Gastrointestinal Imaging • Original Research

Wilson et al.
Volume Imaging in the Abdomen with Ultrasound

Gastrointestinal Imaging
Original Research

FOCUS ON:

Volume Imaging in the Abdomen

With Ultrasound: How We Do It
Stephanie R. Wilson1 OBJECTIVE. The objective of our study was to evaluate the feasibility of volumetric ac-
Chander Gupta1 quisition of the abdominal organs using performance guidelines that we developed in our pre-
Michael Eliasziw 2 liminary experience.
Alan Andrew 3 MaterialS AND METHODS. Mechanical volumetric acquisitions of each abdomi-
nal organ, including the liver, gallbladder, pancreas, kidneys, spleen, bowel, and aorta, were
Wilson SR, Gupta C, Eliasziw M, Andrew A performed in 200 consecutive patients.
RESULTS. One thousand four hundred fifty-four volume data sets were graded for fea-
sibility of performance and technical adequacy from I (impossible, incomplete) to V (excel-
lent, complete). The most successfully imaged organ was the right kidney (grades IV and V,
95.0%) and the least successfully imaged, the spleen (grades IV and V, 69.0%). Very good to
excellent grades (IV and V) were obtained in 1,215 (83.6%) of the 1,454 volumes. One hun-
dred twelve (7.7%) of the 1,454 volumes were failures (grades I and II). The three organs with
the highest success compared with the right kidney were the left kidney, gallbladder, and
liver. The data sets of all the other organs showed a statistically significant difference in the
feasibility of performance from the right kidney. Liver acquisition failures were associated
with end-stage liver cirrhosis (n = 6), fatty liver (n = 3), and obesity (n = 3). Other acquisition
failures, similar to conventional sonography, were associated with bowel gas interference and
poor acoustic window. The technical limitations include poor resolution in the B and C planes
and a limited range of frequencies; these limitations can be overcome in the future with ma-
trix transducers and introduction of the technology to a broader frequency range.
CONCLUSION. Volumetric acquisition in the abdomen performed using defined guide-
Keywords: 3D volume imaging, abdomen, abdominal lines is feasible with recognized limitations. Technology advances will improve this imaging
imaging, bowel, imaging guidelines, ultrasound technique technique in the future.
DOI:10.2214/AJR.08.2273

Received December 18, 2008; accepted after revision
February 26, 2009.
S. R. Wilson is on the Advisory Board for Ultrasound,
Philips Healthcare, and received a research grant from
Lantheus Medical Imaging.
1
Department of Diagnostic Imaging, University of Calgary
Foothills Medical Centre, 1403 29 St., NW, Calgary, AB
T2N 2T9, Canada. Address correspondence to S. R.
Wilson (stephanie.wilson@albertahealthservices.ca).
2
Department of Community Health Services, University
of Calgary, Calgary, AB, Canada.
3 an aspect of pathology, they often fail to
Department of Medical Imaging, Toronto General
Hospital, University of Toronto, Toronto, ON, Canada.
AJR 2009; 193:79–85
0361–803X/09/1931–79
© American Roentgen Ray Society
T
raditionally, data storage for ab-
dominal ultrasound has included
some combination of the follow-
ing: single frames; cine clips,
performed particularly to show relationships
or motion; and video of portions or all of an
examination. Most often, single frames of
the abdominal organs are acquired by sonog-
raphers and then are approved by a physician
before the patient’s departure from the imag-
ing department. It is well recognized, how-
ever, that although single images might show
show adequately the entire picture and also
the relationships of the pathology. Therefore,
rescanning all or a portion of an examination
by the responsible physician is common, par-
ticularly in tertiary institutions where the
case material may be complex.
Ultrasound has many advantages for di-
agnostic imaging including excellent spatial
and contrast resolution, a relatively low cost,
and lack of ionizing radiation. However, there
are two additional important aspects of ultra-
sound acquisition that maintain ultrasound as
a major player in the assessment of abdomi-
nal pathology: its real-time and multiplanar
capabilities, which allow imaging in the ide-
al plane for the best interpretation of pathol-
ogy within a region of interest. Both of these
advantages are included in the most recently
introduced technique for ultrasound imaging
known as “volumetric image acquisition.”
Today, the acquisition of a volume of ul-
trasound data is performed freehand or by
a mechanically driven multielement array
transducer that can acquire a data set as the
array sweeps through a predetermined angle

