Pocket Anatomy & Protocols For Abdominal Ultrasound 1ed

Pocket Anatomy
& Protocols for
Abdominal
Ultrasound
Steven M. Penny, MA, RT (R), RDMS (AB, PS, OB/GYN)

Sonography Programs Director
Johnston Community College
Smithfield, North Carolina
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REVIEWERS
Sandra Broadhead, RDMS, RT(R)

Sonographer, Alta View Hospital
Sandy, Utah
Graduate, Weber State University
Ogden, Utah
Krista Downey, ARDMS, ARRT

Graduate
Weber State University
Ogden, Utah
Graduate
Utah State University
Logan, Utah
Traci B. Fox, EdD, RT(R), RDMS, RVT

Associate Professor
Department of Medical Imaging and Radiation Sciences
Thomas Jefferson University
Philadelphia, Pennsylvania
Martie Grant, MEd

Faculty, Diagnostic Medical Sonography Program
Northern Alberta Institute of Technology
Edmonton, Alberta, Canada
Jennifer Myers, RDMS, RT(R)

Student
Department of Medical Imaging and Radiologic Sciences
College of Health Professionals
Thomas Jefferson University
Philadelphia, Pennsylvania
Danika Ashley Washington, BS, AAS

Diagnostic Medical Sonographer
United States Airforce
Keesler Air Force Base, Mississippi
PREFACE
Diagnostic medical sonography has become an imaging modality that is utilized

regularly, not only as a screening tool, but as an investigative instrument that can
identify abnormalities of the abdomen and small parts, and thus positively influencing
the clinical course of many of our patients. At the core of our clinical practice lies the
establishment of a thorough imaging protocol, a protocol that not only demonstrates
normal sonographic anatomy, but also affords the practitioner the ability to recognize
anatomic variants and, most importantly, pathologic conditions. This book has been
created for, and will mostly serve those with minimal sonography experience, best.
Thus, sonography students and other medical students will appreciate its format and
structure. But it can also serve the advanced practitioner as a reference guide and a
quick review of normal sonographic anatomy and physiology as well. Accordingly, the
primary goal of Pocket Anatomy & Protocols for Abdominal Ultrasound is to offer the
sonographic imager a readily accessible resource that assists with clinical assessment,
protocol establishment, and the identification of normal sonographic anatomy.
HOW TO USE THIS POCKET BOOK

Each chapter in this small in size, though information-packed, resource is created with
clinical practice in mind. Consequently, this book can be used prior to beginning an
exam as a review of imaging requirements, clinical questions, sonographic anatomy, and
protocol suggestions. During the exam, one can return to its pages for insight and
assistance. After the exam, it can be utilized as a reference for normal measurements,
common pathology, and image correlation. The following suggested steps are also
provided to offer a means whereby one can maximize the utilization of this resource
appropriately in the clinical setting.
STEP #1: POCKET IT!

We have created this book to fit in the clinical setting. Therefore, put this book in a
pocket or have it readily available on a shelf nearby so that you can use it as a resource
if needed. If space allows, it could even be placed on the ultrasound system for quick
access.
STEP #2: REVIEW NORMAL ANATOMY AND PHYSIOLOGY

Though the purpose of this book is not to offer a thorough anatomy and physiology
review of each organ or structure, it does contain enough information to provide a quick
recap of anatomy and physiology for each organ or structure prior to sonographic
analysis. Anatomic drawings are provided as well.
STEP #3: REVIEW PATIENT PREPARATION AND SUGGESTED

EQUIPMENT
This book provides some patient preparation information and positioning techniques
that may be useful. Also, it offers equipment suggestions, including transducer types and
frequencies to employ for optimal image quality. Prior to the exam beginning, be sure to
have all equipment in optimal working condition in order to ensure safe and accurate
patient care.
STEP #4: REVIEW NORMAL SONOGRAPHIC ANATOMY

Briefly review normal sonographic anatomy. Though you will expectantly have the book
with you, a preemptive quick anatomic review over normal sonographic appearances
and anatomy would be beneficial. Short video clips of sonographic anatomy are
provided online for you as well.
STEP #5: REVIEW THE SUGGESTED PROTOCOL

The American Institute of Ultrasound in Medicine (AIUM), in conjunction with other
medical organizations, works to establish indications and recommendations for
sonographic imaging. In each chapter, AIUM-specific recommendations for individual
abdominal structures are offered. With these recommendations in mind, a fundamental
protocol has been provided in each chapter. Nonetheless, we recognize that protocols
vary between medical institutions, and thus alterations may be required to our suggested
construct. However, the protocols contained herein will prospectively provide a
fundamental groundwork, upon which additions or subtractions can be made by the
practitioner in conjunction with previously established routines and advancements in
future technology.
STEP #6: CLINICAL INVESTIGATION

An important role of the sonographer is the obligation to obtain a thorough clinical
history. In each chapter, specific clinical history questions are provided. If these
questions are asked prior to commencing the examination, they will hopefully help one
establish a clinically focused evaluation, resulting in individualized examination-
specific protocol adjustments and a more tailored sonographic study.
STEP #7: PERFORMING THE EXAMINATION
Refer to the pages of this book throughout the examination when needed for sonographic
anatomy, scanning tips, a “where else to look” section for each topic, and normal
measurements.
STEP #8: ESSENTIAL PATHOLOGY FOCUS

Lastly, although this is not a sonographic pathology textbook, some most common
pathologies, including clinical history related to those pathologies and images, are
provided in this book. The list of pathologies is not extensive in order to encourage the
portability of the text, so we suggest having additional pathology-focused materials
nearby in this regard.
FINAL WORDS
With ever-evolving changes and advancements in medicine, it is our obligation as
medical professionals to stay abreast of specialized recommendations, imaging
requirements, and protocol additions that can often dramatically improve patient care.
And although this book provides a much-needed fundamental clinical reference, it is
incumbent upon us all to continue to learn more and work to exploit, to the best of our
ability, the irreplaceable uses of ultrasound in medicine as we care for our patients.
Thank you for choosing this book as a resource. I pray that Pocket Anatomy & Protocols
for Abdominal Ultrasound serves you and your patients well.
Steven M. Penny
ACKNOWLEDGMENTS
I would first like to thank my family for allowing me the time away from them to work
on this project. Thanks must also be offered to my editorial team and the staff at Wolters
Kluwer, especially Sharon Zinner, Eric McDermott, and Caroline Define, for their
encouragement and guidance throughout this new project. I am also grateful to my
coworkers at Johnston Community College and my past and current students for the
daily interaction that require me to continually learn, providing me with intellectual
stimulation and the need for professional growth. Lastly, I would like to express
gratitude to those who have chosen to work in the noble profession of diagnostic
medical sonography—my colleagues—for constantly pursuing excellence and for
providing instrumental vital patient care all over the world.
CONTENTS
REVIEWERS • PREFACE • ACKNOWLEDGMENTS
1: Abdominal Sonography Overview
2: Pancreas
3: Liver
4: Gallbladder and Biliary Tract
5: Urinary Tract
6: Spleen
7: Abdominal Aorta and Inferior Vena Cava
8: Gastrointestinal Tract
9: Male Pelvis
10: Neck and Face
11: Breast
12: Infant Hips, Neonatal Brain, and Neonatal Spine
INDEX
CHAPTER 1
Abdominal Sonography Overview

INTRODUCTION
This brief overview chapter provides information pertaining to the AIUM indications
for a sonogram of the abdomen and/or the retroperitoneum. General sonographic
terminology, patient positioning, and common sonographic artifacts are provided.
Furthermore, a summary chart of abnormal laboratory findings and possible
sonographic pathologies is presented. This chapter also includes a summary of the
focused assessment with sonography for trauma (FAST) examination and a reminder
to practice proper body mechanics while performing sonographic examinations in
order to reduce the likelihood of work-related musculoskeletal disorders.
AIUM INDICATIONS FOR AN ABDOMEN AND/OR

RETROPERITONEUM SONOGRAM1
Abdominal, flank, and/or back pain.
Signs or symptoms that may be referred from the abdominal and/or retroperitoneal
regions, such as jaundice or hematuria.
Palpable abnormalities such as an abdominal mass or organomegaly.
Abnormal laboratory values or abnormal findings on other imaging examinations
suggestive of abdominal and/or retroperitoneal pathology.
Follow-up of known or suspected abnormalities in the abdomen and/or
retroperitoneum.
Search for metastatic disease or an occult primary neoplasm.
Evaluation of cirrhosis, portal hypertension, and transjugular intrahepatic
portosystemic shunt (TIPS) stents; screening for hepatoma; and evaluation of the liver
in conjunction with liver elastography.
Abdominal trauma.
Evaluation of urinary tract infection and hydronephrosis.
Evaluation of uncontrolled hypertension and suspected renal artery stenosis.
Search for the presence of free or loculated peritoneal and/or retroperitoneal fluid.
Evaluation of suspected congenital abnormalities.
Evaluation of suspected hypertrophic pyloric stenosis, intussusception, necrotizing
enterocolitis, or any other bowel abnormalities.
Pretransplantation and posttransplantation evaluation.
Planning for and guiding an invasive procedure.
EQUIPMENT SELECTION AND QUALITY CONTROL1

Ultrasound equipment will naturally vary between institutions.
It is the institution’s obligation to offer high-quality sonographic examinations, and
therefore these providers should consequently supply equipment that balances
sensibility and state-of-the-art features for their sonographic practitioners to utilize.
Institutions should be mindful of the potential for practitioner musculoskeletal injuries
and thus should purchase equipment that encourages the use of correct ergonomics.
Ultrasound machines should be capable of standard real-time imaging, have color,
power, and spectral Doppler abilities, and be capable of providing diagnostic images
for interpretation by a certified interpreting physician.
Curved sector transducers and/or linear transducers are commonly utilized for
abdominal and retroperitoneal sonography (Fig. 1-1).
For most preadolescent pediatric patients, mean frequencies of 5 MHz or greater are
preferred, and in neonates and small infants, a higher-frequency transducer is often
necessary.
For adults, mean frequencies between 4 and 6 MHz are most commonly used.
Figure 1-1. Transducers for abdominal imaging. A: Curvilinear array. Curvilinear,
curved, or convex array transducer. Used commonly in abdominal examinations. B:
Linear phased array transducer may be used for superficial abdominal imaging and
some gastrointestinal studies as well. (Part A adapted with permission from Penny S, Fox
T, Godwin CH, eds. Examination Review for Ultrasound: Sonographic Principles &
Instrumentation. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams & W ilkins; 2011.
Part B reprinted with permission from Penny SM, ed.Introduction to Sonography and Patient
Care. Philadelphia, PA: Wolters Kluwer; 2015.)
Higher frequencies, including the use of a linear transducer, are often used and needed
when evaluating the abdominal wall, liver surface, and bowel.
Quality control and improvement, safety, infection control, patient education, and
equipment performance monitoring should be in accordance with the AIUM Standards
and Guidelines for the Accreditation of Ultrasound Practices found at
https://www.aium.org/accreditation/accreditation.aspx
THE ALARA PRINCIPLE1

Sonography should be practiced by trained health care practitioners.
According to the AIUM, “The potential benefits and risks of each examination should
be considered. The ALARA (as low as reasonably achievable) principle should be
observed when adjusting controls that affect the acoustic output and by considering
transducer dwell times.”
Sonographers should strive for image optimization, while simultaneously minimizing
total ultrasound exposure in order to practice the ALARA principle.
SONOGRAPHIC TERMINOLOGY2
Common sonographic descriptive terms are provided in Table 1-1.
Keep in mind, the normal echogenicity of the abdominal organs from brightest to
darkest are as follows: renal sinus, pancreas, spleen, liver, renal cortex, renal
pyramid, and gallbladder.
Table 1-1 SONOGRAPHIC TERMS AND A BRIEF EXPLANATION
SONOGRAPHIC
DESCRIPTIVE TERM EXPLANATION
Anechoic Without echoes
Complex Consists of both solid and cystic components
Echogenic Structure that produces echoes; often used as a
comparative term
Heterogeneous Of differing composition
Homogeneous Of uniform composition
Hyperechoic Having many echoes
Hypoechoic Having few echoes
Isoechoic Having the same echogenicity
COMMON ARTIFACTS2,3
Ultrasound artifacts abound during sonographic imaging, with several of them
providing useful diagnostic information (Table 1-2).
Table 1-2 COMMON ULTRASOUND ARTIFACTS
ARTIFACT DESCRIPTION
Acoustic shadowing (Fig. 1-2) Occurs when sound encounters a high
attenuator
Comet tail (Fig. 1-3) Type of reverberation artifact caused by small
structures
Dirty shadowing (Fig. 1-4) Acoustic shadowing containing reverberation
artifact
Edge shadowing (Fig. 1-5) Sound refracts off of round surfaces
Mirror image Occurs when sound reflects off of a strong
reflector and creates a duplicate of the
anatomy which can be seen deeper in the
image
Posterior enhancement Occurs when sound encounters a weak
(through transmission) (Fig. 1- attenuator
6)
Refraction (Fig. 1-7) Causes the duplication of anatomy because of
the sound beam striking an interface at
nonperpendicular angles
Reverberation (Fig. 1-8) Bouncing of the sound beam between two or
more interfaces
Ring-down (Fig. 1-9) Caused by sound interacting with small air
bubbles causing the bubbles to vibrate
Figure 1-2. Acoustic shadowing. A gallstone (arrowhead) is located in the neck of the
gallbladder (GB) producing an acoustic shadow (arrow). (Reprinted with permission from
Klein J, Pohl J, Vinson EN, Brant W E, Helms CA, eds. Brant and Helms’ Fundamentals of
Diagnostic Radiology. 5th ed. Philadelphia, PA: Wolters Kluwer; 2018.)
Figure 1-3. Comet tail artifact. A sharply defined cystic lesion within the right thyroid
lobe shows floating punctate echogenic foci with a tapering tail (arrow). (Reprinted with
permission from Brant W E, Helms C, eds.Fundamentals of Diagnostic Radiology. 4th ed.
Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)
Figure 1-4. Dirty shadowing. Dirty shadowing is noted emanating from the
emphysematous gallbladder wall that contains air. (Reprinted with permission from Hsu
W C, Cummings FP, eds. Gastrointestinal Imaging: A Core Review. Philadelphia, PA: Wolters
Kluwer; 2016.)
Figure 1-5. Edge shadowing. Distinct shadowing can be seen emanating from the edge
of this cyst. (Reprinted with permission from Shirkhoda A, ed. Variants and Pitfalls in Body
Imaging. 2nd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.)
Figure 1-6. Posterior enhancement. Posterior enhancement, also referred as through
transmission, is seen (arrow) posterior to this cyst. (Reprinted with permission from Klein
J, Pohl J, Vinson EN, Brant WE, Helms CA, eds. Brant and Helms’ Fundamentals of Diagnostic
Radiology. 5th ed. Philadelphia, PA: Wolters Kluwer; 2018.)
Figure 1-7. Refraction artifact. A: Transverse view of the upper abdomen with the
transducer positioned lateral to the midline shows the left lobe of the liver (L), aorta
(A), vena cava (C), and a single azygos vein (arrow). B: With the transducer positioned
in the midline, rectus muscle refraction has resulted in duplication of the azygos vein
(arrows). (Reprinted with permission from Siegel MJ, ed.Pediatric Sonography. 4th ed.
Figure 1-8. Reverberation. A: View of a hepatic cyst shows multiple reverberation
echoes filling much of the lumen of the cyst. B: By repositioning the transducer so that
the cyst is deeper in the image, the reverberation artifacts are eliminated and the cyst
is entirely anechoic. (Reprinted with permission from Siegel MJ, ed.Pediatric Sonography.
4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.)
Figure 1-9. Ring-down artifact. Ring-down artifact noted emanating from an echogenic
needle. (Reprinted with permission from Shah KH, Mason C, eds.Essential Emergency
Procedures. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2015.)
BASICS OF DOPPLER SONOGRAPHY3

Color Doppler (CD) and Power Doppler (PD)
CD allocates varying colors to traveling red blood cells depending upon their
velocity and the direction of their flow relative to the location of the transducer.
For most ultrasound machines, flow toward the transducer is allocated red, while
flow away from the transducer is allocated blue (Fig. 1-10).
Faster speeds are typically depicted with brighter colors and slower velocities are
depicted with darker colors.
Optimal CD imaging is obtained with oblique imaging, whereas a perpendicular
orientation will be void of color.
In abdominal imaging, CD is often utilized to depict flow direction within vascular
structures, such as the portal vein, and to identify flow within specific abdominal
organs and identified masses. Increased CD within an organ or structure is indicative
of hyperemia and may be a sign of inflammation or infection.
PD is a more sensitive form of CD (Fig. 1-11).
Figure 1-10. Color Doppler. The color map on the left side of the image shows red as
the dominant color above the baseline indicating flow relatively toward the color
Doppler beam direction. Blue is the dominant color below the color map baseline
indicating flow relatively away from the color Doppler beam direction. (Reprinted with
Figure 1-11. Comparison of color Doppler and power Doppler. Color Doppler (left)
and power Doppler (right) studies show the enhanced sensitivity of the power
Doppler acquisition, particularly in areas perpendicular to the beam direction, where
the signal is lost in the color Doppler image. Flow directionality, however, is not
available in the power Doppler image. (Reprinted with permission from Bushberg JT,
Seibert JA, Leidholdt EM, Boone JM, eds.Essential Physics of Medical Imaging. 3rd ed.
PD exploits the amplitude of the Doppler signal.
PD does not typically provide flow direction.
PD is useful in providing evidence of flow in smaller or low-flow vessels.
Excessive motion can inhibit the effective use of PD.
Pulsed-wave Doppler (PW)
PW is utilized to analyze the flow characteristics of a specific vascular structure,
with the ability to evaluate a specific area within that vessel.
The pulsed sound is placed in a sample gate, thus providing Doppler information
from the specific selected point within the chosen vessel.
PW can provide flow direction.
Flow toward the transducer is often displayed above the baseline, while flow away
from the transducer is often displayed below the baseline.
Be sure to evaluate whether the flow direction control has been inverted before
making a final diagnostic conclusion.
Flow pattern can also be analyzed with PW. Veins typically have a continuous
rhythmic flow pattern in diastole and systole.
Arteries typically have an alternating pitch, with high peaks in systole and lower
crest in systole.
Resistive patterns can be depicted with PW.
Vessels can be described as having a low- or high-resistant pattern.
Low-resistive patterns are depicted by a biphasic systolic peak and a
comparatively high level of diastolic flow (Fig. 1-12).
High-resistive patterns are depicted by a high systolic peak and low level of
diastolic flow (Fig. 1-13).
The resistive patterns for specific abdominal vessels can be found in the organ or
structure chapters provided in this text.
Continuous-wave Doppler (CW Doppler)
CW Doppler is a technique in which the sound beam is continuously emitted from
one crystal, while a second crystal received the returning signal.
CW Doppler is not typically utilized in abdominal imaging.
Figure 1-12. Low-resistance pattern. A: Diagram of an arterial spectral waveform in a
low-resistance bed. Note the relatively high diastolic flow. B: Pulsed Doppler sonogram
from a low-resistance system. (Reprinted with permission from Sanders RC, ed.Clinical
Sonography: A Practical Guide. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Figure 1-13. High-resistance pattern. A: Diagram of an arterial spectral waveform in a
high-resistance bed. B: Pulsed Doppler sonogram from a high-resistance system.
(Reprinted with permission from Sanders RC, ed.Clinical Sonography: A Practical Guide. 5th
ed. Philadelphia, PA: Wolters Kluwer; 2015.)
GENERAL CLINICAL HISTORY QUERIES
Why did your doctor order this sonogram? Though some patients may be poor
historians, others may be capable of providing much beneficial information regarding
their current and past clinical record.
Where is your pain? If possible, have the patient point with one finger to the most
painful region. Assessing the area of complaint prior to an abdominal sonogram can
provide some beneficial insight. Figure 1-14 provides a helpful map with associated
common pain locations for various organ and structures.
How long have you had pain? This question can reveal a chronic or an acute situation.
Have you had any nausea or vomiting? Nausea and vomiting can be associated with
many gastrointestinal issues. If possible, inquire as to how often vomiting has
occurred.
Are you a diabetic or have high blood pressure? Diabetics and those suffering from
high blood pressure can have related clinical issues. This is a good question to assess
the overall health of the patient.
Have you had any recent weight loss? Unexplained weight loss is a worrisome
clinical history complaint that has been associated with some forms of cancer. Inquire
as to how much weight loss has occurred and over how much time as well.
Figure 1-14. Area of pain for various abdominal complaints. (Reprinted with permission
from Moore KL, Dalley AF, Agur AM, eds.Clinically Oriented Anatomy. 7th ed. Philadelphia,
PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.)
Have you had any relevant surgeries (specific to the organ or structures being
examined)? This question is helpful in providing a surgical history in order to
establish the possible absence of organs or the existence of known deviations from
normal anatomy that may be encountered during the sonographic examination.
SUMMARY OF RELEVANT LABORATORY VALUES AND KEY

