig: testiclés must be addressed. Frequently, the as seen in An unsuccessful sone nant transformation, should be supplemented by an MR examination. oin demands differ rntial diagnostic clarification between inflammation and torsion since the The sudden onset of severe scrotal pain radiating into th ischemic tolerance of testicular tissue before irreversible necrosis is only 6 hours. In inflammation, perfusion is maintained, and can be seen by (color) Doppler sono- graphy as a characteristic arterial flow profile ( ) in the testicular tissue frequently increased on the affected side, Torsion, in contrast, shows decreased perfusion in relation to the other side or lacks perfusion entirely Fig. 57.14 Fig. 57.1b OFehItIS SE ePIAIAVMAIEIS is usually accompanied by — OEElE is established by the Valsalva maneuver or color edematous thickening of the testicle (98) or epididymis (99) coded Doppler sonography. Occasionally, herniated bowel If the findings are inconclusive, comparing both loops (46), a hydrocele (64), and the ipsilateral testicle (98) sides to determine their relative size can be helpful. A can be visualized together on one sonographic section thickened and partially multilayered scrotal wall (100) can be A hydrocele can accompany a testicular malig seen as manifestation of an accompanying edematous reac- nancy. Most, but not all, t@StiGilaf {MORE cause a hetero: ion, geneous parenchymal pattern. A well-differentiated semi A homogeneous anechoie fluid collection (64) invariably noma can be homogeneous and present as an unremarkable epresents a hydFocele The diagnosis of a ‘Vati= sonographic pattern. Fig. 57.5a Fig. 573b Fig. 57.4b Fig. 57.5b10 os To visualize the [atertis (39) and (Ovaiés (91), transabdominal sonographic im nary bladder (38) as acoustic window (Figs.5t ng of the lesser pelvis requires a distended -¢). To Fig. 58.14 Better visualization can be accom: plished by using eiidévaginaliprobes (Fig. $8.2), which can be positioned close to the targs ‘organs of the uterus (39) and ovaries (1) (Fig. $8.3) and can be operated at (5-10 MHz) with her spatial resolution, er frequencies a correspondingly Transvaginal sonography can be performed without 1 filled urinary bladder Fig. 58.20 In acquil upside down, located inferiorly in the body and at the inferior border of the images) upward (superiorly). This orientation, to which the novice is unaccustomed, shows the urinary bladder (38) ;mparison to transabdominal images, the images are 1d from below and the endovaginal im: The sound waves propagate from the probe Normal Findings achieve the necessary depth penetration, low frequencies (3.5-3.75 MHZ) with the corresponding decreased spatial res olution have to be selected (refer to p. 8). cranial poster ¢ anterior \~ [caudal sagittal view Fig. 58.2b and the anterior abdominal wall (1-3) at the upper border on coronal images, far away from the probe. On sagittal sections (Fig. $8.3), the urinary bladder is on the right side of the if viewed from the right side of the aminers prefer the images as viewed from the left side, with image tient. Some ex the anterior structures then seen on the left side of the image Fig. 58.3¢pemaieaenal organs The width of the (@ndOmettiuin’ (78) varies with the men- an echogenic rim (:) After ovulation, the midline strual cycle: immediately after menstruation, a thin, echo- echo (+) gradually disappears in the secretory endometrium ‘echo is seen At the time of ovulation, until only an e nic endometrium is reco genic, linea the endometrium is separated from the myometrium (39) by nized. Fig. 59.14 Fig. 59.1b Fig. 59.2b Fig. 59.3b The homogeneously _hypoechoi formal imyometfium can be traversed by vessels Corpus (39) a in echogenic 1 (H) of the endometrium (78) ould be thinner than 1S mm, and post {appear as anechoic areas cervix (40) donor differ menopausal thinner than 8 mm, unless obliquity, the endometrial heii should only be measured on the long tudinal uterine section, An intrauterine WeviEe(IUD) (92) flection with posterior shadowing (48) and should be within the fundic region of the uterine cavity. The distance of the IUD (@) from the upper end of the en: dometrium should be less than 5mm and from the pole of the fundus (D) less han 20 mm An increase in hese distances stiggests an IUD thatis dislocated toward the cervix, (40) and provides inadequate contra- ception,10 | Female Genital Organs 0. The normal uterus is demarcated by an echogenic serosa and hypoechoic myometrium (39) The most common benign uterine tumors, the fibroids (myomas). arise from the smooth musculature and are usu: ally located in the corpus of the uterus. For planning the sur gical enucleation of fibroids, itis relevant to distinguish intra: transmural (Fig. 60.1) and submucosal (Fig. 60.2) fibroids from subserosal fibroids on the surface of the uterus 60.3) (54). The submucosal location close to the uterine exhibits a homogs Fig. 60.1b Fig. 60.2b In menopause, OFMONE FEplACeMent {hEFAPY with estrogen can lead to estro gen producing ovarian tumors, or persistent follicles can induce endometrial hyper- which can eventually transform adenocarcinoma (84) if the high plasia 4 estrogen levels are maintained (Fig endometrial thickness exceeding menopausal, respectively), Malignant crite 1S or 8mm cal os, for instance after conization, and by a cervix tumor include conspicuous [premenopausal heterogeneous echogenicity, and an