Professional Documents
Culture Documents
Definition
Ultrasonography is study of internal organs or blood vessel using high frequency sound waves, the actual test called ultrasound scan or sonogram.
Definition
Ultrasound are sound waves of frequencies greater than audible to human ear i.e. greater than 20,000Hz.
rabiezahran@Gawab.com
Basic Ultrasound Physics: Sound is a series of pressure waves(mechanical waves) propagating through a medium. One cycle of the acoustic wave is composed of a complete positive and negative pressure change. The wavelength is the distance traveled during one cycle, the frequency of the wave is measured in cycles per second or Hertz (Cycles/s, Hz).
rabiezahran@Gawab.com
Principle * A sound waves travels in a pulse & when it is reflected back it becomes an echo. The pulse-echo principle is used for ultrasound imaging. * A pulse generated by one or more piezoelectric crystals in an ultrasound probe or transducer. * Ultrasound probe crystal is shocked by single extremely short pulse of electricity to vibrate at a frequency determined by its thickness.
rabiezahran@Gawab.com
sound waves travel faster in solids than liquids or gases. The major cause of attenuation in soft tissue is absorption,
rabiezahran@Gawab.com
Ultrasonography
Advantages - No ionizing radiation - Safe in pregnancy - No known side effect - Cheap, portable machine - Minimum preparation of patient . - Painless, noninvasive - Direct vision for biopsy Disadvantages * Sonographer should be expert in diagnosis . * Performing & interpreting the examination can be extremely difficult.
Ultrasonography Machine
Introduction
rabiezahran@Gawab.com
1. Ultrasound waves
They are waves of very high frequency ranging between 3.5 10 MHz and up to 20 MHz in endosonography. When the frequency the resolution and penetration .
rabiezahran@Gawab.com
In adults the frequency used =3.5 MHz. In children the frequency used=5 MHz.
MHz.
2. Echo pattern
It means the reflection of waves , and this depends on the material which is penetrated by US.
rabiezahran@Gawab.com
2. Echo pattern Echofree : When ultrasound waves pass through fluids ( ascites- simple cyst- blood vessels) no reflection occurs and these areas appears as black areas with posterior enhancement .
rabiezahran@Gawab.com
rabiezahran@Gawab.com
2. Echo pattern Echogenic : When ultrasound waves pass through solids (bones stone) all waves are reflected and appears as white color with posterior shadow .
rabiezahran@Gawab.com
Posterior shadow
rabiezahran@Gawab.com
3. Transducers
a. Shape
Linear Sector Linear convex
b. Frequency
Single Dual Range
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Liver
rabiezahran@Gawab.com
Liver 1. Size . 2. Focal lesion . 3.Diffuse liver disease . 4.Hepatic vasculature . ( portal vein & hepatic veins ) 5. Intrahepatic biliary radicles .
rabiezahran@Gawab.com
Liver
Size: Lt. Lobe span Rt. Lobe span (5-10 cm). (8-15 cm).
rabiezahran@Gawab.com
Liver 1. Size . 2. Focal lesion . 3.Diffuse liver disease . 4.Hepatic vasculature . ( portal vein & hepatic veins ) 5. Intrahepatic biliary radicles .
rabiezahran@Gawab.com
Liver
Focal lesions
rabiezahran@Gawab.com
Liver (focal lesion) 4 .Echopattern a. Echofree e.g. hepatic simple cyst, hydatid
cyst.
5.Differential diagnosis
rabiezahran@Gawab.com
Images show a large (8 cms.) rounded, well defined, hyperechoic, noncalcific mass in the right lobe of liver. There is a moderate amount of acoustic enhancement posterior to the lesion.
rabiezahran@Gawab.com
Heterogeneous echogenicity
rabiezahran@Gawab.com
Liver metastases
Heterogeneous echogenicity
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Echo-free
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Liver 1. Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5. Intrahepatic biliary radicles.
rabiezahran@Gawab.com
Liver
Liver
Pp thickening
rabiezahran@Gawab.com
Liver
Pp thickening
rabiezahran@Gawab.com
Liver
Liver
rabiezahran@Gawab.com
Liver
rabiezahran@Gawab.com
Liver
rabiezahran@Gawab.com
Liver
Bright liver
rabiezahran@Gawab.com
Liver 1.Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5. Intrahepatic biliary radicles.
rabiezahran@Gawab.com
Liver
Hepatic Vasculature
A- Portal Vein: - The diameter is normally up to 12mm, in fasting adults. - From 13-17mm in suspected cases of portal hypertension.
rabiezahran@Gawab.com
Liver
Hepatic Vasculature
->17 it is sure portal hypertension. NB: - In some cases of portal hypertension the P.V diameter is within normal due to the presence of collaterals.
