.......
1. What is ultrasound? ................................................................................................................. 2
2. Properties of Ultrasound .......................................................................................................... 2
3. Artifacts .................................................................................................................................. 3
4. Doppler Examination ............................................................................................................. 5
5. Harmonic Imaging ................................................................................................................ 6
6. Preparation for Examination .................................................................................................. 6
7. Tuning the Instrument ............................................................................................................ 7
8. Selection of Probe .................................................................................................................. 7
9. Preparation of Patients Condition ......................................................................................... 7
10. Patient Postures and Divisions of Abdomen .......................................................................... 7
11. Image Display Methods ......................................................................................................... 8
12. Scanning Procedure ............................................................................................................... 8
13. Handling the Probe ................................................................................................................ 8
14. Morbid Organs Suspected from Pains ................................................................................... 8

  
   
  ...................................................................

I. Liver .......................................................................................................................................... 9
1. Basic Scanning Method .................................................................................................... 9
2. Checkpoints ...................................................................................................................... 12
II. Gallbladder ............................................................................................................................. 17
1. Basic Scanning Method .................................................................................................... 17
2. Checkpoints ...................................................................................................................... 17
III. Common Bile Duct ................................................................................................................ 20
1. Basic Scanning Method .................................................................................................... 20
2. Checkpoints ...................................................................................................................... 20
IV. Pancreas ................................................................................................................................. 20
1. Basic Scanning Method ................................................................................................... 20
2. Checkpoints ...................................................................................................................... 20
V. Spleen ...................................................................................................................................... 23
1. Basic Scanning Method .................................................................................................... 23
2. Checkpoints ...................................................................................................................... 23
VI. Kidneys and Adrenal Glands ................................................................................................. 24
1. Basic Scanning Method .................................................................................................... 24
2. Checkpoints ...................................................................................................................... 24
VII. Abdominal Aorta .................................................................................................................. 28
1. Basic Scanning Method .................................................................................................... 28
2. Checkpoints ...................................................................................................................... 28

Elements of Ultrasound Examination

1. What is ultrasound?
Ultrasound is a sound wave of which the frequency is
beyond the audible frequency band of 20 Hz to 20 kHz
and which is not intended to be heard with human
ears. Generally, an ultrasonograph uses a frequency
band of 1 MHz to 20 MHz.
Ultrasound is propagated in a living body as a compressional wave.

(4)Refraction: Ultrasound is not wholly reflected at a

boundary surface between two different media but
some part is reflected and the rest permeates the
boundary surface while changing the angle. Such the
phenomenon is called refraction, which is expressed
by Snells law.
 




  



   

 
 







 
 


Frequency stands for the rate at which a phenomenon

is repeated. The basic unit is the Hertz(Hz), which
represents one complete cycle per second.
C=F
(where, C: Sound velocity, F: Frequency,
and : Wavelength)
2. Properties of Ultrasound
(1) Propagation: Transmission of ultrasonic is called
propagation. A medium is required for the ultrasonic
to propagate.
(2) Sound velocity: Sound velocity (C) is expressed in
a distance the ultrasonic propagates through the medium for a unit time.
(where, C: Sound velocity,
: Bulk-modulus, : Density)
Reference sound velocity with ultrasonograph:1530m/s
(3) Refletion: An ultrasonograph images ultrasonic
reflected echo. The reflection occurs at a boundary
surface between two media with different acoustic
impedances (Z).
Z= C
(where, Z: Acoustic impedance,
C: Sound velocity, and : Density)

 







(5) Attenuation: In the course of propagation in a living

body, ultrasonic energy attenuates due to absorption,
scattering and diffusion. Especially important is attenuation by absorption.





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(6) Resolution: Ability to differentiate two closely

adjacent parts.
Distance resolution: Minimum discriminable
distance (Dx) between two reflecting sources which
align in the advancing direction of ultrasonic beam.



Lateral resolution: Minimum discriminable distance

(Dy) between two reflecting sources which align
at a right angle to the advancing direction of ultrasonic beam.


 

 




  

Slice resolution: Resolution in the thickness direction of a probe.




    
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3. Artifacts
Due to physical properties of ultrasound, false echo
images may be displayed like some matters are present though nothing exists there. Such artifacts include
those which adversely affect images and those which
are useful for diagnosis.
(1) Multiple reflection: Ultrasonic beam may repeatedly be reciprocated between reflectors or between
the probe and a reflecting surface, thereby creating a
false image.

(2) Side lobe: Beside the main lobe of ultrasonic

radiated from a probe onto the central axis of the
beam, the ultrasonic radiation yields a side lobe.
Since an ultrasonograph cannot distinguish between
the main and side lobes and displays all reflected
waves as if they are on the main pole, thereby
resulting in an artifact.
(3) Lens effect: When ultrasonic enters at a certain
angle from some tissue to another with a different
acoustic impedance, it is refracted like a light due to
Snell's law. A comination of tissues causing such the
refraction is called acoustic lens and the resultant
artifact is called lens effect.