irregular outline A hypoechoic collection of blood («) in the uterine cavity (hema. ) can be caused both by postinflammatory adhesions at the cervi mors of the Ut cavity can easily mistaken for endometrial polyps (65). Fi- broids usually have a homogeneous or a concentrically lamellated echo pattern with distinct demarcation and a smooth surface, but can contain calcifications with corre- sponding acoustic shadowing or a central necrosis. The size of fibroids should always be measured and controlled by serial examinations to discover the rare sarcomatous transforma- tion by revealing any rapid growth. Only in early pregnancy can a sudden increase in size be attributed to a benign lesion. Fe Fig. 67.1b Fig. 67.2b Cerebrospinal fluid Spaces! The (ehoroid plexus can harbor small, unilateral cysts) enerally without pathologic consequence. Bilateral cysts however, are associated wi malformations. A hydrocephalus as seen with aqueduct stenosis or as isomy 18 and, less frequently, with renal and cardiac part of a spina bifida, is accompanied in 70-90% of cases by other intra- and extra cerebral malformations. After the 20th gestational week, the ratio of the ventricu lar to the hemispheric diameter, also called the ventricular index. is used for as alus, sessing the ventricles, with a ratio of 0.5 considered indicative of hydroc The ratio at the level of the frontal horns (AHVR) is slightly exceeded by the ratio at the level of the occipital horn (PHVR) Measuring the diame the ventricles and hemispheres can be difficult because the lateral vent often is not clearly demarcated from the cerebral parenchyma Fig. 67.62 Fig. 67.66Spina bifida consists of incomplete closure of the spinal canal together with a defect in the spinal arches of varying The spine (35) i and coronal degree isualized in the sagittal plane, Subsequently each vertebra is reviewed in the transverse plane in a craniocaudal direction Fig. 68.2b In spina’ bifida centers are splayed laterally and the spinal open (- =). Measuring the maternal serum a-fetoprotein identifies only spina bifida aperta, but not the covered form, both posterior ossification since this will best reveal any interruption of the chain of the posterior elements, including the spinous process. The t must delineate the three ossification centers (35) of each segment as a triangle of closely adjacent structures. The fetal aorta (15) is seen anteriorly spina bifida occulta. The indirect sonographic signs of spina bifida ( signs) have already been il- lustrated on page 67 Fig. 68.44 Fig. 68.4bTransverse and coronal sections of the face are usually ‘orbital Facial bones and neck evaluated for decreased (hypotelorism) or increased (hypertelorism) int distance, and the sagittal sections for an atypical profile. A lip-palate cleft generally is lateral and can best be appreciated a coronal section, The normal upper lip (+ 1 gap in the echogenic upper lip on the » ) appears as continuous structure Nuchial translueeney(NT): After the Ist trimester, edema of the facial soft tis sues or cervical subcutaneous tissue (hygroma colli) that exceeds 3 mum in width in dicates imparied lymphatic drainage and in one third of cases itis associated with chromosomal abnormalities, such as monosomy X (Turner syndrome), trisomy 21 (Down syndrome), and trisomy 18, To distinguish @ prominent nuchal membrane from an amniotic membrane along the posterior cervical area, the finding should >vements have heen observed. Furthermore, a tangen: tially visualized cervical skin can mimic a double contour (-) which i in variably less than 3 mm in width. The more severe the elevation of the posterior cervical skin and the older the mother, the more likely a chromosomal abnormality be re-evaluated after fetal m Fig. 69.2b Fig. 69.3b z0 Let Fig. 69.4b 69 Fisk for foil wie Ba Negi 209 [year | Fig. 69.2¢ HYdFOpSNCHATISE Increased fluid retention in sufficiency, metabolic disorder, infec tion-induced or congenital fetal ane mia, rhesus immunization, mosomal abnormalities. In monochorionic twins, the hydrops ‘of one twin is caused by fetofetal trans. fusion through arteriovenous shun In addition to showing an ascites (68) sonography can visual ize pleural and pericardial effusions (79) and possibly a general ized cutaneous edema.> ___T1] Pregnancy Heart aad VeSels; The (cardiovascular system is the first functioning organ system of the fetus. As from the 6th ges- tational week, fetal heart motion can be seen. Absent fetal heartbeats and growth retardation, usually accompanied by indistinctly outlined erally require dilatation and curettage. Because of their high sound energies, Doppler and color Doppler sonography should be used selectively, for instance, in cases of suspected growth retardation or cardiac malformation (refer to p. 63). fetus, indicate fetal demise and First, the pOSitiGA OF thE!hEar has to be determined: it should be one third to the right and two-thirds to the left of a straight line drawn from the spine to the anterior thoracic Fig. 70.1 Fig. 70.26 A small ASD or VSD as well as cardiac anomalies with right-to-left shunts can be definitively excluded only by color-coded echocardiography performed by an. ex- perienced examiner. Transposition of the great arteries Diagnosis of Fetal Malformations wall on the transverse section. The sagittal section must be oriented to visualize the aortic arch (18) and its brachio- cephalic branches (82, 