rabiezahran@Gawab.com
Liver
Liver
Portal Vein Thrombosis
rabiezahran@Gawab.com
Liver
Portal Vein Thrombosis
rabiezahran@Gawab.com
Liver
Collaterals
The presence of any collaterals is a sure sign of Portal Hypertension 1- Para umbilical vein : seen in the falciform ligament. 2- Coronary vein : seen in the inferior surface of the left lobe. Normally less than 5 mm. It is related to oesophageal varices.
rabiezahran@Gawab.com
Liver
Collaterals
3- Splenic hilum collaterals: lieno-renal collaterals (benign) around splenic vein& directed to the kidney lienogastric : Directed to stomach. related to fundal varices..
rabiezahran@Gawab.com
Liver
rabiezahran@Gawab.com
Liver
Coronary vein
rabiezahran@Gawab.com
Liver
Liver
Dilated HVs.
rabiezahran@Gawab.com
Liver
Attenuated HVs
rabiezahran@Gawab.com
Liver
Normal HVs.
rabiezahran@Gawab.com
Liver
Attenuated HVs
rabiezahran@Gawab.com
Liver
Attenuated HVs
rabiezahran@Gawab.com
Liver 1. Size. 2. Focal lesion. 3.Diffuse liver disease. 4.Hepatic vasculature. (portal vein & hepatic veins) 5.Intrahepatic biliary radicles .
rabiezahran@Gawab.com
Liver
* Normally they are not seen, when dilated as in Obstructive Jaundice pdouble barrel sign (portal vein tributary and intrahepatic bile radicle ).
rabiezahran@Gawab.com
Intra-hepatic Biliary Radicles *When the obstruction is intra-hepatic (e.g hilar cholangio-carcinoma) there is no dilatation of CBD. * when the obstruction is extra hepatic there is dilatation of CBD. more than 8 mm
rabiezahran@Gawab.com
Liver
rabiezahran@Gawab.com
Liver
rabiezahran@Gawab.com
Liver
rabiezahran@Gawab.com
Gall Bladder
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Gall Bladder
Gall Bladder
Size
Long axis 6-12 cm , short axis 3-5 cm
- Contracted < 5 cm. - Distended > 12 cm when the patient is fasting.
rabiezahran@Gawab.com
Gall Bladder
Gall Bladder
Wall thickness
- Measured in the side in contact with the liver. - Normally it is up to 3 mm. - From 3-5 mm >>> suspect thick wall.
rabiezahran@Gawab.com
Liver
Wall thickness
rabiezahran@Gawab.com
Gall Bladder
Gall Bladder
Contents
* Stones:
seen inside the gall bladder in all positions, mobile except at the neck. they appear white with posterior shadow.
Gall Bladder
Contents
Parasite:
Fasciola appears pearl shape. Move as a whole. Ascaris rare appears as thrill inside G B.
Gall Bladder
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Gall Bladder
rabiezahran@Gawab.com
Gall Bladder
rabiezahran@Gawab.com
Gall Bladder
rabiezahran@Gawab.com
Gall Bladder
rabiezahran@Gawab.com
Gall Bladder
rabiezahran@Gawab.com
Mirizzi syndrome
This syndrome is caused by impacted calculus in the Gall bladder neck or cystic duct causing extrinsic compression of the common hepatic duct. A common predisposing factor for this is the low insertion of the cystic duct into the common hepatic duct. This makes the cystic duct almost parallel to the common hepatic duct.
rabiezahran@Gawab.com
is an out-pouching of the wall of the gallbladder at the junction of the neck of the gallbladder and the cystic duct.
rabiezahran@Gawab.com
Spleen
rabiezahran@Gawab.com
Spleen
Size
Measure the diagonal axis: Normally it covers the upper 1/3 of the left kidney. - Longest axis (diagnostic) - Relation to kidney. - Relation to costal margin.
rabiezahran@Gawab.com
< 12 cm.
* Causes:
Lymphoma. Cyst (simple-hydatid ). Infarction of a part (triangular area & base toward the edge). Sarcoma.
