pulsed wave-spectral and color
aliasing-all waves not returned, raise the pulse rep freq
as depth increases PRF decreases
spectral- horizontal axis is time, vertical is the direction and velocity
keep gate tight in artery, open it out in vein
angle
velocity scale
doppler gain
filtration
Color
set focus to at or just below the box
0 is best angle, anything <60 will do
Liver
Anatomy
Couinaud’s sections are divisions of the liver based on vascular anatomy. Falciform lig divides right and left lobes in classic.
But in Couinaud, the division between the right and middle/left is the middle hepatic vein.
Left hepatic divides the left into left medial and left lateral.
Right hepatic divides right into right anterior and right posterior.
Quadrate-Left medial segment.
Caudate-posterior to lig venosum (used to be umbilical vein). Spared by most liver disease b/c it has a separate blood flow.
Riedel’s Lobe-extension of right liver in a tongue-like shape
Glisson’s capsule covers the liver
Falciform used to be ligamentum teres normally drains into l portal vein
Ligamentum venosum forms the anterior border of the caudate lobe
Normal Ligamentum Teres (aka falciform) is brightly echogenic, triangular or rounded, it may cast shadows
15.5 cm is upper limit of liver length
Portal vein-splenic, smv, imv.
Middle hepatic Vein separates the left medial segment from the right anterior segment. This vessel courses in the main lobar fissure
Anterior border of the caudate is the fissure for the ligamentum venosum
This structure acts as a landmark for the paraumbilical: ligamentum teres. It extends from this ligament to the left portal vein
Long thin extension on the inferior aspect of the right lobe: Reidel’s lobe
Caudal border of the left portal vein: Ligamentum teres
What differentiates hepatic veins from portal veins: portal veins have the triad coursing with them
Anterior and to the left of the ligamentum venosum=Left lobe
Thin capsule around the liver=Glisson’s capsule
Hepatic veins course interlobar and intersegmental
Sagittal of the left lobe, ligamentum venosum and caudate lobe
anterior to the ligamentum venosum is the left lobe, posterior to it is the caudate
Picture of ligamentum teres
runs from portal vein
Picture of portal vein branch (right post), posterior segment, left portal vein, caudate lobe
Right post of portal vein is located in RIGHT POSTERIOR SEGMENT
Caudate is behind the left portal vein
The Left portal is anterior to the Right and is C-shaped when imaged longitudinally
To demonstrate the three hepatic veins going into IVC-Subcostal oblique with probe angled superiorly and to the patient’s right
To see dome, use subcostal with pt in deep inspiration
AFP elevation=hepatocellular carcinoma
Adenoma
Solid hypoechoic mass with hypervascularity in liver with a patient on OCPs=hepatic adenoma
Cavernous Hemangioma
homogenous hyperechoic lesion measuring 2.4 cm in the posterior aspect of the right lobe=cavernous hemangioma
most common benign tumor-cavernous hemangioma
Cavernous hemangiomas-very slow flow, may not be detected by doppler. they are small well defined, hyperechoic masses, consist of vascular network, more common in women than men, usually asymptomatic
Focal Nodular Hyperplasia
Young female with well defined solitary mass with central scar measuring 4 cm. On doppler, prominent blood vessels coursing within the scar.-Focal nodular hyperplasia. second most common benign liver mass. more common in women (especially of childbearing age) well demarcated single mass <5 cm usually with central scar
Fatty Liver
Diffuse increased echogenicity with focal hypoechoic area anterior to the portal vein in 49 obese male=fatty liver with focal sparing
Focal fatty liver is usually found in anterior to the portal vein at the porta hepatic
Reversible, caused by obesity, may be diffuse or focal, may show rapid change in appearance with time, increased attenuation of sound beam through the liver
increased echo compared to the kidney, hyperechoic patches are usually seen periportal, around the gb, and at the liver margins
Cirrhosis
Surface nodularity, altered echo texture, ascites, regenerative nodules, not shrunken caudate lobe. Caudate lobe is actually relatively enlarged as it is spared.
search for portal hypertension.
luminal narrowing of hepatic veins/color and spectral doppler reveal high velocities through strictures-cirrhosis because the thin walled veins are compressed.