117, 123) (Fig. 70.1). In addition to the cardiac valves, the four-chamber view should identify both atria (116) and both ventricles (118) (Fig. 70.2) and exclude any ventricular septum defect (VSD) or atrial septum defect (ASD). By tilting the probe slightly from this plane, the in- flow of blood into the left ventricle through the mitral valve (118) as well as the outflow through the aortic valve (119) can be visualized in this so-called ffive-chamber view (Fig. 70.3) Moreover, a VSD in the membranous portion of the septum is better delineated in this plane. (TGA) might not be apparent on the four-chamber view and itis therefore necessary to look for crossed outflow tracts and aortic and pulmonic valves on the short axis view.11| Pregnancy Diagnosis of Fetal Malformations The evaluation of the (GIitfaet’ must among other findings, exclude a ‘double bubble” sign, which would suggest a duodenal atresia or stenosis, The anechoie “bubbles” correspond to. the stomach and to the duodenum pro: ximal to the stenosis, respectively, both filled with fluid. This finding should be confirmed in a second plane, to avoid a false positive diagnosis due to double sectioning of the stomach in a tangen. tial plane. It should be kept in mind that a hernia of the anterior abdominal wall (120) (Fig. 71.1) next to. the imbilical vessels (96) is physiologic intil the 11th gestational week and should not be mistaken for a true om: phalocele. Fig. 71.1b After the 15th gestational week, [renal mlfOrmalions are The normal renal parenchyma (29) already shows the less often indirecily revealed by a decreased amount of amniotic echogenic pyramids (30) separate from the anechoic collect uid (oligohydramnios) or its absence (anhydramnios) or by ing system (31) on the longitudinal section (Fig, 71.2). A an empty urinary bladder because the amount of amniotic summary of the intrauterine growth of the kidney is found in fluid corresponds to the renal excretion of urine at this time. Figure 71.2¢ E a Sm 5 . 290 [week *_neeeese Fig. 71.2a Fig. 71.25 Fig. 71.2 Obstruction of the collecting system as seen with ureteropelvic stenosis, is best recognized by comparing both sides on a transverse section through the renal hilum (Fig. 71.3), Polycystic renal disease becomes manifest in adulthood (type Potter IID), prenatally as numerous visible renal cysts (type Potter II), or as a microcys: tic, hyperechoic kidney (type Potter 1). Type Potter III polycystic renal disease might induce a prenatal, diffusely in- creased echogenicity, but this coexists Fig. 71.34 Fig.71.3b with a normal amount of amniotic fluid and a filled urinary bladder.Skeletal System: In the second and third trimester, /haindS and f8et development of the phalangeal ossification centers (121) and the metatarsal bones (122). In this way, syndactyly as part of other congenital malformation syndromes can be excluded. are checked for complete Furthermore, supernumerous phalanges can be found, such A polydactyly can be associated with shortened ribs and concomitant pulmonary hypoplasia. Not only are the shortened also the bell-shaped thorax. bs apparent, but The search for a @liibf66t anomaly should not be ne lected The clubfoot does not only appear club-like deformity, but also as deviated shortened tubular Impaired enchondral ossification as part of aehondto- plasia is frequently recognized only in the 3rd trimester by shortened tubular bones and a head of disproportionately large appearence111| Genitals and Prenatal Diagnosis To conclude this section, you can again test how much detail you remember and how much still has to be memorized. The answers to question 1 and questions 3 to 6 can be found in the Bi An 18-year-old male patient presents with severe pain in the let scrotum, of sudden onset 3 hours ago ing into the left groin, What is your presumptive diagno sis? How much time do you have to proceed” What sone graphic method do you select? BUA Si-year-old female patients referred to you fora sono phic evaluation of the pelvis. The patient had her menopause at the age of 52 years and currently does not take any hormone preparation. Endovaginal sonography produced the finding illustrated in Figure 73.1. The en ometrium measures 18 mm in width. What diagnosis do you suspect and what measures do you initiate? BI How do you recognize impending ovulation sonographi cally? What are the postovulatory changes? How many days after the last menstruation/after fertilization can the successful implantation be documented sonographically? Write down the six biometric measurements next to this, text. Add to each parameter the first and last gestational week of its meaningful application. At what gestational week is one parameter replaced by another parameter? BH What are the direct and indirect sonographic criteria of spina bifida? Is a blood test of the mother sufficient? GH What renal malformations do you know? Name at least three sonographic criteria, Quiz for self-assessment What is the imaging plane? Try to give a differential diagno sis for both cases. The answers can be looked up on page 77. Questions for Self-Assessment preceding pages, the answer to the quiz. image of question 2 is given on page 77 at the end of the book.Thyroid Gland The thyFoid laid is examined with a 7.5-MH7z linear trans- ducer. With the head slightly extended, transverse sections of he entire gland are obtained or, if the entire width of the