Sonographic

Examination

OBJECTIVES
Objectives of sonography are;
! To learn the normal cross sectional anatomy &
structural details (normal sonographic findings of the
patient).
! To find out the abnormalities observed on
sonographic examination.
! To co-relate the sonographic examination findings
with physical examination
! To confirm the diagnosis sonographically
! To categorize the trauma patients as per organ trauma
score as first line assessment
! To diagnose and to plan sonographic management in
selected patients
! To find out innovations in both clinical & sonographic
examinations

Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

 02

SONOGRAPHIC
EXAMINATION IN
GENERAL
Muhammad Shuja Tahir, FRCS (Eden), FCPS Pak (Hon)

Sonographic examination is performed with the help of an

ultrasound machine. It can be performed for most of the
body parts but requires different probes and machines. It
used to be performed by specialists of the field during last
few decades.

Now a days, most of the doctors are able to perform

sonography on their own with reasonably accurate
interpretation. The skill can further be improved if the
sonography is learnt at earlier stage (during student
years) as it has become an essential part of diagnostic
work up.

The time has come that medical students start learning

sonographic examination as adjuvant to clinical
examination. It should be performed in a structured
manner so that omissions can be avoided.

It has reasonably high sensitivity and specificity. It has

much higher accuracy rate. It achieves nearly 100%
accuracy when combined with clinical examination.

INTRODUCTION AND COUNSELING

One must introduce him/herself to the patient and should
plan whether the patient will go to the ultrasound
examination room or the examination will be conducted

SURGERY - CLINICAL EXAMINATION SYSTEM 20


on the bedside in the ward (in case of a serious
and heamodynamically unstable patients. The
patient should be informed about the mechanics
of the examination so that patient clearly knows
what exactly is going to happen to him/her,
which of the body parts are to be uncovered and
how much and for how long. One should be very
polite and decent during the examination.
The examination is conducted at an appropriate
and comfortable room temperature. The
contact gel is applied to the area to be examined
sonographically.
Never forget to clean and cover the uncovered
parts of patients at the end of examination. The
patient is informed about completion of
examination.
SPECIAL INTERVIEW
Relevant history should be asked from the
patient so that the sonographic examination is
conducted objectively. History of Jaundice, pain
in epigastrium or right hypochondrium, nausea,
vomiting, abdominal pain, distension or trauma
should be asked. History of last menstrual
period, menstrual abnormalities (Amenorrhea,
heavy menstrual bleeding) should be noted.
History of abdominal masses should be asked.
Dysuria, pain in lumber area and haematuria are
also noted if present.
EXPOSURE AND POSITION
Elective examination is conducted in ultrasound
examination room. The patient is asked to lie
down on the examination couch.
The patient should preferably wear the hospital
gown after removing the shirt to facilitate the
sonographic examination and to avoid soiling of
SURGERY - CLINICAL EXAMINATION SYSTEM
SONOGRAPHIC EXAMINATION IN GENERAL 03
clothes with jelly.
The patient lies in supine position on the couch
and the abdomen is exposed from lower chest
to the lower abdomen. The thighs and genatalia
remain covered. Patient is shifted to right or left
lateral positions as required for examination.
Emergency, trauma or serious haemo-
dynamically and unstable patients who can not
be shifted to ultrasound room are examined on
the bedside by bringing the machine to the side
of the bed.
No special preparation is required for most of
the conditions. Gall bladder examination is done
on a fasting patient and pelvic examination is
conducted on patient with full urinary bladder.
The sonographic examination is performed in a
methodical and structured form to avoid
missing important observations.
SONOGRAPHIC EXAMINATION
The machine is checked for normal functioning.
Its computer attachments are checked for
accepting photographs. Printer and its papers
are checked and one is ready for conducting
Normal abdominal sonography
21

