technique doppler on gall bladder[1]

8/13/2019 Technique Doppler on Gall Bladder[1]

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http://www.med-ed.virginia.edu/Courses/rad/edus/index1.html

Technique

Scanner

The electrical signals are sent to the scanner from the transducer and analyzedto produce an image. The image is a result of the strength of the echo(brightness=sound intensity) and the time at which the echo is received. Theultrasound image is displayed as tiny white pixels on a black background. Thegray-scale image can portray structures from a spectrum of anechoic tohyperechoic. nechoic or echolucent structures have complete absence of

echoes and therefore appear black. !yperechoic or echogenic structures havemore echoes (whiter) than surrounding tissue.


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"mage of a scanner.


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#

. nechoic structure (fluid filled cyst) indicated by red arrow. #. !yperechoic structure (renalstone) indicated by red arrow produces an acoustic shadow ($).

Transverse images are displayed with the patient%s right side on the left side ofthe the image like a &T scan. 'ongitudinal images are displayed with the cranial

aspect of the patient%s anatomy at the left side of the image.


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#

. Transverse image of normal abdomen. #. 'ongitudinal image of normal abdomen.

Technique

Transducer


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transducer is a device that translates one form of energy to another. nultrasound transducer contains a piezoelectric crystal that can translate electricalsignals into mechanical energy or mechanical energy into electrical signals. Thetransducer uses a pulse-echo techni ue to obtain an image. "nitially a soundwave is produced by electricity within the transducer and directed into the patient.

The reflected sound waves are received by the transducer and converted intoelectrical signals and an image can be created.

The *ltrasound (*$) transducer sends a series of *$ beams into patient tissue. The *$ imageis produced by the pattern of reflected beams (echoes). The depth of an echo is determined bymeasuring the round trip time-of-flight from beam transmission to echo reception. ssuming thatthe speed of sound in human tissue is a constant +, m/sec the depth of an echo can beaccurately plotted on the resulting *$ image.

Linear, sector, and curved array are three formats of a transducer that determine the shapeand field of view. Linear array transducers produce rectangular images and offer the bestoverall image quality. Sector array transducers produce slice-of-pie-shaped images andare optimal for examining larger organs from between the ribs. Curved array transducers

combine advantages of the sector and linear formats and are optimally used when thesonographic window is large.


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&urved ( ) linear (#) and sector (&) array transducers provide differing shapes in the ultrasoundfield-of-view.

Medical ultrasound is performed using very high sound frequencies in the range of -!"M#$. %he best image resolution is obtained by using the highest transduced frequency

possible. #owever, the higher frequencies are more limited in ability to penetrate tissue.%hus, lower frequencies are often used, accepting lower resolution as a trade-off for

better penetration for deeper imaging.

Technique

Terms

Anechoic 0 lacking internal echoes.

Acoustic Enhancement 0 occurs when sound passes through an anechoicstructure. 1o echoes are reflected and so they are all available to pass through.2ore echoes are seen deep to the anechoic structure because more sound isavailable.


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"mage of a large renal cyst shows the classic findings of a simple cyst. The fluid contents areanechoic (red arrow) the walls are thin and sharply defined and acoustic enhancement (3) isevident deep to the cyst.

Acoustic Shadowing 0 occurs when the sound wave encounters a very echodense structure nearly all of the sound is reflected resulting in an acousticshadow.

4allstone (red arrow) within the the gallbladder produces a bright echo and causes a darkacoustic shadow ($).


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Technique

Terms-Doppler

The Doppler shift is the difference in sound fre uency between the *$ beamtransmitted into tissue and the echo produced by reflection from the moving redblood cells (5#&s). The 6oppler beam intercepts moving blood within a bloodvessel at an angle called the Doppler angle . "f an ob7ect moves away from theultrasound transducer the wavelength increases and fre uency decreasesbased on velocity (v) = fre uency (f) x wavelength ( ). "f the ob7ect moves

toward the transducer the wavelength decreases and the fre uency increases.The amount of fre uency shift is proportional to the velocity of the moving 5#&s.#y using the Doppler equation and the computer intrinsic to the *$ units the6oppler shift can be measured.

Doppler Equation =(8 x f x v x cosine of 6oppler angle)/&

f = transducer fre uency (2!9) v = velocity of 5#&s & = constant (velocity ofsound in soft tissue)


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#

. 6rawing illustrates the 6oppler fre uency shift. :t is the fre uency of the transmitted 6opplerbeam and :r is the fre uency of the 6oppler echo returned to the transducer. #. 6rawingillustrates the 6oppler beam and 6oppler angle used to communicate to the *$ computer theestimated direction of blood flow.