gland cannot be encompassed, of each lobe separately sections are obtained hhrough cach thyroid lobe The trachea (84) with its air shadows in the midline and the carotid arteries (82) and jugular veins (83) with their echo-free lumina later ally Serve as general orientation on the transverse sections. The thyroid parenchyma (81) is situated between the trachea and the vessels, Anterior to the trachea, a thin parenchymal hand (isthmus) connects both thyroid lobes (comy Thereafter, sagittal With the patient performing a Valsalva ma down with the vocal chords closed), the jugular veins distend due to blocked venous drainage (F This makes euver (bearing The normal \thyfoid [parenchyma (81) is slightly more echogenic than the anteriorly located sternohyoid muscle Fig. 74.12 Fig. 74.2b Fig. 74.2a Fig. 74.34 indings (89) and the more lateral sternocleidomastoid muscle (85). On cross section ‘what posteromedial in location and is visualized as a round noncompressible structure. In contrast, the jugular vein (83) runs more anterolaterally, exhibits a typical phasic pulse and can be compressed by assess the size of the thyroid gland, the maximum transverse and sagittal (anteroposterior) diameters of each lobe are Both values are multiplied by the maximum length as measured on the e divided by two. Within the result corresponds the carotid artery (82) is some- applying graded (!) pressure. To measured on transverse sections sagittal sections (F and of approximately 10 to the volume (in ml) of each lobe. Excluding the isthmus, which can be ignored because of its small size, the volume of the thyroid g in women. Small thyroid cysts (64) might not cause any distal acoustic enhancement (Fig. 74.3) and must be differentiated from hypoechoic nodules (compare p.75). Intrathyroidal vessels are rarely delineated. and should not exceed 25 ml in men and 20 ml Fig. 74.2¢ Fig. 74.3¢12| Thyroid Gland The most common diffuse thyroid con- dition is iodine deficiency goiter. The thyroid gland (81) is diffusely enlarged and. its echogenicity is slightly en- hanced (Fig. ‘A. homogeneous hypoechogenicity (the thyroid gland hhas become iso-echoie with the muscu: lature) is characteristic of Graves dis: lease or inflammatory conditions such as Hashimoto thyroiditis b Focal changes have to be separated into benign cysts (64) and solid lesions (Fig. 75.3), by employing the usual cri teria that establish a cyst (compare p.29). Solid lesions comprise ade. nomas (54) as seen in Figure 75.4 and nodular degenerative changes as well as malignant prog Diffuse and Focal Changes Fig. 75.1 Anatomy of the thyroid region. Vagus nerve (a, fibrous capsule of thyroid (b, isthmus (c,platysma (4), omohyoid muscle (), skin (1), bcutaneous fat tissue (2 (81), common carotid artery (82), toid muscle (85), anterior and medial scal esophagus (34), sp nternal jugular vein ( us muscles (88), 5 e (35), lateral lobes of thyroid trachea (Bd), sternocleidomas mohyoid muscle (8), sternathyroid muscle (90) Frequently, ailéifieatiOns are encountered in the thyroid parenchyma, generally representing areas of degenerative or postinflammatory regression that do not require further evaluation. The decisive information for further assessment of a hypoechoic nodule is provided by the radionuclide thyroid ‘Scan because the functional status of a nodule cannot be yeraphic features. Scintigraphically functioning nodules (“hot” nodules) primarily correspond to deduced from its son adenomas, (“cold” nd are areas of adenomatous hyperplasia or true non-functioning hypoechoic nodules nodules) must arouse suspicion of mali generally subjected to sonographically tion biopsy whereas aspira Tho! they also should be considered for needle aspiration biopsy unless their true nature can be established by combini results of laboratory tests, sonography, and scintigraphy. hyperechoic nodules are less likely to be mali ee Fig. 75.2b Fig. 75.3bSolution to Fig. 16.2 (question 7) Solution to Fig. 22.1 (question 4) Mal Solutions to the Quiz Solution to Fig. 33.1 (question 6): Sonographic section: sagittal section of the upper abdomen, parame the inferior vena cava (16). Organs: liver (9), heart, and pancreas G3). Structures: diaphragm (13), hepatic veins (10), portal branch (11), conns tive tissue (5), caudate lobe betw. and 16. Abnormal finding: echo-free space be- tween the myocardium and diaphragm. Diagnosis: pericardial effusion (79). wgnosis: epicardial fat, Sonographie section: sagittal section of the upper abdomen at the level of the left renal vein crossing the aorta. Vessels and structures: refer to key on the unfolded back cover. Dilatation?: no, only dilated left renal vein due to compression between aorta (15) and SMA (17), still physiologic. Solution to Fig. 33.3 (question 6) ‘Sonographic section: oblique subcostal section of the right upper quadrant of the abdomen Diagnosis: Focal fatty infiltration (63) of the liver (9) and multiple hepatic metastases (56) with hypoechoic rim. Note: two episodes of spreading since new and older meta- static foci are visible! Differential diagnosis: none, the find- ing is pathognomonic. metastatic Solution to Fig. 36.3 (question 2): Sonographic section: sagittal section long the right MCL Diagnosis: subdiaphragmatic hepatic metastasis ($6) with hypoechoic rim, pleural effusion (69), Differential diagnosis: hemangioma in- stead of a metastasis considering the echogenicity of the