{"id":5456,"date":"2011-06-16T01:55:19","date_gmt":"2011-06-16T01:55:19","guid":{"rendered":"http:\/\/crashtext.org\/misc\/doppler.htm\/"},"modified":"2013-02-02T23:55:31","modified_gmt":"2013-02-03T04:55:31","slug":"doppler","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/ultrasound\/doppler.htm\/","title":{"rendered":"Doppler"},"content":{"rendered":"

pulsed wave-spectral and color<\/span><\/p>\n

aliasing-all waves not returned, raise the pulse rep freq<\/p>\n

as depth increases PRF decreases<\/p>\n

 <\/p>\n

spectral- horizontal axis is time, vertical is the direction and velocity<\/p>\n

 <\/p>\n

keep gate tight in artery, open it out in vein<\/p>\n

angle<\/p>\n

velocity scale<\/p>\n

doppler gain<\/p>\n

filtration<\/p>\n

 <\/p>\n

Color<\/p>\n

set focus to at or just below the box<\/p>\n

 <\/p>\n

0 is best angle, anything <60 will do<\/p>\n

 <\/p>\n

 <\/p>\n

Liver<\/p>\n

<\/span>Anatomy<\/span><\/h2>\n

Couinaud\u2019s sections are divisions of the liver based on vascular anatomy. Falciform lig divides right and left lobes in classic.<\/p>\n

But in Couinaud, the division between the right and middle\/left is the middle hepatic vein<\/b>.<\/p>\n

Left hepatic divides the left<\/b> into left medial and left lateral.<\/p>\n

Right hepatic<\/b> divides right into right anterior and right posterior.<\/p>\n

Quadrate-Left medial segment. <\/b><\/p>\n

Caudate-posterior to lig venosum (used to be umbilical vein). Spared by most liver disease b\/c it has a separate blood flow.<\/p>\n

Riedel\u2019s Lobe<\/b>-extension of right liver in a tongue-like shape<\/p>\n

Glisson\u2019s capsule<\/b> covers the liver<\/p>\n

Falciform used to be ligamentum teres normally drains into l portal vein<\/p>\n

Ligamentum venosum forms the anterior border of the caudate lobe <\/b><\/p>\n

Normal Ligamentum Teres<\/b> (aka falciform) is brightly echogenic, triangular or rounded, it may cast shadows<\/p>\n

15.5<\/b> cm is upper limit of liver length<\/p>\n

 <\/p>\n

Portal vein-splenic, smv, imv.<\/p>\n

 <\/p>\n

Middle hepatic Vein separates the left medial segment from the right anterior segment. This vessel courses in the main lobar fissure<\/b><\/p>\n

 <\/p>\n

Anterior border<\/b> of the caudate is the fissure for the ligamentum venosum<\/p>\n

 <\/p>\n

This structure acts as a landmark for the paraumbilical: ligamentum teres. It extends from this ligament to the left portal vein<\/p>\n

 <\/p>\n

Long thin extension on the inferior aspect of the right lobe: Reidel\u2019s lobe<\/b><\/p>\n

 <\/p>\n

Caudal border of the left portal vein: Ligamentum teres<\/p>\n

 <\/p>\n

What differentiates hepatic veins from portal veins: portal veins have the triad coursing with them<\/p>\n

 <\/p>\n

Anterior and to the left of the ligamentum venosum=Left lobe<\/p>\n

 <\/p>\n

Thin capsule around the liver=Glisson\u2019s capsule<\/b><\/p>\n

 <\/p>\n

Hepatic veins course interlobar and intersegmental<\/p>\n

 <\/p>\n

Sagittal of the left lobe, ligamentum venosum and caudate lobe<\/p>\n

anterior to the ligamentum venosum is the left lobe, posterior to it is the caudate<\/p>\n

 <\/p>\n

Picture of ligamentum teres<\/p>\n

runs from portal vein <\/b><\/p>\n

 <\/p>\n

Picture of portal vein branch (right post), posterior segment, left portal vein, caudate lobe<\/p>\n

Right post of portal vein is located in RIGHT POSTERIOR SEGMENT<\/p>\n

Caudate is behind the left portal vein<\/p>\n

The Left portal is anterior to the Right and is C-shaped <\/b>when imaged longitudinally<\/p>\n

 <\/p>\n

To demonstrate the three hepatic veins going into IVC-Subcostal oblique with probe angled superiorly and to the patient\u2019s right<\/p>\n

 <\/p>\n

To see dome, use subcostal with pt in deep inspiration<\/p>\n

 <\/p>\n

AFP elevation=hepatocellular carcinoma<\/p>\n

 <\/p>\n

<\/span>Adenoma<\/span><\/h3>\n

Solid hypoechoic<\/b> mass with hypervascularity in liver with a patient on OCPs=hepatic adenoma<\/p>\n

 <\/p>\n

<\/span>Cavernous Hemangioma<\/span><\/h3>\n

homogenous hyperechoic<\/b> lesion measuring 2.4 cm in the posterior aspect of the right lobe=cavernous hemangioma<\/p>\n

most common benign tumor-cavernous hemangioma<\/p>\n

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<\/p>\n

<\/span>Focal Nodular Hyperplasia<\/span><\/h3>\n

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<\/b><\/p>\n

<\/span>Fatty Liver<\/span><\/h3>\n

Diffuse increased echogenicity with focal hypoechoic area anterior to the portal vein in 49 obese male=fatty liver with focal sparing<\/p>\n