AJR:193, July 2009 79


of acquisition during a breath-hold. The vol-
umetric data set results from the combina-
tion of information through each plane of the
sweep. The data acquired then allow elec-
tronic presentation of images in the acquisi-
tion A plane; the perpendicular B plane; and
the unachievable plane in real-time sonogra-
phy, the C plane. These data may then be re-
viewed either online or off-line as cine files in
the three planes or as series of images, anal-
ogous to the stacking of images used on CT
and MRI. Multiplanar reconstruction (MPR)
allows the creation of image planes that are
at unique and often unattainable angles. The
surface-rendered image, familiar in obstetric
volume imaging [1], plays a small role in im-
aging the abdomen, where fluid surrounding
the surface of organs is not the norm.
In spite of identified problems with reso-
lution and image display, volumetric imag-
ing techniques are increasingly popular and
accepted in obstetric [1–6] and cardiac [7, 8]
ultrasound. It is thought intuitively that ab-
dominal ultrasound might not lend itself well
to volumetric imaging for several reasons in-
cluding the multiplicity of organs, each re-
quiring its own volume data set; the large
size and variable shapes of organs; and the
presence of bowel gas, which may interfere
with visualization.
In 2007, the capability to perform volumet-
ric evaluation of the abdominal organs was in-
troduced to our ultrasound facility. In this ar-
ticle, we present the feasibility of performing
volumetric acquisitions of data of the abdomi-
nal organs of 200 consecutive patients using
our performance guidelines developed in a
preliminary experience at our institution.
Materials and Methods
This technical study was approved by the
institutional review board. Patients provided
signed informed consent for the addition of volu­
metric scans to their routine examination. Two
hundred consecutive patients referred to our ultra­
sound department for an abdominal ultrasound
examination underwent a routine examination
fol­lowed by a volumetric acquisition of each
abdominal organ, including the liver, gallbladder,
pancreas, kidneys, bowel, aorta, and spleen. If
an abnormality of the bowel was encountered, a
volume acquisition of the region of interest in the
bowel was also included. No consideration was
given to the body mass of the patient or the quality
of the scan. Volumetric acquisitions of all organs
were attempted in consecutive patients.
The study group included 97 men and 103
women who ranged in age from 18 to 85 years
80 AJR:193, July 2009
Wilson et al.
(mean age, 51.5 years). Our referral base included supine or lateral decubitus, and the optimal phase
three dominant patient populations: those with risk of respiration for the breath-hold. Last and most
factors for chronic liver disease sent for hepatoma important, the prescan allows the recognition of
surveillance (n = 61) or hepatoma evaluation (n = abnormalities within the organ.
15), those with known or suspected inflammatory The volume acquisition was performed with
bowel disease (IBD) referred to determine the a breath-hold to minimize motion artifact in the
extent and activity of bowel disease (n = 99), and data set, using the optimal plane and transducer
those referred from our hepatobiliary and pancreatic placement. A broad focal zone, set at the center
surgical oncology team (n = 13). Other indications of the acquisition plane, is ideal to encompass as
(n = 12) included various medi­cal problems such much of the region of interest as possible. The data
as elevated liver function test results, elevated set was reviewed live and stored if acceptable or
creatinine level, and renal mass characterization. was repeated if unacceptable. Ultimately, before the
All volumetric scans were obtained on an completion of the examination, determination that
ultrasound system (iU22 with a V6-2 transducer, all observed abnormalities had been included within
Philips Healthcare). The V6-2 volumetric probe is the volume was essential. If the acquired volume
a mechanical volumetric data acquisition probe. was insufficient, it was repeated or additional
The piezoelectric crystals are moved mechanically acquisitions were performed as necessary.
in an arc with equal movement to each side of the In the following sections, we discuss organ-
selected center point. The extent of each sweep is specific guidelines for volumetric acquisition.
determined by selection of an angle of acquisition, The kidneys—The ideal volume is acquired
between 50° and 75°. The hand holding the in the long axis of the kidney in either a sagittal
transducer is maintained in a fixed position for the or a coronal plane (Fig. 1). An angle of sweep
duration of volume capture. of approximately 50° is generally adequate, but
Volumetric data were analyzed on two de­ the angle should be enlarged to include focal
dicated off-line software systems (View Forum abnormalities or enlargement of the kidney.
6.1 and Q Laboratory, Philips Healthcare). The liver—The acquisition plane is aligned on
the long axis of the right and left portal veins as
Ultrasound Volumetric Data they originate from the main portal vein at the porta
Acquisition Technique hepatis (Fig. 2). This acquisition is obtained with a
All of the volumetric acquisitions were per­ subcostal oblique orientation of the transducer,
formed according to guidelines formulated based which is placed in the epigastrium. From the
on a succession of introductory scans obtained straight transverse plane, the edge of the transducer
in our ultrasound department from August on the patient’s right side should be moved slightly
2007 until March 2008. These guidelines are caudad and the edge of the transducer on the
summarized in Table 1 and include four steps: patient’s left should be moved cephalad. Angling
a prescan, the volume acquisition, a volume the transducer to the patient’s right shoulder during
review, and an additional scan to include any the optimal phase of suspended respiration shows
missed components in the volume data set before the hepatic venous confluence, the porta hepatis
storage and completion of volumetric scanning. with the long axis of the right and left portal veins,
The prescan includes a real-time evaluation of and the structures of the hepatoduodenal ligament
the organ in question, performed with several in succession in the volume if a sweep is performed
important objectives. First, the prescan guides from cephalad to caudad.
transducer placement—subcostal or intercostal, The focal zone for liver volume imaging should
for example—and the optimal plane and size of be large and centered at the porta hepatis. In
the angle for the acquisition volume. Further, it patients with cirrhosis, the focal zone can be
determines the optimal patient position, either changed according to the size of the liver. In cases
TABLE 1:  Guidelines for Volume Imaging of the Abdominal Organs
Event Objective of Event
Prescan Determine optimal scan plane, acquisition angle, and patient position
Real-time determination of organ normalcy or pathology
Volume acquisition Performed during a breath-hold with an appropriate focal zone
Volume review Ensure entire organ is included in acquisition
Ensure abnormality is included in acquisition
Additional scan Add single images or volumes as required
Make as few volumes as required to show pathology
 Volume Imaging in the Abdomen with Ultrasound