lesion, Sonographic section: sagittal section of the right upper quadrant of the abdo- men along the paramedian plane Diagnosis: Hyperechoic, partially het- erogeneous space-occupying lesion (61). Here: hemangioma with draining vein (10) arising from it Differential diagnosis: tumor, hyper: choic metastasis Sonographic secti section of the right upper quadrant of the abdomen, liver (9) Diagnosis: cholecystitis with markedly thickened wall (80), Differential diagnosis: postprandial biliary sludge in the gallbladder, para- sitic involvement of the liver or gall: bladderPatikckorks! Solution to Fig. 46.1 (question 6): Solution to Fig. 46.2 (question 6): Solution to Fig. 50.1 (question 5): intercostal plane of the right flank in left lateral decubi- tus position. Organs: liver (9), renal parenchyma 29) with renal pelvis (31), lung (47), abdominal oblique musculature (4). diaphragm (13), intestinal loop (46) i renal cyst (64) with distal ement (70), \drenal tumor Imaging plane: endovaginal visualiza- tion of the uterus. Diagnosis: endometrial hyperplasia (7%) >8mm_ in a postmenopausal woman without estrogen replacement therapy (refer to question). Recommendation: fractionated dilata tion and curettage to exclude an endo- metrial carcinoma. Sonographic section: intercostal plane Of the right flank in left lateral decubi- tus position. Organs: liver (9), abdominal oblique vasculature (4), interstinal loop (46) with acoustic shadowing (48), renal par- cenchyma (29), renal pelvis (31), upper renal pole (27), lower renal pole (28). Diagnosis: renal cell carcinoma (54), hypoechoic tumor with space-occupy- ing effect, Differential diagnosis: renal _lym- phoma, metastasis, hyperplastic column of Bertin, hemorrhagic renal cyst. Sol suprapubic longi- tudinal (sagittal) section of the lower abdomen. Organs: urinary bladder (88), uterus 39, intestinal loop (43) Dingnosis:blood clot ($2) layered along the posterior wall of the urinary blad- der. Differential Diagnosis: Arch artifacts 1) and reverberation echoes (1) in the anterior aspect of the urinary blad- der; layered conerements, thickness ar- tifacts —> shaking! Sonographic section: high section of the left flank in the right lateral decubi- tus position, Organs: spleen (37), lung (47), colon (43), diaphragm (13). Parenchyma: not normally homo- ‘geneous, but patchy with several inter- spersed hyperechoic foci. Diagnosis: multiple splenic. heman- giomas, Differential diagnosis: _ hyperechoic metastases, vasculitis due to SLE, his: tiocytosis X. Solution to Fig. 73.3: Sonographic Section: oblique section of the left lower quadrant of the abdo- Organs: abdomi: colon (43). Diagnosis: multilayered wall-thicken- ing caused by colitis. Differential Diagnosis: ischemia of the intestinal wall caused by thrombosis of the mesenteric vein or occlusion of the mesenteric artery. oblique muscles (4).Peek eee nd In preparation for the pract planes that Sagittal views: anterior t J \n aes Fig. 78.1 Transversal views: pe fee lis posterior Fig. 78.1¢ The next difficulty consists of visualizing structures amidst acoustic shadows cast by intestinal air. The solution is not the addition of more coupling gel, as the nov- ice often believes, but a graded increase in the pressure applied to the transducer together with proper breathing instructions for the patient, explained further and illustrated on the next page. ae - Fig. 78.2 cal sections, the student should become familiar with the spatial orientation in a three-dimensional space. As an introduction, only two re perpendicular to each other should be considered: the vertical (sagittal) plane and the horizontal (transverse) plane, As suggested on page 4. a cone coffee filter should be used to envisage how the sound waves in these two planes propagate from the transducer through the body All Sagittal Séetions are convention ally viewed as seen from the patient's right side (Fig. 78.1b). Consequently, the cranial aspect of the patient is dis- played on the left and the caudal aspect on the jright (Fig. 78.1 d), After turning the transducer 90° (Fig. 78.14), the sonographic Foss sections, like axial CT sections, are viewed from the patient's feet, result- ing in an inverted display of the visalized structures (Fig. 78.1) ‘What both sections have in common is that the image displays the anterior abdominal wall, including transducer, on the top and the posterior structures on the bottom. This orient forms to the customary display of con: ventional radiographs, CT, and MRI Standing in front of the patient, the liver, for instance, is seen on the left though in actual fact it is on the patient’ right side If, despite every maneuver, the porta hepatis could not be visualized because of meteorism or a postprandial st aan attempt should be made to visualize the porta hepatis intercostally through the liver (Fig. 78.2). Should this also fail, the patient is asked to turn onto the left side and to continue tum- ing beyond the lateral decubitus position (Fig. 78.3). The liver is pushed by its own weight against the anterior abdominal wall and displaces the air-containing intestinal loops lly. This frequently opens up the view for the portal vein and lesser omentum.Tips and Tricks for the Beginner Optimal adaption of the pressure on the transducer To avoid any patient discomfort, the beginner is often relue. tant (o press the transducer firmly on to the abdomen. If this is the