Focal fatty liver is usually found in anterior to the portal vein at the porta hepatic<\/p>\n

Reversible, <\/b> caused by obesity, may be diffuse or focal, may show rapid change in appearance with time, increased attenuation of sound beam through the liver<\/p>\n

increased echo compared to the kidney, hyperechoic patches are usually seen periportal, around the gb, and at the liver margins<\/p>\n

<\/span>Cirrhosis<\/span><\/h3>\n

Surface nodularity, altered echo texture, ascites, regenerative nodules, not shrunken caudate lobe. Caudate lobe is actually relatively enlarged as it is spared.<\/p>\n

search for portal hypertension.<\/p>\n

luminal narrowing of hepatic veins\/color and spectral doppler reveal high velocities through strictures-cirrhosis because the thin walled veins are compressed.<\/p>\n

 <\/p>\n

If you can\u2019t 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. <\/b>Always eval for budd chiarri in pts with new ascites, hepatomegaly and pain <\/b><\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

Pt with liver cirrhosis and suspected portal hypertension, evaluate size-spleen and portal vein diameter<\/p>\n

Regenerating nodules are a feature of-cirrhosis<\/p>\n

 <\/p>\n

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<\/b>, ascites, hepatofugal flow in portal<\/p>\n

<\/span>Portal Hypertension<\/span><\/h3>\n

Hepatofugal flow in the portal vein-portal hypertension. hepatopetal flow<\/b>-towards the head and towards the liver. fugal is away from the liver<\/p>\n

Pt c TIPS-connects portal vein and the hepatic vein<\/p>\n

 <\/p>\n

normal liver with enlarged hepatic veins and ivc=right side heart failure<\/p>\n

 <\/p>\n

majority of blood to the liver-portal vein, majority of oxygenated from hepatic artery<\/p>\n

 <\/p>\n

recanulized paraumbilical vein can be seen in-portal hypertension<\/p>\n

 <\/p>\n

best sonographic window for the prior is-sagittal subcostal through the left lobe at the level of the ligamentum teres<\/p>\n

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<\/p>\n

Cutoff for portal vein enlargement=13 cm<\/p>\n

 <\/p>\n

Best view for coronary vein-sagittal view of the splenic vein near the midline<\/p>\n

 <\/p>\n

Cavernous transformation-look for it in the porta hepatic, occurs following portal vein thrombosis<\/b>. It is characterized by multiple serpginous venous channels in the porta where the portal vein was located. Flow direction is hepatopetal (into the liver)<\/p>\n

 <\/p>\n

<\/span>Mets<\/span><\/h3>\n

Liver metastasis-can be single or multiple, hypo or hyperechoic, can have mixed echo, or can look like cystic masses<\/p>\n

<\/span>Cysts<\/span><\/h3>\n

Hepatic cysts-thin wall, posterior enhancement<\/b>, anechoic, decreased attenuation<\/b>, increased through transmission<\/p>\n

 <\/p>\n

Single large mass, well defined, smooth walls, homogenous low-level echoes<\/b> in anterior right lobe of 48 y\/o female, no Doppler signals-Hemorrhagic cyst<\/b><\/p>\n

<\/span>Hepatitis<\/span><\/h3>\n

Fever, elevated LFTs, RUQ tender, liver is enlarged with decreased echogenicity, GB wall is thick, thick echogenic bands around the portal veins(periportal cuffing)<\/p>\n

Acute hepatitis is starry sky appearance<\/b> from liver parenchyma contrasted with bright bile ducts<\/p>\n

 <\/p>\n

 <\/p>\n

Sonographic appearance of air bubbles-brightly echogenic foci with ring-down artifact<\/p>\n

 <\/p>\n

Infestation by a parasite in sheep\/cattle raising countries-Hydatid disease <\/b><\/p>\n

 <\/p>\n

Invasion of the portal vein-hepatocellular carcinoma<\/p>\n

 <\/p>\n

Pts with AIDS get-kaposis in the liver<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

Bull\u2019s eye or target lesion in the anterior right lobe-liver met from lung ca<\/p>\n

<\/span>Transplant<\/span><\/h3>\n

Post liver transplant with extrahepatic fluid collection-can be biloma, hematoma, loculated ascites or abscess<\/p>\n

Liver transplant involves anastamoses of IVC, portal vein, hepatic artery, bile duct<\/p>\n

no ultrasound findings to eval transplant rejection<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

Ultrasound during liver surgery-7 mhz linear probe-placed directly on the liver<\/p>\n

 <\/p>\n

Increased through-transmission, right lobe, adjacent to the capsule, large, rounded homogenous mass poorly defined wall in pt with fever and pain-amebic abscess <\/b><\/p>\n

 <\/p>\n

most common liver malignancy-metastatic disease<\/b><\/p>\n

Biliary Tree<\/p>\n

Main (Interlobar) fissure<\/b> is the landmark for the GB. hyperechoic linear structure that runs between the right portal vein and the GB.<\/p>\n