Fig. 1—Value of C plane, coronal reconstructed image, is shown in 33-year-old Fig. 2—Ideally performed volume acquisition of normal liver in 27-year-old
woman with Crohn’s disease with incidentally detected cystic change in kidney. man shows plane of acquisition in long axis of portal vein as center image of
The A, acquisition sagittal plane (left image), and B, axial reconstructed image nine-on-one display. Hepatic vein confluence is shown on bottom right image,
(right top), show a cystic region in the central portion of the kidney representing and structures of hepatoduodenal liver are shown on top left image. Therefore,
either a hydronephrotic calyx or parapelvic cyst. On the C plane (right bottom), the acquisition has encompassed entire liver parenchyma.
cystic area is not continuous with the renal pelvis, confirming parapelvic cyst. On
the B and C plane images, the turquoise line is the acquisition plane. On the B plane
image, moving the green line moves the plane from top to bottom. Moving the red
line on the C plane image moves the plane from right to left. The reference axes are
shown in purple for each plane.

of end-stage cirrhosis, in which the liver is small
and shrunken, the focal zone can be decreased.
However, every effort should be made to keep the
focal zone centered at the porta hepatis. Time gain
compensation may require slight modification to
ensure even visualization of the liver parenchyma
through the entire organ. Liver volumes always
require the maximal angle for the acquisition, 75°.
The gallbladder—The patient is ideally fasting
to encourage distention of the gallbladder lumen.
The best acquisition plane is in the long axis of the
gallbladder with the patient in either the supine or
left lateral decubitus position, as determined by
the survey scan (Figs. 3 and 4). The focal zone
should be narrow and centered on the gallbladder.
The acquisition angle is often left at the default
setting of 55° and is increased only if a larger field
of view is required.
The pancreas—Supine positioning of the pa­
tient is generally optimal. The phase of respiration
for breath-hold and acquisition is determined
with experimentation, as with single-frame
imaging. A scan plane that incorporates the long
axis of the gland is essential for obtaining a good
acquisition (Fig. 5). Most often, the end of the
transducer on the patient’s left side is rotated
slightly cephalad and the end of the transducer
on the patient’s right side is caudad. This
positioning, of course, reflects the most common
positional location of the pancreas, with the
pancreatic head located at a more caudal plane
than the pancreatic tail.
The focal zone is centered on the pancreas volume. Alternatively, if the spleen is better seen
at the initiation of the acquisition and should be with subcostal transducer placement, obtaining the
reasonably narrow to best show the entire gland. volume in the long axis of the spleen is best. This is
The angle of the acquisition, generally around 50– true especially if the spleen is enlarged.
75°, must be sufficient to include the celiac axis on The bowel—The best acquisition plane of the
the cephalad border of the pancreas and also the bowel is the long axis so that both the bowel and
most caudal aspect of the pancreatic head. the perienteric soft tissues are included. The focal
The spleen—The technique for splenic volume zone should be relatively narrow and should be
acquisition is the most variable for the abdominal centered on the abnormal bowel loop. The angle
organs and reflects the difficult visualization of of acquisition is set at the default, about 50°.
the spleen related to its high position in the left The aorta—The volume is acquired in the
upper quadrant deep to the inferior costal margin. long axis of the aorta in two segments: the first to
