http://www.meded.virginia.edu/Courses/rad/edus/index1.

html

Technique
Scanner
The electrical signals are sent to the scanner from the transducer and analyzed to 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. The ultrasound image is displayed as tiny white pixels on a black background. The gray-scale image can portray structures from a spectrum of anechoic to hyperechoic. nechoic or echolucent structures have complete absence of echoes and therefore appear black. !yperechoic or echogenic structures have more echoes (whiter) than surrounding tissue.

"mage of a scanner.

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

Transverse images are displayed with the patient%s right side on the left side of the 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.

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

Technique
Transducer

transducer is a device that translates one form of energy to another. n ultrasound transducer contains a piezoelectric crystal that can translate electrical signals into mechanical energy or mechanical energy into electrical signals. The transducer uses a pulse-echo techni(ue to obtain an image. "nitially) a sound wave is produced by electricity within the transducer and directed into the patient. The reflected sound waves are received by the transducer and converted into electrical signals) and an image can be created.

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

Linear, sector, and curved array are three formats of a transducer that determine the shape and field of view. Linear array transducers produce rectangular images and offer the best overall image quality. Sector array transducers produce slice-of-pie-shaped images and are 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 the sonographic window is large.

&urved ( )) linear (#)) and sector (&) array transducers provide differing shapes in the ultrasound field-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 anechoic structure. 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 is available.

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

Acoustic Shadowing 0 occurs when the sound wave encounters a very echo dense structure) nearly all of the sound is reflected) resulting in an acoustic shadow.

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

Technique
Terms-Doppler
The Doppler shift is the difference in sound fre(uency between the *$ beam transmitted into tissue and the echo produced by reflection from the moving red blood cells (5#&s). The 6oppler beam intercepts moving blood within a blood vessel at an angle called the Doppler angle. "f an ob7ect moves away from the ultrasound transducer) the wavelength increases and fre(uency decreases based 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) the 6oppler 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 of sound in soft tissue)

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

The 6oppler e(uation demonstrates that the maximum fre(uency shift will be obtained by directing the 6oppler interrogation beam at a 6oppler angle of . degrees since cosine of . degrees is +. !owever) most blood vessels course parallel to the skin and zero 6oppler angle is seldom obtainable. "n addition) no 6oppler shift is obtained at ;. degrees since cosine of ;. degrees is .. Thus) the optimal 6oppler angle lies between -, and <. degrees. There are three types of 6oppler displays. "n the Doppler spectral display) velocity 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 the baseline and the direction away from the transducer is below the baseline. $pectral waveforms vary over time with cardiac contraction with highest flow velocities during systole and lowest flow velocities during diastole.

"mage demonstrating 6oppler spectral display.

"n the color Doppler display) velocity and direction are color-coded. &olor 6oppler imaging superimposes 6oppler flow information on a standard grayscale real-time *$ image. The color map is divided into two parts by a black bar that corresponds to zero flow point on the 6oppler spectral display. The color above the black bar is used to show flow relatively toward the 6oppler beam and the 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 the darker colors indicate lower mean velocities.

"mage demonstrating color 6oppler display.

"n the duplex Doppler display) gray scale is simultaneously combined with spectral 6oppler.

&mage demonstrating duplex 'oppler display.

Gallstones
Clinical 4allstones affect +.-+,= of the population and are a ma7or cause of gallbladder (4#) morbidity. $ymptomatic gallstones presents with characteristic right upper (uadrant discomfort or pain (biliary colic). 2ost gallstones are mixtures of cholesterol) calcium bilirubinate) and calcium carbonate.

1ormal appearing gallbladder indicated between arrows.

Exam #egin the exam with the patient in the supine position. The patient can be moved to the left posterior obli(ue or upright position to demonstrate stone mobility. >btain full length of gallbladder from the portal vein to fundus and transverse images at representative levels. 2easure 4# wall thickness perpendicular to wall. >btain full length of common bile duct (&#6) or as much as possible) and measure &#6. c(uire longitudinal and transverse views of pancreatic head. 6ocument any stones or biliary dilatation. "f stones are seen) evaluate if they are mobile or impacted. 2ove the patient into upright or lateral decubitus positions to demonstrate stone mobility.