ABDOMINAL FINDINGS (TABLE 1-3)4
Table POSSIBLE LABORATORY FINDINGS AND POTENTIAL

1-3 ABDOMINAL PATHOLOGIES
LABORATORY FINDING KEY ABDOMINAL FINDINGS

↑ Alanine aminotransferase Biliary tract, pancreatic, or hepatic disease
(ALT)
↑ Alkaline phosphatase (ALP) Biliary obstruction, liver cancer, pancreatic
disease, gallstones
↑ Amylase Pancreatitis (acute or chronic), pancreatic
carcinoma, pancreatic duct or biliary duct
obstruction, or gallbladder disease
↑ Aspartate aminotransferase Pancreatic disease or liver damage
(AST)
↑ Bilirubin Liver disease, biliary obstruction, or other
biliary disease
↑ Blood urea nitrogen (BUN) Renal disease, renal obstruction, dehydration,
gastrointestinal bleeding, or congestive heart
failure
↑ Calcitonin Thyroid cancer, lung cancer, and anemia
↑ Creatinine (Cr or Creat) Renal damage, renal infection, or renal
obstruction
↑ Gamma-glutamyltransferase Liver disease or biliary obstruction
(GGT)
↑ Lipase Acute pancreatitis, gallbladder disease, or
pancreatic or biliary duct obstruction
↑ Partial thromboplastin time Liver disease, anticoagulation therapy, and
(PTT) hereditary coagulopathies
↑ Serum calcium Parathyroid abnormalities
↑ Thyroid-stimulating hormone Hyperthyroidism
(TSH), thyroxine (T4), or
triiodothyronine (T3)
↑ White blood cell (WBC) Inflammatory disease or infection
↓ Albumin Liver disease
↓ Alkaline phosphatase (ALP) Wilson disease
↓ Hematocrit Hemorrhage
↓ Partial thromboplastin time Vitamin K deficiency
(PTT)
↓ Thyroid-stimulating hormone Hypothyroidism
(TSH), thyroxine (T4), or
triiodothyronine (T3)
PATIENT POSITIONING FOR ABDOMINAL SONOGRAPHY

Most often, abdominal sonographic imaging is initially conducted in the supine
position.
Other patient positions may be utilized throughout the exam, including upright and
decubitus positioning (Fig. 1-15).
Decubitus and upright positions should be utilized in order to assess the mobility of
intraluminal objects such as the presence of suspected gallstones or urinary bladder
masses.
Figure 1-15. Various patient positions utilized in abdominal imaging. T he upright
position is not depicted here. (Reprinted with permission from Penny SM, ed.Introduction to
Sonography and Patient Care. Philadelphia, PA: Wolters Kluwer; 2015.)
LABELING OF SONOGRAPHIC EXAMINATIONS

It is optimal to label the sonographic image with the scan plane utilized and the organ
or structure being assessed.
If another position other than supine is utilized during the examination, then providing
the altered patient position is most advantageous for the interpreting physician.
Accompanying digital arrows or specific text identifying organs, pathology, or
structures can be beneficial for interpretation.
Some organs, such as the breast, may have specific labeling requirements (e.g., clock
face or quadrant) per institutional guidelines.
Short videos or cine clips can provide insight into the relationship of organs,
pathology, and structures. Specific labeling (e.g., medial-to-lateral or superior-to-
inferior) may be required.
COMPLETE ABDOMEN AND RIGHT UPPER QUADRANT

SUGGESTED PROTOCOL
Complete abdominal sonogram protocol
The assessment can be performed in the following manner with patient in the supine
position initially:
Pancreas*
Liver
Gallbladder and biliary tree
Right kidney
Aorta and IVC
Spleen
Left kidney
Decubitus examination of the gallbladder and biliary tree
When abnormalities, such as hydronephrosis, are suspected, the urinary bladder and
pelvis should be assessed for associated pathology.
Upright imaging of the pancreas may be helpful if supine imaging is not
accommodating.
Upright and prone imaging of the gallbladder may be helpful as well.
Focal areas of pain should be assessed as well.
Right upper quadrant protocol
The assessment can be performed in the following manner with patient in the supine
position initially:
Pancreas
Liver
Gallbladder and biliary tree
Right kidney
Decubitus examination of the gallbladder and biliary tree
When abnormalities, such as hydronephrosis, are suspected, the left kidney, urinary
bladder, and pelvis should be assessed for associated pathology.
Upright imaging of the pancreas may be helpful if supine imaging is not
accommodating.
Upright and prone imaging of the gallbladder may be helpful as well.
Focal areas of pain should be assessed as well.
FLUID RECOGNITION
Chest
Pleural effusions may be visualized with sonography during an abdominal sonogram
and should be documented (Fig. 1-16).
Peritoneal cavity
The abdomen has several locations that are common abdominal fluid collection
points, also referred to as ascites.
Right subhepatic space (Fig. 1-17)
Also referred to as Morison pouch.
Located between the right lobe of the liver and the right kidney.
A common place for ascites to collect in the right upper quadrant.
Lesser sac
Located between the pancreas and the stomach.
A common location for a pancreatic pseudocyst to be located.
Subphrenic spaces
Located inferior to the diaphragm.
Figure 1-16. Pleural effusion. In this longitudinal image, fluid is noted superior to
the liver and diaphragm, which is consistent with a right pleural effusion. (Image
reprinted with permission from Cosby K, Kendall J, eds.Practical Guide to Emergency
Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:72.)
Figure 1-17. Ascites in Morison pouch. Fluid (arrows) is noted in the right
subhepatic space, which is also referred to as Morison pouch. (Reprinted with
permission from Bachur RG, Shaw KN, eds.Fleisher and Ludwig’s Textbook of Pediatric
Emergency Medicine. 7th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Paracolic gutters
Bilateral gutters extend along the lateral margin of the peritoneum.
Posterior cul-de-sac
In females, this space is located between the uterus and rectum.
It is also referred to as the rectouterine pouch or pouch of Douglas.
It is the most common place for fluid to collect in the pelvis.
Anterior cul-de-sac
Space located between the urinary bladder and uterus.
Also referred to as the vesicouterine pouch.
If ascites is identified in the right upper quadrant, an overall assessment of the other
abdominal quadrants may be warranted to assess the general amount of ascites
present.
FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA

EXAMINATION5
Sonography can be used to provide a quick analysis of the abdomen for evidence of
intraperitoneal fluid.
The FAST examination is used to evaluate the torso for bleeding after traumatic
injury, particularly blunt trauma.
See the training guidelines of the physician provider’s specialty society regarding
training and qualifications to perform the FAST exam.
If appropriately trained, physician extenders, emergency medical personnel, and
sonographers can obtain the sonographic images.
Acute hemorrhage initially appears as an anechoic fluid collection. However, as
blood clots, often rapidly, these fluid collections may appear complex, hypoechoic, or
even isoechoic to surrounding structures.
Common windows for assessment include (Fig. 1-18):
Right upper quadrant view
Includes an assessment of the right subhepatic space (Morison pouch), right pleural
space, subphrenic spaces, and right paracolic gutter.
Figure 1-18. Common FAST exam transducer placement locations. Four sites of
focused assessment of sonography for trauma (FAST ) examination: subcostal,
hepatorenal, splenorenal, and pelvic. (Reprinted with permission from Berg SM, Bittner
EA, Zhao KH, eds.Anesthesia Review: Blasting the Boards. Philadelphia, PA: Wolters
Kluwer; 2016.)
Left upper quadrant view

Includes an assessment of the perisplenic space above the spleen and below the
diaphragm, left pleural space, and left paracolic gutter.
Pelvic view
Includes evaluation of the pelvic spaces, including the anterior and posterior culs-
de-sac.
Pericardial view
Includes subcostal images of the sagittal and transverse four-chamber views of the
heart, pericardial space, and an analysis of the inferior vena cava and hepatic veins.
Anterior thoracic view
Includes an analysis of the lung pleura for the normal sliding typically noted. This is
most often imaged in the second or third intercostal space with a higher frequency
transducer because of the superficial imaging required.
An assessment for pneumothorax is provided by evaluating for signs of a lung point,
which represents the site where the lung adheres to the parietal pleura immediately
adjacent to the pneumothorax.
Other supplementary views may be utilized, including inferior vena cava views, right
and left paracolic gutter views, pleural space views, parasternal views, and apical
views.
INFECTION CONTROL AND MACHINE MAINTENANCE

Transducers and transducer cords should be cleaned with an appropriate disinfectant
solution or wiped according to the manufacturers’ recommendations. The ultrasound
machine keyboard and surfaces should be routinely cleaned as well.
Stretchers should also be cleaned before and after each patient.
A scheduled preventative maintenance plan for all ultrasound equipment should be
established based on the manufacturers’ recommendations to ensure that diagnostic
quality images are maintained and patient safety is optimized.
ERGONOMICS2
Ergonomics is the scientific study of creating tools and equipment that help humans
adapt to the work environment.
Proper ergonomics in sonographic practice includes the use of proper room design
and appropriately adjustable equipment.
Sonographers should utilize equipment that minimizes the likelihood of developing a
work-related musculoskeletal disorder.
Best practices include the following:
Minimize sustained bending, twisting, reaching, lifting, pressure, and awkward
postures.
Place the patient as close to you as possible to reduce reaching and shoulder
abduction.
Use correct body mechanics when moving patients.
Relax muscles periodically throughout the day.
Position equipment to reduce awkward postures and promote neck, back, shoulder,
and arm comfort.
If pain manifests, take a short break, and change your position immediately.
REFERENCES
1. AIUM practice parameters for the performance of an ultrasound of the abdomen
and/or retroperitoneum. http://www.aium.org/resources/guidelines/abdominal.pdf.
Accessed November 24, 2018.
2. Penny SM. Introduction to Sonography and Patient Care. Philadelphia, PA: Wolters
Kluwer; 2016:58.
3. Sander RC, Hall-Terracciano BH.Clinical Sonography: A Practical Guide. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016:21–38; 61–93.
4. Penny SM. Examination Review for Ultrasound: Abdomen & Obstetrics and
Gynecology. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2018:168–178.
5. AIUM practice parameter for the performance of the focused assessment with
sonography for trauma (FAST) examination.
https://www.aium.org/resources/guidelines/fast.pdf. Accessed November 24, 2018.
* Some institutions may request initiating the examination with an analysis of the aorta and inferior vena
cava.
CHAPTER 2
Pancreas
INTRODUCTION
The pancreas is often a hurriedly abandoned abdominal organ because of the
challenges that it presents to the sonographer in regards to visualizing the entire organ
with sonography. Surrounding bowel gas and large body habitus often lead to
limitations for ultrasound beam interrogation, which in turn produces subsequent
frustration for the sonographer. Nonetheless, because the pancreas is a vital
abdominal organ, the necessary time should be invested exhausting varying
techniques—including upright imaging and decubitus positioning—in order to
visualize its entire structure. The pancreas is infrequently exclusively imaged with
sonography, and thus an assessment of the liver and biliary tree are typically
performed as well. Thus, the pancreas is often routinely included in the sonographic
assessment of the right upper quadrant and complete abdomen.
AIUM RECOMMENDATIONS FOR SONOGRAPHY OF THE

PANCREAS1
Assess the pancreas in the following manner:
The pancreas should be assessed for parenchymal abnormalities (e.g., masses, cysts,
calcifications, etc.).
The distal common bile duct should be evaluated in the region of the pancreatic head.
The pancreatic duct should be assessed for dilatation, which can be confirmed by
measurement.
The peripancreatic anatomy should be observed for abnormalities such as
lymphadenopathy, pancreatic pseudocysts, and/or fluid.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE

PANCREAS2,3
Sections of the pancreas include the head, uncinate process, neck, body, and tail (Fig.
2-1).
The pancreas is located in the anterior retroperitoneum and epigastric region
(traverses the midline), with the head positioned within the C-loop of the duodenum
and tail resting medial to the splenic hilum.
The head is typically more caudally located compared to the body and tail.
The main pancreatic duct may be referred to as the duct of Wirsung.
The main pancreatic duct merges with the common bile duct at the ampulla of Vater
and empties digestive juices through the sphincter of Oddi, also referred to as the
major duodenal papilla (Fig. 2-2).
The pancreas is both an endocrine and exocrine gland.
The endocrine function of the pancreas is to produce glucagon, insulin, and
somatostatin.
The exocrine function of the pancreas includes the production of the digestive
enzymes amylase, lipase, sodium bicarbonate, trypsin, chymotrypsin, and
carboxypolypeptidase.
Figure 2-1. Basic pancreas anatomy. (Image reprinted with permission from Moore KL,
Dalley AF II, Agur AMR, eds.Clinically Oriented Anatomy. 6th ed. Philadelphia, PA: Wolters
Kluwer Health/Lippincott Williams & Wilkins; 2009.)
Figure 2-2. Anatomy of the pancreas and the biliary tree. (Reprinted with permission
from Anatomical Chart Company. Digestive System Anatomical Chart. Philadelphia, PA:
Lippincott Williams & Wilkins; 2000.)
Surrounding vasculature (Fig. 2-3):

Pancreatic head—right lateral to the superior mesenteric vein, anterior to the inferior
vena cava, inferior to the portal vein
Uncinate process—posterior to the superior mesenteric vein and anterior to the
abdominal aorta
Pancreatic neck—anterior to the portal confluence
Pancreatic body—anterior to the superior mesenteric vein, splenic vein, and superior
mesenteric artery
Pancreatic tail—anterior to the splenic vein
Figure 2-3. Surrounding vasculature of the pancreas. (Reprinted with permission from
Moore KL, Dalley AF II, Agur AMR, eds.Clinically Oriented Anatomy. 7th ed. Philadelphia, PA:
Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.)
PATIENT PREPARATION FOR SONOGRAPHY OF THE

PANCREAS
Patient preparation is focused on eliminating adjacent or overlying bowel gas that may
inhibit sound beam penetration.
NPO for 6–8 hrs is optimal, though fewer hours may be required, especially for
pediatric cases or those requiring emergency sonographic investigation.
SUGGESTED EQUIPMENT
3–5-MHz transducer (higher frequencies can be used for thin patients and a large
footprint transducer may be used to assist in the compression of the abdomen)
General abdominal setting (most machines)
Positional sponges for decubitus images
CLINICAL INVESTIGATION FOR SONOGRAPHY OF THE

PANCREAS
Laboratory values are listed in Table 2-1.2,4
Evaluate prior imaging reports and images including CT, MRI, radiography, ERCP,
and any other appropriate tests.
Critical clinical history questions related to the pancreas:
History of pancreatitis? The sonographic appearance of the pancreas may be altered
in the presence of acute pancreatitis or chronic pancreatitis. Diffuse acute
pancreatitis may appear as a hypoechoic, enlarged pancreas, while chronic
pancreatitis leads to atrophy of the gland and it may contain calcifications and an
enlarged main pancreatic duct.
History of abdominal surgery (pancreatic surgery or cholecystectomy)? A history of
abdominal surgery of the pancreas, especially if part of the pancreas was removed,
will alter the appearance of the pancreas sonographically.
Epigastric or back pain? Pancreatitis could result in epigastric and/or back pain.
Nausea and/or vomiting? Patients with pancreatitis could suffer from nausea and
vomiting.
History of gallstones? Gallstones can lead to pancreatitis.
Fever? Patients with pancreatitis will often have a fever.
Diabetic? Diabetes may alter the echogenicity of the pancreas, often producing a
diffusely hyperechoic appearance.
Unexplained weight loss? Patients with pancreatic cancer or chronic pancreatitis may
suffer from unexplained weight loss.
Table LAB FINDINGS AND POSSIBLE ASSOCIATED PANCREAS

2-1 PATHOLOGY
LAB FINDING Potential Pancreas Pathology2,4

↑ Bilirubin and Biliary obstruction, pancreatic disease, or possible
urobilirubin liver disease
↑ Amylase Acute pancreatitis, biliary or associated pancreatic
obstruction, or other pancreatic disease such as
pancreatic cancer
↑ Lipase Acute pancreatitis, biliary or associated pancreatic
obstruction, or other pancreatic disease such as
pancreatic cancer
↑ ALT Biliary tract disease or associated pancreatic disease
↑ ALP Pancreatic disease such as chronic pancreatitis,
cholelithiasis, biliary obstruction, or possible liver
disease
↑ AST Pancreatic disease or associated liver disease
↑ WBC Pancreatitis, cholecystitis, cholangitis, or other
inflammatory diseases/infection
NORMAL SONOGRAPHIC DESCRIPTION OF THE PANCREAS

The normal pancreas is said to be hyperechoic to the liver, though it may be isoechoic
or even hypoechoic in patients with minimal body fat. Nonetheless, careful clinical
assessment should be completed when an enlarged, hypoechoic pancreas is
visualized, as this may represent sonographic signs of acute pancreatitis.
A hyperechoic pancreas may represent fatty infiltration of the pancreas.
In the head of the pancreas, there may be two anechoic circular structures.
The anterior structure is most likely the gastroduodenal artery.
The posterior structure is most likely the common bile duct.
The main pancreatic duct may appear as a linear tubular structure traversing the
pancreatic body.
In transverse, the anechoic vasculature structure of the portal splenic confluence and
splenic vein should be seen marking the posterior borders of the pancreas.
SUGGESTED PROTOCOL FOR SONOGRAPHY OF THE