Nonetheless, we recommend a supine patient posi­ include the upper abdominal aorta and the second,
tion and an intercostal transducer placement to show the aortic bifurcation.
the maximal span of the spleen in a single image, Supine patient positioning and a narrow acqui­
suspension of respiration, and acquisition of the sition angle are most often optimal.
Fig. 3—Surface-
rendered image (left)
in acquisition plane of
gallbladder in 42-year-old
man with multiple calculi
shows calculi are aligned
in linear fashion. Wall of
gallbladder is smooth. B
plane (bottom right) and
C plane (top right) images
at same level show single
calculus. The turquoise
line on the two right-
hand images reflects
the orientation of the
surface-rendered image
relative to the B and C
planes.

AJR:193, July 2009 81

 Wilson et al.

Data Analysis
For each organ examined, the volumetric
acquisitions were graded for technical success or
feasibility of performance from I (total failure [i.e.,
0%]) to V (total success [i.e., 100%]) at the time of
their performance by the sonographer or physician
performing the scanning. Initially the volume
sweep was reviewed on the iU22 ultrasound
system. If the radiologist or the technologist was
satisfied with the quality of the sweep, it was stored
on the hard drive of the iU22 ultrasound system.
The stored sweeps were then transferred to the
workstations, Q Laboratory and View Forum. The
data were transferred from the ultrasound system
to the dedicated off-line workstations at the same
time or at a later date. The data were not altered
before review by the radiologist. The radiologist
reconstructed the data in all three planes using
the Q Laboratory or View Forum workstation. Fig. 4—Value of coronal reconstruction (left) of gallbladder is shown in 85-year-old woman. Note clear
depiction of gallbladder fundus, neck, and cystic duct. Right images include A plane, acquisition (top right), and
Depending on the complexity of the findings in a
B plane (bottom right) at same level. C plane, while showing valuable anatomic information, also shows loss
particular case, the reconstruction and review time of resolution as compared with A and B planes. The turquoise lines represent the coronal plane in this case.
varied from 10 to 20 minutes for all the volumes in On the acquisition plane image, moving the green line moves the plane from right to left. On the B plane image,
a single patient. moving the red line moves the plane from front to back.
A grade of V was associated with a technically
successful acquisition with complete inclusion of mm, which produces the best resolution, to thicker method of acquisition was ignored. However, our
the organ and its abnormality within the volume. slices, which progressively lose resolution and also equipment provided only a single transducer, a V6-
A grade of I occurred when an acoustic window have a more substantial skip area that may result 2, with a mean operating frequency suitable for
allowing the acquisition of a volume of data could in omission of information from the file. scanning patients and organs to a standard depth
not be obtained. Grades of II, III, and IV describe In grading the feasibility of the performance of of up to 15 cm. This transducer did not allow
poor (25%), satisfactory (50%), and good (75%) volumetric acquisitions, the loss of resolution in successful acquisitions of superficial organs,
acquisition results, respectively. When a grade of I the B and C planes associated with the mechanical especially in thin patients, and we graded the
(failure) or II (poor) was assigned to an organ, two
additional assessments were made: the technical
success of routine single-frame imaging and the
reason for the failed or poor volumetric scan.