case (| | |), physiologic air remains in the intestinal lumen (46), causing acoustic shadowing (45) that can, for i stance, interfere with visualizing the posteriorly located pan- creas (33) (Fig. 79.1). Even the bile duct (66) or the portal vein (11) is frequently obscured by duodenal air or an air-dis- tended stomach, ‘The solution lies in jinereasing the pressure applied to the fansducer (444), but the increase should be gradual rather than sudden to avoid any defense reflex or antagonis tic reaction by the patient. By carefully displacing the intesti- nal air, this maneuver displaces the interfering air shadows (45), and the panereas (83) and common bile duct (66) come into view (Fig. 79.1). The same principle can be applied to the mid and lower abdomen, for instance, for improving the Visualization of retroperitoneal lymph nodes. Fig. 79.14 Fig. 79.1b Competent breathing instructions Initially, there is some reluctance to tell the patient how to breathe during the examination, though the quality of the sonographic examination of the abdomen strongly depends, ‘on the depth of the inspiratory effort necessary, for example, todisplace the liver caudally adequate for its visualization. In neutral respiratory position (Fig. 79.3a), not only are the liver and spleen obscured by the overlying lung bases, but also the pancreas by an air-containing stomach (26). The low Position of the liver (9) ithaximuum inspiration (Fig. 79.3b) displaces air-containing intestinal loops and stomach (26) in feriorly and opens the pancreatic region (33) for sonographi viewing, The same principle can be applied to facilitate the evaluation of the kidneys. Respiratory maneuvers rarely play a role in the lower abdomen, Fig. 79.2 Should this approach fail, the stomach can be filled with de gassed water (tea), following administration of Buscopan (to climinate any peristaltic activity). This results in good sound transmission through the stomach. The water should be taken through a straw to avoid inadvertent swallowing of air. Finally, the examiner can sustain the patient's cooperation better by not only giving instructions to inhale such as “take a deep breath through your mouth and hold your breath but also by telling the patient to exhalle before overdoing the ‘holding of his or her breath (or after the desired image has been captured by freezing the display). This advice is not as trivial as it seems because the inexperienced examiner often fails to achieve good respiratory cooperation, thereby dis couraging the patient and further straining the patient's res: piratory condition,‘This workbook is intended for physicians, technicians, and medical students who are new to sonography and wish to fa- miliarize themselves with the technique of sonographic image formation and the interpretation of sonographic im- ages. It also takes into consideration the fact that many nov- ices generally have a limited budget for purchasing textbooks on their chosen field. 1 therefore thank everybody who contributed to the work- book and strived for a low production cost. The members of Georg Thieme Verlag accommodated all our special requests, and wishes concerning the layout of the material, and accom- panied and supported the progress of the workbook at all times. Owing to the exceptional engagement and support of Dr. Lothje, Dr. Bergman, and Mr. Lehnert, the third German edition and the English translation, with Dr. Winter as trans- lator, could be completed in a very short period of time. The Department of Science and Research of North Rhine-West- phalia and Toshiba contributed to the printing costs, making the affordable price a reality. This interactive workbook is based on the experience I have gathered since 1992 in Dusseldorf as head of the pilot, project on medical didactics “Anatomy of Imaging Modali ties” The pilot project is gratefully supported by the program, “Quality in Teaching” conducted by the Department of Science and Research of North Rhine-Westphalia. The con- a Acknowledgment cept of teaching sonography combined with practical exer- cises in small groups could not have been achieved without the feedback and constructive criticism of the students and pPyhsicians in our program and without the continuous cooperation of numerous instructors taken from the ranks of our students I wish to thank Jorg Kambergs, Andreas Saleh, Ghazaleh Tabatabai, and Jochen Tirk, who supported my work for many years and offered valuable suggestions, Furthermore, I wish to mention the willing support of the models Simone Katawinkel, Wolfgang Bongers, Joana and Wiirmehen Hofer for the photographs illustrating the posi- tioning of the probe. 1 am obliged to Prof. U. Modder, Prof. H.