The 6oppler e uation demonstrates that the maximum fre uency shift will beobtained by directing the 6oppler interrogation beam at a 6oppler angle of degrees since cosine of degrees is +. !owever most blood vessels courseparallel to the skin and zero 6oppler angle is seldom obtainable. "n addition no6oppler shift is obtained at ; degrees since cosine of ; degrees is . Thusthe optimal 6oppler angle lies between , and < degrees.

There are three types of 6oppler displays. "n the Doppler spectral displayvelocity is plotted on the vertical scale (y axis) and time is plotted on the

horizontal scale (x axis). The directions towards the transducer is above thebaseline and the direction away from the transducer is below the baseline.$pectral waveforms vary over time with cardiac contraction with highest flowvelocities during systole and lowest flow velocities during diastole.


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"mage demonstrating 6oppler spectral display.

"n the color Doppler display velocity and direction are color-coded. &olor6oppler imaging superimposes 6oppler flow information on a standard gray-scale real-time *$ image. The color map is divided into two parts by a black barthat corresponds to zero flow point on the 6oppler spectral display. The colorabove the black bar is used to show flow relatively toward the 6oppler beam andthe color below the black bar is used to show flow relatively away from the

6oppler beam. The brighter colors correspond to higher mean velocities and thedarker colors indicate lower mean velocities.


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"mage demonstrating color 6oppler display.

"n the duplex Doppler display gray scale is simultaneously combined withspectral 6oppler.

&mage demonstrating duplex 'oppler display.


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Sonographic Diagnosis:

+) 3chogenic foci in 4# lumen

8) coustic shadowing

4allstone (red arrow) within the gallbladder produces a bright surface echo and causes a darkacoustic shadow ($).

?) 5olling stone sign - movement of gallstones with 4# with position change


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#

Rolling Stone Sign . . @ith the patient supine the gallstone (red arrow) is near the neck of thegallbladder. #. @ith the patient in left lateral decubitus position the gallstone (red arrow) rolls tothe gallbladder fundus.

Acute Cholecystitis

Clinical


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Diagnosis for Acute Cholecystitis:

2a7or &riteria4allstones

$onographic 2urphyDs sign 2inor &riteria

@all thickening E ? mmAericholecystic fluid

The gallbladder (4#) is filled with echogenic sludge ($l) and a gallstone (red arrow) is impacted inthe gallbladder neck. The gallbladder wall (red arrowheads) is markedly thickened indicative ofwall edema and there are pericholecystic fluid (blue arrows) pockets surrounding the gallbladder.

iliary Dilatation

Clinical

*$ is approximately ; accurate in differentiating obstructive from non-obstructive 7aundice by depicting the presence of biliary dilatation. &auses forbiliary dilatation are impacted gallstone in or at ampulla benign stricturepancreatic carcinoma cholangitis biliary surgery and chronic pancreatitis.


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"n the transverse image the common bile duct (red arrowheads) is anterior to the portal vein (AF)and the gallbladder (red arrow) is also visualized.

Exam

#egin with the patient in the left posterior obli ue position. Aatient may also beplaced in the supine position. >btain longitudinal and transverse views of rightand left lobe of liver and include longitudinal images of liver/diaphragm interface.

2easure intrahepatic bile duct common hepatic duct (&!6) and as fardistal as possible. c uire longitudinal view of bile duct in pancreatic head andtake measurement. 6ocument patency in portal veins hepatic veins andhepatic artery.

Sonographic !indings:

+) $hotgun sign 0 intrahepatic biliary ducts ("!#6) become tortuous and theirdiameter exceeds 8 mm or exceeds of the diameter of the ad7acent AF.

&olor 6oppler is used to confirm the absence of blood flow in the enlarged biliarytubes.


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Shotgun Sign . Transverse image reveals dilated bile duct (red arrow) anterior to the portal vein(red arrowhead) resembling a double-barrel shotgun.

8) &onfluence of enlarged intrahepatic biliary ducts ("!#6) create a stellateappearance of merging tubes.

6ilated "!#6 (red arrows) are seen as tortuous tubular structures in the liver. &olor 6opplermakes differentiation of bile ducts (red arrows) and blood vessels (red arrowheads) easy.


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?) is considered dilated in adults if its diameter E Bmm.

6ilated common bile duct (red arrow) measured at ;.B mm.