sonography.
The jelly is put over the probe and examination is
started in a well organized and structured
manner. It is started from right hypochondrium.
The probe is moved from right hypochondrium
to epigastrium and then to left hypochondrium.
ABDOMEN AND PELVIS
These patients usually don't require any special
preparation normally. The patients who present
for biliary examination should be fasting for 6-
12 hours so that the gall bladder is distended at
the time of examination.
The pelvic examination is performed with full
bladder. The pelvic organs are better examined
in the presence of distended urinary bladder.
One should know the patient's problem before a
fruitful examination is conducted.
BILIARY SONOGRAPHY
It is performed for the diagnosis of following
conditions;
! Cholecystitis
! Cholelithiasis
! Choledocholithiasis
Abdominal and pelvic sonography
SURGERY - CLINICAL EXAMINATION SYSTEM
SONOGRAPHIC EXAMINATION IN GENERAL 04
The gall bladder is recognized and seen. Its
photograph is taken. Cystic duct, hepatic ducts
common hepatic duct and common hepatic
duct and common bile duct and intra hepatic
biliary ducts are examined.
Abnormalities of biliary tree are noted and
photographs are taken of stones or any other
solid mass present in gall bladder or biliary tree.
The examination is conducted in both
longitudinal and transverse views.
When sonographic examination of gall bladder
is done on a fasting patient, the stones show as
hyperechoic shadow. The mass has a posterior
acoustic shadow confirming the diagnosis.
Thick walled gall bladder with other suggestive
features is seen in cholecystitis.
Sonographic Murphy’s test is positive when
gentle examination of gall bladder is so painful
as to stop breathing momentarily. It is seen in
acute cholecystitis or empyema of gall bladder.
The hyperechoic shadow of billiary stones seen
in jaundiced patients in common bile duct is
called choledocholithiases. It is usually
Cholelithiasis
22
 SONOGRAPHIC EXAMINATION IN GENERAL 05

associated with dilated proximal billiary
canaliculi to suggest obstructive jaundice.
Presence of stones in the gall bladder help to
simplify the diagnosis in a patient having severe
colic. Small stone or even gravel can be picked
up on sonography.
LIVER
Sonographic examination of liver helps in
diagnosis and assessment of extent of liver
problem.
Liver (Cross sectional anatomy ) is examined
from front, lateral and posterior aspect for
parenchymal inspection. Abnormalities are
noted. Size of liver is assessed. Presence or
absence of ascities is noted.
The liver may show mixed echopattern, discrete
opacities or masses with increased vascularity
in case of primary liver tumour such as
Hepatoma.
The liver may show tears of different size (length
and depth) following liver trauma. Sonographic
examination helps in assessing the liver injury
score. It also helps in regular monitoring of
trauma patients who are managed non-
operatively.
Sonographic examination is per formed
regularly, daily or even twice or three times a

The liver parenchyma is normally grey on

scanning. It shows intra hepatic billiary ducts,
intra hepatic portal tributaries and intra hepatic
arterial tributaries. The liver parenchyma
changes to hyper echoic form in cases of liver
damage and resulting fibrosis in case of post
hepatitis-C cirrhosis (Chronic liver disease).
Normal Liver ultrasound
It may show isolated hyperechoic mass or
multiple masses in cases of secondary tumours
(deposits) in liver when primary tumour is
somewhere else in the body.

Liver may show isolated hypoechoic area or

multiple hypoechoic areas in the liver in cases of
various types of liver abscesses (Amoebic or
pyogenic).

Multiple hypoechoic areas (Multiple unilocular

or multilocular cystic areas) are seen in cases of
hydated cysts of liver. Hydatid cyst liver

SURGERY - CLINICAL EXAMINATION SYSTEM 23


day. Sonographic assessment may be required
in case of haemodynamically compromised
patients.
SONOGRAPHY FOR ASCITES
Sonography reveals this problem easily. The
presence of fluid (even very small amount) can
be diagnosed. The intra peritoneal fluid may be
present in pelvis or in the peritoneal cavity.
Ascites on ultrasound examination
STOMACH
Normally an empty stomach cannot be
visualized on sonographic examination. It can
be seen when filled with fluids. The diseased
stomach may reveal complex mass if it is
present in the stomach. Gastric outlet
obstruction can be diagnosed as large amount
of fluid keeps the stomach distended even after
few hours fasting.
PANCREAS
The pancreas is seen normally when the probe
lies over epigastrium. It can be easily
appreciated when enlarged and inflamed or
when a tumour, cyst or psuedocyst of pancreas
is present.
SURGERY - CLINICAL EXAMINATION SYSTEM
SONOGRAPHIC EXAMINATION IN GENERAL 06
SPLEEN
The spleen is nearly of the same size as of the
kidney (1x3x5 inches). The parenchyma is
appreciated and noted. All abnormalities of
spleen are noted and photographs are taken for
record.
It can be seen on sonographic examination
which reveals its anatomical landmarks clearly.
The size can be measured. Any sign of injury,
tear, hematoma, cystic mass or abscesses can
be diagnosed.
The sonography helps in monitoring of splenic
injury in patients on (NOM) non operative
management. Sonographic injury grading can
also done.
Rupture spleen on sonography
APPENDICITIS
When appendix is infected, sonography helps to
confirm the diagnosis. The probe is put at Mac
Burney’s point in right iliac fossa and moderate
degree of pressure is exerted. The appendix is
seen, fecolith may be seen or inflammatory
mass with bull's eye appearance is seen.
Sometimes free fluid around appendix is seen.
24