PANCREAS
Survey the pancreas in transverse
With the patient in the supine position, obtain a brief survey of the pancreas by
scanning superiorly and inferiorly through the pancreas completely.
Perform a brief cine clip (Video 2-1).
Transverse pancreas (demonstrate head, neck, body) (Fig. 2-4)
Place the transducer in the midline of the body in the epigastrium, just below the
xyphoid process of the sternum (Fig. 2-5).
Using the left lobe of the liver, angle slightly inferior to visualize the head, neck, and
body of the pancreas.
The transducer may be slightly tilted or angled to the patient’s right side and
inferiorly to see the pancreatic head.
Helpful vascular landmarks include the portal splenic confluence and superior
mesenteric vein, which are located posterior to the neck of the pancreas. The
splenic vein is located posterior to the body (Fig. 2-6).
Two, round anechoic structures may be seen in the head of the pancreas, the most
anterior structure is most likely the gastroduodenal artery, and the most posterior
structure is most likely the distal common bile duct (Fig. 2-7).
Analyze the borders of the pancreas and its echogenicity.
The normal pancreas should be uniform in echogenicity.
Assess the pancreas for possible dilatation of the pancreatic duct.
Evaluate the pancreas for solid masses, ductal stones, calcifications, and cystic
lesions.
Figure 2-4. Transverse pancreas. A,B: Pancreas in the transverse plane
demonstrating the left lobe of the liver, the pancreatic head (Panc Head), the
pancreatic body (Panc Body), the pancreatic tail (Panc Tail), the superior mesenteric
artery (SMA), the inferior vena cava (IVC), the abdominal aorta (AO), and the spine.
Figure 2-5. Correct scanning plane to obtain a transverse pancreas. (Reprinted with
permission from Agur AMR, Dalley AF, eds. Grant’s Atlas of Anatomy. 14th ed. Philadelphia,
PA: Wolters Kluwer; 2016.)
Figure 2-6. Transverse sonogram of the pancreas demonstrating adjacent
vasculature. T he pancreatic head (PH) is noted right lateral to the superior
mesenteric vein (SM V). T he splenic vein (SV) can be seen outlining the posterior
aspect of the pancreatic tail (PT ). AO, aorta; IVC, inferior vena cava; RRA, right renal
artery; U, uncinate process. (Image courtesy of Philips Medical Systems, Bothell, WA.)
Figure 2-7. Sonographic image of the transverse pancreatic head. In this image, the
gastroduodenal artery (GDA) and common bile duct (CBD) are noted within the head
of the pancreas. IVC, inferior vena cava; SM A, superior mesenteric artery; SV,
splenic vein. (Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and
Superficial Structures. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
If required, measure the head and body of the pancreas (Figs. 2-8 and 2-9).
Transverse pancreas (demonstrates tail)
Slightly tilt or angle the transducer to the patient’s left side and inferiorly to see the
pancreatic tail.
The splenic vein is located posterior to the body and tail of the pancreas.
If required, measure the tail of the pancreas (Fig. 2-10).
Longitudinal pancreas (Fig. 2-11)
Place the transducer just right of the midline in the longitudinal plane, just below the
xyphoid process, to obtain a longitudinal image of the pancreas.
Note the head of the pancreas anterior to the IVC and inferior to the portal vein.
From the level of the head, scanning the left lateral, note the body left of the midline
anterior to the aorta and superior mesenteric artery.
To visualize the tail, place the patient in the right lateral decubitus position.
However, this may not be optimal (see Additional images section below).
Additional images
Longitudinal or transverse right lateral decubitus pancreatic tail (Fig. 2-12)
The pancreatic tail rests medial to the splenic hilum.
The patient should be in the right lateral decubitus position. In longitudinal or
transverse, scanning through the spleen, one can possibly visualize the pancreatic
tail medial to the splenic hilum.
Transverse upright pancreas
Having the patient sit upright or stand can assist in the visualization of the pancreas
occasionally.
Transducer placement is in the midline of the body in the epigastrium, just below the
xyphoid process of the sternum. Somewhat lower transducer placement may be
warranted with the patient in the upright position.
Figure 2-8. Pancreatic head measurement. In the transverse plane, a measurement of
the pancreatic head (between calipers) can be obtained. (Reprinted with permission from
Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed. Philadelphia, PA:
Wolters Kluwer; 2017.)
Figure 2-9. Pancreatic body measurement. In the transverse plane, a measurement of

the pancreatic body (between calipers) can be obtained. (Reprinted with permission from
Figure 2-10. Pancreatic tail measurement. In the transverse plane, a measurement of
the pancreatic tail (between calipers) can be obtained. (Reprinted with permission from
Figure 2-11. Longitudinal pancreas. A,B: Longitudinal image of the pancreas
demonstrating the left lobe of the liver, gastroesophageal junction (GE), celiac trunk
(C), pancreas (P), splenic vein (S), abdominal aorta (A), and superior mesenteric artery.
(Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and Superficial
Structures. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 2-12. Right lateral decubitus pancreas. A,B: Longitudinal spleen in RLD
demonstrating the splenic hilum and the area of the pancreatic tail. C,D: Transverse
spleen in RLD with color Doppler demonstrating the splenic hilum and the area of the
pancreatic tail.
SCANNING TIPS
Use the left lobe of the liver as an acoustic window.
Use compression to displace bowel gas in the area of the pancreas.
Ask the patient to completely exhale while scanning.
Ask the patient to push his/her abdomen out or tighten abdominal muscles (Valsalva
maneuver).
Have the patient take in a deep breath and hold that breath while you scan.
Once the exam is complete, utilize upright imaging over the area of the pancreas if the
pancreas was not visualized.
If not contraindicated, have the patient ingest a small amount of water. Water within
the stomach and proximal duodenum can be used to provide an acoustic window to
highlight the head and other sections of the pancreas.
Try imaging the pancreas in various decubitus positions to better visualize all of its
structure.
Image the tail of the pancreas from the left lateral splenic window adjacent to the
splenic hilum.
If the patient has had or is currently suffering from pancreatitis, carefully analyze the
lesser sac, which is located between the stomach and pancreas, for signs of a
pancreatic pseudocyst.
If the common bile duct appears enlarged in the head of the pancreas, attempt to
follow the duct to the liver and evaluate the liver for signs of biliary dilatation as
well.
NORMAL MEASUREMENTS OF THE PANCREAS3,5,6

Male pancreas is on average larger than females.
Anteroposterior dimension measurements are obtained in the true transverse plane.*
Head = 2–3.5 cm
Body = 2–3 cm
Tail = 1–2 cm
Main pancreatic duct = ∼2 mm (may be up to 3.5 mm near the head, 2.5 mm in the
body, and 1.5 mm in the tail) (Fig. 2-13)
Figure 2-13. Transverse pancreas with pancreatic duct. T he main pancreatic duct
(arrowhead) is noted within the neck and body of this pancreas. (Reprinted with
permission from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed.
Philadelphia, PA: Wolters Kluwer; 2017.)
ESSENTIAL PANCREATIC PATHOLOGY2

Acute pancreatitis—inflammation of the pancreas (Fig. 2-14)
Clinical findings:
Elevated amylase, lipase, WBC, and ALT and other liver function tests
Decrease in hematocrit (with hemorrhagic pancreatitis)
Back pain or abdominal pain
Fever
Nausea and vomiting
Sonographic findings:
Pancreas may appear normal
Diffusely, enlarged hypoechoic pancreas
Focal pancreatitis may appear as a focal, hypoechoic enlargement
Peripancreatic fluid
Pancreatic pseudocyst (most likely in the lesser sac)
Biliary dilatation
Assess for splenic vein thrombosis and pseudoaneurysms of the splenic artery
Figure 2-14. Acute pancreatitis. Transverse image of the pancreas in a patient with
acute pancreatitis. T he pancreas is edematous and enlarged. SM A, superior
mesenteric artery; SV, splenic vein. (Reprinted with permission from Kawamura D,
Nolan T, eds. Abdomen and Superficial Structures. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2017.)
Chronic pancreatitis—chronic inflammation of the pancreas with atrophic changes

(Fig. 2-15)
Clinical findings:
Possible elevation of amylase, lipase, and ALP
May be asymptomatic
Persistent epigastric pain
Jaundice
Back pain
Anorexia
Vomiting
Weight loss
Constipation
Heterogeneous or hyperechoic gland
Poor margins with parenchymal calcifications
Pancreatic pseudocyst (most likely in the lesser sac)
Dilated pancreatic duct
Stones within the pancreatic duct
Assess for possible portosplenic vein thrombosis
Figure 2-15. Chronic pancreatitis. Transverse image of the pancreas in a patient

with chronic pancreatitis. Calcifications are seen throughout the body and tail of
the pancreas. AO, aorta; D, pancreatic duct; IVC, inferior vena cava; PH, pancreatic
head; SM A, superior mesenteric artery; SV, splenic vein. (Image courtesy of Philips
Medical Systems, Bothell, WA.)
Pancreatic carcinoma—most likely in the head of the pancreas (Fig. 2-16)

Clinical findings:
Elevated amylase, lipase, ALP, and other liver function tests
Weight loss
Loss of appetite
Jaundice
Courvoisier gallbladder (enlarged palpable gallbladder)
Epigastric pain
Hypoechoic mass in the head of the pancreas (some cancerous tumors may have
cystic components)
Dilated common bile duct proximal to the mass
Dilated pancreatic duct
Enlarged gallbladder
Assess the liver and other abdominal organs carefully for signs of metastasis
Figure 2-16. Pancreatic carcinoma. A solid, hypoechoic mass (between calipers) is
noted within the head of the pancreas with associated dilation of the pancreatic duct
(arrow). (Image reprinted with permission from Siegel MJ, ed.Pediatric Sonography. 4th ed.
WHERE ELSE TO LOOK

Evaluate the entire biliary tree if pancreatic duct dilatation is suspected for further
enlargement, stones, or other signs of obstruction.
For patients with known pancreatitis, search the abdomen carefully for signs of a
pancreatic pseudocyst. This cyst may appear mostly cystic but may have solid
components as well.
IMAGE CORRELATION
Normal pancreas on CT and MRI (Fig. 2-17)
Acute pancreatitis on CT (Fig. 2-18)
Chronic pancreatitis on CT (Fig. 2-19)
Figure 2-17. T he normal pancreas on CT and M RI.A: Illustration of the approximate
axial anatomic level through the pancreas for B and C. B: Abdomen axial CT image
through the pancreas level. C: Abdomen axial M R image through the pancreas level.
(Reprinted with permission from Erkonen W E, Smith W L, eds.Radiology 101. 3rd ed.
Figure 2-18. Acute pancreatitis on CT. An enlarged pancreas (between arrows) is noted
in this CT of the abdomen, which is consistent with acute pancreatitis. (Reprinted with
permission from Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch GR, eds.
Greenfield’s Surgery. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.)
Figure 2-19. Chronic pancreatitis on CT. A: Unenhanced CT image through the
pancreatic body reveals extensive coarse calcifications throughout the pancreas
(white arrows) . B: In the same patient, this enhanced CT image at the head of the
pancreas shows coarse calcifications in the head (white arrow). T here is also sludge in
the dependent portion of the distended gallbladder (black arrow). (Reprinted with
permission from Pope TL Jr, Harris JH Jr, eds.Harris & Harris’ The Radiology of Emergency
Medicine. 5th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)
REFERENCES
Accessed June 27, 2018.
3. Kawamura DM, Nolan TD.Diagnostic Medical Sonography: Abdomen and
Superficial Structures. 4th ed. Philadelphia, PA: Wolters Kluwer; 2018:171–212.
4. Hopkins TB. Lab Notes: Guide to Lab and Diagnostic Tests. 2nd ed. Philadelphia,
PA: F.A. Davis Company; 2009.
5. Curry RA, Tempkin BB. Sonography: Introduction to Normal Structure and Function.
4th ed. St. Louis, MO: Elsevier; 2016.
6. Rumack CM, Wilson SR, Charboneau JW, et al.Diagnostic Ultrasound. 4th ed. St.
Louis, MO: Elsevier; 2011.
* Both imaging and clinical assessment must be correlated when pancreatic size or duct diameter is
suspiciously enlarged.
CHAPTER 3
Liver
INTRODUCTION
Though occasionally evaluated solitarily, the liver is often included with the
sonographic analysis of the entire right upper quadrant or abdomen. When the liver is
indeed solitarily examined, it is most often done so following other imaging studies,
such as computed tomography scan as a follow-up procedure. Consequently, it is
important most often to examine the surrounding structures in concert with the liver,
including the abdominal aorta, inferior vena cava (IVC), gallbladder, biliary ducts,
right kidney, and pancreas.

LIVER1
Assess the liver in the following manner:
Investigate each hepatic lobe (right, left, and caudate), and if possible, the right
hemidiaphragm and the adjacent pleural space.
Evaluate the liver parenchyma for focal and diffuse abnormalities.
Compare the liver echogenicity with the echogenicity of the right kidney.
Evaluate the major hepatic and perihepatic vessels, including the IVC, the hepatic
vein, the main portal vein, and if possible, the right and left portal vein.
Image the liver surface with a high-frequency transducer to assess for signs of surface
nodularity in patients who may have cirrhosis.
For vascular examinations, use Doppler evaluation to document blood flow
characteristics and the blood flow direction. The structures that may be examined
include the main and intrahepatic arteries, the hepatic veins, the main and intrahepatic
portal veins, intrahepatic portion of the IVC, collateral venous pathways, and
transjugular intrahepatic portosystemic shunt (TIPS) stents.
Use elastography in patients who are predisposed to having hepatic fibrosis.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE LIVER

The liver is the largest parenchymal organ in the body, and it takes up most of the right
upper quadrant and extends to the midline. In some individuals, the liver may come in
contact with the spleen.
The liver has three main lobes: right, left, and caudate.
The right and left lobes are separated by the middle hepatic vein, main lobar fissure,
and gallbladder fossa.
Right lobe:
Located mostly on the right side of the abdomen.
Separated into anterior and posterior segments by the right hepatic vein.
Left lobe:
Located mostly in the midline.
Separated into medial and lateral segments by the left hepatic vein.
Caudate lobe:
Located in the midline, posterior to the left lobe.
Bordered anteriorly by the ligamentum venosum and posteriorly by the IVC.
The liver can be divided into eight surgical sections as well (Fig. 3-1).
The porta hepatis, also referred to as the liver hilum, is the area of the liver where the
main portal vein and hepatic artery enter the liver and common bile duct exits the liver
(Fig. 3-2).
The main portal vein is created from the union of the superior mesenteric vein and
splenic vein.
The main portal vein enters the liver, bringing blood from the mesentery and other
organs, and branches into right and left portal veins.
The left portal vein branches into medial and lateral tributaries.
The right portal vein branches into anterior and posterior tributaries.
The right, middle, and left hepatic veins drain into the IVC (Fig. 3-3).
The hepatic artery is a branch of the celiac trunk.
The liver performs many vital functions in order to maintain homeostasis including but
not limited to:
Blood reservoir
Removal of waste products and detoxification
Vitamin and mineral storage
Creation of bile
Carbohydrate, fat, and amino acid metabolism
Figure 3-1. Parts, divisions, and segments of liver. Each part, division, and segment has
an identifying name; segments are also identified by Roman numerals. (Reprinted with
permission from Moore KL, Dalley AF, Agur AM, eds.Clinically Oriented Anatomy. 7th ed.
Figure 3-2. Drawing of the porta hepatis and surrounding structures. (Reprinted with
Figure 3-3. Vascular anatomy of the liver, including the portal vein, hepatic veins, and
hepatic artery. (Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and
PATIENT PREPARATION
Patient preparation is focused on eliminating bowel gas and having the potential of a
fully distended gallbladder at the time of the examination.
If the examination is performed without fasting, proper documentation should take
place.
SUGGESTED EQUIPMENT 1
3–5-MHz transducer (higher frequencies can be used for thin patients)
A high-frequency linear transducer to evaluate the contour of the liver for signs of
nodular irregularity, especially in patients who have abnormal liver function
Harmonics or supplementary artifact removal technology to eliminate false echoes
CLINICAL INVESTIGATION
Laboratory values are listed in Table 3-1.2
Evaluate prior imaging reports and images including CT, MRI, radiography, and any
other appropriate tests.
Table Laboratory Values Associated With Liver Function and

3-1 Possible Pathologies2
LAB FINDINGS POTENTIAL PATHOLOGY

↑ Alanine aminotransferase Biliary obstruction, hepatitis, hepatocellular
(ALT) disease, obstructive jaundice
↑ Alkaline phosphatase (ALP) Cirrhosis, extrahepatic biliary obstruction,
gallstones, hepatitis, liver cancer, pancreatic
cancer
↑ Aspartate aminotransferase Cirrhosis, fatty liver, hepatitis, liver metastasis
(AST)
↑ Gamma-glutamyltransferase Diffuse liver disease and posthepatic
(GGT) obstruction
↑ Lactate dehydrogenase Cirrhosis, hepatitis, obstructive jaundice
(LDH)
↑ Serum bilirubin Biliary obstruction, acute hepatocellular
disease, cirrhosis, hepatitis, other liver cell
diseases
↓ Albumin Chronic liver disease and cirrhosis
Prothrombin time (PT) Prolonged = liver metastasis or hepatitis
Shortened = extrahepatic duct obstruction
↑ Alpha-fetoprotein (AFP) Liver carcinoma
Critical clinical history questions:
History of nausea and/or vomiting? Patients with biliary-associated complaints often
have nausea and/or vomiting.
History of right upper quadrant pain? If so, inquire about the length of time and the
exact location of the pain if possible.
History of abdominal surgeries? This is important because the patient may have had a
cholecystectomy or other biliary or liver surgery.
History of hepatitis? The sonographic appearance of the liver may be altered with
hepatitis.
History of alcoholism or cirrhosis? The liver should be thoroughly assessed when
cirrhosis is suspected for signs of portal hypertension and other complications,
including portal vein thrombosis. Patients with cirrhosis who have a TIPS should
undergo a thorough Doppler analysis of the shunt and other hepatic vascular anatomy.
NORMAL SONOGRAPHIC DESCRIPTION OF THE LIVER

The liver should be homogeneous and slightly more echogenic than or equal to that of
the right kidney.
The liver is typically isoechoic or more hypoechoic to the normal spleen.
The normal liver parenchyma is occasionally interrupted by anechoic vascular
structures.
SUGGESTED PROTOCOL FOR SONOGRAPHY OF THE LIVER