Epigastric "ain

AAA #A$dominal Aortic Aneurysm%

Clinical

pproximately ; -;, of abdominal aortic aneurysms ( ) are confined to the

infrarenal aorta. are usually not repaired until they exceed -, cm inmaximum diameter. The risk of rupture within , years is 8, at , cm diameter. smaller than , cm have a ? risk of rupture over + years. *$ is used tomonitor the rate of enlargement of . The average increase is 8 mm/yrdiameter.


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'ongitudinal image through the normal abdominal aorta ( ) with a diameter of 8 cm.

Exam

#egin with the patient in the supine position. >btain longitudinal and transverseimages of entire abdominal aorta and a transverse view of bifurcation to show theiliac arteries. 4et a longitudinal image of each iliac artery. "mage the superiormesenteric artery ($2 ) and celiac artery. "mage renal arteries if origins are

seen.

measurementsG A measurement in longitudinal and transverse views.2easure transverse diameter. 2easurements are outer wall to outer wall. "f

is found obtain coronal views of right and left kidneys for renal length.


+) bdominal aorta E ? cm measured from inner wall to inner wall.


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Transverse image demonstrating focal enlargement of the aorta (red arrows) with a diameter of cm.

8) !ypoechoic mural thrombus within .

3nlarged view of the right common iliac artery shows the large amount of intraluminal thrombus(T) commonly found in aneurysms of the aorta and iliac arteries. The patent lumen is indicatedby the red arrow.


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?) 5upture of is suggested by fluid or hematoma around the aorta.

Transverse image demonstrates rupture of an aortic aneurysm (red arrows) while the redarrowheads indicate the intact aortic wall.

Technique

"ancreatitis

Clinical

cute pancreatitis is most commonly caused by alcohol abuse or a gallstoneimpacted in the distal common bile duct. "nflammatory changes vary from mildinterstitial edema to extensive necrosis with hemorrhage. Aatient usuallypresents with deep epigastric pain that radiates to the back nausea vomitingabdominal tenderness fever leuckocytosis and elevated pancreatic enzymes.Aancreatic pseudocysts are sometimes found several weeks after pancreatitis.


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"n the transverse image the pancreas is recognized by identifying its ad7acent vasculatureGinferior vena cava (F) abdominal aorta ( ) and the superior mesenteric artery (a). The 7unctionof the splenic vein (sv) with the superior mesenteric vein marks the commencement of the portalvein (AF) and is recognized by its teardrop shape. The head (!) body (#) and tail (T) of thepancreas course anterior and parallel to the splenic vein (sv).

Exam

#egin with the patient in the supine position or the upright position. 2ultipleviews of the pancreas are re uired in the transverse plane (long axis of thepancreas) and longitudinal plane with identification of head uncinate neck bodyand tail. Fisualization of the pancreas in patients with a lot of air in the stomachmay re uire additional maneuvers such as filling the stomach with water. "nthose cases where the pancreas is poorly visualized in spite of additionalmaneuvers always document the pancreatic area in both transverse andlongitudinal planes.

:or a thorough survey of the pancreas a minimum of six images are re uiredthree transverse and three longitudinal. 6epending on the patient additionalpictures may be needed to show the entire pancreas. 6ocumentation of

pathology (masses pseudocysts nodes) re uires additional images.

Sonographic !indings G

+) 6iffuse enlargement of pancreas with ill-defined margins and hypoechoicparenchyma


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8) Aeripancreatic fat decreased in echogenicity with hypoechoic strandingdensities

?) !emorrhage may cause hyperechoic masses of clot of blood

#

Acute Pancreatitis. . Transverse scan. #. 'ongitudinal scan. The head of the pancreas (!) isenlarged as revealed by the red arrowheads and decreased in echogenicity because of edema.The surrounding structures are superior mesenteric vein (v) superior mesenteric artery (a)abdominal aorta ( ) and inferior vena cava ("F&).


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) Aeripancreatic fluid collections in lesser sac perirenal areas and small bowelmesentery

Transverse image shows huge fluid collection (:) surrounding the pancreas (A).

&'( "ain

Appendicitis

Clinical

The differential diagnosis is often between gynecological and 4" pathology. 5*H *$ exam plus appendix or a pelvis plus appendix may have to be donedepending on the clinical situation. &T is the preferred exam in the obese orelderly or in patients who are in so much pain that a technically ade uate

ultrasound cannot be performed. The classic presentation is of a + -? year oldperson with right lower uadrant pain nausea vomiting and leukocytosis. Thepresence of fever is evidence of perforation.


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Transverse image reveals normal appendix (between red arrows and I cursors) and itsechogenic submucosa (red arrowhead).