Appendicitis on sonography
Loops of small bowel may be seen adherent to
the appendix.
Sonographic MacBurney’s test is positive when
minor pressure at MacBurney’s point causes
severe pain at right iliac fossa.
KIDNEY
Ultrasonography helps in differentiating
between different causes of acute abdominal
emergencies such as;
The sonography shows abnormal findings of
urinary tract. It shows presence of stone or any
other cause of obstruction in the renal or
Normal kidney on ultrasound examination
SURGERY - CLINICAL EXAMINATION SYSTEM
SONOGRAPHIC EXAMINATION IN GENERAL 07
ureteric area. Presence of hydronephrosis or
hydroureter indicates the diagnosis.
Right lumber area is examined in both
longitudinal and transverse views. Right kidney,
right diaphragm upper part of right ureter and
right side of large gut are seen. Intra peritoneal
fluid (Ascities), blood and leaked intestinal
secretions are seen.
Left lumber area is examined in the similar
fashion in both views. Left kidney, diaphragm,
stomach, left large gut and spleen are seen.
Fluid collection under the diaphragm or
peritoneal cavity is seen.
The supra pubic and umbilical areas are
examined. Distended bladder is seen then other
intra peritoneal viscera are seen. Uterus and
ovaries are seen in female patients. Normal
uterus usually has empty cavity. Normal ovaries
show differently during changing period of
menstrual cycle. During midcycle, follicles are
seen. The ovaries are smaller and atrophic in old
menopausal women.
INTERVENTIONAL SONOGRAPHY
It is microinvasive method of treatment in the
patients with trauma or deep abscess such as
Core needle biopsy under ultrasound guidance
25

Focused Abdominal Scan for Trauma (FAST)
liver abscess, subphrenic abscess, breast
abscess perinephric abscess and pelvic
abscess. Sono-graphic guided biopsy from
primary, secondary or metastatic deposits can
be obtained with precision and higher accuracy.
FOCUSED ABDOMINAL SCAN FOR TRAUMA
F.A.S.T
Ultrasound guided aspiration or drainage of
haematoma or abscess can be performed with
minimum trouble to patient.
FAST has almost replaced diagnostic peritoneal
lavage to detect haemoperitoneum.
Ultrasound has made a lot of impact in the
management of seriously injured patients. Intra
peritoneal or intrathoracic collection and
haemorhage can be detected easily in severely
injured patient who is not fit for any other
diagnostic procedure.
SURGERY - CLINICAL EXAMINATION SYSTEM
SONOGRAPHIC EXAMINATION IN GENERAL 08
LUMP
Sonography is helpful in improving the
diagnosis of a lump which may be present either
subcutaneously or deep in the body. It may be
related to viscera or abdominal wall or
peritoneal, thoracic or pelvic cavity.
Correct size of the lump can be measured in
various dimensions.
Nature of lump can be assessed. Whether it is
solid, cystic or of mixed type of tissues.
It further helps to assess the nature of adjacent
tissues and helps to verify any abnormality
present or associated with the lump.
RESPIRATORY SYSTEM (CHEST)
Sonography for respiratory system is
performed occasionally when there is strong
suspicion of fluid or blood collection in the
pleural cavity. It does not help in assessment of
normal respiratory functions or anatomy of
thorax.
Ultrasound examination for pleural effusion
26
 09

SONOGRAPHIC EXAMINATION IN GENERAL

Preparation How to prepare a patient for sonography of;

Gall bladder
Kidneys
Bladder
Uterus
Prostate

F.A.S.T What is F.A.S.T?

Intervention How liver abscess is drained under ultrasound guidance?

Cleaning the patient

Completion Covering the patient
Counseling

SURGERY - CLINICAL EXAMINATION SYSTEM 27