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(6) Acoustic shadow: When ultrasonic passes through

a boundary surface between two tissues with considerably different acoustic impedances, it is strongly
reflected on the surface and does not permeate the
reflecting surface, and thus the part deeper than the
boundary surface has no ultrasonic transmitted, resulting in an anechoic area (acoustic shadow).


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(4) Lateral shadow: A spherical tissue with a smooth

periphery and a different acoustic impedance from
the neighboring tissue initiates a sound wave refraction at the lateral part, resulting in a lateral acoustic
shadow.

      



(7) Grating lobe: Some part of the ultrasonic wavefront composed by an oscillator array goes to other
than the targeted direction, producing a false image.
This is a kind of side lobe.

C1
C2

(8) Mirror image: Ultrasound which is reflected on a

strong reflecting matter may be reflected on the next
structure and may return to the probe through the same
path as it was radiated. In such a case, the structure is
displayed on the extended line of the radiated ultrasonic beam. Such the phenomenon where ultrasound
reflected from a smooth surface matter with strong
reflection power returns as from a mirror is called
mirror effect.
The resultant artifact is called mirror image.

 

 
 

      

(5) Augmented posterior echo: Reflected sound pressure of the ultrasonic beam which passes through a
part such as a cyst causing less attenuation than surrounding tissues is relatively augmented.

 




 



 






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Maximum detectable flow velocity,
(9) Slice thickness:
A section displayed with an ultrasonograph has the
same thickness as the probe elements. Thus, structures
at different sections are displayed on a single frame.




V=

C
2:cos

Fd
Fo

where,
C : Sound velocity in living body
Fo : Transmission frequency
Fd : Doppler shift frequency
: Angle of blood flow to ultrasonic beam
Increasing the pulse repetition frequency (PRF) makes
the measurable sample volume shallower but the
maximum measurable velocity higher.

  
   

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The wider the angle of ultrasonic beam to blood flow,

the larger the error becomes. On the other hand, as
the angle is approaching 0, the maximum measurable
blood flow velocity is lower. To suppress an error to
a clinically allowable level of lower than 20%, the
angle should be 60 or less.
Pulse Doppler Method:
By applying a gate to the time corresponding to a
targeted depth, the blood flow signal of that region
only can be taken out.

  
  




4. Doppler Examination
Intrinsically, the ultrasonic frequency does not change.
But if the sound source or what hears the sound is
moving, the frequency changes (Doppler shift).
Such the phenomenon is called Doppler effect. For
example, as an ambulance is approaching, the siren
is becoming louder and as it is going away, the siren
is becoming lower.
An ultrasonograph uses the Doppler effect to enable
detection of blood flow velocity.

Color Doppler Method:

This method displays the blood flow information of
B mode image obtained by applying the same principle
as the pulse Doppler method. For the purpose, the
moving target indicator (MTI) separates moving
blood cells from other tissues.
The blood flow approaching the probe beccomes
reddish and the blood flow going away from the probe
becomes blue.

5. Harmonic Imaging
A reflected wave contains not only components in the
same frequency band as when transmitted but also
harmonic components whose frequency is a multiple
of the original frequency.
Images initiated by the multiplied ultrasonic frequency
is called harmonic images.
There are two types of harmonic image. One is the
tissue harmonic image resulting from the ultrasonic
propagation through tissues which causes distortion.
The other is the contrast harmonic image resulting from
the contrast agent-initiated distortion of ultrasonic
waveform.

6. Preparation for Examination

At the start of the daily task and before the patient
enters the examination room as well as during and
after examination,
Check that the equipment including the monitor,
probe, switches and image server is well tuned to
optimum accuracy and is cleaned.
Check that temperature, humidity and brightness of
the room are proper for ultrasound examination.
Check that the pillow, bed and examination clothes
(bath towel) are well arranged.
Grasp the doctors request for examination and
understand what should be examined.
Check that echo jelly is warm.
Confirm the name of the patient, introduce yourself
to the patient and explain the harmless ultrasound
examination to lessen the patients anxiety.
Perform the examination while observing patients
conditions and symptoms.
Before finishing the examination, make sure that all
necessary images are saved.
After completing the examination, wipe the probe
and skin-contacted parts with alcohol. Properly
arrange the cord, bed and pillow.

 

    

 







 



Too fast movement of the probe disables scanning

from end to end.
(Sufficient sector scanning is not possible)
Easy-to-trace regions only are observed while
difficult-to-trace regions are skipped.
Too much attention is concentrated to an interpretation and others are missed. The number of morbid
states is not always one.
The method of letting the patient inhale or scanning
after the patient inhales is uncertain. This tires the
patient due to repeated inhalations.
The same examination result as the previous lets you
feel easy though a morbid state may exist.
Interpretations are loosely understood, making it
difficult to grasp interpretations as a morbid state.
Devoted to scanning of determined routine images
only.




