Abdominal Ultrasound: Step by Step Berthold Block, MD Private Practice Braunschweig Germany 2nd edition 912 Illustrations Thieme Stuttgart · New York Library of Congress Cataloging-in-Publication Data is available from the publisher. This book is an authorized translation of the 4th German edition published and copyrighted 2009 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Der Sono-Trainer: Schritt- für-Schritt-Anleitungen für die Oberbauchsonographie. Translator: Terry C. Telger, Fort Worth, TX, USA Illustrators: Viorel Constantinescu, Bucharest and Jörg Decker, Stuttgart 1st Chinese edition 2008 1st English edition 2004 1st French edition 2005 1st German edition 2000 2nd German edition 2003 3rd German edition 2005 4th German edition 2009 1st Korean edition 2005 1st Russian edition 2007 1st Spanish edition 2011 Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage. © 2004, 2012 Georg Thieme Verlag, Rüdigerstraße 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001 USA http://www.thieme.com Cover design: Thieme Publishing Group Typesetting by Ziegler + Müller, Kirchentellinsfurt, Germany Printed in Italy by LEGO S.p.A., Vicenza ISBN 978-3-13-138362-4 1 2 3 4 5 6 Preface to the Second Edition The first edition was published in 2004 as The Practice of Ultrasound. My goal at that time was to walk the user through the basic principles of upper abdominal ultrasound scanning. I am pleased that this concept is being revived and that a second edition of the book can now be published. Once again the author recommends keeping the book close at hand during the ultrasound examination. The closing chapter of this edition serves as a “Sono Consultant.” It has been designed to provide systematic guidance in interpreting suspicious findings and determining how ultrasound can be applied to specific clinical questions. Several of my colleagues supplied me with valuable ultrasound images for inclusion in the previous edition. For the current edition I am particularly indebted to Dr. Johannes Linder, who has again provided me with high-quality images drawn from his clinical practice. I wish my readers success in learning this modality and hope that they enjoy the practice of abdominal ultrasound scanning. Berthold Block, Braunschweig, Germany Acknowledgments I express my thanks to the following colleagues, who contributed images that I did not have in my own files, supplied me with images of better quality, or helped me with their comments and advice. Christian Boemeke, MD Joachim Dembowski, MD Matthias Geist, MD Dipl.-Med. Beate Geyer Stefan Hänel, MD Peter Irresberger Meinolf Karthaus, MD, Associate Professor Ingo Kluthe, MD Horst Kierdorf, MD, Professor Bernd Krakamp, MD Ingo Krenz, MD Ralf Kuhlmann, MD Hubert Langhorst, MD Bernd Limberg, MD, Professor Johannes Linder, MD Bernd Milbert, MD Hilmar Milbradt, MD Joachim Pieper, MD Roland Rother, MD Harwig Schoendube, MD I extend special thanks to Professor Hartmut Schmidt, MD, Münster. I also thank Mr. Viorel Constantinescu for turning my rough sketches into precise sectional diagrams. The great majority of ultrasound images were obtained with a Siemens scanner. The author is grateful to the Siemens Corporation for generously providing the scanner on loan. I thank the staff at Thieme Publishers Stuttgart for their constant and courteous help and support. Berthold Block Table of Contents 1 General How to Use This Book Examination Technique and Equipment Who do you examine first when learning to scan? How do you adjust the ultrasound machine? What can you do with the transducer? 2 Basic Physical and Technical Principles Ultrasound Definitions Propagation of sound Production and detection of ultrasound waves: the pulse-echo principle Diagnostic ultrasound: propagation of ultrasound in biological tissue Producing an Image A-Mode B-Mode M-Mode Artifacts Noise Acoustic shadowing Posterior acoustic enhancement Reverberations Beam-width artifact Side-lobe artifact Mirror-image artifact Lateral edge shadow 3 Blood Vessels: The Aorta and its Branches, the Vena Cava and its Tributaries Organ Boundaries Locating the aorta and vena cava Demonstrating the aorta and vena cava in their entirety Organ Details Demonstrating arterial and venous pulsations Evaluating the vessel walls and lumina Identifying and defining the branches of the aorta and vena cava Anatomical Relationships Relationship of the aorta and vena cava