Display
Before a grade was assigned, the data were
reviewed with multiple-frame cine files in the
acquisition A, perpendicular B, and C planes.
The acquired volume data can be displayed in
various formats. Cine files, which allow real-time
evaluation of the entire region of interest, can be
viewed not only in the acquisition plane but also
in the B and C planes with the use of MPR. From
these files, single images, similar to those obtained
with standard technique, are also possible in any
plane. Unique to the technique is the ability to
produce a multislice image that can have variable
slice thickness. We generally prefer a nine-on-one
format with the center point set on the pathology
or center point of the organ. This point is also
generally the fulcrum of the acquisition. The Fig. 5—An ideally acquired single volumetric acquisition of the normal pancreas in a 30-year-old man with an
number of images in a multislice image file can angle of acquisition of 60° in the long axis of the gland provides axial images of the entire pancreas as shown
be chosen according to the need and size of the in this nine-on-one display. The center point of the acquisition, in the long axis of the gland, is shown in the
center image. The pancreatic head is best shown on the top left image; and the celiac axis and suprapancreatic
organ, ranging from three images to as many as
tissues, on the bottom middle and right images. The three images on the right side of the figure show on top, the
the sonologist wants. The thickness of the slices A plane; middle, the B plane; and bottom, the stack levels for the nine-on-one in the coronal plane. The colored
can also be selected according to the need from 1 lines represent the midpoint of the acquisitions in each plane.