A harmonic generation level is proportional to the

square of the sound pressure and the propagation velocity.
Thus, stronger ultrasonic makes the propagation distance
longer, thereby easily generating harmonic. In sound
pressure, the side lobe which causes an artifact is lower
than signals around the main lobe, and thus it is hard to
generate harmonic. Accordingly, imaging the harmonic
enables acquisition of a clear image with less artifact.

7. Tuning the Instrument

Tune the monitor, gain, dynamic range and sensitivity
time control (STC) as follows:
(1) Monitor:
Adjust the brightness and contrast, which should be
made proper to the examination room or ward where
the instrument is operated.
(2) Gain:
Since reflection from inside the living body is delicate,
it should be amplified for proper imaging.
Adjust the amplification degree so that the whole
image may exactly be displayed with proper
sensitivity.

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(3) STC:
The sensitivity time control adjusts the amplification
gain according to the depth. That is, it corrects the
ultrasonic energy that attenuates according to the
distance to the reflection source.
Adjust the STC so that the reflection source may
uninformly displayed.
(4) Dynamic range:
Dynamic range is the range of a faint reflected wave
to a strong reflected wave available on display. With a
wide dynamic range, faint-to-strong reflected waves
are imaged, resulting in a soft image with weak
contrast. With a narrow dynamic range, weak and
strong reflected waves are cut off, resulting in a hard
image with high contrast.

 
 


 
 

8. Selection of Probe
Sector probe for the heart and abdominal organs
Convex probe for abdominal organs
Linear probe for superficial organs
Special probes for paracentesis; intra-abdominal/
intrathoracis orgains (rectum, vagina, urethra,
esophagus and blood vessel); and for application
during surgical operation
9. Preparation of Patients Condition
Fasting for examination of the gallbladder, pancreas,
etc.
Filled urinary bladder for examination of the uterus,
ovary, prostate, urinary bladder, etc.
10.Patient Postures and Divisions of Abdomen
Patient postures for ultrasound examination include
supine, lateral, half-sitting, standing, prone and
knee-chest positions.







 




Generally, there are 9-division and 4-division

methods to express the boundaries and divisions of
the abdomen.




  


 


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11. Image Display Methods

Transverse image (horizontal image):
Transverse section is traced as viewed from the tail
of patient.
Longitudinal image (sagittal sectional view):
Traced as viewed from the right of patient. That is,
the side of patient head will be positioned to the left
of image.
12. Scanning Procedure
Though standardization of the scanning procedure is
examined at concerned societies and associations, most
institutions use unique procedures at the present. In any
way, it is important to use a procedure of efficiently
scanning without missing any significant symptom.

13. Handling the Probe

The probe may be handled in either of two ways. One
is the parallel scanning method where the probe is
traveled over the scanning region. The other is the sector
scanning method where the probe is turned with one
end fixed to a certain point like drawing a fan.
This sector scanning method is the most important
technic. That is, by swinging the probe up and down and
left and right, regions behind a narrow part such as
intercostal space can be observed for further efficient
examination in a wide range.
In practical examination, it is important to scan a region
from multiple directions, taking into considerations the
parts which are apt to be missed.

14. Morbid Organs Suspected from Pains

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Regions in which a morbid state is apt to be missed

include the segments below the right lobe dome of liver
(S7 and S8), the lateral edge of the left lobe of liver, the
lateral bottom edge of the right lobe of liver (S6), the
inferior pole of the right kidney, superior and inferior
poles of the left kidney, the hook and tail of the pancreas
and the bottom of the gallbladder. These regions easily
receive gases from lungs and intestines, making it difficult to be sufficiently scanned.

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3) Lateral Periphery of Left Lobe

In longitudinal scanning of the epigastricum,
swing the probe to the left (to the pancreas) from
over the abdominal aorta and observe until the left
hepatic lobe cannot be seen.
Be careful that the region is apt to be missed.
The gastric body may be traced from the cardia
and the swelling pancreas may be traced.

Basic Scanning Methods and Checkpoints

I. Liver
1. Basic Scanning Method
(1) Longitudinal Scanning of Epigastricum
1) Over Abdominal Aorta
Apply the probe vertically to the median of the
epigastricum. After confirming the abdominal
aorta, trace the left hepatic lobe with the patient
under deep inhalation.
Shown below is the section to measure the size of
the left hepatic lobe. To judge the size, it is important to radiate the ultrasonic beam vertically to the
liver.
If the liver is atrophied or raised, move the probe
toward the head and swing it toward the head.

(2)Transverse Scanning of the Epigastricum

1)Left Hepatic Vein
At the median of the epigastrium, put the probe
under the left costal arch from the side and swing
it toward the head. Then, the left hepatic vein will
be traced.

2) Over Inferior Vena Cava

In longitudinal scanning of the epigastricum, slighly
swing the probe to the right from over the abdominal
aorta. The inside of the left hepatic lobe will be traced.
In the deep part, the caudate and inferior vena cava
are traced.