Portal vein and the neck of the GB.<\/p>\n

Normal transverse diameter is 4 cm.<\/p>\n

Hydropic GB<\/b>-transverse diameter of 5.3 cm. seen with choledocholithiasis<\/p>\n

GB wall thickness is normally <3mm.<\/p>\n

 <\/p>\n

WES sign<\/b>-wall, echo, shadow.<\/p>\n

 <\/p>\n

Parallel channel sign-CBD gets big enough to be same size as portal vein<\/p>\n

 <\/p>\n

Fundus of gb folded over body-Phrygian cap<\/p>\n

 <\/p>\n

Common cause of smudgy artifacts-reverb, side lobes, slice thickness<\/p>\n

 <\/p>\n

GB sono preparation-fasted 8-12 hrs prior to exam<\/p>\n

 <\/p>\n

Abnormal thickening can be-inflammation, hepatic dysfunction, CHF, GB wall varices,<\/p>\n

 <\/p>\n

Diagnostic accuracy of GB sono-> 90%<\/p>\n

 <\/p>\n

Increase stone shadowing-increase frequency and focusing<\/p>\n

 <\/p>\n

Porcelain gallbladder-wall contains various amounts of calcifications,<\/p>\n

 <\/p>\n

Distal CBD-posterior and slightly lateral to the pancreatic head<\/p>\n

Look at the distal CBD for choledocolithiasis<\/p>\n

Measure duct in longitudinal near porta. Need to see IVC in the image<\/p>\n

 <\/p>\n

CBD pierces uncinate process tissue behind head of pancreas. just anterior to renal vein<\/p>\n

 <\/p>\n

Pt just ate-contracted GB with diffuse wall thickening<\/p>\n

 <\/p>\n

Cholecystitis-calculus obstruction of the GB neck or cystic duct<\/p>\n

 <\/p>\n

Dilated non-tender gb-look for mass in the head of the pancreas. Courvousier\u2019s<\/p>\n

 <\/p>\n

Low level echoes in the GB looks like sludge, GB wall is not thickened.<\/p>\n

 <\/p>\n

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.<\/p>\n

Rokitansky-Aschoff sinuses-Adenomyomatosis=small mucosal hernaitions into the muscular wall of the GB. May get filled with cholesterol<\/p>\n

 <\/p>\n

Polyps do not shadow<\/p>\n

 <\/p>\n

Tumefactive sludge-avascular mass with low level echoes. polypoid masslike shape. moves slowly with positional changes. if it is vascularized suspect carcinoma instead<\/p>\n

 <\/p>\n

GB wall is vascular, this can help differentiate between wall edema and pericholecystic fluid<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

hypervascularity of acute cholecystitis-doppler of cystic artery<\/p>\n

 <\/p>\n

Acalculous cholecystitis-wall thickening, murphy\u2019s, perichole fluid, GB wall edema without stones<\/p>\n

 <\/p>\n

Differentiate between bowel gas and posterior shadowing-roll pt into left lateral decub.<\/p>\n

 <\/p>\n

Edge shadowing=refraction artifact<\/b><\/p>\n

 <\/p>\n

Gallbladder carcinoma-irregular mass in the lumen with hypervascularity<\/b>, multiple stones in the lumen-GB carcinoma<\/p>\n

 <\/p>\n

Best way to identify intrahepatic Biliary system is to image-intrahepatic portal veins<\/p>\n

 <\/p>\n

Pneumobilia-air in the bile ducts<\/p>\n

 <\/p>\n

Differentiate duct dilation from hepatic vein dilation-dilated ducts demonstrate irregular torturous walls, bile ducts will not have flow with doppler<\/p>\n

 <\/p>\n

Common bile duct-junction of the cystic and common hepatic<\/p>\n

 <\/p>\n

Thickening of bile duct walls-may be sclerosing cholangitis, pancreatitis, choledocolithiasis, cholangiocarcinoma<\/p>\n

 <\/p>\n

Junctional folds-maze like projections into GB<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

cystic dilation of the CBD is choledochal cyst<\/p>\n

 <\/p>\n

they seem to think that serum billi helps differentiate between intra and extra cause of jaundice<\/p>\n

 <\/p>\n

Differentiate the duct from the hepatic artery-doppler from artery but not duct<\/p>\n

 <\/p>\n

Help to visualize distal CBD-roll pt to right posterior oblique or right lat recumbent<\/p>\n

 <\/p>\n

most common<\/b> anatomic variant-GB folds<\/p>\n

 <\/p>\n

most accurate test for acute chole=cholescintigraphy<\/p>\n

 <\/p>\n

Porcelain gb are at risk for-GB carcinoma<\/p>\n

 <\/p>\n

Roll pt into LLR if you are unsure of a neck stone<\/p>\n

 <\/p>\n

Administered cholecystokinin<\/b> to a patient-causes the GB to contract<\/b> in a normal study.<\/p>\n