82 AJR:193, July 2009

 Volume Imaging in the Abdomen with Ultrasound

Fig. 6—Bar chart Volumetric acquisitions of the liver, un-

Right kidney (n = 200) 2 12 9 86 shows results of
feasibility of volume
like those of the right kidney, however, were
Left kidney (n = 200) 3 1 3 24 69
acquisitions in 200 graded I or II in 12 patients (6%); this poor
consecutive patients. performance is attributed to end-stage cir-
Gallbladder (n = 171) 2 3 4 6 85 rhosis (n = 6), gross fatty liver (n = 3), or
morbid obesity (n = 3). Less common prob-
Liver (n = 200) 2 4 5 15 74 lems causing acquisition failure in two ad-
ditional patients were a gigantic exophyt-
Pancreas (n = 200) 5 4 14 25 52
ic liver mass measuring greater than 20 cm
Aorta (n = 200) 5 4 14 25 52 in diameter and an enormous caudate lobe
in a cirrhotic liver, both of which prevented
Bowel (n = 83) 11 7 6 13 63 placement of the transducer in a satisfactory
position to allow acquisition of the complete
Spleen (n = 200) 7 4 20 23 46
volume of data.
Grade of Success (% of Organs) Volumetric acquisitions of the pancreas
I II III IV V and the aorta showed identical and more var-
ied results. Both showed excellent (grades IV
and V, 76.5%) and also very poor (grades I
TABLE 2: Success of Volumetric Acquisitions as Compared with the Most
Successful Organ, the Right Kidney (Reference Standard) and II, 9%) results. Acquisition failures, sim-
ilar to those encountered in routine pancre-
% of Difference atic scanning, were related to interference by
Acquisitions from Right 95% CI of
Organ No. Graded IV or V Kidney (%) Difference p of Difference bowel gas in the epigastrium preventing vi-
sualization of all or of a portion of the gland.
Right kidney 200 95.0 — — —
Poor visualization of the aorta was associat-
Left kidney 200 92.5 −2.5 –7.2 to 2.2 0.30 ed with both interference by bowel gas and
Gallbladder 171 91.2 −3.8 –9.0 to 1.4 0.15 morbid obesity.
Liver 200 88.5 −6.5 –11.8 to –1.1 0.02 Many of the splenic volumes included a
band of interference as a rib shadow that was
Pancreas 200 76.5 −18.5 –25.1 to –11.9 < 0.001
frequently incorporated in the volume acqui-
Aorta 200 76.5 −18.5 –25.1 to –11.9 < 0.001 sition. Nonetheless, this shadow did not, in
Bowel 83 75.9 −19.1 –28.8 to –9.4 < 0.001 most cases, make the data uninterpretable,
Spleen 200 69.0 −26.0 –33.1 to –18.9 < 0.001 and splenic acquisitions were graded IV or
V in 69.0% of the cases and I or II in 11%.
Note—Dash (—) indicates not applicable.
The grades for splenic acquisitions showed a
acquisition as poor if the area of interest could not evaluated to determine the feasibility of per- direct relationship with splenic size: All ac-
be adequately resolved for a proper evaluation. formance and technical adequacy. quisitions of spleens greater than 13 cm in
The frequency distribution of grades I–V for The results for feasibility of performance length were graded IV or V.
volumetric acquisitions of each of the organs was of volumetric acquisition are summarized In 83 of the 99 patients with possible or
calculated, and the percentage of scans with grades graphically as a horizontal bar chart in Fig- known IBD, abnormal bowel was shown on
IV or V (good or total success) was computed for ure 6. The most successfully imaged organ, the baseline scan. Volumetric acquisitions
each organ. For the comparative analysis, the the right kidney (grades IV and V, 95.0%), is were obtained in these patients, with 75.9%
most successfully imaged organ was chosen as the displayed at the top and the least successfully of the acquisitions graded as IV or V. Be-
reference standard. The acquisitions of each organ imaged organ, the spleen (grades IV and V, cause many of the patients with abnormal
were compared with the reference standard using 69.0%), is shown at the bottom. bowel were very thin, the single transducer
a chi-square test. Table 2 shows the percentage of volumet- available, a V6-2, with an operating frequen-
ric acquisitions graded as IV and V (75– cy in the range of 2–6 MHz, was too low to
Results 100% success) with CIs by organ, as com- resolve the bowel and perienteric soft tissue
Two hundred consecutive patients signed pared with the most successfully studied positioned in the near field, especially in thin
consent forms for our study. This study organ, the right kidney, and a p value for the women. This accounts for a substantial num-
group provided us with volumetric data on difference between the successes. The three ber of bowel cases (18%) graded as I or II.
200 livers, pancreata, aortas, both right and organs with the highest success as compared
left kidneys, and spleens. Volume data were with the reference standard were the left Discussion
also acquired on 171 gallbladders because kidney, gallbladder, and liver. The remain- The diagnostic accuracy of volumetric
many of the patients had undergone prior ing organs—the pancreas, aorta, bowel, and scanning in the abdomen has not been estab-
cholecystectomy. In patients with IBD and a spleen—showed statistically significant dif- lished. However, determination of the tech-
positive baseline scan, an additional 83 vol- ferences in the percentage of acquisitions nical feasibility of successful performance of
umetric acquisitions of the bowel were pro- graded as good or as a total success as com- abdominal volumetric acquisitions is neces-
vided. Therefore, 1,454 volumes of data were pared with the reference organ. sary before determining diagnostic capabil-

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 Wilson et al.