Survey the liver in transverse or longitudinal:
Ask the patient to extend his or her right arm up above his or her head in order to
expand the intercostal spaces.
With the patient in the supine position, obtain a brief survey of the liver by scanning
superiorly and inferiorly (transverse) or medially and laterally (longitudinal).
Perform a brief cine clip in longitudinal and transverse (Video 3-1 and Video 3-
2).
Longitudinal liver:
Assess the left lobe in the midline of the body and provide images of the left lobe by
scanning medially and laterally. Scan toward the patient’s left side completely to
assess the entire left lobe (Fig. 3-4).
Image the caudate lobe and hepatic section of the IVC in longitudinal.
From the midline, if possible, angle laterally toward the patient’s right side to
demonstrate the parenchyma of the right lobe. Angle the transducer from the midline
toward the patient’s right side.
Demonstrate the level of the falciform ligament and main lobar fissure (Fig. 3-5).
Position the transducer on the patient’s right side and assess the right lobe of the
liver.
Provide a liver–kidney interface image (Fig. 3-6). Evaluate the echogenicity of the
liver compared to the right kidney, assess for fluid in the right subhepatic space
(Morrison pouch), and for signs of a right-sided pleural effusion.
Provide several images of the right lobe of the liver while scanning through the
patient’s provided sonographic windows by angling the transducer throughout the
windows (Fig. 3-7).
Transverse liver:
Assess the left lobe and caudate lobe in the midline of the body and provide images
of the left lobe and caudate lobe by scanning superiorly and inferiorly (Fig. 3-8).
From the midline, if possible, angle superiorly and laterally toward the patient’s right
shoulder to demonstrate the parenchyma of the right lobe. Some obliquity of the
transducer may be required.
Provide images of the hepatic veins and IVC (Fig. 3-9).
Provide images of the portal veins and their branches (Fig. 3-10).
Position the transducer on the patient’s right side and assess the right lobe of the
liver.
Provide several images of the right lobe of the liver, including the most superior and
inferior aspects of the liver.
Figure 3-4. Left lobe of the liver in longitudinal. A,B: Longitudinal left lobe (Lt lobe
liver) and caudate lobe. T his image also demonstrates the location of the
ligamentum venosum (Venosum), pancreas (Panc), left hepatic vein (LHV), anterior
musculature (muscle), heart, and spine.
Figure 3-5. Longitudinal image of the main lobar fissure. A,B: The main lobar fissure
(MLF) is noted in this image of right lobe, gallbladder, and right portal vein (RPV).
Also demonstrated is the right kidney and diaphragm.
Figure 3-6. Liver–kidney interface. A,B: Image of the right lobe of the liver and the
right kidney (Right kid) can be used to examine the echogenicities of the liver and
the right kidney.
Figure 3-7. Longitudinal images of the right lobe. Normal sonographic image of the
right lobe of the liver and the diaphragm. (Reprinted with permission from Kawamura
D, Lunsford B, eds. Abdomen and Superficial Structures. 3rd ed. Philadelphia, PA: Wolters
Figure 3-8. Transverse image of the left lobe. A,B: Transverse image of the left
lobe (LT lobe) and caudate lobe (Caudate). T he ligamentum venosum (VEN) can be
seen separating the left lobe and caudate lobe, with inferior vena cava (IVC)
posterior to the caudate. T he left portal (LT port) and right lobe can also be seen
(RT lobe).
Figure 3-9. Transverse hepatic veins. A transverse section through the liver at the
level of the hepatic veins. ASRL, anterior segment of the right lobe; ARHV,
accessory right hepatic vein; LSLL, lateral segment left lobe; LHV, left hepatic vein;
M HV, middle hepatic vein; M SLL, medial segment left lobe; PSRL, posterior
segment of the right lobe; RHV, right hepatic vein. (Reprinted with permission from
Provide an image of the porta hepatis and branches of the portal veins if possible
(Fig. 3-11).
Provide several images of the right lobe of the liver while scanning through the
patient’s provided sonographic windows by angling the transducer throughout the
windows.
Additional images:
Some institutions’ sonographic protocols, such as a complete abdominal sonogram
or right upper quadrant, include required images of the pancreas, gallbladder, bile
ducts, and right kidney. Please see the associated chapters in this text for further
guidance.
Doppler assessment of the hepatic vasculature:
Provide images that include Doppler interrogation of the main portal vein, hepatic
artery, and hepatic veins to demonstrate normal flow patterns (Fig. 3-12).
Figure 3-10. Transverse portal veins. A: Transverse image of the left portal vein
(LPV) demonstrating its medial and lateral branches. B: Transverse image of the
right portal vein (RT PORTAL) and its posterior and anterior branches. (Part A
reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and Superficial
Figure 3-11. An oblique plane through the right upper quadrant visualizes the
portal vein (PV) as it enters the liver and branches into the right portal vein (RPV)
and the left portal vein (LPV). (Courtesy of Philips Medical System, Bothell, WA.)
– Upon Doppler interrogation, the main portal vein should normally yield
evidence of monophasic, hepatopetal flow (toward the liver).
Respiration may alter flow patterns within the main portal vein and
postprandial patterns may demonstrate an increase in portal vein flow.
– With Doppler examination, the hepatic veins should demonstrate
triphasic, hepatofugal flow (away from the liver).
With Doppler examination, the hepatic artery should demonstrate low-resistance,
hepatopetal flow.
If requested, measure the right lobe of the liver according to your institutions
protocol.
Provide an image of the surface of the left lobe of the liver with a high-frequency
linear transducer in patients with potential or suspected cirrhosis (Fig. 3-13).
Figure 3-12. Hepatic vasculature. A: Color Doppler of the hepatic artery. B: Color
Doppler and spectral tracing of the normal hepatic artery. C: Color Doppler and
spectral of the normal main portal vein. D: Color Doppler and spectral of the normal
middle hepatic vein. (Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen
and Superficial Structures. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 3-13. Sonogram of the liver surface with a linear transducer. A: An assessment of
the surface of the liver should normally yield a smooth surface (arrow). B: A patient with
cirrhosis often has a nodular appearing liver surface (arrow). (Reprinted with permission
from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed. Philadelphia,
SCANNING TIPS
Deep, sustained inspiration can be helpful to assist in the visualization of the complete
liver in most individuals.
Some adjustment to sound penetration parameters may be required for patients who
have a fatty liver or who are obese.
Right lateral decubitus positioning can be helpful.
NORMAL MEASUREMENTS OF THE LIVER3–5

Midhepatic or midclavicular line = <15 cm (Fig. 3-14)
Enlargement of the liver may be visually suspected if the right lobe extends beyond the
lower pole of the right kidney.
ESSENTIAL LIVER PATHOLOGY2

Focal lesions:
Cavernous hemangioma—benign hepatic mass most commonly seen in women:
Clinical findings:
Asymptomatic
Hyperechoic mass most often seen in the right lobe (Fig. 3-15)
Hepatic cysts:
Clinical findings:
Asymptomatic and may have normal liver function labs
May have a history of autosomal dominant polycystic kidney disease (ADPKD)
Hemorrhagic cysts or large cysts may cause pain and discomfort
Anechoic mass with posterior enhancement (Fig. 3-16)
May have an irregular shape and may be multiple
Diffuse liver disease:
Fatty liver (hepatic steatosis):
Clinical findings:
Asymptomatic
Alcohol abuse
Diabetes mellitus
Elevated liver function tests (AST and ALT)
Hyperlipidemia
Obesity
Pregnancy
Figure 3-14. Measurement of the liver in the midclavicular line. (Reprinted with
permission from Sanders RC, ed. Clinical Sonography: A Practical Guide. 5th ed.
Figure 3-15. Cavernous hemangioma. T his hyperechoic mass demonstrates the
most common sonographic appearance of a cavernous hemangioma. (Reprinted
with permission from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures.
4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 3-16. Hepatic cysts. A: Hepatic cysts are noted as anechoic spaces within
the liver. B: T his patient also had renal cysts and was suffering from ADPKD.
(Reprinted with permission from Kawamura D, Lunsford B, eds.Abdomen and
Superficial Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott
Williams & Wilkins; 2012.)
Diffusely echogenic liver (Fig. 3-17):
– Fatty sparing—a hypoechoic area may be spared of fat and is often
located adjacent to the gallbladder, porta hepatis, or an entire lobe
may be spared
– Focal infiltration—a hyperechoic focal area is demonstrated
Increased attenuation of the sound beam
Hepatic vasculature may be difficult to visualize
Cirrhosis:
Clinical findings:
Ascites
Diarrhea
Elevated liver function tests
Fatigue
Initial hepatomegaly
Jaundice
Splenomegaly
Weight loss
Initial hepatomegaly
Shrunken, echogenic right lobe (Fig. 3-18)
Enlarged caudate and left lobe
Nodular liver surface (noted best with a high-frequency linear transducer)
Splenomegaly
Ascites
Monophasic flow within the hepatic veins
Hepatofugal flow within the portal veins
Hepatic metastasis:
Clinical findings:
Abnormal liver function tests
Weight loss
Jaundice
Right upper quadrant pain
Hepatomegaly
Abdominal swelling and ascites
Hyperechoic, hypoechoic, calcified, cystic, or heterogeneous mass (Fig. 3-19)
Mass with a notable hypoechoic rim and central echogenic portion
Diffusely heterogeneous liver
Possible ascites
Figure 3-17. Fatty liver. Image of a fatty liver. Note the difficulty for sound beam
penetration and lack of distinct border and vascularity. (Reprinted with permission from
Figure 3-18. Cirrhotic liver. Image of a cirrhotic liver surrounded by ascites. (Reprinted
with permission from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed.
Figure 3-19. Liver metastasis. Multiple masses are visualized in this liver representing
liver metastasis. (Reprinted with permission from Kawamura D, Lunsford B, eds.Abdomen
and Superficial Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams
& Wilkins; 2012.)
WHERE ELSE TO LOOK

Thoroughly evaluate the liver for signs of biliary obstruction. If noted, carefully
evaluate the gallbladder and the pancreas for a recognizable cause for the obstruction.
If cirrhosis is suspected, carefully evaluate the left portal vein for signs of
recanalization of the paraumbilical vein, which is a sonographic sign of portal
hypertension.
If cirrhosis is suspected, evaluate the spleen for associated splenomegaly.
If liver cysts are discovered, evaluate the kidneys carefully for associated cysts as
well.
IMAGE CORRELATION
CT and MRI of the liver (Figs. 3-20 and 3-21)
Figure 3-20. A: Abdomen axial CT image through the liver and spleen. B: Abdomen axial
M R image through the liver and spleen. Normal. (Reprinted with permission from Erkonen
W E, Smith W L, eds.Radiology 101. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott
Figure 3-21. CT and M RI of the liver at the level of the right lobe. T his level is just
caudad to the level in Figure 3-20. A: Abdomen axial CT image through the liver and
spleen. B: Abdomen axial M R image through the liver and spleen. (Reprinted with
permission from Erkonen W E, Smith W L, eds.Radiology 101. 3rd ed. Philadelphia, PA:
REFERENCES
Accessed September 19, 2018.
3. Rumack CM, Wilson SR, Charboneau JW, et al.Diagnostic Ultrasound. 4th ed.
Philadelphia, PA: Elsevier; 2011:78–145.
4. Federle MF, Jeffrey RB Jr, Woodward PJ, Borhani A.Diagnostic Imaging Abdomen.
2nd ed. Altona, Manitoba, Canada: Amirsys; 2010:III:1:1–173.
5. Sanders RC, Hall-Terracciano B. Clinical Sonography: A Practical Guide. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016:408–422.
CHAPTER 4
Gallbladder and Biliary Tract

INTRODUCTION
Sonography of the gallbladder is a common imaging examination. In fact, sonography
is the gold standard for imaging of the gallbladder, and is especially utilized for
patients with suspected cholelithiasis and accompanying cholecystitis. If achievable,
varying patient position can assist in the identification of cholelithiasis. When
gallbladder hydrops is present, especially accompanied by biliary dilatation, a
thorough assessment of the entire biliary tract is warranted for the cause.

GALLBLADDER AND BILIARY TRACT 1
Assess the gallbladder in the following manner:
The gallbladder should be distended, which will often require some time for fasting
before the exam commences. Fasting time varies in regard to the age of the patient
and overall physical condition.
The exam should include long-axis and transverse views of the gallbladder in the
supine position and, in addition, decubitus imaging should be performed when
feasible. Erect or prone imaging may be helpful as well.
A measurement of the gallbladder wall should be obtained.
The patient should be assessed for the Murphy sign, which is tenderness to the
transducer compression over the gallbladder (Fig. 4-1).
Assess the biliary tract in the following manner:
The intrahepatic ducts may be evaluated by obtaining views of the liver showing the
right and left branches of the portal vein.
Figure 4-1. T he Murphy sign. T he Murphy sign is pain directly over the gallbladder
elicited by transducer pressure. (Reprinted with permission from Bickley LS, Szilagyi P,
eds. Bates’ Guide to Physical Examination and History Taking. 8th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2003.)
Color Doppler should be utilized in order to differentiate hepatic arteries and portal
veins from bile ducts.
The intrahepatic and extrahepatic bile ducts should be evaluated for dilatation, wall
thickening, intraluminal findings, and other abnormalities.
The bile duct in the area of the porta hepatis should be measured and documented.
When visualized, the distal common bile duct in the pancreatic head should be
evaluated.

GALLBLADDER AND BILIARY TRACT 2
Gallbladder (Fig. 4-2):
The cystic duct connects the gallbladder to the biliary tract.
The gallbladder has a partially inflated balloon shape that consists of a neck, body,
and fundus.
The neck is the narrowest segment of the gallbladder and is thus the most common
location for gallstones to become trapped.
The body is the widest segment of the gallbladder.
The fundus is the most dependent part of the gallbladder and is thus the most likely
part to contain gallstones.
Figure 4-2. Detailed anatomy of the gallbladder. (Image reprinted with permission from
Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer
Health/Lippincott Williams & Wilkins; 2010.)
The gallbladder is used as a bile reservoir.

When food reaches the duodenum, cholecystokinin is released by the cells of the
duodenum, which causes the gallbladder to contract and partially empty itself of bile.
Blood supply to the gallbladder is via the cystic artery, which is most likely a branch
of the right hepatic artery.
Bile ducts (see Fig. 4-2):
The biliary tract transports bile from the liver to the duodenum to be mixed with
undigested foods.
Bile consists of cholesterol, bilirubin, biliverdin, and bile acids.
Exceedingly small biliary radicles, which are the most proximal segments of the
biliary tract, are scattered throughout the liver parenchyma.
The biliary radicles eventually converge to form the right and left hepatic duct.
The right and left hepatic ducts join to form the common hepatic duct.
The cystic duct connects the gallbladder to the biliary tract and contains tiny
structures that prevent collapse of the duct referred to as spiral valves of Heister.
The common bile duct is the duct segment located distal to the cystic duct.
The common bile duct joins the main pancreatic duct near the pancreatic head and the
contents of pancreatic digestive juices and bile empty into the proximal duodenum.
GALLBLADDER AND BILIARY TRACT 2,3
Patient preparation is focused on having the potential of a fully distended gallbladder
at the time of the examination.
If the examination is performed without fasting, proper documentation should take
place.
SUGGESTED EQUIPMENT
3–5-MHz transducer (higher frequencies can be used for thin patients)
Harmonics or supplementary artifact removal technology to eliminate false echoes

GALLBLADDER AND BILIARY TRACT
Laboratory values are listed in Table 4-1. 2,4
Evaluate prior imaging reports and images including CT, MRI, radiography, ERCP,
and any other appropriate tests.
Critical clinical history questions:
History of cholecystectomy? (Fig. 4-3) This is a vital question, especially if the
gallbladder is not initially visualized in the right upper quadrant. Keep in mind that
the common duct may be larger in patients who have had a cholecystectomy.
History of right upper quadrant pain? Patients with cholecystitis often have right
upper quadrant pain.
History of gallstones? Some patients may know that they have been previously
diagnosed with gallstones. Gallstones can lead to biliary obstruction and acute
cholecystitis.
Postprandial right upper quadrant pain? Right upper quadrant pain after eating a fatty
meal may be a sign of acute cholecystitis.
Shoulder or chest pain? Shoulder or chest pain can be a sign of acute cholecystitis.
Nausea and/or vomiting? Patients with acute cholecystitis or biliary obstruction can
suffer from nausea and vomiting.
History of liver or pancreatic disease? Any previous history of liver or pancreatic
disease should intensify sonographic scrutiny of the gallbladder and biliary tract.
Table LAB FINDINGS AND POSSIBLE ASSOCIATED GALLBLADDER
4-1 OR BILIARY TRACT PATHOLOGY
LAB FINDING Potential GB/Biliary Tract Pathology2,4

↑ Bilirubin and Biliary obstruction or possible liver or pancreatic disease
urobilirubin
↑ Amylase Biliary or associated pancreatic obstruction or other
pancreatic disease
↑ Lipase Biliary or associated pancreatic obstruction or other
pancreatic disease
↑ ALT Biliary tract disease or associated pancreatic disease
↑ ALP Cholelithiasis or biliary obstruction and possible liver or
pancreatic disease
↑ AST Liver or pancreatic disease
↑ GGT Liver disease, biliary obstruction, cholangitis
↑ WBC Cholecystitis, cholangitis, or other inflammatory
diseases/infection
Figure 4-3. Typical location of abdominal scars following a laparoscopic
cholecystectomy. If the patient is unclear about past cholecystectomy and a gallbladder
is not visualized, assess the patient for signs of abdominal scars in these locations.
(Modified with permission from Fischer J, ed. Fischer’s Mastery of Surgery. 7th ed.
NORMAL SONOGRAPHIC DESCRIPTION OF THE

Gallbladder:
The gallbladder should be completely anechoic and typically has a balloon-shaped
appearance.
The gallbladder wall should be thin (measuring <3 mm).
Folds may be present within the neck, body, or fundus.
Bile ducts:
The intrahepatic ducts are not normally identifiable. If seen, the intrahepatic ducts
appear as two parallel hyperechoic lines.
In longitudinal orientation to the porta hepatis, the common hepatic duct and common
bile duct appear as tubular structures with an anechoic center.
In the transverse plane at the level of the pancreas, the distal common bile duct may
be seen within the pancreatic head posterior to the gastroduodenal artery.
SUGGESTED PROTOCOL AND NORMAL ANATOMY OF THE

Gallbladder:
Survey the gallbladder:
The gallbladder fossa can be found by locating the main lobar fissure (Fig. 4-4).
With the patient in the supine position, obtain a brief survey of the gallbladder in
(either or both) the longitudinal and transverse scan planes.
A cine loop may be performed (Video 4-1 and Video 4-2).
Longitudinal gallbladder (Fig. 4-5):
Images should be oriented to the long axis of the gallbladder and thus the transducer
may need to be placed in an oblique orientation to obtain the entire length of the
gallbladder. The neck, body, and fundus should be demonstrated (Fig. 4-6).
Scan completely through the gallbladder by angling the transducer or sliding it (i.e.,
medial to lateral), trying to maintain longitudinal orientation to the gallbladder.
Assess for the Murphy sign by applying transducer pressure to elicit possible
associated discomfort.
Assess for intraluminal objects, like gallstones, polyps, or masses.
Assess for wall thickening and pericholecystic fluid.
Transverse gallbladder (Fig. 4-7):
Images should be oriented 90° to the long axis of the gallbladder and thus the
transducer may need to be placed in an oblique orientation to obtain these images.
Scan completely through the gallbladder by angling the transducer or sliding it (i.e.,
superior to inferior), trying to maintain transverse orientation to the gallbladder.
Transverse neck, body, and fundus should be evaluated. The neck should be located
near the porta hepatis, and thus angling/sliding superiorly will demonstrate the neck,
while angling/sliding inferiorly will demonstrate the fundus.
Assess for the Murphy sign by applying transducer pressure to elicit possible
associated discomfort.
Transverse or longitudinal gallbladder wall measurement (Figs. 4-8 and 4-9):
Some institutions prefer a transverse gallbladder wall measurement, while others
prefer a longitudinal measurement.
Ensure that the transducer is perpendicular to the wall before obtaining a
measurement. An oblique wall measurement may yield a false thickening.
Figure 4-4. Main lobar fissure. The main lobar fissure can assist in the identification
of the gallbladder. A: It appears to connect the gallbladder neck to the portal vein.
B: Diagram demonstrating the relationship of the main lobar fissure (M LF) and the
gallbladder. (Reprinted with permission from Cosby KS, Kendall JL, eds.Practical Guide
to Emergency Ultrasound. 2nd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott
Figure 4-5. Longitudinal gallbladder. A,B: Longitudinal image of the gallbladder
(GB) demonstrating the neck, body, and fundus. (Part A is reprinted with permission
from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed.
Figure 4-6. Oblique orientation needed to obtain true longitudinal image of the
gallbladder. A: Longitudinal image of the gallbladder. B: Drawing of the orientation
often required to obtain a true longitudinal image of the gallbladder. (Reprinted with
Figure 4-7. Transverse gallbladder. Transverse image of the gallbladder (GB)
body. (Part A is reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and
Figure 4-8. Transverse gallbladder wall measurement. A,B: Transverse image of
the gallbladder (GB) and corresponding measurement of the gallbladder wall
(between calipers).
Figure 4-9. Longitudinal gallbladder wall measurement. A,B: Longitudinal image of
the gallbladder (GB; arrows) with a thickened wall. (Part A is reprinted with permission
from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed.
Left lateral decubitus images:

Repeat longitudinal (see Fig. 4-5) and transverse (see Fig. 4-7) images of the
gallbladder in the left lateral decubitus position.
Additional images:
If the patient is capable, prone and upright images can be obtained to further evaluate
the gallbladder.
Bile ducts:
Long common duct:
The image should be oriented to the long axis of the porta hepatis to demonstrate the
length of the common hepatic duct and common bile duct (Fig. 4-10).
Measurements of the ducts are obtained from the inner wall to the inner wall.
Typically, the common duct will be seen anterior to the hepatic artery, though this
relationship may be reversed in some individuals (Fig. 4-11). Color Doppler will
help in the identification of the common duct, because while the hepatic artery will
demonstrate blood flow, the common duct will not.
Color Doppler can be used to demonstrate the intrahepatic ducts, though they are not
typically seen (Fig. 4-12).
Lengthen the common bile duct as much as possible in order to assess it in its
entirety, including the segment near the pancreatic head (Fig. 4-13).
Some interpreting physicians may require a measurement of the duct to be taken
anterior to the hepatic artery (Fig. 4-14).
Figure 4-10. Longitudinal sonogram (A) and drawing (B) of the porta hepatis
demonstrating the relationship of the common bile duct (CBD), hepatic artery (HA), and
main portal vein (PV). (Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen
Figure 4-11. Reverse relationship of the common duct and hepatic artery. Occasionally,
a replaced hepatic artery is seen. T he artery is located anterior to the duct, rather than
between the duct and portal vein. (Reprinted with permission from Kawamura D, Lunsford
B, eds. Abdomen and Superficial Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer
Figure 4-12. Normal measurements of the bile ducts. T he ducts are measured inner wall
to inner wall. A: Intrahepatic duct (between calipers). B: Common bile duct, <8 mm and
(C) common hepatic duct, <6 mm at the porta hepatis. D: Normal duct measurements at
the porta hepatis. CBD, common bile duct measurement (between calipers); CHD,
common hepatic duct; HA, hepatic artery; PV, portal vein. (Reprinted with permission from
Figure 4-13. Distal common bile duct. T he common bile duct (CBD) can be seen
(between calipers) near the pancreatic head (PANC). PV, portal vein; HA, hepatic artery.
(Reprinted with permission from Kawamura D, Lunsford B, eds.Abdomen and Superficial
Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams & W ilkins;
2012.)
Figure 4-14. Measurement of the common duct anterior to the hepatic artery. (Reprinted
with permission from Kawamura D, Lunsford B, eds.Abdomen and Superficial Structures. 3rd
ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)
SCANNING TIPS
Gallbladder:
Deep suspended inspiration will assist in displacing the gallbladder inferiorly.
Evaluate the gallbladder through the right-side rib windows when necessary. A
smaller transducer face may be helpful.
If the gallbladder is not visualized:
Inquire about previous cholecystectomy
Inquire about fasting status
Possible WES (wall-echo-shadow) sign could be present, which occurs when the
gallbladder is completely filled with gallstones and only the anterior wall of the
gallbladder can be seen sonographically. A distinct shadow will be seen originating
from the gallbladder fossa.
The gallbladder body and fundus can be mobile. In real time, actively scan the
gallbladder while the patient changes positions.
Assess the gallbladder neck carefully for gallstones, because this is the most common
location for gallstones to become lodged.
Gallstones will most likely be mobile and shadow, while polyps will not be mobile
and should not shadow.
Gallbladder shape is variable.
The Phrygian cap is a fold in the fundus of the gallbladder (Fig. 4-15).
The junctional fold is a fold in the neck of the gallbladder (Fig. 4-16).
Bile ducts:
Deep suspended inspiration will assist in displacing the liver inferiorly.
Left lateral decubitus or scanning through the right-side rib windows can aid in the
assessment of the biliary tree.
Utilize color Doppler while analyzing the porta hepatis to differentiate the common
duct from the hepatic artery.
If the biliary tract is dilated, try to follow the common bile duct over to the head of
the pancreas for signs of choledocholithiasis or possibly an obstructing pancreatic
head mass.
Figure 4-15. T he Phrygian cap. A Phrygian cap is a fold in the fundus of the gallbladder.
Figure 4-16. Junctional fold. A junctional fold is a fold in the neck of the gallbladder. A:
Transverse. B: Longitudinal. (Reprinted with permission from Kawamura D, Lunsford B,
e d s . Abdomen and Superficial Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer
NORMAL MEASUREMENTS OF THE GALLBLADDER AND

BILIARY TRACT
Gallbladder3:
Size = 8–10 cm in length and 4–5 cm in diameter
Normal gallbladder wall thickness = <3 mm
Biliary tract2,3:
Intrahepatic ducts diameter = <2 mm
Common hepatic duct diameter = <7–8 mm (depending on the patient’s age and other
factors)*
Common bile duct diameter = <7–8 mm (depending on patient’s age and other
factors)*
Bile duct wall thickness = <5 mm
ESSENTIAL GALLBLADDER AND BILIARY TRACT

PATHOLOGY2
Gallbladder pathology:
Cholelithiasis—gallstones
Clinical findings:
Asymptomatic
Biliary colic
Abdominal pain after high-fat meals
Epigastric pain
Nausea and vomiting
Shoulder or chest pain
Sonographic findings (Fig. 4-17):
Hyperechoic, mobile shadowing focus or foci
Evaluate for signs of cholecystitis (see this chapter heading Acute cholecystitis)
Gallbladder sludge:
Clinical findings:
Asymptomatic
Biliary stasis (extended amount of time fasting, TPN)
Layering low-level, nonshadowing, dependent echoes within the gallbladder
Figure 4-17. Mobility of gallstones. A: Multiple gallstones are noted in the fundus
of the gallbladder. B: T he gallstones have moved with a change in patient
positioning. (Reprinted with permission from Cosby KS, Kendall JL, eds.Practical
Guide to Emergency Ultrasound. 2nd ed. Philadelphia, PA: Wolters Kluwer
Figure 4-18. Gallbladder sludge. (Image courtesy of Philips Healthcare, Bothell, WA.)
Gallbladder polyps:
Clinical findings:
Asymptomatic
Hyperechoic, nonshadowing, and nonmobile focus or foci attached to the
gallbladder wall that project within the lumen
Polyps measuring over 1 cm could be suggestive of gallbladder carcinoma
Adenomyomatosis—accumulation of cholesterol crystals within the gallbladder
wall:
Clinical findings:
Asymptomatic
Figure 4-19. Gallbladder polyp. A polyp (arrow) is noted within this gallbladder.
(Reprinted with permission from Yamada T, Alpers DH, Laine L, Kaplowitz N, Owyang C,
Powell DW, eds. Textbook of Gastroenterology. 4th ed. Philadelphia, PA: Lippincott

Focal gallbladder wall thickening with evidence of comet-tail artifact emanating
from the wall
Acute cholecystitis—inflammation of the gallbladder:
Clinical findings:
Right upper quadrant, epigastric, or possibly shoulder or chest pain
Elevation in WBC, ALP, ALT, GGT, and possibly bilirubin with obstruction
Fever
Nausea and vomiting
Figure 4-20. Adenomyomatosis. Comet tail artifact is noted emanating from the
wall of the anterior gallbladder, which indicates the presence of
adenomyomatosis. (Reprinted with permission from Kawamura D, Lunsford B, eds.
Abdomen and Superficial Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer

Gallstones*
Positive Murphy sign
Gallbladder wall thickening
Gallbladder enlargement (hydrops)
Pericholecystic fluid
Sludge
Biliary tract pathology:
Choledocholithiasis—gallstone within the biliary duct(s):
Clinical findings:
Jaundice
Elevated ALP, ALT, GGT, and bilirubin with obstruction
Hyperechoic, shadowing focus or foci within the bile duct(s)
Figure 4-21. Acute cholecystitis. A: Longitudinal image in a patient with a positive
Murphy sign. Note the gallstones, sludge, thickened, edematous wall, and
pericholecystic fluid (arrow) . B: Transverse image of another patient with acute
cholecystitis and thickened wall (calipers). C: Hydropic gallbladder and increased
color Doppler flow in a patient with positive Murphy sign, sludge, and acute
cholecystitis. D: Longitudinal image of acute cholecystitis, stone, sludge, and
increased Doppler flow. (Reprinted with permission from Kawamura D, Nolan T, eds.
Abdomen and Superficial Structures. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 4-22. Choledocholithiasis. A: Longitudinal sonogram reveals a dilated
common bile duct (CBD) (between calipers) measuring 7 mm in diameter in a
young patient. B: A 4-mm echogenic, shadowing focus (arrow) is seen at the level
of the pancreatic head. C: Color Doppler demonstrates the twinkle sign posterior
to the stone. (Reprinted with permission from Lee E, ed. Pediatric Radiology: Practical
Imaging Evaluation of Infants and Children. Philadelphia, PA: Wolters Kluwer; 2017.)
Possible dilatation of the biliary tree and enlargement of the gallbladder

Color Doppler applied over the area of the stone will reveal twinkle artifact (see
Fig. 4-22C)
Cholangitis—inflammation of the bile ducts:
Clinical findings:
Fever
Jaundice
Elevated WBC, ALP, ALT, GGT, and bilirubin with obstruction
Biliary dilatation
Sludge
Thickening of the bile duct walls
Possible choledocholithiasis
Figure 4-23. Cholangitis. Note the thickened wall of the common bile duct (CBD). HA,
hepatic artery; PV, portal vein. (Reprinted with permission from Kawamura D, Lunsford B,
WHERE ELSE TO LOOK

Analyze the liver first for signs of intrahepatic biliary dilatation.
Keep in mind, that biliary dilatation typically occurs proximal to the level of
obstruction, so if dilatation is present, ensure that the entire length of the common bile
duct is assessed.
Evaluate the pancreatic head carefully for signs of a mass, especially when there is
evidence of biliary dilatation or gallbladder enlargement.
IMAGE CORRELATION
Gallstones on CT (Fig. 4-24)
Acute cholecystitis on CT (Fig. 4-25)
Figure 4-24. Incidental gallstones on CT. A: Enhanced CT image shows a rim-calcified,
oval gallstone (arrow) lodged in the gallbladder neck. B: Image through the gallbladder
fundus shows a large, faceted stone (arrow) in the gallbladder fundus in the same
patient. C: Image through the gallbladder neck in a different patient shows a 9-mm,
uniformly calcified stone (arrow) in the gallbladder neck. D: Image through the
gallbladder fundus in a third patient shows gas-filled gallstones (arrows). (Reprinted with
permission from Pope TL Jr, Harris JH Jr, eds.Harris & Harris’ The Radiology of Emergency
Medicine. 5th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.)
Figure 4-25. Cholecystitis on CT. Contrast-enhanced CT demonstrating gallbladder wall

thickening and pericholecystic fluid (arrowhead) from acute cholecystitis. (Reprinted with
permission from Singh A. Gastrointestinal Imaging: The Essentials. Philadelphia, PA: Wolters
Kluwer; 2016.)
REFERENCES
2. Penny SM, ed. Examination Review for Ultrasound: Abdomen & Obstetrics and
3. Kawamura DM, Nolan TD, eds.Diagnostic Medical Sonography: Abdomen and
4. Hopkins TB. Lab Notes: Guide to Lab and Diagnostic Tests. 2nd ed. Philadelphia,
PA: F. A. Davis Company; 2009.
* Bile
duct diameter can be larger after cholecystectomy and the diameter may increase with age. Both
imaging and clinical assessment must be correlated when ductal dilatation is suspected.
* Patients
can have acalculous cholecystitis as well, in which all clinical and sonographic signs are present
though no gallstones are seen.
CHAPTER 5
Urinary Tract
INTRODUCTION
Sonography of the urinary tract is a commonly requested examination. In fact, there
are many disorders of the urinary tract in which sonography can provide a vital initial
imaging screening. And thus, a thorough routine protocol must be established in order
to identify pathology of the urinary tract. This chapter will provide essential anatomy
and physiology, protocol, anomalies, and pathology of the adult urinary tract.
Relevant clinical findings, including laboratory findings, are also provided.

URINARY TRACT 1
Assess the urinary tract in the following manner:
Kidneys (including vascular assessment and adrenal glands):
The sonographic evaluation of the kidneys should include long-axis and transverse
views.
A measurement of the maximum length of the kidneys should be obtained.
Decubitus, prone, or upright positioning may be helpful to better evaluate the
kidneys.
The echogenicity of the right kidney should be compared to the echogenicity of the
liver, while the echogenicity of the left kidney should be compared to that of the
spleen.
Renal cortical thickness should be evaluated.
The renal cortices, sinuses, renal pelves, and perirenal region should be evaluated
for signs of abnormalities, including dilatation of the collecting system, calculi, and
masses.
Color Doppler may be used to detect calculi via the twinkle artifact.
Vascular assessment of the kidneys should include:
The renal artery and renal vein should be evaluated for patency.
For suspected renal artery stenosis, angle-adjusted measurements of the peak
systolic velocity of the proximal, central, and distal portions of the extrarenal main
renal artery should be used when possible.
The peak systolic velocity of the adjacent abdominal aorta should be documented
for calculating the ratio of the renal to aortic peak systolic velocity.
Spectral Doppler evaluation of the intrarenal arteries may be helpful for providing
an indirect sign of proximal stenosis in the main renal artery.
Urinary Bladder:
Transverse and longitudinal images of the distended urinary bladder should be
provided.
An evaluation of intraluminal and wall abnormalities should be provided.
The distal ureter should be assessed for abnormalities, including obtaining ureteral
jets with color Doppler imaging when a urinary tract obstruction is suspected.
In women, transvaginal imaging may be utilized to evaluate for distal ureteral
stones.
Transverse and longitudinal images of the postvoid residual can provide a
quantitative analysis.
The male prostate gland may be measured and incidental gynecologic findings
should be noted.
Adrenal glands:
The adrenal gland area should be evaluated in the adult, although normal adrenal
glands are less commonly seen in older children and adults.
Any masses should be documented.
Longitudinal and transverse images of the adrenal glands in newborns and young
infants may be obtained, especially when clinically indicated.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE URINARY

TRACT
The urinary tract consists of the kidneys, ureters, bladder, and urethra.
Kidney anatomy and physiology:
The paired kidneys are bean-shaped, retroperitoneal organs located in the posterior
aspect of the right and left upper quadrants (Figs. 5-1 and 5-2).
Each kidney consists of two parts, which are the renal parenchyma and the renal
sinus.
The renal parenchyma includes the renal medulla and the renal cortex, and it
includes the renal pyramids.
The renal sinus includes the renal collecting system, including the calices and the
renal pelvis.
The kidney can be divided into an upper or superior pole, midportion, which
includes the renal hilum, and a lower or inferior pole.
The kidneys perform many vital functions, including detoxification and filtration of
the blood, blood pressure regulation, and maintaining normal pH, iron, and salt
levels in the blood.
There are several renal variants that may alter the appearance of the kidney (Table
5-1).
Ureteral anatomy:
The bilateral ureters are small tubes that connect the kidney to the bladder.
The proximal ureter unites with the renal pelvis at the ureteropelvic junction (UPJ).
The distal ureter unites with the bladder at the ureterovesicular junction (UVJ).
The ureters provide a means whereby urine can travel from the kidneys to the urinary
bladder.
Bladder and urethral anatomy:
The urinary bladder, located in the anterior pelvis, is a temporary storage organ for
urine.
The bladder includes an area referred to as the trigone, which is where the two UVJs
and the opening for the urethra are located (Fig. 5-8).
The urethra is a tube that extends from the trigone of the bladder to the outside of the
body.
Voiding or urination is the process of allowing urine to exit the bladder through the
urethra.
Figure 5-1. External and internal appearance of kidneys. A: T he right kidney. B: Renal
sinus, as seen through the renal hilum. C: T he anterior lip of the renal hilum has been
cut away to expose the renal pelvis and calices within the renal sinus. D: T his coronal
section of the kidney shows the organ’s internal structure. T he renal pyramids contain
the collecting tubules and form the medulla of the kidney. The renal cortex contains the
renal corpuscles. (Reprinted with permission from Moore KL, Dalley AF, Agur AM, eds.
Clinically Oriented Anatomy. 7th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott
Figure 5-2. Kidney anatomy including vascularity. (Reprinted with permission from Penny
SM, ed. Examination Review for Ultrasound. Philadelphia, PA: Wolters Kluwer Health/Lippincott
Table 5-1 RENAL VARIANTS AND DESCRIPTION
MOST COMMON RENAL

VARIANTS DESCRIPTION
Duplex collecting system (Fig. Two separate renal sinuses with separate
5-3) collecting systems
Junctional line (or junctional An echogenic line or triangular structure most
parenchymal defect) (Fig. 5- likely in the upper pole of the kidney that
4) results from the fusion of two parenchymal
renal embryonic renunculi
Dromedary hump (Fig. 5-5) Bulge on the lateral border of the kidney,
often on the left kidney
Ectopic kidney (pelvic kidney) A kidney in the wrong locations, most often in
the pelvis
Extrarenal pelvis (Fig. 5-6) The renal pelvis is located outside of the renal
hilum
Horseshoe kidneys (Fig. 5-7) Two kidneys that cross the midline and attach
at the lower poles by a bridge of tissue called
an isthmus
Figure 5-3. Duplex collecting system. T he upper pole (UP) and lower pole (LP) contain
separate dilated renal collecting systems. (Reprinted with permission from Siegel MJ, Coley
B, eds. Core Curriculum: Pediatric Imaging. Philadelphia, PA: Lippincott W illiams & W ilkins;
2005.)
Figure 5-4. Junctional line. A, B: A junctional parenchymal defect or line (arrows) is
noted in these kidneys. (Reprinted with permission from Siegel MJ, ed.Pediatric
Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams & W ilkins;
2010.)
Figure 5-5. Dromedary hump. A, B: A dromedary hump (arrow) is noted in these images
as extrarenal tissue in the midportion of the kidney. (Reprinted with permission from
Sanders RC, ed. Clinical Sonography: A Practical Guide. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2015.)
Figure 5-6. Extrarenal pelvis. T he renal pelvis (P) is located outside of the renal hilum
in this right kidney (RK). (Reprinted with permission from Kawamura D, Nolan T, eds.
Figure 5-7. Horseshoe kidneys. T he right kidney (RT K) and left kidney (LT K) are
attached by a thin band of tissue, the isthmus, which is noted in this image anterior to
the spine (SP). (Reprinted with permission from MacDonald MG, Seshia MM, eds.Avery’s
Neonatology. 7th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Figure 5-8. Basic urinary bladder anatomy. (Reprinted with permission from Porth C, ed.
Essentials of Pathophysiology. 4th ed. Philadelphia, PA: Wolters Kluwer; 2014.)

URINARY TRACT
There is typically no patient preparation for a sonogram of the urinary tract. However,
some institutions may require that the patient be well hydrated.
A distended urinary bladder is warranted to best evaluate for intraluminal
abnormalities and wall thickening.
3.5–5-MHz transducer:
Higher frequencies can be used for thin patients, and a small-footprint transducer may
be required to visualize through narrow intercostal spaces.
General abdominal or renal setting (most machines)

URINARY TRACT 2
Laboratory values are listed in Table 5-2:
Critical clinical history questions related to the urinary tract:
History of urinary tract infection(s)? Recurring urinary tract infections can damage
the kidneys. Also, an analysis for signs of kidney stones, pyelonephritis, thickening of
the urinary bladder wall, and debris in the renal collecting system or urinary bladder
should take place.
History of nephrectomy or other urinary tract surgery (e.g., bladder surgery)? Not
only will the kidney be absent, but the motive for the previous nephrectomy may be
relevant. For example, a history of renal cell carcinoma is valuable information to
obtain because a detailed analysis of the remaining kidney for signs of carcinoma
should commence.
History of kidney stones? A careful analysis for evidence of stones should be
conducted, especially if clinical symptoms are suggestive.
History of diabetes mellitus or high blood pressure? Diabetes and high blood
pressure can damage the function of the kidneys. The structure, and thus the
sonographic appearance of the kidneys may also be altered with uncontrolled
diabetes and/or high blood pressure.
History of blood in the urine (gross or microscopic hematuria)? Hematuria can be a
sign of renal stones, infection, or even malignancy.
History of renal anomalies? Some individuals may be aware that they have
duplicated collecting systems, unilateral renal agenesis, or horseshoe kidneys.
Table LAB AND URINALYSIS FINDINGS AND POSSIBLE ASSOCIATED

5-2 URINARY TRACT PATHOLOGY
LAB FINDING POTENTIAL PATHOLOGY

↑ WBC (leukocytosis) Urinary tract infection or inflammation
↓ WBC (leukopenia) Chemotherapy, radiation therapy, toxic reaction
↓ Hematocrit Acute hemorrhage
↑ Blood urea nitrogen Renal failure, renal parenchymal disease, urinary tract
(BUN) obstruction, dehydration, diabetes mellitus,
hemorrhage
↓ Blood urea nitrogen Liver disease, malnutrition, overhydration, smoking,
(BUN) pregnancy
↑ Creatinine Renal failure, chronic nephritis, urinary tract
obstruction, diabetes mellitus, compromised renal
blood flow
↓ Glomerular filtration Renal insufficiency or chronic renal disease
rate (GFR)
↑ Lactate Renal infarction or chronic renal disease
dehydrogenase (LDH)
↑ Bacteria Acute pyelonephritis or urinary tract infection
(bacteriuria)
Pyuria Urinary tract infection
Hematuria Acute or chronic pyelonephritis, calculi, renal cell
carcinoma, renal infarction, or trauma
↑ Protein (proteinuria) Urinary tract infection, glomerulonephritis, urinary tract
masses, nephrotic syndrome, pyelonephritis, or calculi
↑ Specific gravity Dehydration
↓ Specific gravity Renal failure and pyelonephritis
NORMAL SONOGRAPHIC DESCRIPTION OF THE URINARY

TRACT
The normal kidneys appear as bean-shaped organs. The cortex typically appears to
consist of medium- to low-level echoes, while the sinus has more of an echogenic
appearance. The kidney cortices should either be isoechoic or more hypoechoic than
the normal liver or spleen.
The ureters are not typically seen sonographically. If the ureters are noted, an
investigation for urinary obstruction should be conducted.
In the distended state, the urinary bladder appears as an anechoic structure outlined by
a thin hyperechoic wall. In transverse, the distended urinary bladder may appear as a
square-shaped, anechoic structure within the pelvis.
The UVJs may be demonstrated best in transverse as small bilateral bulges in the
inferoposterior aspect of the urinary bladder wall.

