M.
Shuja Tahir
Faisalabad, Pakistan
Investigations
ULTRASONOGRAPHY
GENERAL PRINCIPLES
U ltrasonography is the visualization
of the body tissue and viscera with
the help of high frequency sound waves
which are generated by applying an
alternating current to a transducer
made of piezo electric material.
The ultrasound scanning is a non
invasive technique and a great degree
of information can be obtained without
any discomfort to the patient. It is a
harmless procedure. When repeatedly
used, it does not have any harmful
effect on the patient or the fetus in
pregnant ladies.
The use of ultrasonography has
Liner probe showing its
steadily increased throughout the
area of scanning world and today it has become almost
a part of clinical examination.
(sonographic examination). The
ultrasonic method of investigation is
simple, economical, non invasive,
easily repeatable, instantaneous and
easily available. Ultrasound guided
procedures are becoming more
Linear Probe common and popular to confirm
diagnosis and to offer treatment in
many conditions.
ADVANTAGES
! The ultrasound scanning is non
invasive.
! The patient does not face any
Convex Probe physical hazard.
! Minimum time is required for
examination.
! The examination may be repeated
frequently without causing any
damage to the patient.
! Adequate information may be
achieved with this investigation.
! The results of sonography can be
193 April to June 2010
IR-047
!
documented and kept for future
reference.
It is not painful
! It is not destructive (non traumatic)
! Dynamic image is available.
! It can visualize moving targets such
as blood vessels and heart valves.
! Duplex imaging has improved the
diagnosis and management of
vascular lesions.
! The machine is low cost and may
be acquired by a greater number of
doctors.
! It has made a rapid progress in
clinical applications. Soft tissues
can also be investigated with it.
! It is a mobile machine and can be
taken anywhere anytime.
! Surgical intervention can be done
with safety under ultrasound
guidance.
LIMITATIONS
Ultrasound scanning is an investi-
gation and not treatment. It has its
limitations as well;
! It cannot diagnose every disease or
all the details of every disease
process.
! Lungs cannot be examined
adequately.
! It is not very simple and easy to
interpret and it is operator
dependent.
! It requires adequate knowledge of
anatomy specially cross sectional
and physiology to interpret the
results correctly.
! Surgical intervention is not possible
in all disease processes.
Various lesions can be visualized on
ultrasonography depending upon their
INDEPENDENT REVIEWS
texture such as;
Echopattern Visible color Type of lesion
Hypoechoic or Black color Cystic mass
echo poor
Hyperechoic White color Solid mass
echogenic
Mixed Gray color or Complex mass
echogenicity areas of black
& white
The transducer (Probe) is placed over
to the area to be examined by placing a
coupling agent (usually water soluble
gel) to the skin to diminish the loss of
ultrasound waves at the interface
between the transducer and the skin.
The transducer so applied, emits a
pulse of sound waves that pass through
soft tissue until an interface between the
structures of different tissue densities is
reached. When this occurs some of the
energy proportional to the difference
in densities at the interface is reflected
and echoed back to the transducer.
This in turn stimulates the transducer
while in listening phase to generate a
small electric voltage which is amplified
and altered into visual signals. The
voltage sampling and handling is
performed electronically. These signals
are displayed on the monitor screen as
a picture of the structures being
scanned.
Better resolution of the body organs
can be achieved by better and
improved signal handling, analysis,
recording and reproduction of the
signal on the monitor.
New developments in the electronics
and computers have improved the
April to June 2010 INDEPENDENT
signal handling and thus producing
better picture resolution to a great
degree.
The low frequency transducers (probes)
provide better sensitivity and
penetration while high frequency
probes provide high resolution,
contrast but less penetration.
Commonly used probes have
frequencies from 2-20 MHZ. Low
frequency probes are used in fatty Mechanical sector probe
patients and for deeper structures. showing its area of scanning
High frequency probes are used for
superficial parts.
The transducers (probes) have been
developed which produce wide
spectrum of sound waves. The filters
are used to allow the low frequency
ultrasound waves to pass through and Mechanical Sector Probe
high frequency echoes are picked up
electronically. This method achieves
better tissue penetration and better
resolution at the same time.
All these developments have led to a
Intra-cavity Prob (Trans-rectal)
very reliable, extremely helpful and
detailed study of internal organs of the
body without causing any damage.
The picture of internal organs is seen
on the monitor in grey scale. It can be
photographed or photocopied or
Intra-cavity Probe
printed on a computer printer in (Trans-vaginal)
positive or negative mode. The fluid is
seen as jet black. The solid tissue
without fluid is seen as white. The
tissues having solid and fluid
components show as different shades
of grey depending upon the amount of
fluid or solid component.
The black color is due to lack of echoes
(Hypo-echoic or echo poor). The white
color is due to increased echoes
REVIEWS 194
 (Hyper-echoic or echogenic).
Different types of transducers (probes)
are used. Their utility is different and
these can be selected to achieve
optimal observations in various
situations.
Intra-operative Probe
(T-shape) LINEAR PROBE
It is the simple type of probe. It
produces rectangular image. It shows
the structures directly underneath the
probe. It is best used for obstetrics
patients. It is easy to use and offers easy
interpretation of the scan.
Intra-operative Probe
(I-shape) CONVEX PROBE
Convex probe is a variation of linear
probe made in a convex form. It gives
better information than linear probe
and is more durable and easier to use
than mechanical sector probe. It is
most commonly used probe these days.
Interventional Probe
SECTOR PROBE
It is mechanical sector probe. It
provides pie-shape image. It gives
maximum information as it shows the
structures of an area of diverging cone
or wedge from probe onwards. It picks
up the areas or information which
could have been missed otherwise.