 <\/p>\n

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<\/b><\/p>\n

 <\/p>\n

Jaundice pain and nausea with a history of gb out-choledocolithiasis<\/p>\n

 <\/p>\n

In suspected cholangiocarcinoma, look for-dilation of the Biliary tree<\/p>\n

 <\/p>\n

Can get reverb artifact<\/b> in anterior just behind wall<\/p>\n

 <\/p>\n

Turn them in llr to eval mobility of stones<\/p>\n

 <\/p>\n

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<\/b><\/p>\n

 <\/p>\n

A tumor that may be intrahepatic or extrahepatic bile duct is known as-cholangiocarcinoma<\/p>\n

 <\/p>\n

Old guy with ruq pain, gallstones and bright echoes in gb wall with ringdown-emphysematous cholecystitis<\/p>\n

 <\/p>\n

Pancreas<\/p>\n

picture of the anatomy of the pancreas (p33)<\/p>\n

body tail uncinate process<\/p>\n

 <\/p>\n

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<\/p>\n

vessel anterior to uncinate process and posterior to the pancreas neck confluence of portal and splenic vein<\/p>\n

Uncinate wraps around SMV<\/p>\n

SMA is posterior to pancreatic neck<\/p>\n

 <\/p>\n

 <\/p>\n

long axis view of head and body of pancreas-midline transverse scan with left side of the probe just slightly caudad<\/p>\n

 <\/p>\n

name of main pancreatic duct-duct of wirsung<\/b><\/p>\n

 <\/p>\n

accessory pancreatic duct-duct of santorini****<\/b><\/p>\n

 <\/p>\n

CBD relation to pancreas-CBD is posterior to the head of the pancreas<\/p>\n

 <\/p>\n

Pancreatic divisum-the two pancreatic ducts have not fused<\/p>\n

 <\/p>\n

anterior aspect of the head of the pancreas-gastroduodenal artery<\/b><\/p>\n

posterior aspect of the head of the pancreas-CBD <\/b><\/p>\n

 <\/p>\n

coursing transversely at level of the upper panc. head-left renal vein<\/p>\n

 <\/p>\n

thin patient-curvilinear 5 mHz<\/p>\n

 <\/p>\n

repeated pancreatitis, use doppler-to increase chances of finding pseudoaneurysms<\/p>\n

 <\/p>\n

most difficult part to visualize-tail<\/p>\n

 <\/p>\n

frequency for endoscopic uts-10 MHz<\/p>\n

 <\/p>\n

most common malignant tumor-adenocarcinoma.<\/b> risk factors-smoking, high fat diet, diabetes, chronic pancreatitis. stage with ct. most commonly found in the head of panc. appears as hypoechoic mass<\/b>. look for lymphadenopathy and liver mets<\/p>\n

 <\/p>\n

hyperechoic mass<\/b> in the head of the pancreas, dilation of panc and cb ducts, diffuse calcification in pancreas-chronic pancreatitis<\/p>\n

Cancer=hypoechoic <\/b><\/p>\n

 <\/p>\n

looking for complications of pancreatitis-look for pseudoaneurysm, pseudocyst, phlegmon, abscess<\/p>\n

 <\/p>\n

pt with pancreatic transplant-placed in iliac fossa, rejection is indicated by-high-resistance doppler signals and heterogeneous parenchyma<\/p>\n

 <\/p>\n

non-encapsulated collection of necrotic and edematous peripancreatic tissues-phlegmon<\/p>\n

 <\/p>\n

in USA most common cause is stone, etoh is 2nd cause<\/p>\n

 <\/p>\n

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)<\/p>\n

 <\/p>\n

obese pt with small hypoechoic tumor in tail-insulinoma. they\u2019re fat b\/c of overeating during hypoglycemic attacks. insulinoma-use 10 MHz<\/p>\n

 <\/p>\n

duodenum encircles-the head<\/p>\n

 <\/p>\n

splenic vein is posterior and caudal to pancreas<\/p>\n

 <\/p>\n

celiac trunk is located at the superior border<\/p>\n

 <\/p>\n

posterior border of the pancreatic head-IVC<\/p>\n

 <\/p>\n

Courses anterior to the uncinate-SM vein<\/p>\n

 <\/p>\n

small tubular structure coursing cephalocaudad anterior to the pancreas-gastroduodenal artery<\/p>\n

 <\/p>\n

picture on p. 42 and\u00a0 questions 190-193<\/p>\n

190<\/p>\n

191<\/p>\n

192<\/p>\n

193<\/p>\n

Transverse picture of the aorta and the sma with the left renal vein running between. Body of pancreas is anterior to the SMA.<\/p>\n

 <\/p>\n

Head has the largest dimensions<\/p>\n

 <\/p>\n

Normal pancreas is iso or hyperechoic in relation to the liver<\/p>\n

 <\/p>\n

Tail of the pancreas touches-left kidney, splenic flexure of the colon, and spleen<\/p>\n

Kidney\/Urinary Tract<\/p>\n

left and right kidneys attached at their lower poles-horseshoe kidney.<\/b> isthmus is anterior<\/b> to the abd aorta<\/p>\n

 <\/p>\n

renal cortex-should be iso or perhaps hypoechoic in comparison to liver<\/p>\n

 <\/p>\n

angiomyolipoma may cause speed artifact<\/p>\n

 <\/p>\n

normal kidney-9-14 cm<\/b><\/p>\n

 <\/p>\n

1.5 cm thickening of the left lateral renal cortex-dromedary hump<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