URINARY TRACT 1
Survey the kidney:
Start on the right side of the patient and complete the entire kidney protocol before
moving to the left kidney or bladder.
Ask the patient to extend his or her left arms up above his or her head in order to
Suspended or deep inspiration may be helpful to evaluate the kidneys.
With the patient in the supine position, obtain a brief survey of the kidney by scanning
superiorly and inferiorly (transverse) or medial to lateral (longitudinal).
Evaluate the renal cortices, sinuses, renal pelves, and perirenal region for signs of
abnormalities, including dilatation of the collecting system, calculi, and masses.
Perform a cine clip in longitudinal and transverse (Video 5-1 and Video 5-2).
Longitudinal (right or left) kidney (repeat on contralateral side):
Lengthen the kidney in the longitudinal plane, which may require the transducer to be
slightly obliqued.
Note the echogenicity of the kidney compared to the liver or spleen.
Ensure that the cortex is clearly visualized around the sinus.
Measure the length of the kidney (Fig. 5-9).
An anteroposterior dimension of the kidney may be obtained as well.
If requested, apply color Doppler to the kidney to demonstrate vascular sufficiency.
Also, color Doppler can assist in the identification of small renal calculi by
demonstrating the twinkle sign or artifact.
Longitudinal (right or left) kidney medial (repeat on contralateral side):
Obtain an image of the medial aspect of the kidney, noting the area of the renal
pelvis.
Assess the area of the adrenal glands, which in adults are most likely located medial
to the upper pole of each kidney.
Longitudinal (right or left) kidney lateral (repeat on contralateral side):
Obtain an image of the lateral aspect of the kidney.
Transverse (right or left) kidney upper pole (repeat on contralateral side):
Rotate the transducer 90° to the image of the kidney that was obtained in longitudinal
and begin by evaluating the upper or superior pole of the kidney (Fig. 5-10).
Scan completely through the kidney superiorly in transverse.
Transverse (right or left) kidney mid (repeat on contralateral side):
The renal hilum will appear as a section where the kidney tissue is disrupted
medially by the renal vasculature. Therefore, the midportion of the kidney often
appears as a “C.”
Color Doppler may be applied to the kidney at the renal hilum level in order to
demonstrate the renal vasculature and to differentiate these blood vessels from a
prominent or dilated renal pelvis (Fig. 5-11).
The thickness of the kidney should be measured, if requested (Fig. 5-12).
Transverse (right or left) kidney lower pole (repeat on contralateral side):
Image the lower or inferior pole of the kidney (Fig. 5-13).
Scan completely through the kidney inferiorly in transverse.
Figure 5-9. Longitudinal kidney with length measurement (A and drawing B). (Part A
reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and Superficial
Figure 5-10. Transverse upper pole kidney image. In this image, the upper pole of
the right kidney (RK) can be noted adjacent to the inferior vena cava (IVC) and
posterior to the right lobe of the liver (A and drawing B).
Figure 5-11. Transverse mid kidney image with color Doppler (A and drawing B).
Figure 5-12. Transverse mid kidney image with measurement (A and drawing B).
(Part A reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and
Figure 5-13. Transverse lower pole kidney image. In this image, the upper pole of
the right kidney (RK) can be noted adjacent to the inferior vena cava (IVC) and
posterior to the right lobe of the liver (A and drawing B).
Survey the urinary bladder:

With the patient in the supine position, obtain a brief survey of the kidney by scanning
superiorly and inferiorly (transverse) or anterior to posterior (longitudinal).
Obtain a video clip of the urinary bladder, if requested.
Longitudinal urinary bladder:
Image the bladder in the longitudinal plane (Fig. 5-14).
Scanning medial to lateral completely through the bladder, evaluate the lumen of the
urinary bladder and the urinary bladder wall.
Transverse urinary bladder:
Image the bladder in the transverse plane (Fig. 5-14).
Figure 5-14. Longitudinal and transverse images of the urinary bladder. T he

longitudinal image is on the left and the transverse image is on the right. (Reprinted
with permission from Cosby KS, Kendall JL, eds. Practical Guide to Emergency Ultrasound.
2nd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.)
Scanning superior to inferior completely through the bladder, evaluate the lumen of
the urinary bladder and the urinary bladder wall.
Transverse bladder (with color Doppler):
The trigone of the bladder is located posteroinferior in the bladder.
Apply color Doppler to the trigone region of the urinary bladder.
Demonstrate ureteral patency by providing ureteral jet images of both UVJs. Color
Doppler should be seen emanating from each UVJ (Fig. 5-15).
Additional images:
Some institutions may require measurements of the renal cortex for signs of cortical
thinning. In the longitudinal plane, measure from the outer border of the renal cortex
to the outer border of the renal sinus.
Prevoid and postvoid residual bladder volumes can be obtained. To acquire these
images, obtain a longitudinal and transverse image and measure in three dimensions.
Some institutions may request an analysis of the abdominal aorta for signs of
abdominal aortic aneurysms and other vascular abnormalities.
After identifying hydronephrosis, postvoid images of the bladder and kidneys can
provide further information.
Figure 5-15. Transverse image of the urinary bladder with color Doppler demonstrating
ureteral jets. In this image, only the left ureteral jet can be seen. (Reprinted with
permission from Dunnick NR, Newhouse JH, Cohan RH, Maturen KE, eds. Genitourinary
Radiology. 6th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
SCANNING TIPS
Don’t be too quick to place the patient in decubitus positions to examine the kidneys,
because in some individuals, the kidneys may be evaluated more readily in the supine
position.
Deep inspiration may help to visualize the kidneys in some patients, while in others,
simply suspended breathing may help.
A small-footprint transducer may be better to demonstrate the kidneys in thin patients
with narrow intercostal spaces.
Scanning posteriorly through the back muscles may be helpful in pediatric patients.
Be careful to not misidentify an enlarged prostate as a bladder mass.
Transvaginal imaging may be utilized to evaluate for distal ureteral stones in women.
Figure 5-16. Obtaining a bladder volume. Scanning the bladder in the transverse and
sagittal or longitudinal planes, identifying the largest diameters, and applying the
formula Bladder volume = (A ë B ë C ë 0.52) allows estimation of bladder volume in mL.
A = bladder width (cm), B = bladder height (cm), C = bladder length (cm). (Reprinted with
permission from Barash PG, Cahalan MK, Cullen BF, et al., eds.Clinical Anesthesia. 8th ed.
NORMAL MEASUREMENTS OF THE URINARY TRACT *2–5

Renal length (adults):
8–13 cm in length
2–3 cm in anteroposterior dimension
4–5 cm in width
Renal volume:
Length × Width × Height × 0.523 = mL
Renal cortex (adults):
1 cm or more
Bladder volume: (Fig. 5-16)
Length × Width × Height × 0.52 = mL
Bladder capacity is between 150–600 mL
Bladder wall thickness:
3 mm or less when distended
5 mm or less when empty
ESSENTIAL URINARY TRACT PATHOLOGY2

Hydronephrosis—dilation of the renal collecting system (Fig. 5-17):
Figure 5-17. Hydronephrosis. Two longitudinal images of hydronephrotic kidneys. A.
Mild hydronephrosis. B. Moderate hydronephrosis. (Reprinted with permission from
Common causes of hydronephrosis include the following:

Urolithiasis
UPJ or UVJ obstruction
Ureterocele: ballooning of the ureter into the bladder
Benign prostatic hypertrophy
Pregnancy
Pelvic masses: ovarian tumor or uterine fibroids
Clinical findings:
May be asymptomatic
Could have signs or symptoms based on the cause of obstruction such as hematuria
or pain when associated with a urolithiasis
Distention of the renal collecting system with anechoic fluid
Possible dilation of the ureter and enlargement of the bladder depending upon the
level of obstruction
Urolithiasis (Fig. 5-18):
Clinical findings:
Hematuria
Renal colic: pain in the area of the stone
Oliguria
Urinary tract infection
Echogenic focus that produces acoustic shadowing
Evidence of the “twinkle sign” or “twinkle artifact”: increased Doppler artifact
posterior to the stone
Hydronephrosis and/or dilation of the ureter proximal to the stone may be present
Renal cysts—anechoic mass(es) within or on the kidney that produce posterior
enhancement (Fig. 5-19):
Autosomal dominant polycystic kidney disease:
Clinical findings:
Asymptomatic until third or fourth decade of life
Decreased renal function
Urinary tract infections
Renal stones
Flank pain
Hematuria
Palpable abdominal mass (representing enlarged kidney)
Figure 5-18. Urolithiasis with twinkle sign. Kidney stone (arrows) demonstrating
the twinkle sign, which is described as increased color Doppler signal posterior
to a stone. (Reprinted with permission from Siegel MJ, ed. Pediatric Sonography. 4th ed.
Bilateral enlarged kidneys with multiple renal cysts of varying sizes
Possible cysts within the liver, spleen, and/or pancreas
Renal cell carcinoma (Fig. 5-20):
Clinical findings:
Hematuria
Weight loss
Palpable mass
Figure 5-19. Renal and liver cysts. A: Multiple liver cysts are noted in this image of
a patient with ADPKD. B: Multiple cysts are located throughout this kidney, which is
indicative of ADPKD. (Reprinted with permission from Kawamura D, Lunsford B, eds.
Figure 5-20. Renal cell carcinoma. A solid hypoechoic mass (M) is noted within the
upper pole of this right kidney (RK) which is being imaged in the longitudinal plane.
Smoker
Hypertension
Flank pain
Hypoechoic, isoechoic, or hyperechoic solid mass on the kidney
Could appear as a complex cyst
Assess the renal vein and inferior vena cava (IVC) for possible tumor invasion
Chronic renal failure (Fig. 5-21):
Clinical findings:
Diabetes
Malaise
Figure 5-21. Chronic renal failure. T he right kidney (RK) (A) and the left kidney (LK)
(B) are notably more echogenic than normal, indicating chronic renal failure.
(Images courtesy of Taco Geertsma, MD, Hospital Gelderse Vallei, Ede, The Netherlands.)
Elevated BUN and creatinine

Fatigue
Hypertension
Hyperkalemia (high levels of serum potassium)
Bilateral, small echogenic kidneys
Cortical thinning
Possible renal cysts
Ureterocele—ballooning of the distal ureter into the bladder:
Clinical findings:
Asymptomatic
Anechoic, balloon-shaped structure within the lumen of the urinary bladder near the
UVJ
Cystitis—inflammation of the urinary bladder
Clinical findings:
Pain in the bladder with urination
Hematuria
Dysuria
Diffusely thickened urinary bladder wall measuring >4 mm in thickness
Perhaps some intraluminal, layering debris in bladder
WHERE ELSE TO LOOK

An enlarged prostate can cause urinary symptom, so an assessment of the prostate
transabdominally can be performed briefly in males.
Don’t forget to analyze the adrenal gland area in adults, because occasionally adrenal
masses or cysts can be discovered sonographically.
Large uterine or ovarian masses cause hydronephrosis and urinary symptoms.
When a solid renal mass is identified, be sure to assess the IVC closely for signs of
tumor invasion through the renal vein.
IMAGE CORRELATION
Normal CT of the kidney (Fig. 5-22)
Kidney stone on CT (Fig. 5-23)
Figure 5-22. Normal CT of the kidneys. A: Noncontrast image of the kidneys. B: Contrast
image of the kidneys. (Reprinted with permission from Smith W L, ed.Radiology 101. 4th ed.
Figure 5-23. CT of kidney stone. A bright calcium stone is noted within the right kidney.
(Reprinted with permission from Dunnick NR, Newhouse JH, Cohan RH, Maturen KE, eds.
Genitourinary Radiology. 6th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
REFERENCES
Accessed October 14, 2018.
Philadelphia, PA: Wolters Kluwer; 2016:421–435, 553–576, 596–604.
4. Seigel MJ. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer;
2011:384–460.
5. Rumack CM, Wilson SR, Charboneau JW, Levine D.Diagnostic Ultrasound. 4th ed.
* Renal size varies with age, gender, and other factors. Therefore, be careful to assess the entire clinical
account when evaluating the size of the kidneys. For example, an evaluation of the laboratory values and
other clinical history should be performed routinely, if possible, before claiming that the kidneys are either
too large or too small.
CHAPTER 6
Spleen
INTRODUCTION
The spleen, located in the left upper quadrant, may be a challenging organ to assess
sonographically because of its normally small size. In some individuals, the
problematic protecting ribs that lie adjacent to the spleen may offer only a
sonographic glimpse at its form and structure. Nonetheless, the spleen should be
evaluated systematically, especially if the patient has suffered from splenic trauma or
if splenomegaly with associated portal hypertension is suspected clinically.

SPLEEN1
Assess the spleen in the following manner:
The spleen should be assessed for parenchymal abnormalities (e.g., masses, cysts,
calcifications, etc.).
The echogenicity of the spleen should be compared to the left kidney when possible.
The left hemidiaphragm and the left pleural space should also be evaluated.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE SPLEEN2,3

The spleen is an intraperitoneal organ located in the left upper quadrant (Fig. 6-1).
The spleen has a concave inferior surface and a convex superior surface and is about
the size of the human fist.
The splenic artery, which enters the spleen at the splenic hilum, is a branch of the
celiac axis, a main branch of the abdominal aorta just above the superior mesenteric
artery (Fig. 6-2).
The splenic vein exits the splenic hilum and travels medially toward the pancreas,
outlining the pancreatic tail posteriorly, ultimately continuing on to join with the
inferior mesenteric vein and superior mesenteric vein to help create the main portal
vein (Fig. 6-2).
The spleen is the largest mass of lymphoid tissue in the body.
The spleen acts as a center for erythropoiesis in the fetus and can revert to that
function in adults. It is also a blood reservoir, it cleans or destroys defective red
blood cells, and it acts in the immune response and thus is a protective organ against
disease.
Figure 6-1. Location of the spleen. (Reprinted with permission from Moore KL, Dalley AF,
Agur AM, eds. Clinically Oriented Anatomy. 6th ed. Philadelphia, PA: Wolters Kluwer
Figure 6-2. Vascularity of the spleen. (Images reprinted with permission from Kawamura D,
ed. Diagnostic Medical Sonography: Abdomen and Superficial Structures. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins; 1997:267.)
PATIENT PREPARATION FOR SONOGRAPHY OF THE SPLEEN

Though fasting is often not necessary, it may be helpful in eliminating some adjacent
bowel gas in some individuals, especially if the splenic hilum or splenic vasculature
is of great interest.
A distended stomach, which lies anterior to the spleen, could simulate pathology such
as a pancreatic pseudocyst, so an inquiry should be performed as to the patient’s
fasting status.
3.5–5-MHz transducer
Higher frequencies can be used for thin patients and a small-footprint transducer may
be required to visualize through narrow intercostal spaces

SPLEEN2,3
Laboratory values are listed in Table 6.1.
Critical clinical history questions related to the spleen2:
History of splenectomy? Not only will the spleen be absent, but the motive for the
previous splenectomy may be relevant.
History of splenic or left upper quadrant trauma? If the patient has a history of
splenic trauma, there may be evidence of such trauma upon sonographic
investigation, such as a notable laceration or hematoma. If trauma occurred long ago,
calcifications may be present in the spleen representing a chronic hematoma.
History of sickle cell anemia? Sickle cell is most often found in African-American,
Middle East, Mediterranean, and Hispanic children of Caribbean descent in the
United States. Splenomegaly may be initially present, but with time the spleen can
appear exceedingly irregular and can even waste away.
Table 6- LAB FINDINGS AND POSSIBLE ASSOCIATED SPLENIC

1 PATHOLOGY

↑ WBC (leukocytosis) Inflammation, infection, hemorrhage, carcinoma, or
acute leukemia
↓ WBC (leukopenia) Radiation therapy, chemotherapy, lupus, vitamin B12
deficiency, viral infections, leukemia, and diabetes
mellitus
↓ Hematocrit Splenic hemorrhage
NORMAL SONOGRAPHIC DESCRIPTION OF THE SPLEEN2,3

The spleen is typically isoechoic to the normal liver, though it may be slightly more
echogenic.
The left kidney is normally more hypoechoic than the spleen.

SPLEEN
Survey the spleen in transverse or longitudinal:
Ask the patient to extend his or her left arm up above his or her head in order to
With the patient in the supine position, obtain a brief survey of the spleen by scanning
superiorly and inferiorly (transverse) or anterior to posterior (longitudinal).
Obtain a brief video clip of the spleen in longitudinal and transverse (Video 6-1
and Video 6-2).
Longitudinal spleen (Fig. 6-3):
Supine interrogation may be helpful for some patients, though the right lateral
decubitus position is most often employed.
Transducer placement is typically along the left midaxillary line, between the
intercostal spaces, which results in a coronal section of the spleen (often labeled
longitudinal or sagittal).
The index or notch on the transducer may need to be tilted or angled slightly
posteriorly to obtain the entire length of the spleen (Fig. 6-4).
Deep inspiration results in inferiorly displacing the spleen. Conversely, complete
expiration may be helpful with some patients.
An attempt to visualize both the superior and inferior aspects of the spleen should be
made.
Figure 6-3. Longitudinal spleen. A, B: Longitudinal spleen at the level of the splenic
hilum (arrows). (Image A courtesy of Philips Medical System, Bothell, WA.)
Figure 6-4. Transducer placement for longitudinal spleen images. A: Transducer

placement is typically along the left midaxillary line, between the intercostal spaces,
which results in a coronal section of the spleen (often labeled longitudinal or
sagittal). B: T he index or notch on the transducer may need to be tilted or angled
slightly posteriorly to obtain the entire length of the spleen. (Reprinted with
permission from Cosby KS, Kendall JL, eds.Practical Guide to Emergency Ultrasound. 2nd
ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.)
Several images may be needed to completely demonstrate the sagittal spleen.