Sonographic Diagnosis: +) 3chogenic foci in 4# lumen 8) coustic shadowing

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

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

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

Acute Cholecystitis
Clinical

cute cholecystits is most commonly casued by impaction of a gallstone in the gallbladder (4#) neck obstructing the 4# and resulting in inflammation of the 4# wall. "schemia and infection may result. Aatients present with pain) right upper (uadrant tenderness) and leukocytosis. bout B.= of patients with acute cholecystitis have diffuse wall thickening. This finding) however) is neither sensitive nor specific for cholecystitis. 6iffuse and marked wall thickening can also be seen in ascites) pancreatitis) hepatitis) &!:) sepsis) A*6 and "6$.

"mage through the long axis of the 4# (4#) demonstrates the gallbladder neck (red arrow). 4# wall thickness is measured between the gallbladder lumen and the hepatic parenchyma (red arrowheads) with normal thickness C ?mm.

Exam #egin the exam with the patient in the supine position. The patient can be moved to the left posterior obli(ue or upright position to demonstrate stone mobility. "mage the full length of gallbladder from the portal vein to fundus with transverse images obtained at representative levels. 2easure 4# wall thickness perpendicular to wall ad7acent to liver. $how the full length of &#6 or as much as possible) and measure the &#6. c(uire longitudinal and transverse views of pancreatic head. 6ocument any stones or biliary dilatation. "f stones are seen) evaluate if they are mobile or impacted. 2ove the patient into upright or lateral decubitus positions to demonstrate stone mobility. 3valuate for focal and maximum tenderness over the gallbladder (2urphyDs sign) by applying pressure with the transducer in the right costal margin.

Diagnosis for Acute Cholecystitis: 2a7or &riteria 4allstones $onographic 2urphyDs sign 2inor &riteria @all thickening E ? mm Aericholecystic fluid

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

iliary Dilatation
Clinical *$ is approximately ;.= accurate in differentiating obstructive from nonobstructive 7aundice by depicting the presence of biliary dilatation. &auses for biliary dilatation are impacted gallstone in &#6 or at ampulla) benign stricture) pancreatic carcinoma ) cholangitis) biliary surgery) and chronic pancreatitis.

"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 be placed in the supine position. >btain longitudinal and transverse views of right and left lobe of liver and include longitudinal images of liver/diaphragm interface. 2easure intrahepatic bile duct) common hepatic duct (&!6)) and &#6 as far distal as possible. c(uire longitudinal view of bile duct in pancreatic head and take measurement. 6ocument patency in portal veins) hepatic veins) and hepatic artery.

Sonographic !indings: +) $hotgun sign 0 intrahepatic biliary ducts ("!#6) become tortuous and their diameter 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 biliary tubes.

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 stellate appearance of merging tubes.

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

?) &#6 is considered dilated in adults if its diameter E Bmm.

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

Epigastric "ain
AAA #A$dominal Aortic Aneurysm%
Clinical pproximately ;.-;,= of abdominal aortic aneurysms ( ) are confined to the infrarenal aorta. are usually not repaired until they exceed --, cm in maximum diameter. The risk of rupture within , years is 8,= at , cm diameter. smaller than , cm have a ?= risk of rupture over +. years. *$ is used to monitor the rate of enlargement of . The average increase is 8 mm/yr diameter.

'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 transverse images of entire abdominal aorta and a transverse view of bifurcation to show the iliac arteries. 4et a longitudinal image of each iliac artery. "mage the superior mesenteric 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.

Sonographic !indings: +) bdominal aorta E ? cm) measured from inner wall to inner wall.

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 indicated by the red arrow.

?) 5upture of

is suggested by fluid or hematoma around the aorta.