Exam

*se a linear probe (generally , 2!z) and in transverse orientation press downthe anterior flank. *se slow graded compression. &ompression should bestrong enough that the anterior abdominal wall is pressed against the psoas

muscle ) "f the patient is in too much pain they may need sedation. "f you cannotpress like this you must say it is a technically inade uate exam. @hen donecorrectly (with ade uate compression) this is a specific and sensitive exam ( E; ). 6onDt mistake the psoas for a abscess. "f unsure compare with theopposite side. "f present measure fecolith and diameter of appendix. 2easureany loculated fluid collection.

The sensitivity of *$ decreases with perforation. @ith careful techni ue aperiappendicial abscess can be picked up with ultrasound. Therefore thoroughlyexamine the 5'H (even the ''H) for an inflammatory mass. "f perforation islikely consider &T instead of ultrasound.

Sonographic Diagnosis

Fisualization of an aperistaltic tubular structure E < mm in diameter orvisualization of an appendix with a fecolith confirms the diagnosis. 4enerally theabnormal appendix is not at all subtle. The wall appears hypoechoic and may be


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strikingly so with impending perforation. loculated fluid collection mayrepresent abscess from a perforated appendix or other bowel source such as"#6 or 4J1 source such as T> .

Transverse image reveals an K-mm diameter non-compressible appendix (between red arrows).

n obstructing appendicolith (red arrow between I cursors) casts an acoustic shadow ($) andobstructs and dilates the appendix ( ) resulting in acute appendicitis.


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"mage in the long axis of the appendix shows long segment loss of visualization of thesubmucosa (red arrowhead) and a focal perforation (red arrow).

!lan* "ain

+ephrolithiasis

Clinical

1ephrolithiasis has its highest prevalence in men aged 8 - years. pproximately +8 of men and , of women experience renal colic caused bystone disease at least once in their lifetimes. 2ost renal stone disease isidiopathic. Aatients usually present with flank plain radiating to the genitalsnausea vomiting and constant motion. *ltrasound reliably demonstrates stonesE ,mm size but smaller stones up to are commonly not detected. &T is

commonly used for detection and is excellent.


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The renal cortex (red arrowhead) is e ual in echogenicity to the liver parenchyma ('). The renalpyramids (blue arrowhead) are slightly hypoechoic compared to the renal cortex. The centralrenal sinus (s) is invested with echogenic fat. The red arrow indicates the location of 2orrisonDspouch.

Exam

Lidneys are usually best seen with the patient in the decubitus position.6ocument kidney size and the position and size of stones cysts or masses.&onfirm if cysts are simple (simple = round or oval smooth walled anechoic andincreased through transmission). "f cysts are not simple they are indeterminateby *$ and may re uire further evaluation by &T.

>btain multiple long and transverse images of each kidney including upper midand lower poles. lso get long axis of both kidneys showing comparison of renalechogenicity to ad7acent liver or spleen. "f hydronephrosis is seen try to imageureter and assess level and cause of obstruction. 'ong and transverse images

of the bladder including ureteral tunnel views if indicated (r/o stone).

2easure kidney size in long A and transverse. 2easure dominant cystsmasses or stones. 1ormal kidney size is K-+? cm long. 1ormal echogenicity isiso or hypoechoic to normal liver.

+on-contrast spiral CT scan: consider using stone protocol &T for asymptomatic calculus instead of ultrasound.


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+) #oth radiopa ue and radiolucent calculi produce highly echogenic foci with

acoustic shadowing.

$olitary renal stone produces a bright echogenic focus (red arrow) in the renal sinus and casts an

acoustic shadow ($).

8) >bstructing stones in the ureter are dectected by following the dilated ureter tothe point of obstruction. &olor 6oppler can produce twinkling sign within or 7ustdistal to urinary tract calculi.


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'ongitudinal image of the bladder reveals a dilated uterovesical 7unction (red arrow) with a smallimpacted stone (red arrow head).

!lan* "ain

,ydronephrosis

Clinical

*$ demonstration of hydronephrosis is not by itself diagnostic of urinaryobstruction. !ydronephrosis is an anatomic finding not a functional one and iscaused by acute or chronic urinary obstruction prostatic hypertrophy stricturesvesicoureteral reflux (F*5) pregnancy high urine output states and congenitaldilatation of the collecting system.


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( )

Bladder. . Transverse. #. 'ongitudinal. 1ormal images of the bladder (#).