If you can’t see the hepatic veins in a cirrhotic pt in B-Mode, switch to color Doppler to confirm patency-otherwise the patient may have budd chiarri. Always eval for budd chiarri in pts with new ascites, hepatomegaly and pain
Indicators of hepatomegaly-rounding of the inferior border, liver longitudinal > 15.5 cm, extension of right lobe below lower pole of kidney, increased AP measurement of the right lobe, not enlargement of the portal vein
Pt with liver cirrhosis and suspected portal hypertension, evaluate size-spleen and portal vein diameter
Regenerating nodules are a feature of-cirrhosis
alcoholic liver cirrhosis look for splenomegaly, dilated veins at splenic helium, also search for portosystemic collaterals to eval for portal hypertension. Look for them at the paraumbilical vein, cornary vein, gastrorenal, intestinal, and hemorrhoidal. Also portal vein>13 cm, ascites, hepatofugal flow in portal
Portal Hypertension
Hepatofugal flow in the portal vein-portal hypertension. hepatopetal flow-towards the head and towards the liver. fugal is away from the liver
Pt c TIPS-connects portal vein and the hepatic vein
normal liver with enlarged hepatic veins and ivc=right side heart failure
majority of blood to the liver-portal vein, majority of oxygenated from hepatic artery
recanulized paraumbilical vein can be seen in-portal hypertension
best sonographic window for the prior is-sagittal subcostal through the left lobe at the level of the ligamentum teres
enlargement of the coronary vein is diagnostic of portal hypertension-aka the left gastric, it empties flow from the esophageal veins into the splenic vein. if flow direction is reversed in this vein, varices result
Cutoff for portal vein enlargement=13 cm
Best view for coronary vein-sagittal view of the splenic vein near the midline
Cavernous transformation-look for it in the porta hepatic, occurs following portal vein thrombosis. It is characterized by multiple serpginous venous channels in the porta where the portal vein was located. Flow direction is hepatopetal (into the liver)
Mets
Liver metastasis-can be single or multiple, hypo or hyperechoic, can have mixed echo, or can look like cystic masses
Cysts
Hepatic cysts-thin wall, posterior enhancement, anechoic, decreased attenuation, increased through transmission
Single large mass, well defined, smooth walls, homogenous low-level echoes in anterior right lobe of 48 y/o female, no Doppler signals-Hemorrhagic cyst
Hepatitis
Fever, elevated LFTs, RUQ tender, liver is enlarged with decreased echogenicity, GB wall is thick, thick echogenic bands around the portal veins(periportal cuffing)
Acute hepatitis is starry sky appearance from liver parenchyma contrasted with bright bile ducts
Sonographic appearance of air bubbles-brightly echogenic foci with ring-down artifact
Infestation by a parasite in sheep/cattle raising countries-Hydatid disease
Invasion of the portal vein-hepatocellular carcinoma
Pts with AIDS get-kaposis in the liver
53 female with weight loss and vague abd pain, liver is heterogenous and has numerous calcified lesions. Most likely metastatic disease from-adenocarcinoma of the colon
Bull’s eye or target lesion in the anterior right lobe-liver met from lung ca
Transplant
Post liver transplant with extrahepatic fluid collection-can be biloma, hematoma, loculated ascites or abscess
Liver transplant involves anastamoses of IVC, portal vein, hepatic artery, bile duct
no ultrasound findings to eval transplant rejection
Scan for these post transplant-biliary sludge, portal vein stenosis, hepatic artery thrombosis, liver malignancy, but not cholecystitis as the donor gallbladder is taken out before transplant
Ultrasound during liver surgery-7 mhz linear probe-placed directly on the liver
Increased through-transmission, right lobe, adjacent to the capsule, large, rounded homogenous mass poorly defined wall in pt with fever and pain-amebic abscess
most common liver malignancy-metastatic disease
Biliary Tree
Main (Interlobar) fissure is the landmark for the GB. hyperechoic linear structure that runs between the right portal vein and the GB.
Portal vein and the neck of the GB.
Normal transverse diameter is 4 cm.
Hydropic GB-transverse diameter of 5.3 cm. seen with choledocholithiasis
GB wall thickness is normally <3mm.
WES sign-wall, echo, shadow.