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

Technique
"ancreatitis
Clinical cute pancreatitis is most commonly caused by alcohol abuse or a gallstone impacted in the distal common bile duct. "nflammatory changes vary from mild interstitial edema to extensive necrosis with hemorrhage. Aatient usually presents with deep epigastric pain that radiates to the back) nausea) vomiting) abdominal tenderness) fever) leuckocytosis) and elevated pancreatic enzymes. Aancreatic pseudocysts are sometimes found several weeks after pancreatitis.

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

Exam #egin with the patient in the supine position or the upright position. 2ultiple views of the pancreas are re(uired in the transverse plane (long axis of the pancreas) and longitudinal plane with identification of head) uncinate) neck) body and tail. Fisualization of the pancreas in patients with a lot of air in the stomach may re(uire additional maneuvers such as filling the stomach with water. "n those cases where the pancreas is poorly visualized in spite of additional maneuvers) always document the pancreatic area in both transverse and longitudinal planes. :or a thorough survey of the pancreas) a minimum of six images are re(uired) three transverse and three longitudinal. 6epending on the patient) additional pictures may be needed to show the entire pancreas. 6ocumentation of pathology (masses) pseudocysts) nodes) re(uires additional images.

Sonographic !indingsG +) 6iffuse enlargement of pancreas with ill-defined margins and hypoechoic parenchyma

8) Aeripancreatic fat decreased in echogenicity with hypoechoic stranding densities ?) !emorrhage may cause hyperechoic masses of clot of blood

Acute Pancreatitis. . Transverse scan. #. 'ongitudinal scan. The head of the pancreas (!) is enlarged 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&).

-) Aeripancreatic fluid collections in lesser sac) perirenal areas) and small bowel mesentery

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 done depending on the clinical situation. &T is the preferred exam in the obese or elderly) 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 old person with right lower (uadrant pain) nausea) vomiting) and leukocytosis. The presence of fever is evidence of perforation.

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

Exam *se a linear probe (generally , 2!z) and in transverse orientation press down the anterior flank. *se slow) graded compression. &ompression should be strong 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 cannot press like this) you must say it is a technically inade(uate exam. @hen done correctly (with ade(uate compression)) this is a specific and sensitive exam ( E ;.=). 6onDt mistake the psoas for a abscess. "f unsure) compare with the opposite side. "f present) measure fecolith and diameter of appendix. 2easure any loculated fluid collection. The sensitivity of *$ decreases with perforation. @ith careful techni(ue) a periappendicial abscess can be picked up with ultrasound. Therefore) thoroughly examine the 5'H (even the ''H) for an inflammatory mass. "f perforation is likely) consider &T instead of ultrasound.

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

strikingly so with impending perforation. loculated fluid collection may represent 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 ($) and obstructs and dilates the appendix ( ) resulting in acute appendicitis.

"mage in the long axis of the appendix shows long segment loss of visualization of the
submucosa (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 by stone disease at least once in their lifetimes. 2ost renal stone disease is idiopathic. Aatients usually present with flank plain radiating to the genitals) nausea) vomiting) and constant motion. *ltrasound reliably demonstrates stones E ,mm size) but smaller stones) up to -.=) are commonly not detected. &T is commonly used for detection and is excellent.

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

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 and increased through transmission). "f cysts are not simple) they are indeterminate by *$ and may re(uire further evaluation by &T. >btain multiple long and transverse images of each kidney including upper) mid and lower poles. lso get long axis of both kidneys showing comparison of renal echogenicity to ad7acent liver or spleen. "f hydronephrosis is seen) try to image ureter 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 cysts) masses or stones. 1ormal kidney size is K-+? cm long. 1ormal echogenicity is iso or hypoechoic to normal liver. +on-contrast spiral CT scan: consider using stone protocol &T for a symptomatic calculus instead of ultrasound.

Sonographic !indings: +) #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 to the point of obstruction. &olor 6oppler can produce twinkling sign within or 7ust distal to urinary tract calculi.