2) Left Branch of Portal Vein

At the median of the epigastricum, transversely
apply the probe and swing it slightly toward the
tail from the direction in which the left hepatic
vein is observed. Then, the left branch of the portal
vein will be traced.
Regions outside and inside the umbilical region
of the left branch of portal vein can simultaneously
be observed, making it easy to understand segments
S1 to S4 of the left hepatic lobe.

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2) Region below Dome

Put down the probe from the section which traces
central and right hepatic veins and observe S8
segment.
It is said that the segment is most apt to be at a
dead angle. Thus, observe carefully.

The caudate can easily be traced but attention

should be paid that the frontal connective tissue
of the portal vein may attenuate the ultrasonic
beam to low energy.
Beginners may mistake the round ligament of liver
as a tumor image. Thus, through longitudinal
scanning, confirm whether it is traced as a striplike structure.
3) Right Branch of Portal Vein
Swing the probe slighly toward the tail from the
section which traces central and right hepatic
veins. The right branch of the portal vein will be
traced.

(3) Scanning under Right Costal Arch

Perform sector scanning from the periphery of
liver to the diaphragm and observe the region
below the right costal arch exactly by dividing the
region into three parts.
Beginners should be careful of insufficient swinging
of the probe in sector scanning.
If dorsal position makes it difficult to trace the
region, place the patient in left lateral position,
which moves the liver inside for easy observation.
1) Central and Right Hepatic Veins
Put the probe under the right costal arch, push it
onto the abdominal wall with the patient under
inhalation and manipulate the probe like letting
it look in the liver. Then, central and right hepatic
veins will be traced with the portal vein in between.

Move the probe parallelly under the right costal arch

to scan the right kidney, right adrenal gland and
inferior edge of the segment S6.



(4) Longitudinal Scanning under Right Costal Arch

1) Liver-Kidney Contrast
Put the probe longitudinally under the right costal
arch with the patient under inhalation. A longaxis view of the right kidney and the right hepatic
lobe will be traced.
The section is most suitable for observation of
the liver-kidney contrast required for evaluation
of fatty liver.
2) Right Hepatic Vein
Move the probe toward the back in the intercostal
space, and the right hepatic vein will be traced.

Also, carefully check for possible abdominal

dropsy in the Morrison fossa and adrenal tumor.
(5) Scanning of Right Intercostal Spaces
Apply the probe in each of the sixth to ninth right
intercostal spaces and scan with the patient under
expiration.
Usually, each intercosal space is scanned under
expiration since scanning with the patient under
inhalation is affected by lungs. In some case,
however, scanning under inhalation may facilitate
observation.
With the axis put in each intercostal space,
perform sector scanning by swinging the probe
up and down and left and right.
If the dorsal position makes it difficult to trace
the section, place the patient in the left lateral
position which moves the liver inside for easy
observation.
A sector probe or micro convex probe may be
used.
1) Segments before Portal Vein
Put the probe slightly toward the abdomen in the
intercostal space, and segments S5 and S8 will
be traced.



3) Segments after Portal Vein

Move the probe further toward the back and
move it like letting it look upward. Segments S7
and S6 will be traced.

2. Checkpoints
(1) Size
a. Tumor: Acute hepatitis, alcoholic hepatitis, fatty liver
b. Atrophy: Fulminant hepatitis, liver cirrhosis
The size of liver varies between individuals
and depends on sex, age and physical
constitution. Thus, there are many cases
where it is difficult to judge the liver normal
or abnormal based on the size.

(3) Surface
a. Smooth: Normal
b. Irregular (particulars, unevenness, wave-shape):
Liver cirrhosis, fulminant hepatitis


      
(4) Parenchymal Echo
a. Low echo: Acute hepatitis
b. High echo: Fatty liver, alcoholic hepatitis,
chronic hepatitis
c. Fine and uniform echo: Normal
d. Coarse and irregular echo: Liver cirrhosis,
chronic hepatitis, fulminant hepatitis
e. Attenuation of deep site echo: Fatty liver

 
 


    
(2) Margin of Liver
a. Sharp: Normal
b. Obtuse: Liver cirrhosis, chronic hepatitis

  
  


    
    
 





 


(6) Intrahepatic Bile Dilatation

Intrahepatic bile duct cancer, intrahepatic lithiasis,
bile duct obstruction

 
      

 


(5) Intrahepatic Vascular System

a. Narrowed intrahepatic vascular system:
Liver cirrhosis
b. Gloomy: Fatty liver, portal vein obstruction,
tumor embolus
c. Hepatic artery dilatation: Osler syndrome,
alcoholic hepatitis
d. Hepatic vein dilatation: Congestive liver

 
  
(7) Extrahepatic Interpretations
a. Collaterial circulation
b. Lymph node swelling
c. Abdominal dropsy, pericardial effusion,
dextrocardial effusion
d. Gallbladder-related interpretations
e. Splenic tumor