Parallel channel sign-CBD gets big enough to be same size as portal vein
Fundus of gb folded over body-Phrygian cap
Common cause of smudgy artifacts-reverb, side lobes, slice thickness
GB sono preparation-fasted 8-12 hrs prior to exam
Abnormal thickening can be-inflammation, hepatic dysfunction, CHF, GB wall varices,
Diagnostic accuracy of GB sono-> 90%
Increase stone shadowing-increase frequency and focusing
Porcelain gallbladder-wall contains various amounts of calcifications,
Distal CBD-posterior and slightly lateral to the pancreatic head
Look at the distal CBD for choledocolithiasis
Measure duct in longitudinal near porta. Need to see IVC in the image
CBD pierces uncinate process tissue behind head of pancreas. just anterior to renal vein
Pt just ate-contracted GB with diffuse wall thickening
Cholecystitis-calculus obstruction of the GB neck or cystic duct
Dilated non-tender gb-look for mass in the head of the pancreas. Courvousier’s
Low level echoes in the GB looks like sludge, GB wall is not thickened.
Comet tail from artifact from anterior GB wall-Adenomyomatosis=echogenic foci within the GB wall. tapered and shorter than ringdown. Form of hyperplastic cholecystoses. Associated with small mucosal herniations into muscular layer of GB wall.
Rokitansky-Aschoff sinuses-Adenomyomatosis=small mucosal hernaitions into the muscular wall of the GB. May get filled with cholesterol
Polyps do not shadow
Tumefactive sludge-avascular mass with low level echoes. polypoid masslike shape. moves slowly with positional changes. if it is vascularized suspect carcinoma instead
GB wall is vascular, this can help differentiate between wall edema and pericholecystic fluid
44 male with diabetes, severe epigast pain rad to back, vomiting, chills, fever. Large GB with nondependent hyperechoic foci assoc. with ringdown artifacts-emphysematous cholecystitis
hypervascularity of acute cholecystitis-doppler of cystic artery
Acalculous cholecystitis-wall thickening, murphy’s, perichole fluid, GB wall edema without stones
Differentiate between bowel gas and posterior shadowing-roll pt into left lateral decub.
Edge shadowing=refraction artifact
Gallbladder carcinoma-irregular mass in the lumen with hypervascularity, multiple stones in the lumen-GB carcinoma
Best way to identify intrahepatic Biliary system is to image-intrahepatic portal veins
Pneumobilia-air in the bile ducts
Differentiate duct dilation from hepatic vein dilation-dilated ducts demonstrate irregular torturous walls, bile ducts will not have flow with doppler
Common bile duct-junction of the cystic and common hepatic
Thickening of bile duct walls-may be sclerosing cholangitis, pancreatitis, choledocolithiasis, cholangiocarcinoma
Junctional folds-maze like projections into GB
Weight loss and midepigastric pain with intra and extrahepatic Biliary dilation and hydropic gb-may be choledocolithiasis, pancreatic carcinoma, or chronic pancreatitis with stricture formation
cystic dilation of the CBD is choledochal cyst
they seem to think that serum billi helps differentiate between intra and extra cause of jaundice
Differentiate the duct from the hepatic artery-doppler from artery but not duct
Help to visualize distal CBD-roll pt to right posterior oblique or right lat recumbent
most common anatomic variant-GB folds
most accurate test for acute chole=cholescintigraphy
Porcelain gb are at risk for-GB carcinoma
Roll pt into LLR if you are unsure of a neck stone
Administered cholecystokinin to a patient-causes the GB to contract in a normal study.
