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You are here: Home / 08. Ultrasound / Doppler

Doppler

June 16, 2011 by CrashMaster

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

 

 

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Filed Under: 08. Ultrasound


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