  
  
  


(8) Presence and Properties of Tumor

a. Shape
1) Cylindroid: Cyst, hepatocellular carcinoma,
metastatic liver cancer
2) Irregular: Abscess, cholangiocellular carcinoma
3) Lumpy: Hepatocellular carcinoma, metastatic liver cancer
4) Diffuse: Hepatocelluar carcinoma, metastatic liver cancer
b. Internal echo
1) Anechoic: Cyst
2) Low echo: Abscess, hepatocellular carcinoma,
metastatic liver cancer
3) Isoechoic: Hemangioma
4) High echo: Hemangioma, hepatocellular carcinoma,
metastatic liver cancer
5) Mixed echo: Hemangioma, hepatocellular carcinoma,
metastatic liver cancer
c. Boundary
1) Clear: Cyst, hemangioma, hepatocellular carcinoma,
metastatic liver cancer
2) Unclear: Abscess, cholangiocellular carcinoma,
metastatic liver cancer

  

  

d. Periphery
1) Low echo band: Hepatocellular carcinoma,
metastatic liver cancer
2) High echo band: Hepatic hemangioma,
hepatocellular carcinoma
e. Posterior echo
1) Attenuated: Metastatic liver cancer, calcification
2) Augmented: Cyst, abscess, hepatocellular carcinoma,
hemangioma

     

   
     

     

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Methods of classifying hepatic segments include

Couinaud's and Healey's. Couinaud's classification of
hepatic segments (S1 to S8) is generally used and
clinically important.
Hepatic segments are classified based on blood flow of
portal veins but the hepatic vein, round ligament of liver
and venous ligament are important indicator for
classification of segments

II. Gallbladder
1. Basic Scanning Method
(1) Longitudinal Scanning of Right Hypochondrium
(Gallbladder Long Axis)
Longitudinal scanning of the right hypchondrium
with the patient under deep inhallation traces a longaxis view of the gallbladder at the hepatic tail.
If it is difficult to trace the image, left lateral
position is recommended.

(4) Scanning of Right Intercostal Space

This is an effective scanning mothod for corpulent
patients or if the liver is raised due to right lung
surgery.
Since a stone may be incarcerated in the neck of
gallbladder, the right intercostal scanning should
be performed.

(2) Transverse Scanning of Right Hypochondrium

Transverse scanning of the right hypochondrium
enables observation of a short-axis view of the
gallbladder and from the neck to the bottom.
Observe the image with the patient under deep
inhalation by parallelly moving the probe from
under the costal arch toward the tail.
2. Checkpoints
(1) Tracing Failure
a. Morbid: Atrophy, gallbladder cancer, filling stone
b. Non-morbid: Meal, corpulence,
gallbladder extracted

(3) Scanning under Right Costal Arch

Horizontal part from the navel part of the left branch
of portal vein is traced with the high echo of the
gallbladder fossa at the upper left.
This method is the easiest method of identifying
the gallbladder.

   

(2) Shape
a. Flexion: Phygian-cap gallbladder
b. Diverticulum: Gallbladder adenomyomatosis

b. Atrophy
Chronic cholecystitis, gallbladder cancer

 



  
 
 

c. Collapse
Acute hepatitis, state after spontaneous discharge
of cholelithiasis or choledocholitiasis

(3) Size
With empty stomach: Long diameter 60 to 80 mm,
Short diameter 20 to 30 mm
Since there are much differences between individuals,
attach much importance to the short diameter and filled
condition.
a. Tumor
Morbid state of gallbladder: Cholelithiasis, acute
cholecystitis, gallbladder cancer, gallbladder
hydropsy
Morbid state of bile duct: Bile duct stone, bile duct
cancer, pancreatic cancer

 

 
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(4) Thick Wall
Normal: 3 mm or less, Fatty: 4 mm or more
a. Whole periphery fattened
Smooth: Acute cholecystitis, chronic cholecystitis,
gallbladder adenomyomatosis, acute hepatitis,
abdominal dropsy retention
Irregular: Chronic cholecystitis

 


 

 

 
  

(6) Around Gallbladder

Abdominal dropsy, extrinsic infiltration, abscess
formation

b. Local periphery fattened

Smooth: Gallbladder adenomyomatosis,
gallbladder cancer
Irregular: Gallbladder cancer

   



  

   

 




The gallbladder is traced and identified on the

extended line of the linear high echo of the
gallbladder fossa which is traced by scanning the
left branch of portal vein.

(5) Internal Abnormalities

Stone
Biliary sludge: Acute hepatitis, long-term nothing
by mouth, inferior bile duct obstruction
Tumor: Gallbladder cancer, adenoma, polyp

Since corpulent patients or patients with much

intestinal gases do not allow tracing of the gallbladder
by scanning under the right costal arch or longitudinal
scanning, scanning of the right intercostal space is
recommended.
For corpulent patients or patients with the liver raised,
place them in a half-sitting position to move the
gallbladder downwards.