Attempting to locate the common hepatic duct at the porta hepatic, portal triad anatomy at this location- common duct is anterior to hepatic artery and portal vein
Jaundice pain and nausea with a history of gb out-choledocolithiasis
In suspected cholangiocarcinoma, look for-dilation of the Biliary tree
Can get reverb artifact in anterior just behind wall
Turn them in llr to eval mobility of stones
bright band of echoes with posterior shadowing in the RUQ, how do you identify it as stone filled GB-connection of the shadows to interlobar fissure, wall-echo-sign, bowel gas would have ring-down artifact
A tumor that may be intrahepatic or extrahepatic bile duct is known as-cholangiocarcinoma
Old guy with ruq pain, gallstones and bright echoes in gb wall with ringdown-emphysematous cholecystitis
Pancreas
picture of the anatomy of the pancreas (p33)
body tail uncinate process
RetroP structure (as are kidneys adrenals and great vessels). Head sits on top of IVC. Uncinate wraps around SMV. GDA and CBD mark lateral border of the head. Neck anterior to SMV/splenic confluence. prominent vessel just posterior to the pancreatic neck-portal-splenic confluence
vessel anterior to uncinate process and posterior to the pancreas neck confluence of portal and splenic vein
Uncinate wraps around SMV
SMA is posterior to pancreatic neck
long axis view of head and body of pancreas-midline transverse scan with left side of the probe just slightly caudad
name of main pancreatic duct-duct of wirsung
accessory pancreatic duct-duct of santorini****
CBD relation to pancreas-CBD is posterior to the head of the pancreas
Pancreatic divisum-the two pancreatic ducts have not fused
anterior aspect of the head of the pancreas-gastroduodenal artery
posterior aspect of the head of the pancreas-CBD
coursing transversely at level of the upper panc. head-left renal vein
thin patient-curvilinear 5 mHz
repeated pancreatitis, use doppler-to increase chances of finding pseudoaneurysms
most difficult part to visualize-tail
frequency for endoscopic uts-10 MHz
most common malignant tumor-adenocarcinoma. risk factors-smoking, high fat diet, diabetes, chronic pancreatitis. stage with ct. most commonly found in the head of panc. appears as hypoechoic mass. look for lymphadenopathy and liver mets
hyperechoic mass in the head of the pancreas, dilation of panc and cb ducts, diffuse calcification in pancreas-chronic pancreatitis
Cancer=hypoechoic
looking for complications of pancreatitis-look for pseudoaneurysm, pseudocyst, phlegmon, abscess
pt with pancreatic transplant-placed in iliac fossa, rejection is indicated by-high-resistance doppler signals and heterogeneous parenchyma
non-encapsulated collection of necrotic and edematous peripancreatic tissues-phlegmon
in USA most common cause is stone, etoh is 2nd cause
Can get pseudocyst from-acute and chronic pancreatitis as well as panc ca. appearance is cyst without or with low level echoes with a well defined wall and internal septations. No epithelial cells (hence pseudo)
obese pt with small hypoechoic tumor in tail-insulinoma. they’re fat b/c of overeating during hypoglycemic attacks. insulinoma-use 10 MHz
duodenum encircles-the head
splenic vein is posterior and caudal to pancreas
celiac trunk is located at the superior border
posterior border of the pancreatic head-IVC
Courses anterior to the uncinate-SM vein
small tubular structure coursing cephalocaudad anterior to the pancreas-gastroduodenal artery
picture on p. 42 and questions 190-193
190
191
192
193
Transverse picture of the aorta and the sma with the left renal vein running between. Body of pancreas is anterior to the SMA.
Head has the largest dimensions
Normal pancreas is iso or hyperechoic in relation to the liver
Tail of the pancreas touches-left kidney, splenic flexure of the colon, and spleen
Kidney/Urinary Tract
left and right kidneys attached at their lower poles-horseshoe kidney. isthmus is anterior to the abd aorta
renal cortex-should be iso or perhaps hypoechoic in comparison to liver
angiomyolipoma may cause speed artifact
normal kidney-9-14 cm
1.5 cm thickening of the left lateral renal cortex-dromedary hump
Kidneys are-retroperitoneal, right kidney is slightly lower, tail of pancreas not in contact with the lateral dorsal aspect of left, the superomedial aspect of the right is touching adrenal, superior pole of both are slightly medial compared to the inferior pole
Central sinus is normally- highly echogenic compared to the cortex
Sonographic criteria of simple cyst-anechoic, acoustic enhancement, sharply defined, smooth wall, round or ovoid
hydronephrosis can be caused by-stone, uterine fibroid, uteropelvic junction obstruct, ovarian mass, but not acute pyelonephritis
Column of Bertin Pseudomass-if isoechogenicity with the rest of the cortex, continuity with the cortex. lack of mass effect or splaying of renal sinus fat, and normal vascularity by color doppler
multicystic, dysplastic kidney (MCDK)-will have multiple varably sized cysts, nonmedial location of the largest cyst, no sinus, bright echogenic tissue between cysts. They will not have a dilated ureter MCDK is usually dx in utero or in early childhood
crossed renal ectopia-both kidneys on same side of abd
wilm’s tumor-children 2-5
sinus has fat, calyces, vessels and infundibli of the collecting system
Ureteral Jets
periodic ureteral jets-normal. look for them to verify no ureter obstruction
look with color doppler to find the urinary jets
prep is moderate hydration, no fasting
31 y/o c htn and multiple cysts-polycystic kidney disease
solid mass in 47 y/o-look for extension into renal vein, search for liver mets, search for retroperitoneal adenopathy
Angiomyolipoma
solid hyperechoic mass in patient with tuberous sclerosis-angiomyolipoma-
renal mass that is highly echogenic due to its high-fat content- angiomyolipoma
uts appearance of the ureteropelvic junction obstruction-pelvialectiasis to level of junction?