Central sinus is normally- highly echogenic compared to the cortex<\/p>\n

 <\/p>\n

Sonographic criteria of simple cyst-anechoic, acoustic enhancement, sharply defined, smooth wall, round or ovoid<\/p>\n

 <\/p>\n

hydronephrosis can be caused by-stone, uterine fibroid, uteropelvic junction obstruct, ovarian mass, but not acute pyelonephritis<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

crossed renal ectopia-both kidneys on same side of abd<\/p>\n

 <\/p>\n

wilm\u2019s tumor-children 2-5<\/p>\n

 <\/p>\n

sinus has fat, calyces, vessels and infundibli of the collecting system<\/p>\n

<\/span>Ureteral Jets<\/span><\/h3>\n

periodic ureteral jets-normal. look for them to verify no ureter obstruction<\/p>\n

look with color doppler to find the urinary jets<\/p>\n

 <\/p>\n

prep is moderate hydration, no fasting<\/p>\n

 <\/p>\n

31 y\/o c htn and multiple cysts-polycystic kidney disease<\/p>\n

 <\/p>\n

solid mass in 47 y\/o-look for extension into renal vein, search for liver mets, search for retroperitoneal adenopathy<\/p>\n

 <\/p>\n

<\/span>Angiomyolipoma<\/span><\/h3>\n

solid hyperechoic mass in patient with tuberous sclerosis-angiomyolipoma-<\/p>\n

renal mass that is highly echogenic due to its high-fat content- angiomyolipoma<\/p>\n

 <\/p>\n

uts appearance of the ureteropelvic junction obstruction-pelvialectiasis to level of junction?<\/p>\n

 <\/p>\n

pyelo-kidneys usually look normal, though may be slightly enlarge or loss of corticomedullary differences<\/p>\n

 <\/p>\n

doppler of normal main renal artery-low resistance with forward flow throughout the cardiac cycle<\/p>\n

 <\/p>\n

bladder outlet obstruction-thickening of bladder wall is muscular hypertrophy<\/p>\n

 <\/p>\n

chronic renal disease-small hyperechoic kidneys<\/p>\n

 <\/p>\n

nephocalcinosis-highly echogenic renal pyramids, possibly with posterior shadowing<\/p>\n

 <\/p>\n

false positives for hydronephrosis-overdistension of bladder,parapelvic cysts, prominent hilar vessels, large extrarenal pelvis<\/p>\n

 <\/p>\n

small round cystic structure projecting into the urinary bladder-ureterocele, from UTIs<\/p>\n

 <\/p>\n

transitional cell carcinoma, may have hematuria and mass in bladder<\/p>\n

 <\/p>\n

2 week old renal transplant, fluid collection with septations and internal debris adjacent to kidney-lymphocele<\/p>\n

 <\/p>\n

interlobar arteries<\/b> course alongside the renal pyramids<\/p>\n

 <\/p>\n

left renal vein<\/b>-between the sma and the aorta (NUTCRACKER)<\/p>\n

 <\/p>\n

right renal artery-posterior to the ivc<\/b><\/p>\n

 <\/p>\n

renal cortex-normally >10 mm<\/p>\n

 <\/p>\n

lymphoma of the kidney-multiple bilateral hypoechoic masses\u00a0 in enlarged kidneys<\/p>\n

 <\/p>\n

on top of renal pyramids and give rise to tiny interlobar arteries-arcuate<\/p>\n

 <\/p>\n

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.<\/p>\n

 <\/p>\n

cysts in 50% of people over 50<\/p>\n

 <\/p>\n

PCKD-autosomal dominant will involve both<\/b> kidneys, progressive renal failure is common, cysts may be complicated by bleeding and infection, htn is common, liver cysts in 30% of pts<\/p>\n

 <\/p>\n

Resistive index is normally .7 or less,<\/b> 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<\/p>\n

 <\/p>\n

look for the pelvic kidney if you only see one<\/p>\n

 <\/p>\n

evaluate all cysts post biopsy with color doppler to evaluate for pseudoaneurysm<\/p>\n

 <\/p>\n

SMA is the most useful landmark for the renal arteries. It is immediately superior to the origin of both sides<\/p>\n

 <\/p>\n

Hemorrhage into the cyst of PCKD kidney-low level echoes within the cyst<\/p>\n

 <\/p>\n

transplant-is in the right lower quadrant<\/p>\n

 <\/p>\n

chronic renal artery occlusion can shrink the kidney<\/p>\n

 <\/p>\n

doppler parameter for rejection-RI<\/p>\n

 <\/p>\n

irregular thickening of the bladder wall in 53 m with hydro and dilated ureter-transitional cell<\/p>\n

 <\/p>\n

Veins are Anterior to the Arteries <\/b><\/p>\n

 <\/p>\n

ureteral outlets are at base of trigone along posterior aspect<\/p>\n

 <\/p>\n

view with best\u00a0 doppler of kidney-patient in posterior oblique, coronal view through posterior axillary line<\/p>\n