Exam

>btain multiple long and transverse images of each kidney including upper midand lower poles. 4et long axis of both kidneys showing comparison of renalechogenicity to ad7acent liver or spleen. "f hydronephrosis is seen try to imageureter and assess level and cause of obstruction. >btain long and transverseimages of the bladder including ureteral tunnel views if indicated (r/o stone)


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"el ic "ain

Adenexal .ass

Clinical

Typical clinical concerns are r/o ovarian cyst/mass/torsion A"6 or appendicitis.

'ongitudinal scan through the urine-filled bladder (#) demonstrates a normal adult uterus (redarrowheads) with smooth contours and pear shape. The cervix (red arrow) is recognized at the

7unction of imaginary lines drawn though the long axis of the uterus and the long axis of thevagina (blue arrowheads).


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( )

Normal Ovary. . Transabdominal. #. Transvaginal. normal ovary (marked by I cursors) isshown with normal follicles (red arrows) outlining the periphery.

Exam

$tart with transabdominal exam with full bladderM then empty bladder and addtransvaginal exam if necessary. >btain multiple sagittal and transverse imagesof uterus for size and echotexture. 2easure the width of the endometrium. "ffibroids are present document their positions. $how and measure ovaries inlong axis (sag A) and transverse. 2easure ovarian cysts that are larger than


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8., cm. $how a representative long image of both kidneys for size echogenicityand evaluation of the collecting system. 'ook for fluid in 2orrisonDs pouch.

,ints for Trans aginal Exam

!aving proper image orientation is the key. Jou should not 7ust rely on the carroton the screen to tell right from left. "f you are in transverse with notch eithertoward or away from you and if you move your hand toward the patientDs left legyou should simply see more on the left side of the screen (which is the patientDsright side). !it the left/right button if not so.

"f you are in sagittal orientation and the notch facing down and if you push yourhand and probe downwards you should see more on the left side of the screen.

lso by convention the bladder is always on the upper left of the screen. "f nothit the left/right button.

To stay oriented think of the transducer as a flashlight. Aoint the probe towardsthe area you want to see. ngle up for anteriorM angle down for cul-de-sacM angleto the right or left for the adnexae. "f you get hopelessly lost get re-oriented byturning the probe so that the notch on the probe is down (towards the floor) andplacing the marker on the left side of the screen. Jou are now correctly orientedfor a sagittal image. :ind the bladder. &heck the degree of magnification (youdon%t want too much or too little)M check how far the probe is inserted in thevagina (beginners often have the probe in too far or not far enough).


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#

. Transvaginal image reveals the uterus fundus (:) and isthmus ("). The red arrow indicates theendometrium and the large white arrow indicates the direction of NupN when scanningtransvaginally in longitudinal plane. #. "mage of transvaginal transducer.


+) :unctional cyst 0 smooth round anechoic thin-walled ovarian cyst larger than8., cm.


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thin-walled cyst (&) with anechoic internal fluid and size larger than 8., cm meets the definitionof a functioning ovarian cyst.

8) !emorrhagic cyst - homogeneous internal echoes fishnet appearanceretracting clots and fibrous strands and fluid-fluid levels.


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( )

Hemorrhagic Cyst - Fishnet Appearance. . The cyst (red arrowheads) on the ovary shows fineinternal echoes with a fishnet appearance of thin linear fibrous strands (red arrows)characteristic of hemorrhage. #. &olor 6oppler of cyst (red arrowheads) demonstrates lack ofinternal blood flow characteristic of hemorrhagic cyst.

?) &ystic teratoma 0 tip of iceberg sign hyperechoic mass with dark acousticshadow and heterogeneous tissues.


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"mage of cystic teratoma (between I cursors) with mixed tissues and bizarre solid tissue (redarrows).

) 3ndometrioma 0 adnexal cystic mass with diffuse low-level internal echoesand hyperechoic foci in the wall.

Transverse image of endometrioma contains blood that is higher in echogenicity than mostendometriomas. "t was initially mistaken for a solid lesion but color 6oppler does not


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demonstrate internal blood vessels. 3chogenic foci in the wall (red arrows) are a subtle butcharacteristic sign of endometrioma.

,) >varian Torsion - diagnosis rests on ovarian enlargement with normal ovarianvolume being up to approximately +, cc. >ther suggestive findings are multipleperipherally based follicles.

&olor 6oppler image through the ovary (red arrowheads) shows absence of blood flowdemonstrating ovarian torsion.

varian malignancy 0 a solid component to an ovarian lesion is the mostsignificant predictor of malignancyM irregular thick wall and septa E ?mmM 6opplerdemonstration of central blood flow within a solid component.