to the diaphragm, liver, and cardia Area surrounding the celiac trunk and the course of the hepatic artery, splenic artery, and left gastric artery Superior mesenteric artery, splenic vein, and renal vessels Iliac vessels Lymph nodes near the retroperitoneal vessels 4 Liver Organ Boundaries Locating the liver Imaging the liver in its entirety Organ Details Shape Size Parenchymal pattern Vessels of the liver Division of the liver into lobes, segments, and subsegments The portal vein and its branches Anatomical Relationships Relationship of the left portion of the liver to the heart and stomach Relationship of the central portion of the liver to the vena cava, stomach, and pancreas Relationship of the right portion of the liver to the gallbladder, duodenum, and kidney Ascites 5 Porta Hepatis Organ Boundaries: Identifying the Vessels in the Porta Hepatis Vena cava and portal vein Hepatic artery and bile duct Transverse and longitudinal survey of the porta hepatis Organ Details: Details of the Vessels in the Porta Hepatis Portal vein 6 Gallbladder Organ Boundaries Locating the gallbladder Imaging the entire gallbladder Variable position of the gallbladder Nonvisualization of the gallbladder Organ Details Regions of the gallbladder Size of the gallbladder Variable shape of the gallbladder Gallbladder wall Gallbladder contents Special acoustic phenomena in gallbladder scanning Anatomical Relationships Relationship of the gallbladder to the liver Relationship of the gallbladder to the portal vein Relationship of the gallbladder to the antrum, bulb, and duodenum 7 Pancreas Organ Boundaries Locating the pancreas Imaging the entire pancreas Variable shape of the pancreas Organ Details Pancreatic parenchyma Pancreatic duct Common bile duct Measuring the pancreatic diameter Anatomical Relationships Relationships of the tail of the pancreas Relationships of the body of the pancreas Relationships of the head of the pancreas 8 Stomach, Duodenum, and Diaphragm Organ Details Stomach wall Organ Boundaries and Relationships Esophagus and cardia Body of the stomach Antrum and duodenum Diaphragm 9 Spleen Organ Boundaries Locating the spleen Imaging the entire spleen Organ Details Shape of the spleen Determining the size of the spleen Echo pattern Anatomical Relationships Relationship of the spleen to the pancreas, kidney, colic flexure, and stomach Relationship of the spleen to the pleura 10 Kidneys Organ Boundaries Locating the right kidney Imaging the entire right kidney Locating the left kidney Imaging the entire left kidney Organ Details Size and shape of the kidneys Renal parenchyma and renal sinus Anatomical Relationships of the Right Kidney Relationship of the right kidney to the liver Relationship of the right kidney to the psoas and quadratus lumborum muscles Relationship of the right kidney to the colon Relationship of the right kidney to the gallbladder Anatomical Relationships of the Left Kidney Relationship of the left kidney to the spleen Relationship of the left kidney to the psoas and quadratus lumborum muscles Relationship of the left kidney to the colon 11 Adrenal Glands Organ Boundaries and Anatomical Relationships Ultrasound morphology of the adrenal glands Location of the adrenal glands Right adrenal gland Left adrenal gland Organ Details Abnormalities of the adrenal glands 12 Bladder, Prostate, and Uterus Organ Boundaries and Relations Bladder and prostate Bladder and uterus Organ Details Prostate Uterus 13 The Systematic Ultrasound Examination Topographic Units Liver Gallbladder and porta hepatis Right kidney Left kidney and spleen Epigastrium and pancreas Midabdomen Lower abdomen Description of Findings and Nomenclature Documentation Written report Image documentation 14 The Sono Consultant I Ultrasound Findings 1. Aorta: Widening 2. Vena cava: Dilatation 3. Liver: Large 4. Liver: Small 5. Liver: Increased echogenicity 6. Liver: Hepatic veins dilated 7. Liver: Circumscribed mass 8. Liver: Echo-free mass 9. Liver: Hypoechoic mass 10. Liver: Isoechoic or hyperechoic mass 11. Liver: Hyperechoic mass with an acoustic shadow 12. Ascites 13. Gallbladder: Stone 14. Gallbladder: Circumscribed wall changes 15. Gallbladder: Thickened wall 16. Gallbladder: Large 17. Gallbladder: Echogenic contents 18. Gallbladder: Acoustic shadowing 19. Common duct: Dilatation 20. Pancreas: Dilated duct 21. Pancreas: Cannot be identified 22. Pancreas: Increased echogenicity