 <\/p>\n

adjust to improve sensitivity to flow-decrease PRF<\/p>\n

 <\/p>\n

Atypical cyst <\/b> has-internal septations, wall calcifications, internal echoes or irregular walls<\/p>\n

 <\/p>\n

dialysis for 4 years-small hyperechoic kidneys with mult cysts<\/b> of varying sizes<\/p>\n

 <\/p>\n

most common solid renal mass of adults-renal cell carcinoma<\/b><\/p>\n

 <\/p>\n

emphysematous pyelo-multiple echogenic foci within parenchyma or sinus with dirty posterior acoustic shadows<\/p>\n

 <\/p>\n

normal renal art waveform<\/b>=low resistance<\/p>\n

 <\/p>\n

medullary nephrocalcinosis-calcified pyramids<\/p>\n

 <\/p>\n

subcapsular hematoma-perirenal collection that flattens the underlying contour<\/p>\n

 <\/p>\n

most common cause of ARF-ATN<\/b><\/p>\n

 <\/p>\n

hypertrophy is normal a few weeks post-transplant<\/p>\n

 <\/p>\n

renal artery is usually anastamosed to external iliac artery<\/p>\n

 <\/p>\n

Scrotum<\/p>\n

mediastinum testis-prominent echogenic linear echo in midline. rete testis is located within it<\/p>\n

 <\/p>\n

orchitis shows hyperemic flow-may have large hydrocele with it<\/p>\n

 <\/p>\n

most common germ cell tumor is seminoma<\/b><\/p>\n

 <\/p>\n

bell clapper deformity-associated with torsion<\/p>\n

 <\/p>\n

abd aorta to testicular to capsular artery to centripetal arteries <\/b><\/p>\n

 <\/p>\n

normal testes artery has low resistance waveform <\/b><\/p>\n

 <\/p>\n

spermatic cord contains-vas deferens, testicular artery, cremasteric artery, deferential artery<\/p>\n

 <\/p>\n

left testicular vein drains into-left renal <\/b><\/p>\n

 <\/p>\n

torsion doppler-low PRF, low filter, high gain, high packet size <\/b><\/p>\n

power doppler may be better b\/c there is no aliasing <\/b><\/p>\n

 <\/p>\n

mass-malignant if irregular shaped testes and intratesticular location, not if large hydrocele<\/p>\n

 <\/p>\n

epididymitis-increased flow by doppler<\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

hydroceles form in-space between two layers of the tunica vaginalis<\/p>\n

 <\/p>\n

transtesticular artery-common anatomic variant, course opposite direction as the centripetal, enters at mediastinum testis, large vein frequently accompanies it<\/p>\n

 <\/p>\n

microlithiasis not associated with orchitis, hypoechoic, hyperemic testis that is enlarged is<\/p>\n

 <\/p>\n

Prostate<\/p>\n

posterior to prostate is the rectum<\/p>\n

 <\/p>\n

cancers most commonly in peripheral zone<\/b><\/p>\n

 <\/p>\n

BPH is transition zone <\/b><\/p>\n

 <\/p>\n

seminal vesicles are posterior and superior to prostate<\/p>\n

 <\/p>\n

left lateral decub positioning<\/p>\n

 <\/p>\n

get uts if abnormal digital exam, elevated PSA, guidance for biopsy, CA response to treatment<\/p>\n

 <\/p>\n

color doppler may allow better imaging of pathological vessels<\/p>\n

 <\/p>\n

ca can be any echogenicity<\/p>\n

 <\/p>\n

For prep-enema; antibiotics before and after if biopsy<\/p>\n

 <\/p>\n

zonal anatomy is the new standard<\/p>\n

 <\/p>\n

prostaticovesical arteries are branches from the internal iliac<\/p>\n

 <\/p>\n

rectum is shown at the bottom of the screen; 7-8 MHz probe<\/p>\n

 <\/p>\n

most lateral tissues are the peripheral zone<\/b><\/p>\n

 <\/p>\n

Seminal vesicles appear-hypoechoic, symmetrical, irregularly shaped<\/p>\n

 <\/p>\n

BPH enlarged gland which may be focal or diffuse<\/p>\n

 <\/p>\n

ejaculatory duct cysts can cause infertility<\/p>\n

 <\/p>\n

anechoic mass in pt with protatitis-abscess<\/p>\n

 <\/p>\n

Spleen<\/p>\n

12-13 cm long, 4-6 in trans<\/p>\n

Width x AP >48 is abnormal<\/p>\n

 <\/p>\n

Structures abutting spleen-left hemidiaphragm, stomach, pancreas, splenic flexure of colon<\/p>\n

 <\/p>\n

best long axis-intercostal coronal with pt supine<\/p>\n

 <\/p>\n

mild to moderate splenomegaly-portal htn, infection, AIDS. lymphoma causes severe splenoemegaly<\/p>\n

 <\/p>\n

Small rounded mass at hilum that is homogenous and isoechoic to spleen-accessory spleen<\/p>\n

 <\/p>\n

moderate splenomegaly most common finding in a patient with aids<\/p>\n

 <\/p>\n

hypoechoic wedge shaped lesion-splenic infarction. Increased confidence in finding by evaluating the lesion with doppler.<\/p>\n