pyelo-kidneys usually look normal, though may be slightly enlarge or loss of corticomedullary differences
doppler of normal main renal artery-low resistance with forward flow throughout the cardiac cycle
bladder outlet obstruction-thickening of bladder wall is muscular hypertrophy
chronic renal disease-small hyperechoic kidneys
nephocalcinosis-highly echogenic renal pyramids, possibly with posterior shadowing
false positives for hydronephrosis-overdistension of bladder,parapelvic cysts, prominent hilar vessels, large extrarenal pelvis
small round cystic structure projecting into the urinary bladder-ureterocele, from UTIs
transitional cell carcinoma, may have hematuria and mass in bladder
2 week old renal transplant, fluid collection with septations and internal debris adjacent to kidney-lymphocele
interlobar arteries course alongside the renal pyramids
left renal vein-between the sma and the aorta (NUTCRACKER)
right renal artery-posterior to the ivc
renal cortex-normally >10 mm
lymphoma of the kidney-multiple bilateral hypoechoic masses in enlarged kidneys
on top of renal pyramids and give rise to tiny interlobar arteries-arcuate
indication for doppler renal study to rule out renal artery stenosis-htn. compute ratio comparing velocity of the renal artery to abdominal aorta. 3.5 or greater renal aortic ratio is abnormal.
cysts in 50% of people over 50
PCKD-autosomal dominant will involve both kidneys, progressive renal failure is common, cysts may be complicated by bleeding and infection, htn is common, liver cysts in 30% of pts
Resistive index is normally .7 or less, a RI of 1 indicates a diastolic flow of 0. can occur with renal vein thrombosis, renal obstruction, chronic renal disease, may also seen with transplant rejection
look for the pelvic kidney if you only see one
evaluate all cysts post biopsy with color doppler to evaluate for pseudoaneurysm
SMA is the most useful landmark for the renal arteries. It is immediately superior to the origin of both sides
Hemorrhage into the cyst of PCKD kidney-low level echoes within the cyst
transplant-is in the right lower quadrant
chronic renal artery occlusion can shrink the kidney
doppler parameter for rejection-RI
irregular thickening of the bladder wall in 53 m with hydro and dilated ureter-transitional cell
Veins are Anterior to the Arteries
ureteral outlets are at base of trigone along posterior aspect
view with best doppler of kidney-patient in posterior oblique, coronal view through posterior axillary line
adjust to improve sensitivity to flow-decrease PRF
Atypical cyst has-internal septations, wall calcifications, internal echoes or irregular walls
dialysis for 4 years-small hyperechoic kidneys with mult cysts of varying sizes
most common solid renal mass of adults-renal cell carcinoma
emphysematous pyelo-multiple echogenic foci within parenchyma or sinus with dirty posterior acoustic shadows
normal renal art waveform=low resistance
medullary nephrocalcinosis-calcified pyramids
subcapsular hematoma-perirenal collection that flattens the underlying contour
most common cause of ARF-ATN
hypertrophy is normal a few weeks post-transplant
renal artery is usually anastamosed to external iliac artery
Scrotum
mediastinum testis-prominent echogenic linear echo in midline. rete testis is located within it
orchitis shows hyperemic flow-may have large hydrocele with it
most common germ cell tumor is seminoma
bell clapper deformity-associated with torsion
abd aorta to testicular to capsular artery to centripetal arteries
normal testes artery has low resistance waveform
spermatic cord contains-vas deferens, testicular artery, cremasteric artery, deferential artery
left testicular vein drains into-left renal
torsion doppler-low PRF, low filter, high gain, high packet size
power doppler may be better b/c there is no aliasing
mass-malignant if irregular shaped testes and intratesticular location, not if large hydrocele
epididymitis-increased flow by doppler