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&olor 6oppler of ovary demonstrates blood flow within irregularly thickened septa (red arrows).

"el ic "ain

"/D

Clinical


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Aelvic inflammatory disease (A"6) is caused by sexually transmitted infectionmost commonly chlamydia or gonorrhea or both. A"6 also occurs as acomplication of appendicitis diverticulitis pelvic abscess and post-abortion orpost-delivery infection. cutely patients present with fever pelvic tendernessand vaginal discharge. The inflammation commonly becomes chronic and

patients present with pelvic mass and dyspareunia. 2ost cases occur in youngsexually active women although +-8 of tubo-ovarian abscesses are reported inpostmenopausal women.

Transvaginal image of a normal ovary with surrouning follicles (red arrows).

Exam

#egin with the patient in the supine position.

Pelvic e am

>btain longitudinal and transverse views of the bladder and longitudinal andtransverse view of uterus (take measurement). 4et longitudinal and transverseviews of each ovary (take measurements). !" torsion o" the ovary is suspected show color 6oppler and spectral tracings of both venous and arterial flow.

ovarian mass # $cm - &olor 6oppler and 6oppler tracings with 5"measurements.


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Fiew of each kidney when necessary (i.e. pelvic mass ectopic pregnancy).

%ndovaginal e am

>btain sagittal and coronal views of uterus and each ovary. 2easure both

ovaries. &oppler and color &oppler all masses # $cm.


+) Ayosalpinx 0 pus-filled dilated fallopian tube is recognized by the echogenicparticulate matter that fills or layers within the tube.

Transvaginal image of a dilated fallopian tube (:T) containing echogenic fluid.

8) Tubo-ovarian complex 0 dilated fallopian tube and inflamed ovary within a

mass formed by adhesions. Aus appears as layering echogenic fluid and gaswithin mass.


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'u(o-Ovarian Comple . markedly dilated fallopian tube (red arrow) partially envelopes theovary (red arrowhead) in a patient with pelvic infection .

"el ic "ain

Ectopic "regnancy

Clinical

n ectopic pregnancy is implantation of a fertilized ovum outside of the fundus orbody of the uterine cavity. *sually bleeding or pain in a patient with a positive#!&4 is the common presentation. 3ctopic pregnancy can never be excluded.@e can confirm an intrauterine pregnancy ("*A) by documenting a yolk sac or alive embryo with a heartbeat. 3ctopic pregnancy is much less likley if an "*A isfound.


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'ongitudinal scan through the urine-filled bladder (#) demonstrates a normal adult uterus (redarrowheads) with smooth contours and pear shape. The cervix (red arrow) is recognized at the

7unction of imaginary lines drawn though the long axis of the uterus and the long axis of thevagina (blue arrowheads).

Exam

$tart transabdominal and get whatever information you can. Jou may confirm an"*A and not need to do 3F. "f there is inade uate bladder distention or if youneed to better visualize the uterine contents or ovaries do 3F. femalechaperon is mandatory.


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Transvaginal image of yolk sac (red arrowhead) and amniotic sac (red arrow). The embryo (3) isseen within the amniotic cavity. The chorion (blue arrowhead) is defined by the outer aspect.

*ltrasound 'andmarks in 1ormal Aregnancy

Finding Expected Visualization Approximate

Weeks*estational sac )#C* + """ by )#C* + /"" by %( 0.1 - 1 2ol3 sac Mean sac diameter + / , + / %( 1.1 - 4

mbryo Mean sac diameter + 4 , + !1 %( 4 - 4.1 5etal heartbeat mbryo + 1mm , any si$e %( 4 - 4.1

,CG: 1ormally doubles every one to two days. @ith ectopic pregnancy the#!&4 can increase (but less than would be expected for "*A) plateau ordecrease. The #!&4 decreases after spontaneous abortion unless there are

retained products of conception. $erial #!&4 measurements are very useful todistinguish between early "*A spontaneous abortion and ectopic pregnancy. follow up ultrasound can be obtained if the serial #!&4 values are confusing.



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Transvaginal image of an extrauterine sac (red arrow) demonstrating the tubal ring sign ad7acentto an ovary (red arrowhead). The tubal sign alone is less specific than a tubal sign with a yolksac.

Transvaginal image of an empty uterus (*) with thickened endometrium (red arrow) representingdecidual reaction in a patient with adenexal mass. 3chogenic fluid (red arrowhead) is seen in thecul-de-sac. The combination of adnexal mass and echogenic cul-de-sac fluid makes this patientvery high risk for ectopic pregnancy.