 


III.     
1. Basic Scanning Method
(1) Oblique Scanning of Right Intercostal Space to
Right Hypochondrium
The extrahepatic bile duct is traced at the abdominal
side of the main trunk of portal vein.


 
 
 

(2) Internal Abnormalities
Emphysema, bile duct stone, bile duct cancer,
pancreatic head carcinoma, bile duct infiltration


  
     

Scan the porta hepatis to trace the main trunk of
portal vein, and then incline the probe slightly to the
right. The bile duct will be traced at the abdominal
side of portal vein.
As the extrahepatic bile duct is descending, it goes
to the right of portal vein and then reaches the head
of the pancreas.
If it is difficult to trace the bile duct, it is recommended
to place the patient in the left lateral position.


   
IV.

2. Checkpoints
Normal Diameter of Bile Duct
Extrahepatic bile duct (bore): 7 mm or less
Intrahepatic bile duct: 1 mm or less
Left and right bile ducts: 3 mm or less




1. Basic Scanning Method

(1) Oblique Scanning from Epigastric Side to Left
(Long Axis of Pancreas)
1) Long Axis of Pancreas
Obliquely scan the region from the median side
to the left under deep respiration with the left
hepatic lobe as an acoustic window.
A long-axis view of the pancreas will be traced at
the abdominal side of pancreatic vein.
Putting the probe slightly upwards right (toward
the pancreatic tail) rather than just beside makes
it easy to trace the long-axis view of the pancreas.
Be careful not to mistake the posterior gastric wall
or pancreatic vein as the pancreatic duct.

(1) Dilatation
Diameter of Common Bile Duct: 8 mm or more
It is desirable to judge based on a maximum diameter.
The dust tends to be delated along with aging or after
the gallbladder is extracted.
Check for stenosis and obstruction.
Bile duct cancer, bile duct stone, pancreatic head
carcinoma, common bile duct dilatation, bile duct
infiltration

3) Pancreatic Tail
Parallelly move the probe from the median to the
left or perfom sector scanning. The pancreatic tail
will be traced.

2) Abdominal Artery
From the position where the long-axis view of the
pancreas is observed, incline the probe slightly to
the head. The common hepatic artery and pancreatic
artery, which are branched from the abdominal artery,
will be traced.

(3) Scanning of Left Intercostal Space (Pancreatic Tail)

After tracing the pancreas and confirming the splenic
hilum, slightly change the angle of the probe.
The pancreatic tail will be traced with the pancreatic
vein. This scanning is indispensable to search for a
possible morbid state of the pancreatic tail.

(2) Longitudinal Scanning of Perigastricum

Confirm the abdominal aorta through the longitudina
scanning of the perigastricum and observe the branch
of the superior mesentric artery. A short-axis view of
the pancreatic body will be traced as an oval image.
1) Pancreatic Head
Parallelly move the probe slightly from the median
to the right.
The pancreatic head and hook will be traced.

  

 
 

By confirming the position of the pancreas through

longitudinal scanning of the epigastricum, adjust respiration and judge the probe pressure and patient position.
Respiration adjustment: In some case the pancreas
may easily be traced under expiration rather than
in inhalation.
Probe pressure: Apply the probe lightly to lean
patients so as not to flatten the pancreas. Apply the
probe strongly to corpulent patients to remove gases.

2) Pancreatic Body
Scanning of the pancreatic body is important for
grasping positional relations of the pancreas, liver,
stomach and vascular system.

 Position change:
To eliminate the effect of gastrointestinal gases,
place the patient in half-sitting or left/right lateral
position.
Especially, right lateral position is recommended
for observation of the pancreatic tail
2. Checkpoints
(1) Size
Measure the thickness.
Head: IVC level 20 to 30 mm
SMV level 15 to 20 mm
Body: SMA level 13 to 20 mm
Tail: 15 mm

(3) Internal Echo Patterns

a. Homogeneity: normal
b. Nonhomogeneity: Acute pancreatitis
Chronic pancreatitis
Pancreatic tumor
(4) Internal Echo Patterns
a. High echo area
Entire: Chronic pancreatitis, aging, diabetes mellitus
Localized: Pancreatic cancer, pancreatic calculus

*Note: The size tends to be atropied along with aging.

a. Entire swelling: Acute pancreatitis, carcinoma of

entire pancreas
b. Localized swelling: Tumor, tumor-forming
pancreatitis
c. Atropy: Chronic pancreatitis, diabetes mellitus,
aging


  
 
  
b. Low echo area
Entire: Acute pancreatitis, carcinoma of entire pancreas
Localized: Pancreatic tumor

 
  
(2) Shape/Surface
a. Smooth: Normal
b. Irregular: Chronic pancreatitis


  

(5) Presence of Pancreatic Duct Dilatation
a. Smooth dilatation: Pancreatic cancer, carcinoma
of papilla, chronic pancreatitis
b. Irregular dilatation: Chronic pancreatitis
c. Beadlike dilatation: Pancreatic cancer
d. Remarkable dilatation: Pancreatic ductal papilloma
e. Penetrating duct sing: Tumor-forming pancreatitis


 
  

 



 


 
   

V. Spleen
1. Basic Scanning Method
(1) Scanning of Left Intercostal Space
A long-axis view of the spleen is obtained by scanning the ninth to eleventh left intercostal spaces.
It can also be traced by moving the probe to the
intercostal space upper by one space than where the
left kidney is traced.
To eliminate the effect of pulmonary gases, observe
the image with the patient under expiration.