infertility-look for varicocele. more common on the left than the right veins larger than 2 mm in supine or 2.5 mm in standing are abnormal. valsalva may emphasize
hydroceles form in-space between two layers of the tunica vaginalis
transtesticular artery-common anatomic variant, course opposite direction as the centripetal, enters at mediastinum testis, large vein frequently accompanies it
microlithiasis not associated with orchitis, hypoechoic, hyperemic testis that is enlarged is
Prostate
posterior to prostate is the rectum
cancers most commonly in peripheral zone
BPH is transition zone
seminal vesicles are posterior and superior to prostate
left lateral decub positioning
get uts if abnormal digital exam, elevated PSA, guidance for biopsy, CA response to treatment
color doppler may allow better imaging of pathological vessels
ca can be any echogenicity
For prep-enema; antibiotics before and after if biopsy
zonal anatomy is the new standard
prostaticovesical arteries are branches from the internal iliac
rectum is shown at the bottom of the screen; 7-8 MHz probe
most lateral tissues are the peripheral zone
Seminal vesicles appear-hypoechoic, symmetrical, irregularly shaped
BPH enlarged gland which may be focal or diffuse
ejaculatory duct cysts can cause infertility
anechoic mass in pt with protatitis-abscess
Spleen
12-13 cm long, 4-6 in trans
Width x AP >48 is abnormal
Structures abutting spleen-left hemidiaphragm, stomach, pancreas, splenic flexure of colon
best long axis-intercostal coronal with pt supine
mild to moderate splenomegaly-portal htn, infection, AIDS. lymphoma causes severe splenoemegaly
Small rounded mass at hilum that is homogenous and isoechoic to spleen-accessory spleen
moderate splenomegaly most common finding in a patient with aids
hypoechoic wedge shaped lesion-splenic infarction. Increased confidence in finding by evaluating the lesion with doppler.
moderate splenomegaly and dilated, tortuous vessels-portal hypertension
structure at splenic hilum-splenic vein
pancreatic tail is inferomedial to spleen
Splenic parenchyma-homogenous with mid to low level echogenicity
Spleen is intraperitoneal
histoplasmosis-multiple focal bright echogenic granulomatous lesions in spleen. Can see the same in sarcoid and tb
Splenic vein drains into-portal vein
Calcified ring at splenic hilum in pt with portal htn-eval c doppler for aneurysm
Retroperitoneum
Striated hypoechoic structure immediately posterior to the right kidney and left kidney-quadratus lumborum muscles
striated structure posteromedial to kidney-psoas
psoas and quadratus are in retrofascial space
kidneys are in the anterior perirenal space
hypoechoic structures measuring greater than 2 cm adjacent to celiac trunk in periaortic area.-lymph nodes
fluid in pararenal space in a patient with elevated amylase most likely represents pseudocyst
retroperitoneal fibrosis-abdominal aorta
Measure any lymph nodes found
Lung can met to the adrenals
Right adrenal gland-posterior to the IVC
Search for adenopathy-splenic hilum, porta hepatic, renal hilum, para-aortic
Solid mass in upper pole of kidney-scan the patient in deep inspiration and expiration to separate these two structures
Adrenal mass masqueraders-thickened diaphragmatic crus, accessory spleen, gastric diverticulum, retroperitoneal lymphadenopathy
Left adrenal gland-lateral to abd aorta and diaphragm crus
Right diaphragmatic crus-posterior to IVC and right renal artery
Lymph nodes >1cm are abnormal
lymphocele-anechoic mass with mult sepatations lateral to midline, 2 cm below abdominal wall
posterior pararenal and retrofascial space contain no solid organs
pseudocyst usually in anterior pararenal
Aorta in anterior pararenal space
Abdominal Vasculature
Splenic vein and superior mesenteric vein form the portal vein
celiac trunk branches into splenic, left gastric, common hepatic (Seagull Sign)
hepatic branches to GDA and Proper. Seen transverse at celiac axis
In transverse, SMA has a fat collar
Playboy Bunny-2 of 3 hepatic veins over IVC
Left renal passes between SMA and Aorta