INTRA-CAVITY PROBE
These probes are small sized at the
front and fit in the cavities easily and
comfortably. These are made for
cavities such as rectum and vagina.
These are used for scanning the organs
through the cavities. These provide
excellent information because of
smaller distance between probe and
the organ to be scanned. Only
problem is of patient compliance.
Single probe to be used in multiple
195 April to June 2010
cavities have also been developed.
These are covered with disposable
covers to avoid cross contamination
among patients.
ENDOSCOPIC PROBE
It is a highly specialized small sized
probe fitted on the endoscopes such as
laparoscope, gastroscope,
colonoscope, urethroscope and
cystoscope. It is used for picking up
early lesions of gastro-intestinal or
urinary tract.
INTRA-OPERATIVE PROBE
It is also a very specialized probe, which
can be sterilized. It is used during
surgery to locate occult lesions.
INTERVENTIONAL PROBE
It is convex probe with a hole inside for
insertion of special needle or some
groove over its middle for the same
purpose. These are used for both
therapeutic purposes and to perform
procedures for confirmation of
diagnosis through guided biopsy which
is not possible otherwise due to depth
of tissue or its relations to delicate
structures.
ENDOSCOPIC ULTRASONOGRAPHY
(EUS)
It is the ultrasonography performed
through endoscopic examination. It is
performed during gastroscopy or
colonoscopy and laparoscopy. It is
extremely helpful and its diagnostic
accuracy is 80-87% in detection and
staging of upper gastrointestinal
malignancy. It helps to measure the:
! Depth of tumour
! Infiltration in wall
! Involvement of lymph nodes.
! Spread to adjacent organs
INDEPENDENT REVIEWS
The size and location of the tumour can
be detected. Its accuracy is double that
of C.T. Scan1. It is currently the best
procedure in the assessment of
subepithelial tumours and extrinsic
compression of esophagus and
stomach2,3.
INTRA-CAVITY ULTRASONOGRAPHY
It is ultrasound examination performed
through body cavities with the help of
specially designed probes to fit in lower
rectum and vagina for examination of
pelvic organs more clearly. It is
possible as the probe is quite near to
the tissue to be examined. A standard
probe can also be used for both
cavities when covered with disposable
covers. These help in the assessment of
prostate and early pick up of
carcinoma. These also help in
investigating of ovum for In-vitro-
fertilization.
INTRA-OPERATIVE ULTRASONO-
GRAPHY
This is the type of ultrasonography
which is used during surgery to locate
the occult lesions which are not
detectable otherwise. The ultrasound
probe used for this purpose can be
sterilized and used in the surgical field.
Special high frequency ultrasound
probes are used under strict aseptic
conditions during surgery to visualize
structures in the operating field.
INTRA VASCULAR ULTRASOUND
(IVUS)
It is intra vascular ultrasound imaging
in which a catheter based miniature
sonographic probe (transducer) is
introduced into vessels. It provides high
resolution, cross sectional real time
imaging of the vessel wall and lumen.
April to June 2010 INDEPENDENT
It helps for aortic measurements, vessel
wall evaluation and stent graph
positioning by using a vector phased-
array intravascular ultra probe with
doppler function.
It is useful both as a diagnostic and
therapeutic adjunct in evaluation of
various arterial and venous disorders.
INTERVENTIONAL SONOGRAPHY
It is the performance of various
procedures under ultrasound
guidance. These procedures may be
helpful in diagnosis or treatment.
! Diagnostic
! Therapeutic
Diagnostic
Ultrasound guided FNAC and biopsy
of the suspected lesions helps to
achieve correct diagnosis with
minimum invasiveness.
Therapeutic
Ultrasound guidance can be used with
reasonable success in many problems
which otherwise would have required
major surgery. Following lesions are
commonly treated with the help of
ultrasound guidance;
! Drainage of liver abscess
! Drainage of breast abscess
! Drainage of pelvic abscess
! Drainage of subphrenic abscess
! Drainage of peri-nephric abscess
! Drainage of pseudocysto pancreas
Transducer Frequency
Transducers of different frequencies
such as 2.5, 3.5, 5.7 and 10MHz are
available. We use probes (transducers)
of frequencies ranging from 2-20 MHz.
Increase in the frequency improves
resolution but decreases penetration.
Decrease in the frequency increases
REVIEWS 196
 penetration but dimisnishes resolution.
High frequency probes are used for thin
patients and soft tissues. Low frequency
probes are used for fatty patients.
Small part scanners:
These are used to visualize the fine
details of superficial structures, usually
at a depth of less than 4 cms from the
skin (eg Thyriod, carotid arteries,
testes, breast, lymph glands and soft
tissue tumors of limbs or abdominal
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The author :
J, Lee T, Stable BE, Eysselein VE.
Muhammad Shuja Tahir
FRCS (Ed), FCPS (Hon) EUS-Guided pancreatic pseudocyst
is professor and head of the drainage. review and experience at
Harbor-UCLA medical centre. Med
department of Surgery at
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Independent Medical
7. Brountzos EN, Panagrotou IE,
College Faisalabad. Bafaloukos DI, Kelekis DA.
shuja@iu-hospital.com
197 April to June 2010
wall). These scanners usually utilize
high frequency probes of 7.5 or 10
MHZ.
Special transducers:
Following special transducers are
availble for ultrasonography;
Endo-rectal transducers
Endo vaginal transducers
Ultrasound guided biopsy transducers
Doppler probe
Intra operative probe
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INDEPENDENT REVIEWS