(83.6%) of the 1,454 acquisitions. A few ac-

quisitions (n = 127, 8.7%) were assigned a
grade of III, consistent with satisfactory-qual-
ity data. Grade III volumetric data, similar to
a satisfactory scan obtained with single-frame
images, allow the reader to make reasonably
accurate observations and interpret the prima-
ry pathology; however, very subtle observa-
tions might not be depicted as optimally.
On an organ-by-organ basis, organs with a
single long and two short dimensions, such as
the kidneys, gallbladder, aorta, and even the
pancreas, lend themselves optimally to vol-
ume acquisition. Further, organs with a good
acoustic window will obviously produce the
best result. Changes in patient position and re-
spiratory techniques may improve the acous-
tic window, as with conventional scanning.
Analysis of failed or poor examinations
in our study showed that the absence of a
good acoustic window was the most consis-
tent explanation for acquisition failure and
could affect any organ. Failure of volumetric
Fig. 7—Less-than-ideally performed single volume acquisition of normal liver in 21-year-old man was obtained acquisition of the liver is highly associated
slightly cephalad to optimal plane through portal veins, with angle of acquisition of 75°. Stacked rendered with severe end-stage cirrhosis, which makes
images, therefore, show portal veins in top middle image rather than central image as result of slight deviation
of technique from guidelines. From this single sweep, images show hepatic vein confluence, portal veins, and
a good acoustic window from a subcostal ap-
also much of liver parenchyma. This particular sweep is not optimal to show hepatoduodenal ligament and proach impossible, and with severe fatty liv-
would require additional single-frame images or additional volume to ensure inclusion of entire liver. er, which limits penetration of the ultrasound
beam. If the liver is visible only from an in-
ity. In our study, we describe the technical of the right and left portal veins, three of the tercostal approach, a volume of data is un-
success of volumetric acquisitions of the ab- key images for liver imaging—the conflu- likely to include the entire organ; in this case,
dominal organs on consecutive adult patients ence of the hepatic veins at the inferior vena either multiple volumes of a single organ or
regardless of the indication for, findings of, cava, the bifurcation of the portal vein at the additional single-frame images should aug-
or quality of their sonographic examination. porta hepatis, and the cross section of the he- ment the obtained volumetric data.
We did not compare the success of volume patoduodenal ligament at the porta hepatis— Similar to traditional single-image data ac-
imaging with that of conventional imaging, are included as part of the acquisition plane quisition for ultrasound, volume imaging of
nor did we compare the diagnostic capability images (Figs. 2 and 7). We have found that if normal bowel is rarely informative. In the pa-
of the two techniques. Rather, this technical the acquisition is not in this plane, MPR will tient with pathology of the bowel, however,
study describes our recommended guidelines often not allow these key images to be suc- volumetric acquisition may provide valuable
for the performance of volume acquisitions cessfully recreated. information and show relationships with a ca-
and then evaluates their success when imple- The choice of the optimal plane and ori- pability beyond standard 2D ultrasound. Volu-
mented in a consecutive population. entation for the acquisition will also allow a metric analysis of the abnormal bowel is eas-
Our preliminary experience with volu- complete examination with the fewest vol- ily performed as long as it is quiet and does not
metric acquisitions showed us that there is ume data sets. This is desirable for two rea- show hyperperistalsis, which may introduce
always an optimal plane for the acquisition sons: first, less demand on the storage sys- significant motion artifact. Furthermore, our
of the data that takes advantage of the natu- tem and, second, reduced time requirements experience has shown us that the volumetric
ral specular echoes of the organ and its sur- for the interpretation because multiple un- technique must be introduced on a wide range
rounding structures. This results in a dis- necessary and redundant volumes require a of transducer frequencies to allow evaluation
play of the anatomy in a familiar manner lengthy interpretation time and are tedious of superficial structures, such as the bowel,
and also allows optimal MPR images in all and cumbersome. However, with complex with an appropriate high-frequency transduc-
planes. This concept motivated us to devel- pathology or large organ size, more than a er. We believe that this single advancement,
op the protocols for performance of volume single volume per organ may be required. although most important for bowel scanning,
acquisitions in the abdomen that we believe Similar to routine single-image sonog- would have decreased the total number of
are requisite for success and that form the ba- raphy of the abdomen, volume acquisition examinations of all organs graded as I or II
sis of the techniques described in this article. has variable success depending on the avail- (112/1,454 [7.7%]) in this study.
For example, in the liver, if the acquisitions able acoustic window. However, in our study, Before the introduction of volumetric im-
are performed on a plane perpendicular to very good to excellent (grades IV and V) vol- aging of the abdomen in our facility, we won-
the main lobar fissure, through the long axis umetric acquisitions were obtained in 1,215 dered if this technique might make the perfor-