Left renal vein is anterior to aorta and posterior to sma
Measure aneurysm sagittal plane along axis of artery
if you can’t obtain a color doppler signal from portal vein decrease the PRF
abd aorta usually tapers towards feet
median arcuate ligament syndrome-pinching of the celiac trunk
median arcuate ligament syndrome-obtain doppler in inspiration or expiration and while supine and standing
htn-renal artery stenosis
waveform in mesenteric arteries-high resistance in fasting patient
doppler of abd vessels, you detect a stenosis in the right renal art-spectral broadening distal to stenosis, increased peak systolic velocity at stenosis, increased pulsatility proximal to stenosis, dampening of the waveform distal to the stenosis
chronic pancreatitis and bruit-pseudoaneurysm of the hepatic or splenic artery
splenic vein empties into portal not IVC
common hepatic artery splits into proper hepatic and gastroduodenal
replaced hepatic artery, right hepatic originates from SMA
vessel between SMA and aorta behind the pancreas-left renal vein NUTCRACKER
gastroduodenal art-caudal course anterior to pancreatic head
small intestine, right colon, and most of the transverse-SMA
chronic mesenteric ischemia-postprandial abd pain and weight loss
look at celiac, sma, ima
cirrhosis of liver from etoh abuse is most common cause of portal htn
hepatic veins drain into IVC
portal vein-mildly undulating flow
aaa are infrarenal commonly
if bowel gas is obscuring the abd, roll into recumbent and image from coronal
image budd chiarri-hepatic veins, ivc, portal vein
hepatic vein flow-triphasic
portal vein provides 70% of blood to liver
greatest angle of incidence when eval tips stent-60 degrees
waveform in the neck of a pseudoaneurysm-high velocity, bidirectional
splenic artery most commonly involved with pseudoaneurysm
right renal artery courses posterior to IVC
splenic vein is posterior and inferior to pancreas
SMV and splenic vein join to form portal vein
hepatic veins are intersegmental
multiple renal arteries are rare
IVC is posterior to caudate lobe
Copy Question 421 pseudoaneurysm doppler
shows reversal of flow
Question 426 portal vein
hepatic veins are triphasic
portal veins are continuous
IVC lies immediately posterior to panc head
dilation > 3cm =AAA
Most aneurysms are infrarenal. Fusiform is a normal summit. aneurysm, saccular has only one side of the vessel distended. Retroperitoneal fibrosis is assoc with mycotic aneurysms; it causes hypoechoic masses to envelop the aorta.
fusiform has gradual transition from normal to abnormal Ectatic is dilated (>3.5) throughout its length
Arteries
High Resistance-high systolic uptake, low diastolic flow
FACE, FEET, SMA beFORE MEAL
Low-low systolic uptake, high diastolic flow
Spleen, Liver, Kidneys, SMA after fatty meal and Brain
Veins
GI Tract
Gut-five layers
Scan with compression to better delineate mass
Doppler differentiates between ischemic and inflammatory masses
Most common malignant tumor-adenocarcinoma
target and pseudokidney are abnormal gut scans
crohns-gut wall thickening, strictures, creeping fat, increased vascularity
Gradual and uniform pressure over area
Appendix diameter >6mm or noncompressible
use 5 MHz linear with short focus
normal gut thickness 3-5 mm
Creeping fat-hyperechoic mass effect, looks like thyroid
Mucosa is innermost lining
Neck
longus coli is behind each lobe of the thyroid
hashimotos shows diffuse enlargement
Graves disease has increased vascularity
four parathyroid glands
adenoma causes hypercalcemia. homogenous, hypoechoic, solid oval shaped usually one of the parathyroids are involved in hyperpara
all four in hyperplasia
ultrasound can detect normal ln
have pt swallow to locate esophagus
papillary carcinoma is most common thyroid
thyrocervical from subclavian
Superficial Structures
10 MHz for breast
Instrumentation
comet tail=metallic
gas=ringdown
refraction=at edges
reverb = anterior surface of gall bladder
Image Gallery
diaphragmatic crura on either side of aorta