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Transvaginal image of a cornual ectopic pregnancy (red arrow). The uterus is demonstrating adecidual reaction (red arrowhead).

Thin-walled ovarian cyst containing anechoic fluid is likely the corpus luteum (red arrowheads)and is not predictive of ectopic pregnancy.


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Testicular "ain

Testicular Torsion

Clinical

Testicular torsion must be identified and treated within a few hours to preventinfarction of the testis. Aatients prone to torsion lack the normal attachment ofthe testis and epididymis to the posterior scrotal wall. The patients usuallypresent with sudden onset of severe unilateral scrotal pain. Testicular torsionmost often is observed in males younger than ? years with most aged +8-+Kyears. The differential diagnosis also includes epididymitis and orchitis.

The normal testis (red arrowheads) has a homogeneous moderately grainy echotexture.

Exam#egin with the patient in the supine position. Alace a white towel below thetesticle. *se a second towel to cover the underside of the penis and move it tothe lower abdomen so the testicles are easily accessible.

$eeing lack of color flow in a testicle makes the diagnosis of torsion. lways usea 0)1 .,2 linear transducer to look at flow in the testicle. &olor settingsG put on


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small parts of testicle. The filter must be on + or 8 and the color velocity scale onthe lowest possible setting for maximum sensitivity. "t is absolutely essential tocompare to the opposite presumed normal testicle to visualize its vessels so thatyou know your color settings are right and you are not 7ust getting color noise.

Gray Scale

>btain long and transverse scans through the scrotum. "nclude upper mid andlower testicle in transverse. 2easure the testicles and the epididymis (abnormalis E +cm). $how hydrocele if present.

Color Doppler

6ocument color flow to the testicles. 1ote any increased flow to the epididymisor testicle which may mean epididymitis or orchitis respectively.


+) 6iffusely hypoechoic torsed testicle compared to the other normal testicle.


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#

:igure . The normal testis (red arrowheads) has a homogeneous moderately grainyechotexture. :igure #. The torsed testis (red arrowheads) has decreased echogenicity ascompared to the normal testis in figure due to edema.

8) 6oppler demonstrates absent or decreased flow in the symptomatic testiscompared to the opposite testis.


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absolutely essential to compare to the opposite presumed normal testicle tovisualize its vessels so that you know your color settings are right and you arenot 7ust getting color noise.

Gray Scale

>btain long and transverse scans through the scrotum. "nclude upper mid andlower testicle in transverse. 2easure the testicles and the epididymis (abnormalis E +cm). $how hydrocele if present.

Color Doppler

6ocument color flow to the testicles. 1ote any increased flow to the epididymisor testicle which may mean epididymitis or orchitis respectively.

Sonographic !indings G

+) 3pididymis is swollen and decreased in echogenicity.


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#

The painful right ( ) epididymis (red arrow) is enlarged and hypoechoic compared to theasymptomatic left (#) epididymis (red arrow). 3ach testicle is indicated by T.

8) 6oppler demonstrates asymmetric hypervascularity of the affected epididymisreflecting arterial and venous dilatation.


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#

Acute %pididymitis . &olor 6oppler images show marked increase in vascularity in the right ( )epididymis (red arrowheads) compared to the left (#) epididymis (red arrow). T indicates lefttestis.

Extremity Swelling

'ower Extremity D3T

Clinical


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6FT is a common clinical problem with significant associated mortality frompulmonary embolism. There are approximately 8 million cases per year andnearly < related deaths per year. 6FT can be a difficult disease todiagnose because the signs and symptoms are non-specific and unreliable.$ome of the signs and symptoms include calf tenderness unilateral limb

swelling tachycardia and tachypnea.

6iagram of the venous drainage of the lower extremityG -Alantar venous archM #-Aosterior tibialveinsM &-Aeroneal veinsM 6- nterior tibial veinsM 3-Aopliteal veinM :-:emoral veinM 4-6eep femoralveinM !-&ommon femoral vein.

Exam

!ave the patient%s upper body elevated + -8 and examine the leg in externalrotation. 6o both legs in high risk patients. "n low risk symptomatic patients dothe symptomatic leg only. "f the 6oppler flow is continuous or dampened samplethe contralateral &:F for comparison.

"n the transverse plane compress each centimeter of the &:F $:F and poplitealvein down to the trifurcation. lso identify and compress the central portions of


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the deep femoral and greater saphenous where these vessels 7oin the &:F. "ncases where portions of the deep venous system are poorly visualized in greyscale longitudinal color images with color filling the vessel can be used toexclude acute 6FT. >btain representative 6oppler tracings from the &:F $:Fand popliteal veins. $pontaneous and phasic flow is normal. "f the flow is not

phasic assess response to augmentation. "f acute thrombus is identifieddetermine the extent with gentle compression.