The spleen can be scanned completely by angling or manipulating the transducer
through the intercostal spaces from anterior to posterior.
The spleen should be uniform in echogenicity, though occasionally small, anechoic
blood vessels may be noted within the parenchyma and can be thus proven to be
vascular structures with color Doppler.
An evaluation of the spleen for solid masses, cysts, and adjacent fluid collections and
lacerations or hematomas should be performed when trauma has occurred.
Figure 6-5. Left-sided pleural effusion. An anechoic fluid collection (arrow) above
the diaphragm in this patient, representing a pleural effusion. This patient also has a
splenic mass (M). (Reprinted with permission from Layon AJ, Gabrielli A, Yu M, Wood KE,
eds. Civetta, Taylor, & Kirby’s Critical Care Medicine. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2017.)
The right hemidiaphragm should be assessed for signs of pleural fluid (Fig. 6-5).
If required, a longitudinal measurement of the spleen can be obtained (Fig. 6-6).
Transverse spleen (Fig. 6-7):
Supine interrogation may be helpful for some patients, though the right lateral
decubitus position is most often employed.
The transducer should be placed in an orthogonal plane (90°) to the longitudinal
image obtained.
The spleen should be scanned completely from superior to inferior in the transverse
plane.
The spleen should be uniform in echogenicity, though occasionally small, anechoic
blood vessels may be noted within the parenchyma and can be thus proven to be
vascular structures with color Doppler.
Figure 6-6. Longitudinal spleen with measurement. Longitudinal measurement of the
spleen (between calipers) at the level of the midaxillary line demonstrating the
splenic hilum (arrowhead). T he spleen measures upper limits of normal. T he spine
(S) can also be seen. (Reprinted with permission from Sanders RC, eds.Clinical
Figure 6-7. Transverse image of the spleen. A, B: Transverse image of the spleen at
the level of the splenic hilum (arrows). (Reprinted with permission from Erkonen W E,
Smith W L, eds. Radiology 101. 2nd ed. Philadelphia, PA: Lippincott W illiams & W ilkins;
2004.)
Figure 6-8. Transverse spleen with measurement. Transverse measurements of the

spleen (between calipers). T his spleen measured upper limits of normal in the
longitudinal plane demonstrated in Figure 6-6. T he area of the stomach (ST) can
also be seen. (Reprinted with permission from Sanders RC, ed.Clinical Sonography: A
Practical Guide. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
The spleen should be evaluated for solid masses, cysts, and adjacent fluid collections
and lacerations or hematomas when trauma has occurred.
The left hemidiaphragm should be assessed for signs of pleural fluid.
If required, a longitudinal measurement of the spleen can be obtained (Fig. 6-8).
Additional images:
Longitudinal or transverse splenic hilum with color Doppler (Fig. 6-9):
Longitudinal orientation may require angling the transducer slightly anterior to see
the medially positioned splenic hilum.
This image is useful when analyzing the splenic hilum for signs of dilated
varicosities associated with splenomegaly and portal hypertension.
Figure 6-9. Color Doppler of the splenic hilum. T his transverse view of the spleen was
taken with the patient supine. T he color box has been reduced to the area of the
splenic hilum (arrowheads). T he curvilinear diaphragm appears as an echogenic
structure (arrow). A rib produces a reverberation artifact and shadowing (open arrow).
T he splenic vein is demonstrated by the large blue-colored structure in the center of
the splenic hilum and the color box. (Reprinted with permission from Sanders RC, ed.
Clinical Sonography: A Practical Guide. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
SCANNING TIPS
Don’t be too quick to place the patient in right lateral decubitus position, because in
some individuals the spleen may be evaluated better in the supine position.
Occasionally, the spleen of thin or pediatric patients may be assessed from posterior,
through the back musculature.
In the right lateral decubitus position, for patients with a large disparity between the
waste and the hips, place a positioning sponge or pillow under the patient’s right side
to lessen the disproportion.
Some patients may have an accessory spleen, most likely located in the area of the
splenic hilum (Fig. 6-10).
Splenomegaly is often suspected sonographically if the spleen extends beyond the
inferior pole of the left kidney in the sagittal plane.
Lymphoma and leukemia may manifest as splenomegaly or focal masses may be
identified.
Figure 6-10. Accessory spleen. Transverse (A) and longitudinal (B) images of the
spleen (S) with an adjacent accessory spleen (arrows) noted in the area of the splenic
hilum. (Reprinted with permission from Sanders RC, ed.Clinical Sonography: A Practical
Guide. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
NORMAL MEASUREMENTS OF THE SPLEEN*3

Length = 12–13 cm
Anteroposterior = <8 cm
Transverse dimension = <4 cm
ESSENTIAL SPLENIC PATHOLOGY2

Splenomegaly—enlargement of the spleen (Fig. 6-11):
Clinical findings:
Palpable, enlarged spleen
History of cirrhosis, leukemia, or lymphoma
Hemolytic abnormality like sickle cell
Trauma
Infection
Elevated WBC and/or red blood cell count
Enlargement of the spleen based on measurements
Spleen notably extends beyond the inferior pole of the left kidney in sagittal
Splenic trauma—the spleen is often injured in cases of blunt trauma (Fig. 6-12):
Clinical findings:
Blunt trauma to the left upper quadrant
Left upper quadrant pain
Possible decreased hematocrit
Evidence of hemorrhage may be found within and/or around the spleen
Acute hemorrhagic stage—complex or hypoechoic
Middle stage—echogenic or isoechoic
Later stage—anechoic or hypoechoic
Chronic stage—complex appearance and may have calcified components
Figure 6-11. Splenomegaly. In the sagittal plane, this spleen is notable large in
comparison to the left kidney. (Reprinted with permission from Kawamura D, Nolan T,
eds. Abdomen and Superficial Structures. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 6-12. Splenic trauma and rupture. A: Longitudinal image of a ruptured spleen
with a notable laceration (small arrows) and blood adjacent to the spleen (larger
arrow). B: Transverse image of the same patient with color Doppler applied. Note
that splenomegaly is also evident on these images. (Images courtesy of Philips
Medical System, Bothell, WA.)
Figure 6-13. Splenic hemangioma. Two hyperechoic masses (arrows) are noted
within this spleen. (Reprinted with permission from Siegel MJ, Coley B, eds.Core
Curriculum: Pediatric Imaging. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.)
Hemangioma—a common benign mass of the spleen that consists of blood vessels
(Fig. 6-13):
Clinical findings:
Asymptomatic
Hyperechoic mass
Splenic infarct—tissue death to a portion of the spleen that results from the
deprivation of oxygen (Fig. 6-14):
Clinical findings:
Patient may have sudden onset of left upper quadrant pain.
Patient may be suffering from sickle cell anemia, bacterial endocarditis, vasculitis,
or lymphoma.
Acute infarct—hypoechoic, wedge-shaped mass within the spleen
Chronic infarct—hyperechoic, wedge-shaped mass within the spleen
Figure 6-14. Splenic infarct. A hypoechoic, wedge-shaped mass (between arrows) is

noted within this spleen representing a splenic infarct. (Reprinted with permission from
WHERE ELSE TO LOOK2

Children with sickle cell anemia are prone to develop gallstones, so a thorough
assessment of the gallbladder may be reasonable.
Implantations of ectopic splenic tissue can be the result of splenic rupture, a condition
referred to as splenosis. These implants can be dispersed throughout the abdomen and
can simulate solid masses. Clinical evaluation is vital for the diagnosis of this
condition.
IMAGE CORRELATION
Normal spleen on CT (Fig. 6-15)
Splenomegaly on CT (Fig. 6-16)
Splenic trauma on CT (Fig. 6-17)
Figure 6-15. CT of a normal spleen. (Reprinted with permission from Smith W L, ed.
Radiology 101. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams & W ilkins;
2013.)
Figure 6-16. Splenomegaly on CT. A dramatically enlarged spleen (arrow) is noted on
the CT image of the abdomen. (Reprinted with permission from Silberman H, Silberman AW,
e d s . Principles and Practice of Surgical Oncology. Philadelphia, PA: Wolters Kluwer
Figure 6-17. Splenic trauma on CT. Splenic trauma in a 12-year-old girl after a
snowboarding accident. Axial contrast-enhanced CT image shows a large splenic
laceration (arrow) with devascularization of a portion of the splenic parenchyma.
(Reprinted with permission from Lee E, ed. Pediatric Radiology: Practical Imaging Evaluation of
Infants and Children. Philadelphia, PA: Wolters Kluwer; 2017.)
REFERENCES
* Women typically have a smaller spleen than men, and the spleen often decreases in size with advancing
age.
CHAPTER 7
Abdominal Aorta and Inferior Vena Cava

INTRODUCTION
This chapter will provide a sonographic protocol for imaging of the abdominal aorta
and inferior vena cava (IVC). Also, vasculature assessment of the various branches
of the abdominal aorta and IVC will be provided. However, assessment of the portal
venous system can be found in Chapter 3, while the evaluation of renal vasculature is
mentioned in this chapter and further information can be found in Chapter 5.

ABDOMINAL AORTA AND IVC
Assess the abdominal aorta and IVC in the following manner:
The abdominal aorta should be examined when there is a palpable or pulsatile
abdominal mass or bruit.
The abdominal aorta should be examined when there is unexplained lower back pain,
flank pain, or abdominal pain.
The abdominal aorta should be examined as a follow-up of previously demonstrated
abdominal aortic aneurysm (AAA) or to assess a previously instilled abdominal
aortic and/or iliac endoluminal stent graft.
The IVC should be evaluated for abnormalities, patency, vena cava filters,
interruption devices, and catheters and their location in respect to the hepatic veins
and/or renal veins.

Abdominal aorta:
The aorta originates at the left ventricle of the heart (Fig. 7-1).
Figure 7-1. Anatomy of the abdominal aorta and its branches. (Reprinted with
permission from Kupinski AM, ed. The Vascular System. 2nd ed. Philadelphia, PA: Wolters
Kluwer; 2017.)
The abdominal aorta, which is the largest artery in the abdomen, is located just left of
the midline within the retroperitoneum.
The abdominal aorta tapers as it travels inferiorly from the diaphragm.
The major branches of the abdominal aorta from superior to inferior include the
following:
Celiac artery:
The celiac artery, also referred to as the celiac trunk or celiac axis, branches into
the common hepatic artery, splenic artery, and left gastric artery.
Superior mesenteric artery
Renal arteries (right and left)
Inferior mesenteric artery
Common iliac arteries (right and left)
Also referred to as the aortic bifurcation
The function of the abdominal aorta is to provide oxygenated blood to the abdomen,
pelvis, and lower extremities.
Figure 7-2. Anatomy of the inferior vena cava and its tributaries. (Reprinted with
permission from Kupinski AM, ed. The Vascular System. Philadelphia, PA: Wolters Kluwer
IVC:
The IVC is created by the union of the two common iliac veins (Fig. 7-2).
The IVC travels cephalad, coursing through the abdomen right lateral to the aorta and
posterior to the liver.
The IVC terminates at the right atrium.
The major veins that drain into the IVC from superior to inferior include the
following:
Hepatic veins (right, middle, and left)
Renal veins (right and left)
Common iliac veins (right and left)
The primary function of the IVC is to return blood from the abdomen back to the
heart.

ABDOMINAL AORTA AND IVC1
Fasting for 8–12 hrs for a sonogram of the abdominal aorta and IVC commensurate
with a complete abdomen examination would be optimal, though emergency
sonograms may need to be immediately performed without patient preparation.
SUGGESTED EQUIPMENT 1,2

Some machines may have abdominal aorta settings, while others may suggest the
general abdominal setting.
For adults, mean frequencies between 4 and 6 MHz are most commonly used.
However, for patients with increased abdominal girth lower frequencies may be
warranted for better penetration.

Laboratory values are listed in Table 7-1.
Critical clinical history questions related to the abdominal aorta and IVC:
Do you have a history of smoking or atherosclerosis? Patients who smoke or who
have atherosclerosis are at increased risk for thrombosis and AAAs.
Do you have pain in the legs, hip, or buttocks after exercise (This is referred to as
claudication and it is secondary to decreased blood supply)? Claudication can be a
sign of vascular obstruction, peripheral artery disease, and aneurismal involvement
of the abdominal aorta or iliac arteries.
Do you have back and/or chest pain? Back and/or chest pain is a symptom of
aneurysms and rupture.
Do you have pain at rest in your limbs? This is a sign of ischemic rest pain and it is
associated with vascular compromise to the extremities which may be associated
with an aneurysm.
History of abdominal surgery or AAA repair? This is important information to have
before beginning the examination. Any pertinent history, such as the preoperative size
of the aneurysm and the type and date of repair is most beneficial.
Table 7- LAB FINDINGS AND POSSIBLE ASSOCIATED AORTIC

1 PATHOLOGY

↑ WBC Inflammation, infection, hemorrhage, or carcinoma
(leukocytosis)
↓ Hematocrit Aortic rupture
NORMAL SONOGRAPHIC DESCRIPTION OF THE ABDOMINAL

AORTA AND IVC
Abdominal aorta:
The abdominal aorta appears as an anechoic tube that begins below the diaphragm
and extends down to the umbilicus, where it bifurcates into the common iliac arteries.
The abdominal aorta is located anterior to the spine and just left of the midline.
IVC:
The abdominal portion of the IVC appears as an anechoic tube that travels from the
diaphragm on the right side, just behind the liver, to the umbilicus where the common
iliac veins join.
The diameter of the IVC can vary with respiration. Suspending respiration will
initially cause the IVC to reduce in diameter, while prolonged suspension of
respirations will cause the IVC to increase in diameter.

ABDOMINAL AORTA AND IVC2
Survey the abdominal aorta in longitudinal or transverse:
With the patient in the supine position, obtain a brief survey of the abdominal aorta
by scanning superior to inferior in longitudinal or transverse.
Assess the abdominal aorta for focal enlargement and intraluminal abnormalities.
Obtain a brief video clip of the abdominal aorta (Video 7-1).
Longitudinal proximal aorta:
Image the proximal abdominal aorta along the long axis of the lumen of the vessel.
Demonstrate the celiac axis and superior mesenteric artery.
Obtain images with and without an anteroposterior measurement of the proximal
abdominal aorta from the outer edge to outer edge (Fig. 7-3).
If an AAA is present, document and record the maximal size and location of the
aneurysm. The relationship of the dilated segment to the renal arteries and to the
aortic bifurcation should be determined if possible.
Figure 7-3. Longitudinal proximal abdominal aorta with measurement. A, B:
Longitudinal image of the proximal aorta (Prox AO), including the celiac artery
(Celiac), superior mesenteric artery (SM A), splenic artery (Splenic), pancreas (Panc),
and left lobe of the liver (Lt lobe liver).
Longitudinal mid aorta:
Image the mid abdominal aorta along the long axis of the lumen of the vessel.
Demonstrate the level of the renal arteries.
Obtain images with and without an anteroposterior measurement of the mid
abdominal aorta from the outer edge to outer edge (Fig. 7-4).
Longitudinal distal aorta:
Image the distal abdominal aorta along the long axis of the vessel.
Demonstrate the distal aorta above the iliac bifurcation.
Obtain images with and without a measurement of the distal abdominal aorta from the
anterior outer edge to outer edge (Fig. 7-5).
Transverse proximal abdominal aorta:
Image the proximal abdominal aorta perpendicular to the long axis of the vessel (Fig.
7-6).
Demonstrate the abdominal aorta below the diaphragm, near the celiac axis.
Obtain images with and without a width measurement of the proximal abdominal
aorta from the outer edge to outer edge.
Transverse mid aorta:
Image the mid abdominal aorta perpendicular to the long axis of the vessel.
Demonstrate the level of the renal arteries (Fig. 7-7).
Obtain images with and without a width measurement of the mid abdominal aorta
from the outer edge to outer edge.
Figure 7-4. Longitudinal mid abdominal aorta with measurement. A,B: Longitudinal
mid abdominal aorta with measurement.
Figure 7-5. Longitudinal distal abdominal aorta with measurement. A,B: Longitudinal
image of the distal aorta with measurement obtained just proximal to the bifurcation.
Figure 7-6. Transverse proximal celiac level. A,B: Transverse image of the proximal
aorta (AO) at the level of the celiac artery (Celiac). Also noted are the spine, inferior
vena cava (IVC), hepatic artery (Hep), left lobe of the liver (Lt lobe liver), and the
pancreas (Panc).
Figure 7-7. Transverse mid abdominal aorta renal level with measurement. A,B:
Transverse at the level of the renal vessels. C: Diagram of the typical orientation of
the renal vessel in transverse. AO, aorta; IVC, inferior vena cava; LRA, left renal
artery; LRV, left renal vein; RRA, right renal artery; SM A, superior mesenteric artery.
(Part A reprinted with permission from Cosby K, Kendall J, eds.Practical Guide to
Emergency Ultrasound. Philadelphia, PA: Lippincott W illiams & W ilkins; 2006:227. Part C
reprinted with permission from Zierler RE, Dawson DL, eds.Strandness’s Duplex Scanning
in Vascular Disorders. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Transverse distal aorta:
Image the distal abdominal aorta perpendicular to the long axis of the vessel.
Demonstrate the aorta just above the iliac bifurcation (Fig. 7-8).
Obtain images with and without a width measurement of the distal abdominal aorta
from the outer edge to outer edge.
Figure 7-8. Transverse distal abdominal aorta. A,B: Transverse image of the
abdominal aorta (AO) just proximal to the aortic bifurcation.
Common iliac arteries:

Longitudinal images of the proximal right and left common iliac arteries should be
obtained. These images should be obtained along the long axis of each vessel (Fig.
7-9).
Transverse images of the proximal right and left common iliac arteries should be
obtained. These images should be obtained perpendicular to the long axis of each
vessel (Fig. 7-10).
Measurement of the widest portion of each common iliac artery should be obtained
from outer edge to outer edge.
If an iliac artery aneurysm is present, the maximal size and location of the aneurysm
should be documented and recorded.
Figure 7-9. Longitudinal oblique image of the proximal common iliac arteries. T his
image demonstrates the distal aorta with the bifurcation, including both the left
common iliac artery (LCIA) and right common iliac artery (RCIA).(Image courtesy of
Philips Medical System, Bothell, WA.)
Longitudinal and transverse IVC:

The hepatic section of the IVC can be demonstrated in longitudinal.
The renal section of the IVC can be demonstrated in the longitudinal and transverse
plane (Fig. 7-11).
The infrarenal section of the IVC can be demonstrated in the longitudinal and
transverse plane.
Additional images1,3:
Color Doppler and/or spectral Doppler imaging with waveform analysis of the aorta
and iliac arteries may be helpful to demonstrate patency and the presence of
intraluminal thrombus.
Suprarenal aorta = low-resistance flow (Fig. 7-12)
Infrarenal aorta = high-resistance flow (Fig. 7-13)
Some facilities may require an additional assessment of the kidneys when the
abdominal aorta is being examined and vice versa.
Figure 7-10. Transverse image of the bifurcation of the aorta. In this image, the right
iliac artery (RI) and left iliac artery (LI) are seen slightly anterior to the inferior vena
cava (IVC) and distal vertebral body (VB). (Reprinted with permission from Cosby KS,
Kendall JL, eds. Practical Guide to Emergency Ultrasound. 2nd ed. Philadelphia, PA:
Extended field of view, dual imaging, and landscape images can provide further
documentation as to the relationship of an AAA.
A Doppler assessment of the main branches of the abdominal aorta may be
performed1,3:
Celiac artery = low-resistance flow:
Common hepatic artery = low-resistance flow
Splenic artery = low-resistance flow
Superior mesenteric artery:
Fasting patient = high-resistance flow (Fig. 7-14)
30–90 min postprandial = low-resistance flow
Renal arteries = low-resistance flow
Common Iliac arteries = high-resistance flow
Color Doppler and/or spectral Doppler imaging with waveform analysis of the IVC
may be helpful to demonstrate patency and the presence of intraluminal thrombus.
IVC = pulsatile near the heart and more phasic near the common iliac veins (Fig. 7-
15)
Hepatic veins = pulsatile, triphasic flow pattern
Renal veins = low-velocity, continuous flow
Figure 7-11. Longitudinal image of the inferior vena cava. A,B: Longitudinal image of
the inferior vena cava (IVC). Also demonstrated are the left lobe of the liver, pancreas
(PANC), and right renal artery (RRA), which is located posterior to the IVC.
Figure 7-12. Low-resistance spectral waveform superior to the celiac artery. (Reprinted
with permission from Kupinski AM, ed. The Vascular System. Philadelphia, PA: Wolters Kluwer
Figure 7-13. Higher-resistance spectral waveform in the distal aorta. (Reprinted with
Kluwer; 2017.)
Figure 7-14. Normal high-resistance flow of the superior mesenteric artery. (Reprinted
with permission from Kupinski AM, ed. The Vascular System. 2nd ed. Philadelphia, PA: Wolters
Kluwer; 2017.)
Figure 7-15. Normal inferior vena cava Doppler analysis. T he flow within the IVC
demonstrates slight pulsatility caused by the proximity of the heart. (Reprinted with
Kluwer; 2017.)
SCANNING TIPS4,5
Deep inspiration or complete expiration may assist in visualizing parts of the
abdominal aorta.
Scanning from the left flank, with the patient in the left lateral decubitus position, may
assist in the visualization of the middle to distal abdominal aorta in obese patients.
NORMAL MEASUREMENTS OF THE ABDOMINAL AORTA AND

