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Intro to Bedside Ultrasound
Abdominal Ultrasound
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University of California-Irvine School of Medicine
Nathan Molina [email protected] Trevor Plescia [email protected] Jack Silva [email protected]
TEACHERS
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Liver
Kidney
Diaphragm
Intestine
Appendix
Spleen
Gallbladder
ABDOMINAL STRUCTURES
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3 MHz curvilinear for heavy patients, 5 or 7 MHz for average or thin patients, high frequency linear for superficial (bowel)
PROBES
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LIVER: RIGHT UPPER QUADRANT
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LIVER LOCATION
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LIVER AND KIDNEY
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NORMAL MORRISON’S POUCH
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ABNORMAL MORRISON’S POUCH
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LIVER VASCULATURE
Hepatic Vein
• We can use Color Doppler to confirm the presence of vessels
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• Probe indicator oriented toward the head
• Two methods for f inding the gallbladder: • X – 7 • Subcostal Sweep
• Have patient take a deep breath to push liver out from under the ribs
• Fan through the gallbladder in both axes
GALLBLADDER SONOGRAPHY
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X = Xiphoid Process
From the X, place the probe 7 centimeters laterally to the patient ’s right
Phased array (P21) probe can be used
Helpful for bigger patients
FINDING THE GALLBLADDER: X - 7
X
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Place probe in sagittal position at midline beneath the xiphoid process
Sweep the probe laterally along the costal margin to visualize the liver and gallbladder
FINDING THE GALLBLADDER: SUBCOSTAL SWEEP
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MILF or Main InterLobar F i ssure is visual ized between the gal lbladder and the portal vein
GALLBLADDER SONOGRAPHY
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MILF or Main InterLobar Fissure is visual ized between the gal lbladder and the portal vein
MAIN INTERLOBAR FISSURE
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MILF
PV
GB
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GALLSTONE WITH POSTERIOR SHADOWING
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CHOLECYSTITIS GALLBLADDER INFLAMMATION
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The “Mickey Mouse Sign” consists of the portal vein, hepatic artery, and common bile duct in the short axis
From the long axis view of the gallbladder, follow the MILF to the portal vein.
Use minor adjustments to try and find the Mickey Mouse sign
Use Color Doppler to confirm common bile duct vs hepatic artery
MICKEY MOUSE CBD Hepatic Artery
Portal Vein
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THE KIDNEY
Ureter
Pelvis
Cortex Capsule
Pyramid
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KIDNEY
Cortex
Pyramid
Pelvis Ureter
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KIDNEY
Anterior or Coronal position Consider decubitus (left side) positioning for posterior view
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NORMAL KIDNEY
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RENAL CYSTS (POLYCYSTIC KIDNEY DISEASE)
Cysts within the renal cortex, not within renal pelvis
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HYDRONEPHROSIS
Fluid buildup within the renal pelvis, not the cortex
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KIDNEY PATHOLOGY
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SPLEEN LOCATION
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SPLEEN FUNCTION-FILTERS RED BLOOD CELLS, IMMUNE RESPONSE
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INTESTINAL ULTRASOUND TECHNIQUE
Start in right upper quadrant and identify the ascending colon by its constancy of position and haustra
Follow ascending colon to right lower quadrant to identify the cecum’s blind -ended loop
The cecum should lead you to the terminal i leum where the appendix is typically found
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Layered appearance Easily compressible Intermittent peristalsis Large intestine has wall
thickness <4 mm Small intestine thinner
than large intestine
NORMAL BOWEL
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ABNORMAL BOWEL
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Non-compressible tubular structure in RLQ, sitting on top of the psoas muscle.
Normal size is 6mm or less. Only visible in pelvic orientation in ~15% of
patients (vs retrocecal orientation)
APPENDIX
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NORMAL APPENDIX
Psoas Iliac artery
Appendix
Abdominal muscle
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ACUTE APPENDICITIS
Diameter is greater than 6mm Color Flow Doppler to see ring of fire
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ABDOMINAL AORTA AND INFERIOR VENA CAVA
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ABDOMINAL AORTA AND INFERIOR VENA CAVA
Use convex probe or curvilinear probe Place probe in sagittal position with
indicator pointing to the patients’ head or transverse with the indicator to the patient’s right
Abdominal Aorta will be slightly to the patient’s left
Inferior Vena Cava will be slightly to the patients’ right
Must push hard Great way to see aortic aneurisms
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SAGITTAL VIEW –
ABDOMINAL AORTA
Aorta
SMA Liver
Splenic vein
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TRANSVERSE ANATOMICAL LANDMARKS
Transverse
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TRANSVERSE VIEW – ABDOMINAL AORTA & IVC
IVC
Splenic vein
Aorta
L. Renal vein
Liver SMA
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ABDOMINAL AORTIC ANEURYSM
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Liver
IVC
RRA
Portal vein(s)
SAGITTAL IVC
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Portal veins
RRA
IVC
SAGITTAL IVC
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SAGITTAL OR TRANSVERSE?
TRANSVERSE
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SMALL IVC = LOW CENTRAL VENOUS PRESSURE
IVC
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IVC DILATED WITHOUT RESPIRATORY CHANGE = HIGH CVP
IVC
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Atlas of Anatomy, Second Edition, By Gilroy, MacPherson, Ross, Schuenke, Schulte, Schumacher. Thieme Medical Publishers, 2012.
Select images from the UCISOM Ultrasound in Education Department
REFERENCES