&alf veins should be examined in patients with anatomic calf pain and a negativefemoral-popliteal exam. :ollow paired posterior tibilal vein from the medialmalleolus proximal. ssess peroneal veins if possible. 4reater and lessersaphenous perforators calf muscle veins and varicosities may be evaluated ifsymptomatic. The region of the leg that is tender should be imaged.

Sonographic !indings of D3T:

+) 'ack of complete compressibility of vein (bewareG a normal femoral vein inadductor canal region may not compress).

8) Fisualization of intraluminal thrombus with complete or partial obstruction ofthe vein lumen.

?) 6istention of the vein compared to the ad7acent artery.


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artery (red arrow) and very minimal flow in the femoral vein (red arrowhead). The femoral veindoes not compress with transducer pressure indicating intraluminal thrombus.

,) &ontinuous nonphasic flow in &:F unilaterally with phasic flow incontralateral &:F suggesting iliac vein outflow obstruction i.e. 6FT of extrinsiccompression.

( )

. 6uplex 6oppler demonstrating phasic flow in a normal peripheral vein. #. 6uplex 6opplerdemonstrating non-phasic flow in a peripheral vein with thrombosis.

Extremity Swelling


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4pper Extremity Deep 3enous Throm$osis #D3T%

Clinical

*pper-extremity 6FT now accounts for about K of all cases of 6FT.$ubclavian vein ($&F) clot is usually associated with arm swelling. Ougularvenous (OF) clot is often asymptomatic.

6iagram of venous drainage of upper extremityG -2edial cubital veinM #-#asilic veinM &-&ephalicveinM 6-#rachial veinM 3- xillary veinM :-$ubclavian veinM 4-3xternal 7ugular veinM !-"nternal

7ugular veinM "-#rachiocephalic veinM O-$uperior vena cava.

Exam

Aatient positionG rm is abducted about , to ; from patient. The head iselevated a little or put patient flat or even in Trendelenburg position to distend

the veins.

*se a linear transducer (, 2!z for average patient ?., 2!z may be needed forobese patients B., 2!z if thin). *se compression on the axillary brachial and

7ugular veins 7ust as you would compress lower extremity veins. The $&F cannotbe directly compressed and re uires more careful examination. 4enerally the$&F is best evaluated from the infraclavicular approach. The central portion canbe usually imaged from the supraclavicular approach.


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Gray scale

:irst 7ust look at the $&F. 1ote changes in size with respiration and sniffmaneuver. normal $&F should collapse at least < . @ith completeobstruction there is no response to these respiratory maneuvers and the vein is

often asymmetrically dilated. 'oo* at the opposite presumed normal side)

Duplex Doppler

&ompare bilateral waveforms. 'ook for absent or very decreased flow in thesymptomatic side compared to the normal side. symmetry indicates a problem.*nlike the lower extremities there may be phasic flow in the $&F even with acompletely occluding thrombus.

Color Doppler

'ook for filling defects which could suggest a thrombus. $low flow can indicate apossible thrombus in the #&F or $&F especially if there is slow flow comparedwith the opposite side . &omparison will also help you with the settings if youare having trouble getting color on the abnormal side. 'ook from both infra- andsupraclavicular approaches.

:igure . Transverse image of internal 7ugular vein (red arrowheads) and carotid artery (redarrow). :igure #. Transverse image with transducer compression applied shows thecompressibility of internal 7ugular vein (red arrowheads) while the carotid artery (red arrow)maintains its shape.


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Sonographic !indings of D3T:

+) 'ack of complete compressibility of vein.

8) Fisualization of intraluminal thrombus with complete or partial obstruction of

the vein lumen.

Longitudinal image of the subclavian shows enlargement and non-compressibility with

the transducer 6red arrowheads7 and an intraluminal thrombus 6red arrow7.

?) 6istention of the vein compared to the ad7acent artery.


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&eep )ein 'hrom(osis-*pper % tremity. &olor 6oppler image of the subclavian vein shows thatthe lumen is distended with hypoechoic thrombus (red arrows). Fery minimal blood flow in thevein is evident. :low is present in an ad7acent artery (red arrowhead).

) bnormal venous 6oppler signals i.e. continuous nonphasic flow reduced orabsent flow with distal augmentation or no obtainable signal.

6uplex 6oppler demonstrating non-phasic flow in a peripheral vein with thrombosis.


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