 <\/p>\n

moderate splenomegaly and dilated, tortuous vessels-portal hypertension<\/b><\/p>\n

 <\/p>\n

structure at splenic hilum-splenic vein<\/p>\n

 <\/p>\n

pancreatic tail is inferomedial to spleen<\/p>\n

 <\/p>\n

Splenic parenchyma-homogenous with mid to low level echogenicity<\/p>\n

 <\/p>\n

Spleen is intraperitoneal <\/b><\/p>\n

 <\/p>\n

histoplasmosis-multiple focal bright echogenic granulomatous lesions in spleen. Can see the same in sarcoid and tb<\/p>\n

 <\/p>\n

Splenic vein drains into-portal vein<\/p>\n

 <\/p>\n

Calcified ring at splenic hilum in pt with portal htn-eval c doppler for aneurysm<\/b><\/p>\n

 <\/p>\n

Retroperitoneum<\/p>\n

Striated hypoechoic structure immediately posterior to the right kidney and left kidney-quadratus lumborum<\/b> muscles<\/p>\n

striated structure posteromedial to kidney-psoas <\/b><\/p>\n

psoas and quadratus are in retrofascial space<\/p>\n

 <\/p>\n

kidneys are in the anterior perirenal space<\/p>\n

 <\/p>\n

hypoechoic structures measuring greater than 2 cm adjacent to celiac trunk in periaortic area.-lymph nodes<\/p>\n

 <\/p>\n

fluid in pararenal space in a patient with elevated amylase most likely represents pseudocyst<\/p>\n

 <\/p>\n

retroperitoneal fibrosis-abdominal aorta<\/p>\n

 <\/p>\n

Measure any lymph nodes found<\/p>\n

 <\/p>\n

Lung can met to the adrenals<\/p>\n

 <\/p>\n

Right adrenal gland-posterior to the IVC<\/p>\n

 <\/p>\n

Search for adenopathy-splenic hilum, porta hepatic, renal hilum, para-aortic<\/p>\n

 <\/p>\n

Solid mass in upper pole of kidney-scan the patient in deep inspiration and expiration to separate these two structures<\/p>\n

 <\/p>\n

Adrenal mass masqueraders-thickened diaphragmatic crus, accessory spleen, gastric diverticulum, retroperitoneal lymphadenopathy<\/p>\n

 <\/p>\n

Left adrenal gland-lateral to abd aorta and diaphragm crus<\/p>\n

 <\/p>\n

Right diaphragmatic crus-posterior to IVC and right renal artery<\/p>\n

 <\/p>\n

Lymph nodes >1cm are abnormal<\/p>\n

 <\/p>\n

lymphocele-anechoic mass with mult sepatations lateral to midline, 2 cm below abdominal wall<\/p>\n

 <\/p>\n

posterior pararenal and retrofascial space<\/b> contain no solid organs<\/p>\n

 <\/p>\n

pseudocyst usually in anterior pararenal<\/p>\n

 <\/p>\n

Aorta in anterior pararenal space<\/p>\n

 <\/p>\n

Abdominal Vasculature<\/p>\n

Splenic vein and superior mesenteric vein form the portal vein<\/p>\n

 <\/p>\n

celiac trunk branches into splenic, left gastric, common hepatic (Seagull Sign)<\/p>\n

hepatic branches to GDA and Proper. Seen transverse at celiac axis<\/p>\n

 <\/p>\n

In transverse, SMA has a fat collar<\/p>\n

 <\/p>\n

Playboy Bunny-2 of 3 hepatic veins over IVC<\/p>\n

 <\/p>\n

Left renal passes between SMA and Aorta<\/p>\n

 <\/p>\n

Left renal vein is anterior to aorta<\/b> and posterior to sma<\/p>\n

 <\/p>\n

Measure aneurysm sagittal plane along axis of artery<\/p>\n

 <\/p>\n

if you can\u2019t obtain a color doppler signal from portal vein decrease the PRF<\/p>\n

 <\/p>\n

abd aorta usually tapers towards feet<\/p>\n

 <\/p>\n

median arcuate ligament syndrome<\/b>-pinching of the celiac trunk<\/p>\n

median arcuate ligament syndrome-obtain doppler in inspiration or expiration<\/b> and while supine and standing<\/p>\n

 <\/p>\n

htn-renal artery stenosis<\/p>\n

 <\/p>\n

waveform in mesenteric arteries-high resistance in fasting patient <\/b><\/p>\n

 <\/p>\n

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<\/p>\n

 <\/p>\n

chronic pancreatitis and bruit-pseudoaneurysm of the hepatic or splenic artery <\/b><\/p>\n

 <\/p>\n

splenic vein empties into portal not IVC<\/p>\n

 <\/p>\n

common hepatic artery splits into proper hepatic and gastroduodenal <\/b><\/p>\n

 <\/p>\n

replaced hepatic artery, right hepatic originates from SMA<\/p>\n

 <\/p>\n

vessel between SMA and aorta behind the pancreas-left renal vein NUTCRACKER<\/b><\/p>\n