 



(6) Presence and Properties of Tumor
(7) Around Pancreas
a. Presence of abdominal dropsy: Influence of
inflammation of acute pancreatitis
b. Presence of lymph node swelling
c. Vascular displacement, stenosis, dilatation,
cuff sign
Abovementioned "b" and "c" are important to
judge the progressive degree of pancreatic cancer.

 
 
  
 

2. Checkpoints
(1) Presence of Splenomegaly


 



  



(7) Presence of Splenvenous Dilatation,

Collateral Circulation Path

(2) Irregular Shape

Infarction, trauma

(8) Presence of Left Pleural Effusion

and Abdominal Dropsy

 
 

If the examiner is female, her hand may not reach

the left intercostal space of the patient. In such a
case, it is recommended to place the patient in
right lateral position.



VI.
    

(3) Change of Parenchmal Echo

Calcification, infarction, trauma,
Gamna-Gandy node

1. Basic Scanning Method

(1) Longitudinal Scanning under Right Costal Arch
For observation of liver-kidney contrast.

(4) Presence of Tumor

Malignant lymphoma, metastatic splenomegaly,
hemangioma, cyst, abscess

(2) Longitudinal Scanning of Right Lateral Abdomen

A long-axis view of the right kidney is traced.
It is traced by applying the probe along the curve
of the body surface from a position slightly
rearward with the patient under inhalation.

 
  


  
 


(3) Scanning of Right Intercostal Space

Radiate the beam from the right intercostal space
to the back.
It is suitable for scanning the superior pole of the
right kidney and the right adrenal gland.

(5) Presence of Accessory Spleen

(6) Presence of Lymph Node Swelling

(7) Scanning of Left Intercostal Space

Scan the left intercostal space with the patient under
expiration. The superior pole of the left kidney will
be traced together with the spleen, enabling
observation of the left adrenal gland.

(4) Scanning under Right Costal Arch

An oblique tomographic view of the right kidney
is traced.
Since the scanning direction corresponds to the
running direction of renal artery and vein, this
method is suitable for tracing the right renal hilus.
Inclining the probe enables tracing of the superior
pole of the right kidney and the right adrenal gland.

(8) Transverse Scanning of Left Lateral Abdomen

A short-axis view of the left kidney is traced.
It is suitable for searching for a possible morbid
state at the periphery of the kidney.

(5) Transverse Scanning of Right Lateral Abdomen

A short-axis view of the right kidney is traced,
enabling observation of the superior to inferior poles
of the right kidney and the region around the kidney.
It is suitable for searching for a possible morbid
state at the periphery of the kidney.

(9) Oblique Scanning from Perigastric Side to Left

For scanning the deep part of pancreatic tail and
the left adrenal gland which is present at the left
boundary of abdominal aorta.
(6) Longitudinal Scanning of Left Lateral Abdomen
A long-axis view of the left kidney is traced.
Since the left kidney is affected by gsses in the
alimentary tract more easily than the right kidney,
scan the left laterial abdomen from the back with
the patient under inhalation.

(2) Shape
a. Protrusion: Renal cell carcinoma, lump
b. Retraction: Renal infarction, chronic pyelonephritis,
fusion remnant
c. Fusion: Horseshoe kidney

(10) Oblique Scanning from Left/Right Back

A long-axis view of the left/right kidney is traced.
Move the probe from the vertebral column to a
left/right downward direction. An entire view of the
left/right kidney will be traced.
The left kidney is slightly larger than the right
kidney and is positioned at a higher level.

 
  

 

 

   
(3) Size
a. Atrophy: Chronic renal failure
b. Swelling: Acute pyelonephritis, acute renal failure,
polycystic kidney disease

If the bilateral kidney is slender, disabling tracing

of the periphery at the inferior pole, it may be a
horseshoe kidney. So, perform transverse scanning
of the abdominal aorta.
Basically, kidneys are scanned with the patient in
dorsal position. But aggressively change the position
to laterial position, etc. as required, especially for
scanning the left kidney.
Due to oppression by the spleen, the left kidney
may bear a lump on the image. It should be
distinguished from a tumor.
Be careful that the renal column may be traced like
a renal pelvis tumor.
2. Checkpoints
(1) Failure in Tracing
a. Pathologic: Atrophy, hypoplasia, aplasia
b. Positional abnormality: Pelvic kidney,
thoracic kidney