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

!lan* "ain
,ydronephrosis
Clinical *$ demonstration of hydronephrosis is not) by itself) diagnostic of urinary obstruction. !ydronephrosis is an anatomic finding) not a functional one) and is caused by acute or chronic urinary obstruction) prostatic hypertrophy) strictures) vesicoureteral reflux (F*5)) pregnancy) high urine output states) and congenital dilatation of the collecting system.

Bladder.

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

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

comprehensive renal exam must include the urinary bladder. "f the bladder is empty) the collapsed bladder or bladder area must be documented. The distal ureters/ureteral tunnels should be imaged if stones are suspected.

Sonographic !indings: +) 6ilation of calyces) pelvis) and ureter. &alyces appear rounded and cystic and communicate with the renal pelvis. 8) bsence of ureteral 7et on the affected side during several minutes of observation confirms complete obstruction.

Hydronephrosis. 5ounded calyces filled with urine (red arrows) connect to the fluid distended pelvis (A).

?) "ntrarenal artery resistive index (5") E ..B. is highly suggestive of obstruction.

"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 (red arrowheads) 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 the vagina (blue arrowheads).

Normal Ovary.

. Transabdominal. #. Transvaginal. normal ovary (marked by I cursors) is shown with normal follicles (red arrows) outlining the periphery.

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

8., cm. $how a representative long image of both kidneys for size) echogenicity and 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 carrot on the screen to tell right from left. "f you are in transverse with notch either toward or away from you and if you move your hand toward the patientDs left leg) you should simply see more on the left side of the screen (which is the patientDs right side). !it the left/right button if not so. "f you are in sagittal orientation and the notch facing down) and if you push your hand 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 not) hit the left/right button. To stay oriented) think of the transducer as a flashlight. Aoint the probe towards the area you want to see. ngle up for anteriorM angle down for cul-de-sacM angle to the right or left for the adnexae. "f you get hopelessly lost) get re-oriented by turning the probe so that the notch on the probe is down (towards the floor) and placing the marker on the left side of the screen. Jou are now correctly oriented for a sagittal image. :ind the bladder. &heck the degree of magnification (you don%t want too much or too little)M check how far the probe is inserted in the vagina (beginners often have the probe in too far or not far enough).

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

Sonographic !indings: +) :unctional cyst 0 smooth) round) anechoic) thin-walled ovarian cyst larger than 8., cm.

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

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

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

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

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

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

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

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

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

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

<) >varian malignancy 0 a solid component to an ovarian lesion is the most significant predictor of malignancyM irregular thick wall and septa E ?mmM 6oppler demonstration of central blood flow within a solid component.

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

"el-ic "ain
"/D
Clinical

Aelvic inflammatory disease (A"6) is caused by sexually transmitted infection) most commonly chlamydia or gonorrhea or both. A"6 also occurs as a complication of appendicitis) diverticulitis) pelvic abscess) and post-abortion or post-delivery infection. cutely) patients present with fever) pelvic tenderness) and vaginal discharge. The inflammation commonly becomes chronic and patients present with pelvic mass and dyspareunia. 2ost cases occur in young) sexually active women) although +-8= of tubo-ovarian abscesses are reported in postmenopausal 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 and transverse view of uterus (take measurement). 4et longitudinal and transverse views 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.

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.

Sonographic !indings: +) Ayosalpinx 0 pus-filled) dilated fallopian tube is recognized by the echogenic particulate 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 gas within mass.

'u(o-Ovarian Comple . markedly dilated fallopian tube (red arrow) partially envelopes the ovary (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 or body 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 a live embryo with a heartbeat. 3ctopic pregnancy is much less likley if an "*A is found.

'ongitudinal scan through the urine-filled bladder (#) demonstrates a normal adult uterus (red arrowheads) 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 the vagina (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 you need to better visualize the uterine contents or ovaries) do 3F. female chaperon is mandatory.