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Spleen
Longest axis
rabiezahran@Gawab.com
Spleen
rabiezahran@Gawab.com
Spleen
rabiezahran@Gawab.com
Normal kidney
rabiezahran@Gawab.com
Anatomy
Kidneys are retroperitoneal, T12 - L4 Right kidney is lower than the left kidney Right kidney is posterio-inferior to liver & gallbladder Left kidney is inferior-medial to the spleen Adrenal glands are superior, anterior, medial to each kidney
Hepatic Veins
Spleen
Celiac axis
Liver
SMA Right kidney Renal artery Renal vein Left kidney
Anatomy
9-12 cm long, 4-5 cm wide, 3-4 cm thick Gerotas fascia encloses kidney, capsule, perinephric fat Sinus
Hilum: vessels, nerves, lymphatics, ureter Pelvis: major and minor calyces
Kidney Anatomy
Major Calyx
Sinus
Sonographic Appearance
Ureters are normally not seen Renal pelvis is black when seen through urine Renal sinus is echogenic due to fat Medullary pyramids are hypoechoic Cortex is mid-gray, less echogenic than liver or spleen. Capsule is smooth and echogenic
Rt. lobe
Spleen
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Degree of Hydronephrosis
Normal
Mild
Moderate
Severe
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Kidney Stone:
rabiezahran@Gawab.com
This huge calculus was discovered on ultrasound imaging of the left kidney. The calculus measuring almost 7 cms. is seen occupying the lower half of the left renal pelvis and the adjacent calyces. There is also mild dilatation of the renal pelvis due to urinary tract obstruction
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Normal pancreas.
rabiezahran@Gawab.com
Normal pancreas.
2- head 31- liver; of the pancreat pancreas ic body; 65- tail of superior 4the mesente Wirsung pancreas ric 's duct; ; artery; 7- IVC. 8Aorta; 9- spine.
10- GB
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Pancreatic cyst
an oval, echo-negative formation with well-defined, even outline visualised within the pancreatic body projection
rabiezahran@Gawab.com
Pelvic ultrasound.
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
rabiezahran@Gawab.com
Uterine fibromyoma .
rabiezahran@Gawab.com
Pleural effusion:
large, clear, hypoechoic fluid collection in the left pleural space. The left lung has collapsed into a small mass of tissue compressed by the effusion. A small fibrotic band is seen traversing the fluid.
rabiezahran@Gawab.com
Case study
rabiezahran@Gawab.com
Case 1 A 38-year-old man comes to the emergency department after falling 15 feet off scaffolding at work. His systolic BP is 90; his heart rate is 125 bpm. He is on a backboard and in a C-spine collar and complains of severe pain in his back and abdomen. You perform the FAST ultrasound scan as part of your trauma evaluation and find the following rabiezahran@Gawab.com
Image case 1 Your diagnosis: Significant amount of intra-abdominal free fluid. Shown here is the peri-hepatic area, also called Morrisons pouch. ED management: Immediate transfer to the operating room for exploratory laparotomy. The patient is clinically unstable and has a presumed intra-abdominal bleed, most likely from a solid organ injury or vascular injury.
rabiezahran@Gawab.com
Case 2 A 42-year-old female patient complains of sudden severe right flank pain. During your interview she is restless and seems unable to find a position of comfort. On exam she is afebrile, her vital signs are stable and she has tenderness over her right flank. You perform a bedside ultrasound and find the following:
rabiezahran@Gawab.com
Your diagnosis: Mild hydronephrosis right. ED management: On extended bedside ultrasound her left kidney appears normal, also her aorta and FAST exam show no abnormalities. Symptomatic treatment with IV fluids and pain control resolve all symptoms. Patient will need urgent outpatient follow-up with urology for renal colic with hydronephrosis without signs of infection and normal renal function.
rabiezahran@Gawab.com
Case 3 A 23-year-old woman presents to the ED with nausea and vomiting for the past few days. Her last period was regular but very light and she cant remember the exact date. She does not take birth control or fertility drugs. Her abdominal exam is unremarkable, on pelvic exam the cervical os is closed. You perform a bedside pelvic rabiezahran@Gawab.com ultrasound:
Your diagnosis: Early intra-uterine pregnancy. (Image courtesy of W. Hosek, M.D.) ED management: Nausea and vomiting resolve with IV hydration and medication. The patient is discharged with outpatient follow-up with OB and started on pre-natal vitamins.
rabiezahran@Gawab.com
Case 4 A 45-year-old patient presents with upper abdominal pain. Her symptoms began after eating a burger. On exam she is tender over the right upper abdomen. She mentions that she had two similar episodes recently, but they were less painful. You start symptomatic treatment, order blood work and perform a bedside ultrasound:
rabiezahran@Gawab.com
Your diagnosis: Acute biliary colic with multiple gallstones. On ultrasound exam you find multiple gallstones but the gallbladder wall and common bile duct appear normal. ED management: Blood work shows no infection or elevation of liver or pancreatic enzymes. The patient improves with symptomatic management and her pain resolves. She is discharged from the ED after surgical consultation and planned outpatient follow-up.
rabiezahran@Gawab.com
rabiezahran@Gawab.com