84 AJR:193, July 2009

 Volume Imaging in the Abdomen with Ultrasound
mance of abdominal ultrasound easier and
reduce operator dependency. We wondered
further about reduction of scanning times
and improved efficiencies. Our initial efforts,
however, have shown us that we needed guide-
lines, as we have described, to allow a high
likelihood of success with the fewest data vol-
umes for analysis. A high skill level with rou-
tine scanning seemingly also translates into
improved volume data acquisition, therefore
not necessarily making the performance of
the scan easier. The benefit of volume data ac-
quisition in terms of time and efficiencies has
been discussed by many authors in the litera-
ture and is beyond the scope of this article.
Further, we found that acquisitions performed
without a plan did not afford good MPR and
also increased the number of acquisitions that
required review on completion of the exami-
nation. In agreement with our commitment to
performing volume acquisitions according to
established protocols, Nelson et al. [9] previ-
ously advocated a rigorous standardized pro-
tocol for both acquisition and review to pre-
serve quality and diagnostic accuracy.
We now are using volumetric data ac-
quisition as an adjunct to rather than as a
replacement of the conventional real-time
multiplanar technique that is so important
in abdominal sonography. The development
and advancement of volumetric imaging
for ultrasound have been hampered by slow
technologic advancement. With mechanical
acquisition of data, resolution in the acqui-
sition A plane is excellent and is analogous
to any other cine sweep through a region of
interest. There is, however, a loss of resolu-
tion in the B plane and an even greater loss
of resolution in the C plane. In the future,
the technique will improve with the intro-
duction of matrix transducers, which will al-
low the electronic acquisition of data in the
volume with the use of a multielement array,
which scans through the entire volume elec-
tronically without actual movement of the
transducer array itself. The loss of resolution
AJR:193, July 2009 85
should be corrected with this electronic data
acquisition. Further, the introduction of a DI-
COM standard for the transmission of vol-
umetric data and more universally available
software platforms for manipulation of ac-
quired data sets will enhance this technique
in the future.
The major weakness of our study is the
inclusion of the routine single-image scan
before volumetric data acquisition. Howev-
er, because volumetric acquisition is an un-
proven technique in imaging the abdomen, it
would not be acceptable to perform the vol-
ume acquisition alone. Further, we were not
using the volumetric data for interpretation
of pathology. Rather, the data sets were eval-
uated only for technical feasibility in terms
of inclusion of the entire organ and also in-
clusion of abnormalities.
Although experiences in both obstetric and
cardiac applications cite huge efficiencies in
terms of the time required to obtain the ul-
trasound scans [1], the efficiency impact of
volumetric acquisition of data in abdomi-
nal ultrasound is yet to be determined [3, 4].
Further, a volume may allow visualization of
a structure relative to its surroundings in a
manner that was not previously possible. The
impact this capability might have on diag-
nostic interpretation is also unknown.
In summary, our study has shown good
success for the performance of volumetric
data acquisitions of the abdominal organs
when guideline protocols for performance
are closely followed. Use of the guidelines
we describe should facilitate the acceptance
and dissemination of this exciting technique
not only for better evaluation of abdominal
pathology, but also for equally important re-
assurance of the absence of pathology in a
particular organ. The ability to view cine
files in all planes and single-frame images in
any plane from one volume acquisition is the
highlight of the technique. We predict that
with the imminent release of new transduc-
er technology for electronic volumetric data
acquisition and the introduction of this tech-
nique over a broader range of transducer fre-
quencies, the potential for this technique will
be realized. Future investigations will eval-
uate the diagnostic capability of volumetric
acquisition as compared with conventional
techniques for the detection, diagnosis, and
surveillance of abdominal pathology and
also the efficiency impact.
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