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

*ltrasound 'andmarks in 1ormal Aregnancy

Finding *estational sac 2ol3 sac ,mbryo 5etal heartbeat

Expected Visualization )#C* + """ by ,-. )#C* + /"" by %( Mean sac diameter + / ,-, + / %( Mean sac diameter + 4 ,-, + !1 %( ,mbryo + 1mm ,-, any si$e %(

Approximate Weeks 0.1 - 1 1.1 - 4 4 - 4.1 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 or decrease. The #!&4 decreases after spontaneous abortion unless there are retained products of conception. $erial #!&4 measurements are very useful to distinguish between early "*A) spontaneous abortion and ectopic pregnancy. follow up ultrasound can be obtained if the serial #!&4 values are confusing.

Sonographic !indings:

+) ny abnormality outside the uterus significantly increases the risk of ectopic pregnancy. 8) $igns of an ectopic include adnexal masses) complex fluid) a ring of echogenic decidualized tissue involving the fallopian tube (tubal ring sign) or fluid in the culde-sac or 2orrisonDs pouch. ?) n acute bleed may be very echogenic and blend in with the pelvic fat in the cul-de-sac and be missed unless youDre specifically looking for it. cute blood can also be anechoic. -) n ectopic will often be on the side of the corpus luteum cyst but does not have to be. #eware of calling an ovarian follicle an ectopicM an ectopic always has an echogenic ring.

Transvaginal image of an extrauterine sac (red arrow) shows a tubal ring sign with thick echogenic wall and contains a yolk sac (red arrowhead). The presence of the yolk sac is diagnostic of extrauterine gestation. The * represents the uterus.

Transvaginal image of an extrauterine sac (red arrow) demonstrating the tubal ring sign ad7acent to an ovary (red arrowhead). The tubal sign alone is less specific than a tubal sign with a yolk sac.

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

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

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

Testicular "ain
Testicular Torsion
Clinical Testicular torsion must be identified and treated within a few hours to prevent infarction of the testis. Aatients prone to torsion lack the normal attachment of the testis and epididymis to the posterior scrotal wall. The patients usually present with sudden onset of severe unilateral scrotal pain. Testicular torsion most often is observed in males younger than ?. years) with most aged +8-+K years. 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 the testicle. *se a second towel to cover the underside of the penis and move it to the lower abdomen so the testicles are easily accessible. $eeing lack of color flow in a testicle makes the diagnosis of torsion. lways use a 0)1 .,2 linear transducer to look at flow in the testicle. &olor settingsG put on

small parts of testicle. The filter must be on + or 8 and the color velocity scale on the lowest possible setting for maximum sensitivity. "t is absolutely essential to compare to the opposite presumed normal testicle to visualize its vessels so that you 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) and lower testicle in transverse. 2easure the testicles and the epididymis (abnormal is E +cm). $how hydrocele if present. Color Doppler 6ocument color flow to the testicles. 1ote any increased flow to the epididymis or testicle) which may mean epididymitis or orchitis respectively.

Sonographic !indings: +) 6iffusely hypoechoic torsed testicle compared to the other normal testicle.

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

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

&olor 6oppler image demonstrates no flow to the painful testis (red arrowheads) characteristic of testicular torsion.

Testicular "ain
Epididymitis
Clinical 3pidydimitis is usually caused by &hlamydia ssp.) but 1eisseria gonorrhoeae is also a common pathogen. "t is most often found in post-pubertal) sexually active males. "t presents as a tender and erythematous (acutely inflamed) epididymis. *rethral discharge) dysuria) fever and pyuria may also be present.