-G. Hartwig, and Dr. Tanja Reihs for their counsel and for providing several cases. A special note of gratitude goes to my wife Stefanie, who advised me during the planning stage, helped train our assistants, and reviewed the manuscript I thank the graphic artists Mrs. Susanne Kniest, and Mrs Sabine Zarges for their valuable help in drawing all sketches and diagrams, and Mr. Markus Pietrek for the professional photographic displays that demonstrate the handling of the transducer. Dusseldorf, fall 1998. Matthias HoferNormal Measurements The normal values listed here are subject to individual varia- tions and should be considered only as guidelines. Different tables apply for children. These representative values were taken from the literature and apply only to measurements in Abdominal aorta luminal diameter: < 2Sem (cranial portion) < 20cm (caudal portion) 25°30em ~ ectasia > 30cm = aneurysm ‘Adrenal glands imaxioal size: S'S em (length) < 10em (widih of an individual limb) Aortomesenteric angle <3) Aortovertebral distance < 0.5 em Biliary ducts Bile duct: < 0.6 cm (if gallbladder is present) <_0.9em (status pest cholecystectomy) intrahepati: < Odom Cervical subcutaneous — width (in prenatal measurements) tissue <"_30 mm (if more: “nuchal edema” or “posterior cervical edema”) Endometrium width (both layers): < 15:0 mm (premenopausal) < 80mm (postmenopausal) wal thickness: <_04.em (postprandial up to 0.7 em) < 11.0em longitudinal (preprandial) ‘maximal diameter: <_ 40cm transverse (preprandial) Tina wide <_0.6em (distal to the last confluence before the inferior vena cava) > “O6cm = right cardie insuficiency Taminal widehe 20 em (< 25 em in young athletes) (ith collapse during forced expiration!) > 23cm without expiration collapse = suspicious of right cardia insufficiency = 20.0 mm (ifinereased: dislodged) 50mm (refer to p59) Hepatic veins Inferior vena cava TUD-fundus distance TUD-endometrium distance Kidneys ‘maximal size: 100-12.0em (lengthwise) 4.0-6.0.cm (transverse) respiratory mobil 30-7em parenchymal width 13-25em Parenchyma-pyelon index: = Tel (under 30 years) 121-161 (31-60 years) = La Gabove 60 years) size in right MCL: < 136m (craniocaudal) < 15 em (depending on body habitus) ‘marginal angle: < 30" (left hepatic lobe, lateral) < 45° (right hepatic lobe, caudal) ‘maximal diameter: =" Loe Liver Lymph nodes the stated standard sections, For vessels, the inner diameter of the vascular lumen is given, without consideration of the vascular wall volume: '5.5-10.0 em (each ovary pre- menopausal) 2.5.3.5 em’ (each ovary post menopausal) Ovaries size of the hea <"3em size of the body =" 250m size of the ait < 250m luminal diameter ofthe duct: ‘02m Juminal wade: = I3em > | Sem = portal hypertension Portal vein Prostate gland size < $0em (transverse) < 30em (craniocaudal) = _ 30m (anteroposterior, sagittal) volume: 25 ml ‘maximal size: <11Dem (length) 7.0em (width) 40m (depth, measured between splenic hilum and surface) Spleen luminal wide: =" Lem 1.2m = portal hypertension oF splenomegaly Splenic vein luminal diameter Sem Superior mesenteric antery < ‘Thyroid gland size: '40-7.0em (craniocaudal) 1.0-3.0em (transverse) 1L0-2.0 em (sagittal) volume (both lobes combined): < 20m (women) < 25ml (men) wall dhickness: < 04.em {if bladder is ful) <_ Rem (after voiding) postvoid residual: = 100m! volume: < 550ml (women) < 7501 (men) Urinary bladder ‘maximal size 50-80 cm longitudinal (nullipara) 1.5-30.em width ‘Uterus Volume calculation Sx Ax BC diameter: 30-70 mm Yotk sac(ame 1 skin 2 Subeutancous fat 3 Abdominal rectus muscle 4 Abdominal oblique muscle 5 Connective tissue, fascie, septa 6 Linea alba 7 Ligamentum teres 8 Faleform ligament 9 Liver 10 Hepatic veins 11 Portal vein and its branches 12 Confluens of the portal vein (superior mesenteric vein + 20) 13 Diaphragm 14 Gallbladder 15 Aorta (thoracc/abdominal aorta) 6 Inferior vena ca 17 Superior mesenteric artery 18 Hepatic artery 19 Splenic artery 20 Splenie vein 21 Mine artery (internallesternal iia artery) 22 External lia vein 23 Internal iliac vein 24 Renal artery 25 Renal vein 26 Stomach (often air-contaning) 27 Upper renal pole 2s Lower renal pole 29 Renal parenchyma 30 Medullary pyramids 31 Renal pelvis +32 Celia axis 33 Pancreas 34 Esophagus 35 Spine (vertebral body/areh) 3 Intervertebral disk 37 Spleen 38 Urinary bladder 39 Uterus (corpus ofthe uterus: myometrium) 40 Uterus (cervix ofthe uterus and porto vaginalis) 441 Vagina 42 Prostate gland 43 Colonirectum, aireontaining 4 Psoas muscle 45 Acoustic shadowing (behind air or calcium) 4465 Small intestine (duodenum jejunum ileum) 447 Gaslair (in the lung ot intestines > acoustic shadows) 48 Pubic bone 48 Stone(s) concrement(), caleifcaton(s) 50 Hematoma, sold and liquid components 51 Scction-thickness artifacts or reverberation echoes 52 Blood clot, thrombotic material 133 Fibrosis, partially ealeitied ‘4 Space-octupying lesion (tumor) '5 Lymph node (lymphoma) [56 Metastases 57 Tumor degeneration (central ncross) 58 Abscess, partially liquid ‘59 Catheter (stent) Air in the biliary ducts (pnewmobilia) ‘61 Tangled vessels (hemangioma) 62 Focal fatty sparing (63 Focal faty infiltration (64 Flui-filled space (cyst) 6 66 o “ ° 7 1 a 8 %6 n ” 8 a 8 se 8s 86 "7 ss 0 0 1 2 % os % 7 8 0 io 2 10s to 106 uw 108 ry 10 m m2 us us us M6 a7 us 119 120 21 ia 1 Epithelial growth (polyp) Bile duct (common hepatie duct and common bile duet [ductus choledo hus) “Thickened bile (sade) Free fluid inthe abdomen (ascites) Free fluid in the pleural cavity (pleural effusion) Distal acoustic enhancement Infarcted area ‘Angiomyolipoms (benign renal tumor) Collection of lymphatic Mid Gastric/intestinal wall Pancreatic duct (ductus paneteaticus) Foley eathete balloon ‘Wall ofthe urinary blader Endometrium Free fui inthe pericardial sac (pericardial effusion) Gallbiadder wall Thyroid gland Carotid artery lugular vein Trachea (ai-containing) Sternocleidomastoid muscle ‘Accessory spleen (differentia diagnosis: ymph node) Hyclonephrosis Anterior scalenus and longus colli muscles Sternohyoid muscle Sternothyroid muscle ovary Intra uterine device (IUD) Follicle Placenta Embryifetws ‘Umbulical cord with vessels Amniotie fu Testicle (ests) Epididymis Scrotum layers of the scrotal wall Gestational sa (chorionic cavity) York sae Lateral ventricle Choroid plexus skull Midline echo of the fats Femor Upper lex Rib Cerebellum Armand (Osscous pelvis (ium) Spinal canal Seapula Ventrcle Aim Brachiocephalie unk Mitral valve Aortic valve Hernial sac Fingers, toes (phalanges) Metacarpalsimetatarsals Subclavian artery Superior mesenteric vein Left gastric veinA abdomen, upper, 17,21 abdomen, fet, 65 abscess hepatic, 30 accessory spleen, 48 fachondroplasi, fetus, 72 ‘coustic shadowing. 