   



b. Oppression/Deformation: Renal column,

renal cell carcinoma
c. Low echo tumor: Renal pelvic tumor,
renal cell cardinoma, neurysm, artriovenous fistula,
renal column
d. Anechoic area: Hydronephrosis, peripelvic cyst
e. Strong echo: Stone


  


  

  

(4) Cortex
a. Thinning: Chronic renal failure, amyloidosis
b. Echo level increase: Chronic renal failure
(5) Medulla
a. Echo level decrease: Acute pyelonephritis, nephrosis
b. Echo level increase: Gouty kidney, medullary sponge
kidney, calcified kidney

   

  



   

(6) High Echo at Central Area

a. Dissociation/bifid image: Double ureter, renal sinus
ipomatosis, hydronephrosis, pyelogenic tumor

(7) Presence and Properties of Tumor

(8) Presence of Adrenal Tumor

Views of abnormal abdominal aorta are dilatation,

aneurysm, dissociation, stenosis and obstruction.
(1) Dilatation
Types of arterial dilatation include a mild morbid
state of flexion/tortuosity to those forming aneurysm.
In the course of forming aneurysm, cases where the
arterial diameter exceeds the normal diameter are
regarded as dilatation, and cases of localized dilatation
by more than 50% the normal diameter (3 cm or more
at the abdomen) are regarded as aneurysm.
Saccular aneurysm is diagnosed if the arterial
diameter is less than 3 cm.

 
VII. Abdominal Aorta
1. Basic Scanning Method
(1) Longitudinal Scanning of Abdominal Median
Put the probe vertically at a slighly left position of
the perigastricum. The abdominal aorta will be traced.

(2) Aneurysm
Aneurysm is diagnosed if the diameter is 4 cm at the
head side from the branch of the renal artery, 3 cm at
the foot side from the branch of the renal artery and
2 cm or more at the common iliac artery.
(2) Transverse Scanning of Abdominal Median
Put the probe horizontally at a slighly left position
of the perigastricum. The abdominal aorta will be
traced at the left and the inferior vena cava,
at the right.
Scan the region up to the branches of the left and
right iliac arteries.

2. Checkpoints
The normal diameter of the abdominal aorta is 3 cm
or less at the head side from the starting point of the
renal artery and 2.5 cm or less at the foot side. The
normal diameter of the common iliac artery is 1 cm
or less.

(3) Dissection
Dissection is the state where the aortic wall is ablated
at the media and the arterial wall contains the original
arterial fossa (true fossa) and a new dissociated fossa.
The dissected membrane is indicated as linear high
echo (intimal flap) in the aortic fossa. With the color
Doppler, blood flow signals are observed in the
arterial fossa divided into two. The fissure of internal
tunic at the periphery where the dissociated fossa is
re-connected with the true fosa is called re-entry, and
can be identified by color Doppler.






 



Fundamental Abdominal Atlas.

Vector-Core, Tokyo, 2005

  

Fundamentals of Ultrasonography and Instruments.

Vector-Core, Tokyo, 1994

  


 


  

Ishiyaku Publishers, Tokyo, 2004

   et al

Abdominal Ultrasonic Screening, Ultrasonic Expert 2,

supplement of monthly Medical Technology.
Ishiyaku Publishers, Tokyo, 2004

(4) Stenosis/Obstruction
It is said that stenosis or obstruction is apt to occur
at a branch of artery. In the abdomen, it is often
observed at a branch of the aorta or the renal artery.

 ! " et al

Ultrasonic Diagnosis Update,

Extraordinary issue of Clinical Radiology, vol. 43, No. 11.
Kanahara Publishing, Tokyo, 1998

 # $

Ultrasonic Medicine Dictionary. Shujunsha, Tokyo, 2000

 ! 
 et al

ABC of Abdominal Echography. Igaku-Shoin, Tokyo, 2001

  % et al

Abdominal Ultrasonic Diagnosis. Shujunsha, Tokyo, 1994

   et al

Ultrasonic Diagnosis of Digestive Organs,

Extra issue of Clinical Gastrointestinal Medicine,
Vol. 11, No. 7. Japan Medical Center, Tokyo, 1996

 # $

Introduction to Abdominal Color Doppler.

Shujunsha, Tokyo, 1995

      

In screening the abodmen of the aged, it is

necessary to check for a possible aortic aneurysm
if not requested.
Abdominal aortic aneurysm does not accompany
any subjective symptom in many cases.
Sometimes it is not found until the diameter
exceeds 5 cm, increasing the risk of rupture.
It is difficult to find aortic aneurysm of corpulent
patients through palpation. It is recommended,
therefore, to check the abdominal aorta from under
the left hepatic lobe to the branches of left and
right common iliac arteries.
If the patient with aortic aneurysm feels
spontaneous pain or tenderness, examine with
rupture or threatened rupture in mind.





  
   


 






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