Exam #egin with the patient in the supine position. Alace a white towel below the testicle. *se a second towel to cover the underside of the penis and move it to the lower abdomen so the testicles are easily accessible. lways use a 0)1 .,2 linear transducer to look at flow in the testicle. &olor settingsG put on small parts of testicle. The filter must be on + or 8 and the color velocity scale on the lowest possible setting for maximum sensitivity. "t is

absolutely essential to compare to the opposite presumed normal testicle to visualize its vessels so that you 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) and lower testicle in transverse. 2easure the testicles and the epididymis (abnormal is E +cm). $how hydrocele if present. Color Doppler 6ocument color flow to the testicles. 1ote any increased flow to the epididymis or testicle) which may mean epididymitis or orchitis respectively.

Sonographic !indingsG +) 3pididymis is swollen and decreased in echogenicity.

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

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

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 left testis.

Extremity Swelling
'ower Extremity D3T
Clinical

6FT is a common clinical problem with significant associated mortality from pulmonary embolism. There are approximately 8 million cases per year and nearly <.)... related deaths per year. 6FT can be a difficult disease to diagnose 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 tibial veinsM &-Aeroneal veinsM 6- nterior tibial veinsM 3-Aopliteal veinM :-:emoral veinM 4-6eep femoral veinM !-&ommon femoral vein.

Exam !ave the patient%s upper body elevated +. -8. and examine the leg in external rotation. 6o both legs in high risk patients. "n low risk symptomatic patients) do the symptomatic leg only. "f the 6oppler flow is continuous or dampened) sample the contralateral &:F for comparison. "n the transverse plane) compress each centimeter of the &:F) $:F and popliteal vein down to the trifurcation. lso identify and compress the central portions of

the deep femoral and greater saphenous where these vessels 7oin the &:F. "n cases where portions of the deep venous system are poorly visualized in grey scale) longitudinal color images with color filling the vessel can be used to exclude acute 6FT. >btain representative 6oppler tracings from the &:F) $:F and popliteal veins. $pontaneous and phasic flow is normal. "f the flow is not phasic) assess response to augmentation. "f acute thrombus is identified) determine the extent with gentle compression. &alf veins should be examined in patients with anatomic calf pain and a negative femoral-popliteal exam. :ollow paired posterior tibilal vein from the medial malleolus proximal. ssess peroneal veins if possible. 4reater and lesser saphenous) perforators) calf muscle veins and varicosities may be evaluated if symptomatic. 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 in adductor canal region may not compress). 8) Fisualization of intraluminal thrombus with complete or partial obstruction of the vein lumen. ?) 6istention of the vein compared to the ad7acent artery.

:igure . cute thrombus (red arrows) in lower extremity vein is hypoechoic and is commonly indistinguishable from flowing blood. The vein is distended at the site of the acute thrombus (red arrows). :igure #. "nability to compress the vein at the 7unction of the thrombusis (red arrows) is prime evidence of thrombus.

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

. 'ongitudinal color 6oppler demonstrating normal blood flow in a peripheral vein. #. 'ongitudinal color 6oppler image with transducer compression applied shows flow in the femoral

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

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

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

Extremity Swelling

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. Ougular venous (OF) clot is often asymptomatic.

6iagram of venous drainage of upper extremityG -2edial cubital veinM #-#asilic veinM &-&ephalic veinM 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 is elevated 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 for obese 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 cannot be directly compressed and re(uires more careful examination. 4enerally the $&F is best evaluated from the infraclavicular approach. The central portion can be usually imaged from the supraclavicular approach.

Gray scale :irst 7ust look at the $&F. 1ote changes in size with respiration and sniff maneuver. normal $&F should collapse at least <.=. @ith complete obstruction) 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 the symptomatic side compared to the normal side. symmetry indicates a problem. *nlike the lower extremities there may be phasic flow in the $&F even with a completely occluding thrombus. Color Doppler 'ook for filling defects) which could suggest a thrombus. $low flow can indicate a possible thrombus in the #&F or $&F especially if there is slow flow compared with the opposite side. &omparison will also help you with the settings if you are having trouble getting color on the abnormal side. 'ook from both infra- and supraclavicular approaches.

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

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.

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

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

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

http899www.med-ed.virginia.edu9Courses9rad9edus9index .html