6 fcoustie window, 12 ‘adrenal glands, 37-50, alpha-fetoprotein, 68 lmmnotic fui, 71 miniotc membrane, 69 aneurysms aati, 13,13, 19,38 fomta, 12 ‘aneurysm, 13,19, 38 ectasia, 13 appendix. 33 atch artifacts 10 artifacts 9-10 ascites, 6, 24, 31,36, 53,69 atrial septal detect, 70 ‘axial overview, 17-22 8 ‘banana sign, 68 biometry, pregnancy. 1-65 byparietal diameter, fetus 6 breathing instructions 79 bubs, fetus, 71 Budd-Chiari syndrome, 25 c caleifiations 49,75, Caroli syndrome, 29 carotid artery, 74 caudal aspect. 78 cholecystitis, 36 cholestasis 4, 35, cirrhosis. 31 lub foot, fetus, 72 ‘ockade phenomenon, 53 collateral circulation, 24 ‘colon, ascending, 52 ‘commen bile dct, 23 Conn syndrome, 43 corpus luteum, 61 cranial aspect, 78 Crohn disease, 53 cross-sectional image, 4 ‘rown-rump length, 64 CCraveithier Baumgarten syndrome, 24 curved array transducer, 8 Cushing synérome, sti urinary bladder, 85 ests 29,38, 62 . 2.0 em (2.5 cm in trained athletes) + Dilated hepatic vein > 6 mm inthe hepatic periphery + Absent caval collapse wit forced inspiration + Possible pleural effusion, intaly almost always onthe right + Normal lumen: suprarenal < 2.5 em + Eotasia 25-8.0 om + Aneurysm: >3om “+ Risk of rupture increased by: progressing dilation diameter > 6 cm excentri lumen saccular dilaton instead ‘of fustform dilation) + Demonstration of portocaval collaterals atthe porta hepatis * Diameter ofthe portal vein at the porta hepatis > 15 mm * Dilatation of the splenic vein > 1.2 cm + Splenomegaly + Demonstration of ascites + Recanalized umbilical vein (Cruveihier-Baumgarten syndrome) * Esophageal varices (by endoscopy) (und yu] sen vr) ‘areal land aay ats Staats Kney Lymph noes ary Pancras Prost ns (Peoatie measurements canbe found onthe Back) rain dnerion tare common be ect ameter cape duets ‘wal ness imevmum dimension wsmun dinero rane of spat movement parenchyma kes fore nee raed san, mt eso flown rg anqtaton rwsman derion volun AP ama 0 bend ‘ue C271 wot known German Brand ot og water wal loess aman omersons © $ omen of nee gn) £1 Gifts ecb) 08 cm gulbiaier preset and nora) £08 om sts post cregtectom) cif Seamesasas ig Seems volt cage cy Sonn ie bas Beas noo, “soogguan tt SaaS geet 3 ieee, seinen enn uses, yo fee 21 PSB << 94 om haan 08 omlatervon) S100° 30 lena) ‘S730 re) 8-8 cmintengn starous)in Children (Adit measurements canbe found onthe back. For ver and spieen the median values (m) = 2S in fem] are rested to body height and measured along the right and let median axilay line (not the MCL). The real measurements [em] are confidence intervals of he standard percentiles: Boy eight) iver Spleen Kidney fem) |m-250 1m. mv2so|n-2s0 me me2sd| SBE 95% Teortes | 47 290 407 528 | 340 4x6 407 85 | 940 219 za 360 | 300 435 San se | 253, 2ee 34s 43 | 350 500 640 Te 05 | 540 2a a7 50 880 730 26-100 | 505, 201 8 530 aso 790 sori | 676 302 4B 674 | 585 740 35 siti | 655 358 528 635 765 695 42i-t90 | 730 3a S31 oar | 680 720 830 sted | 269999 1135 | 440 a5 782 | 740 a7 1000, iMtctsd | 848 m0a2 3238 | dor ser 70: | 79D gas toon Sis | 95 1135 1324 | 435 648 00 | 860 995 130, {eto ta Keres net, PR 6) 38-43 ews 0 SenoyaphceCpnonene m Kade he ‘Normal Volumes ofthe Thyroid Gland int) Both lobes combined, alee according the volume formula (05x Ax 8x0). ics ons fae metS0 met mts0 om mtSD Neonats 051417 a 12,20 civ 08 18 26 0428 caves 15 2482 Apert cave 19 3a 49 19 a5 eaves 32 3782 rr Stoveas 63 8D 12 es fats 0 OB {et Pees ann neta De chris Kinds Soin eran, et Hebe, New You 8 4 Normal CSF Measurements in Neonates Thieme SOW (siucorical wat) ‘san CW (crenoceteba wh) = 4mm Excerpt om: 1 nephew. = émm Wath fares otal hor) = 8mm SBN 191904 < Normal Measurements in Prenatal Ultrasonography Eximation of Fetal Weight log FW = 1.36 + 0.08 AC + 0.18 FL~0.0037 (AC x FL) Pt: Malo 8 et at Sonographic estimation tea wig Fadology 1984) 536 FW Fetal weight ‘AG = Abdominal cicumference FL = Femur length Kidneys: Normal Weight Fa: Chadig , aac IM Obst Ursa: Carlson (192) Se tans Checklist of Criteria for Establishing a Cyst: + Spherical configuration + Echo-tree interior ‘+ Smooth outline + Distal acoustic enhancement + Sharply defined distal wall + Edge shadowing due to critical angle phenomenon ‘+ Absence of thin, hyperechoic capsular line + Paucity of peripheral hepatic vessels + Obtuse angulation of the hepatic veins > 45° + Accentuated echogenic wall ofthe portal vein ‘+ Abrupt caliber changes of the branches ofthe portal vein ‘+ Rogenerating nodules with displacement of adjacent vessels ‘+ Nodular liver contour (advanced stage only) + Contracted liver (advanced stage only) + Signs of portal hypertension cere aves nem) Re: Ses RAM, Neolades KH Urscu mares ea chomosomal ete, In rots in Fel Medi Seres, The PaenenPuIshog Goo, New York, London (990, 174 RNSLRSAT RSS