 <\/p>\n

gastroduodenal art-caudal course anterior to pancreatic head<\/p>\n

 <\/p>\n

small intestine, right colon, and most of the transverse-SMA<\/p>\n

 <\/p>\n

chronic mesenteric ischemia-postprandial abd pain and weight loss<\/p>\n

look at celiac, sma, ima<\/p>\n

 <\/p>\n

cirrhosis of liver from etoh abuse is most common cause of portal htn<\/p>\n

 <\/p>\n

hepatic veins drain into IVC<\/p>\n

portal vein-mildly undulating flow<\/p>\n

 <\/p>\n

aaa are infrarenal commonly<\/p>\n

 <\/p>\n

if bowel gas is obscuring the abd, roll into recumbent and image from coronal<\/p>\n

 <\/p>\n

image budd chiarri-hepatic veins, ivc, portal vein<\/p>\n

 <\/p>\n

hepatic vein flow-triphasic <\/b><\/p>\n

 <\/p>\n

portal vein provides 70% of blood to liver<\/p>\n

 <\/p>\n

greatest angle of incidence when eval tips stent-60 degrees<\/p>\n

 <\/p>\n

waveform in the neck of a pseudoaneurysm-high velocity, bidirectional<\/p>\n

 <\/p>\n

splenic artery most commonly involved with pseudoaneurysm<\/p>\n

 <\/p>\n

right renal artery courses posterior to IVC <\/b><\/p>\n

 <\/p>\n

splenic vein is posterior and inferior to pancreas<\/p>\n

 <\/p>\n

SMV and splenic vein join to form portal vein<\/p>\n

 <\/p>\n

hepatic veins are intersegmental<\/p>\n

 <\/p>\n

multiple renal arteries are rare<\/p>\n

 <\/p>\n

IVC is posterior to caudate lobe<\/p>\n

 <\/p>\n

Copy Question 421 pseudoaneurysm doppler<\/p>\n

shows reversal of flow<\/p>\n

 <\/p>\n

Question 426 portal vein<\/p>\n

hepatic veins are triphasic<\/p>\n

portal veins are continuous<\/p>\n

 <\/p>\n

IVC lies immediately posterior to panc head<\/p>\n

 <\/p>\n

dilation > 3cm =AAA<\/p>\n

 <\/p>\n

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.<\/p>\n

fusiform has gradual transition from normal to abnormal Ectatic is dilated (>3.5) throughout its length<\/p>\n

 <\/p>\n

<\/span>Arteries<\/span><\/h3>\n

High Resistance-high systolic uptake, low diastolic flow<\/p>\n

FACE, FEET, SMA beFORE MEAL <\/b><\/p>\n

Low-low systolic uptake, high diastolic flow<\/p>\n

Spleen, Liver, Kidneys, SMA after fatty meal and Brain<\/p>\n

 <\/p>\n

<\/span>Veins<\/span><\/h3>\n

 <\/p>\n

GI Tract<\/p>\n

Gut-five layers<\/p>\n

 <\/p>\n

Scan with compression to better delineate mass<\/p>\n

 <\/p>\n

Doppler differentiates between ischemic and inflammatory masses<\/p>\n

 <\/p>\n

Most common malignant tumor-adenocarcinoma<\/b><\/p>\n

 <\/p>\n

target and pseudokidney are abnormal gut scans<\/p>\n

 <\/p>\n

crohns-gut wall thickening, strictures, creeping fat, increased vascularity<\/p>\n

 <\/p>\n

Gradual and uniform pressure over area<\/p>\n

 <\/p>\n

Appendix diameter >6mm or noncompressible <\/b><\/p>\n

use 5 MHz linear with short focus<\/p>\n

 <\/p>\n

normal gut thickness 3-5 mm<\/p>\n

 <\/p>\n

Creeping fat-hyperechoic mass effect, looks like thyroid<\/p>\n

 <\/p>\n

Mucosa is innermost lining<\/p>\n

 <\/p>\n

Neck<\/p>\n

longus coli is behind each lobe of the thyroid<\/p>\n

 <\/p>\n

hashimotos shows diffuse enlargement <\/b><\/p>\n

 <\/p>\n

Graves disease has increased vascularity<\/b><\/p>\n

 <\/p>\n

four parathyroid glands<\/p>\n

adenoma causes hypercalcemia. homogenous, hypoechoic, solid oval shaped usually one of the parathyroids are involved in hyperpara<\/p>\n

 <\/p>\n

all four in hyperplasia<\/p>\n

 <\/p>\n

ultrasound can detect normal ln<\/p>\n

 <\/p>\n

have pt swallow to locate esophagus<\/p>\n

 <\/p>\n

papillary carcinoma is most common thyroid <\/b><\/p>\n

 <\/p>\n

thyrocervical from subclavian<\/p>\n

 <\/p>\n

Superficial Structures<\/p>\n

10 MHz for breast<\/p>\n

 <\/p>\n

Instrumentation<\/p>\n

comet tail=metallic<\/p>\n

 <\/p>\n

gas=ringdown<\/p>\n

 <\/p>\n

refraction=at edges<\/p>\n

reverb = anterior surface of gall bladder<\/p>\n

 <\/p>\n

Image Gallery<\/p>\n

diaphragmatic crura on either side of aorta<\/p>\n

 <\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

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