IVC1,3–5
Abdominal aorta:
Supraceliac = 2.5–2.7 cm in men and 2.1–2.3 cm in women
Infrarenal = 2.0–2.4 cm in men and 1.7–2.2 cm in women
Common iliac arteries = <1.5 cm
IVC:
2.5 cm or less
ESSENTIAL ABDOMINAL AORTA AND IVC PATHOLOGY3

AAA—enlargement of the abdominal aorta:
Clinical findings:
Pulsatile abdominal mass
Abdominal bruit
Back pain
Abdominal pain
Lower-extremity pain (claudication)
Diameter of the aorta measures >3 cm (Fig. 7-16).
Thrombus is found within the aorta.
Old thrombus may calcify and shadow.
Most AAAs are located infrarenal and many involve the common iliac arteries.
Most AAAs are fusiform, which is a gradual enlargement of the abdominal aorta.
Abdominal aortic dissection—separation of the layers of the wall of the abdominal
aorta
Clinical findings:
Intense chest pain
Hypertension
Abdominal pain
Lower back pain
Neurologic symptoms
Figure 7-16. Abdominal aortic aneurysm. A: Normal aortic diameter (between
calipers) with an aneurysm visualized distally. B: An abdominal aortic aneurysm is
noted (between calipers). (Reprinted with permission from Kawamura D, Lunsford B,
eds . Abdomen and Superficial Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer
Possible AAA
Intimal flap may be noted (Fig. 7-17)
IVC thrombosis—clot within the IVC:
Clinical findings:
History of venous thrombus and blood clotting issues
Figure 7-17. Aortic dissection. A,B: An intimal flap (arrow) is noted in the presence
of an aortic dissection, which also has a true (T ) and false (F) lumen. (Reprinted with
Figure 7-18. Inferior vena cava thrombus. T hrombus is noted with the inferior vena
cava (arrow). (Reprinted with permission from Penny SM, ed.Examination Review for
Ultrasound. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.)
Hyperechoic clot within the lumen of the IVC (Fig. 7-18)
Thrombus may be isoechoic to surrounding blood
Present, diminished, or absent flow (occluded) within the IVC
WHERE ELSE TO LOOK

Often, the kidneys need to be evaluated in relationship to an AAA. Assess vascular
compromise to the kidneys by evaluating the main renal arteries and their branches
and renal veins.
When an AAA is noted, evaluate associated enlargement of the common iliac arteries.
IMAGE CORRELATION
AAA on CT (Fig. 7-19)
AAA on MRI (Fig. 7-20)
Figure 7-19. Computed tomography of an AAA. A: Typical appearance of an AAA on CT.
B: Computed tomography angiogram image of an AAA. (Reprinted with permission from
Madden M, ed. Introduction to Sectional Anatomy. 3rd ed. Philadelphia, PA: Wolters Kluwer
Figure 7-20. M RI coronal image of an AAA.(Reprinted with permission from Higgins CB, de
Roos A, eds. MRI and CT of the Cardiovascular System. 3rd ed. Philadelphia, PA: Wolters
REFERENCES
1. Kupinski AM. The Vascular System. 2nd ed. Philadelphia, PA: Wolters Kluwer;
2018:309–334, 353–362.
2. AIUM practice parameter for the performance of diagnostic and screening ultrasound
examinations of the abdominal aorta in adults.
https://www.aium.org/resources/guidelines/abdominalAorta.pdf. Accessed
September 15, 2018.
4. Rumack CM, Wilson SR, Charboneau JW, Levine D.Diagnostic Ultrasound. 4th ed.
Philadelphia, PA: Wolters Kluwer; 2016:381–389, 488–494, 536–538.
CHAPTER 8
Gastrointestinal Tract
INTRODUCTION
Though sonography is somewhat limited in its capacity for the analysis of the
gastrointestinal (GI) tract, there are several examinations in which sonography
excels. For example, pyloric stenosis, intussusception, and appendicitis are three
diagnoses that can be achieved solely with sonography. This chapter will include
these three frequently conducted examinations and more information vital for the
abdominal sonographer to appreciate in regards to sonography of the GI tract.
AIUM RECOMMENDATION FOR SONOGRAPHY OF THE GI

TRACT 1
Assess the GI tract in the following manner:
When there is concern for bowel pathology, the bowel may be evaluated for wall
thickening, dilatation, muscular hypertrophy, masses, vascularity, and other
abnormalities.
Sonography of the pylorus and surrounding structures may be indicated in the
evaluation of the vomiting infant.
Graded compression sonography aids in the visualization of the appendix and other
bowel loops.
Measurements may aid in determining bowel wall thickening, and color or power
Doppler imaging may be helpful in assessing hypervascularity.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE GI TRACT 2–4

General bowel anatomy and physiology
The major sections of the GI tract include the mouth, esophagus, stomach, small
intestine, and the large intestine or colon (Fig. 8-1).
Figure 8-1. Gastrointestinal tract anatomy. (Reprinted with permission from Kawamura
D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2017.)
The movement of foods and waste products through the GI tract is via segmentation,
contractile motion, and peristalsis.
The stomach provides a temporary storage place for ingested foods and liquids.
The majority of digestion and nutrient absorption occurs in the small intestines.
The small intestine can be divided into the duodenum, jejunum, and ileum.
The colon, which provides a frame around the small intestine, is responsible for
water absorption and the creation of feces.
The colon can be divided into the cecum, ascending colon, transverse colon,
descending colon, rectum, and anus.
The layers of the bowel wall include the superficial mucosa, deep mucosa,
submucosa, muscularis propria, and serosa. These layers typically offer what is
referred to as gut signature with sonography (Figs. 8-2 and 8-3).
Anatomy and physiology of infantile hypertrophic pyloric stenosis (IHPS)2,3,5
The stomach consists of the fundus, body, and pyloric region or pylorus; the latter is
the most distal portion (Fig. 8-4).
The pylorus consists of the pyloric antrum, which is the opening to the body of the
stomach, and the pyloric canal, which is the pathway to the duodenum.
The pyloric sphincter is typically located slightly right lateral of the midline of the
abdomen, and it controls gastric emptying and is located between the pylorus and the
proximal portion of the duodenum.
IHPS is a defect in the contractility of the pyloric sphincter of the stomach whereby
the sphincter does not permit proper gastric emptying, thus resulting in a gastric outlet
obstruction (Fig. 8-5).
IHPS can lead to projectile vomiting, severe dehydration, and weight loss.
Anatomy and physiology of intussusception
Intussusception is the invagination or telescoping of a proximal section of bowel into
a distal section.
Figure 8-2. Intestinal wall layers. Diagram showing the components of the intestinal
wall with the associated sonographic appearance. (Reprinted with permission from
Sanders RC, ed. Clinical Sonography: A Practical Guide. 5th ed. Philadelphia, PA: Wolters
Kluwer; 2015.)
Figure 8-3. Gut signature. Stratified bowel wall, gut signature. 1: Echogenic superficial
mucosa. 2: Hypoechoic deep (muscularis) mucosa. 3: Echogenic submucosa. 4:
Hypoechoic muscularis propria. 5: Echogenic serosa. (Image courtesy of Kassa Darge,
MD.)
Figure 8-4. Anatomy of the stomach. (Reprinted with permission from Moore KL, Agur AM,
Dalley AF, eds. Essential Clinical Anatomy. 5th ed. Philadelphia, PA: Wolters Kluwer
Figure 8-5. Pyloric stenosis. A: Normally fluid and food products are allowed to travel
freely through the pyloric canal (arrow) . B: With pyloric stenosis, the pyloric
sphincter muscles are thickened and produce a gastric outlet obstruction, inhibiting
the fluid and food products from exiting the stomach. (Reprinted with permission from
Moore KL, Dalley AF, Agur AM, eds.Clinically Oriented Anatomy. 7th ed. Philadelphia, PA:
The proximal portion of the bowel is referred to as the intussusceptum and the distal
portion of the bowel is the intussuscipiens (Fig. 8-6).
Intussusception can occur at any location, but it most often occurs in the right lower
quadrant in the area of the ileocecal valve, and is thus referred to as an ileocolic
intussusception.
Intussusception results in a bowel obstruction and can lead to bowel ischemia and
gangrene of the bowel.
Anatomy and physiology of the appendix3,6
The appendix is a tubular structure that has a base that opens into the cecum and a
head or tip.
The appendix is most likely located near the ileocecal valve in the right lower
quadrant of the abdomen at an area referred to as McBurney point, but its location
can vary.
McBurney point is established by drawing an imaginary line from the right anterior
superior iliac spine along the spinoumbilical line, with the appendix most likely
located one-third of the total distance of the line from the iliac spine (Fig. 8-7).
The location of the appendix can vary during pregnancy (Fig. 8-8).
The function of the appendix is uncertain, though it may serve as a reservoir for
beneficial gut flora, and thus may play a role in gut immunity.
Figure 8-6. Intussusception. Intussusception is the telescoping of a proximal section of
bowel (intussusceptum) into a distal segment (intussuscipiens). (Reprinted with
permission from Fiser SM, ed. ABSITE Review. 3rd ed. Philadelphia, PA: Wolters Kluwer
Figure 8-7. Location of McBurney point and the other potential locations of the
appendix. McBurney point is established by drawing an imaginary line from the right
anterior superior iliac spine along the spinoumbilical line, with the appendix most likely
located one-third of the distance from the right iliac spine. (Reprinted with permission
from Romans L, ed. Computed Tomography for Technologists. Philadelphia, PA: Wolters
Figure 8-8. Various locations of the appendix during pregnancy. (Reprinted with
permission from Beall M, Ross MH, eds.Lippincott’s Obstetrics Case-Based Review.
PATIENT PREPARATION FOR SONOGRAPHY OF THE GI

TRACT 3
General bowel assessment
Sonography should be performed before any imaging requiring barium contrast
agents.
No preparation is typically required, though if the stomach or duodenum is of interest
10–40 oz of water may be ingested through a straw. Waiting 10–15 min after the
administration of the water is suggested before commencing the sonographic
assessment of the stomach.*
A sonogram of the distal colon could possibly require a water enema, especially if
an intraluminal mass is suspected.
IHPS
The infant will need a partially distended stomach.
If there is not enough fluid within the pyloric antrum to highlight the pyloric sphincter,
then a small amount of glucose solution may be administered orally or via a
nasogastric tube.
An assistant may be required to hold the infant in the right lateral decubitus position
and is most helpful.
Intussusception
No patient preparation is required.
agents.
Appendix
No patient preparation is required.
agents.
SUGGESTED EQUIPMENT 3,7

Stomach = 3.5- or 5-MHz curved transducer (wall analysis requires higher
frequency)
Small bowel = 2- to 5-MHz curved transducer or 7.5- to 14-MHz linear transducer
Colon = 2- to 5-MHz curved transducer
Rectal = 7.5-MHz rectal transducer
IHPS
7.5-MHz or higher linear transducer
Glucose solution
Bottle with nipple
Intussusception
3.5- or 5-MHz curved transducer
7.5-MHz transducer or higher
Appendix
7.5-MHz transducer or higher
3.5- or 5-MHz curved transducer
CLINICAL INVESTIGATION FOR SONOGRAPHY OF THE GI

TRACT
Laboratory values are listed in Table 8.1.
Critical clinical history questions related to the GI tract
Localized abdominal pain? General abdominal discomfort may not yield a
significant imaging finding. Thus, an inquiry should be made as to the focal point of
most pain in the abdomen. Scanning over the area of pain can be constructive.
History of vomiting or diarrhea? If the patient has a recent history of vomiting, an
inquiry of the frequency should be obtained. The incidence of diarrhea should be
obtained as well. Inquire about the time in which these disorders began.
Previous abdominal surgery? This is a vital question for any abdominal imaging
study. This also reveals the overall health of the individual.
Unexplained weight loss? This question can offer a general assessment of the
patient’s health and could be an indicator for the presence of a possible malignant
process.
Table 8-1 LAB FINDING AND POTENTIAL GI TRACT PATHOLOGY
LAB FINDING POTENTIAL GI TRACT PATHOLOGY

↑ WBC Bowel inflammation or infection (e.g., diverticulitis,
appendicitis, intussusception, enterocolitis, etc.)
IHPS
First-born male? IHPS most often manifests in first-born, white male babies
between 2 and 6 wks following delivery.
Nonbilious, projectile vomiting? IHPS is most often associated with nonbilious
(does not contain bile), projective vomiting.
Weight loss? Weight loss is often associated with IHPS. Weight gain may be
associated with another diagnosis.
Dehydration? Dehydration is common in infants with IHPS because of the lack of
fluid absorption.
Physician prescribed adjustments to feeding (e.g., change in milk formula)? The
infant’s pediatrician may initially try to change the infant’s milk formula if the child
is formula fed.
Physician prescribed acid reflux–reducing medicine? The infant’s pediatrician may
initially try to prescribe an acid reflux–reducing medication.
Palpable hypertrophic pyloric muscle? This is referred to as the olive sign.
Intussusception
Focal abdominal pain? If the child can point with one finger to the area that pains
him or her the most this is most helpful. Remember, most intussusceptions occur
within the right lower quadrant.
Intermittent abdominal pain? Waves of focal pain in the area of the intussusception
may occur.
Red currant jelly stools? A key clinical feature of intussusception is the presence of
red currant jelly stools.
Appendix
Nausea and vomiting? With appendicitis, abdominal pain will typically occur
before the onset of nausea and vomiting.
General abdominal pain? Appendicitis may initially begin with generalized
abdominal pain and then shift to the right lower quadrant.
Localized abdominal pain? An inquiry should be made as to the most focal point of
pain in the abdomen. Scanning over the area of pain can be constructive.
Rebound tenderness? Rebound tenderness is pain that is encountered after the
removal of pressure.
NORMAL SONOGRAPHIC DESCRIPTION OF BOWEL3,4

Normal bowel should be thin walled (Fig. 8-9).
Normal bowel is compressible.
Normal small bowel is often seen even when not distended with fluid or air (Fig. 8-
10).
Colon may be seen to contain fluid or air (Fig. 8-11).
Peristalsis should be noted.
IHPS
The pyloric muscle should be thin.
Upon real-time investigation, the normal pyloric sphincter should be seen opening,
allowing fluid to freely pass from the stomach into the duodenum (Fig. 8-12).
Intussusception
Normal bowel should be thin walled and compressible.
Peristalsis should be noted.
Appendix
Though the location may vary, the normal appendix may be seen as a blind-ended
tube that extends from the base of the cecum in the right lower quadrant (Fig. 8-13).
A normal appendix may not be visualized in adults.
Figure 8-9. Normal bowel wall. Sonographic image of bowel (Bwl) in the right upper
quadrant adjacent to the liver demonstrating the normal sonographic appearance of
the echogenicity of the intestinal wall layers. (Reprinted with permission from Sanders RC,
ed. Clinical Sonography: A Practical Guide. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Figure 8-10. Normal small bowel appearance. A: Longitudinal image of normal small
bowel (between arrows). B: Transverse image of normal small bowel (between arrows).
T he bowel wall is being measured between the calipers. (Images courtesy of Barbara
Hall-Terracciano.)
Figure 8-11. Normal colon appearance. A, B, C are all representative images of the
colon (arrows). (Images courtesy of Philips Healthcare, Bothell, WA.)
Figure 8-12. Normal pylorus. T he double-lined arrow points to the normal pylorus, the
thin white arrow corresponds to fluid within the lumen of the stomach, and the dotted
arrow points to air entering the first part of the duodenum from the stomach during
normal peristalsis. (Image courtesy of Rajesh Krishnamurthy, Radiologist, Texas Children’s
Hospital, Houston, TX.)
Figure 8-13. Normal appendix. Longitudinal image demonstrates the normal thin-walled
appendix (between arrows). (Image courtesy of Philips Healthcare, Bothell, WA.)
SUGGESTED PROTOCOL FOR SONOGRAPHY OF THE GI

TRACT
Survey the area of most discomfort first
When a patient is complaining of localized pain, have him or her point to the area of
most discomfort and begin your assessment at that point, labeling your image “area
of pain.”
Longitudinal and transverse images
Perform an assessment of the bowel in all four quadrants.
Utilize graded compression sonography, obtaining pictures in both longitudinal and
transverse scan planes with and without compression.
Abnormal bowel is typically not compressible and may not yield visual evidence
of normal peristalsis.
Label your images “with compression” and “without compression.”
Evaluate for altered echogenicity of the bowel wall. A focal area of decreased
echogenicity and thickening of the wall is indicative of inflammation.
Use color Doppler to assess for signs of increased vascularity or hyperemia, which
is a sign of inflammation or infection.
Additional images
Several cine loops with and without compression can be beneficial as well.
IHPS
Survey the upper abdomen in transverse and longitudinal
Place the infant in the supine position initially.
Perform a general survey of the infant’s abdomen to assess the distention of the
stomach. If the stomach is too distended, distortion of the anatomy can result and
could inhibit the visualization of the pyloric region of the stomach.
A minimum examination time of 15 min is suggested.7
Longitudinal pylorus (right lateral decubitus)
Place the patient in the right lateral decubitus position. An assistant may be required
because the infant will need to remain in this position.
While the patient drinks the glucose solution, scan the abdomen actively and assess
the pyloric sphincter in real time.
A transverse transducer position on the abdomen will provide a longitudinal view
of the pylorus (Fig. 8-14).
The fluid will fill the pyloric region of the stomach and provide an enhanced view
of the pyloric sphincter.
Fluid seen traveling from the pyloric region of the stomach, through the pyloric
canal and pyloric sphincter, and into the duodenum is indicative of a negative study
for pyloric stenosis.
An enlarged pyloric sphincter will yield the cervix sign in the longitudinal view
(Fig. 8-14B).
Measure the thickness of the pyloric wall and the length of the pyloric channel (Fig.
8-15).
Transverse pylorus (right lateral decubitus)
A longitudinal transducer position on the abdomen will provide a transverse view
of the pylorus (Fig. 8-16).
Figure 8-14. Longitudinal pyloric stenosis. A: Longitudinal view of the pylorus is
accomplished with a transverse abdominal image. B: Longitudinal sonogram of an
enlarged pyloric sphincter (between arrows). (Image A reprinted with permission from
Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer
Health/Lippincott W illiams & W ilkins; 2010; image B reprinted with permission from Penny
SM, ed. Examination Review for Ultrasound. Philadelphia, PA: Wolters Kluwer
Figure 8-15. Pyloric stenosis measurements. A: A positive pyloric stenosis will yield
a thickened wall that measures ê3 mm (between #1 calipers) and a channel that
measures longer than 17 mm (between #2 calipers). B: Since the channel may be
curved, a trace method (between calipers) may also be used to obtain the length
measurement. GB, gallbladder; STOM, stomach; PANC, pancreas.(Image A reprinted
with permission from Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA:
Wolters Kluwer Health/Lippincott W illiams & W ilkins; 2010; image B reprinted with
permission from Penny SM, ed. Introduction to Sonography and Patient Care. Philadelphia,
Figure 8-16. Transverse pyloric stenosis. A: Transverse view of the pylorus is
accomplished with a longitudinal abdominal image. B: Transverse sonogram of an
enlarged pyloric sphincter (between plus signs). (Image A reprinted with permission
from Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer
Health/Lippincott W illiams & W ilkins; 2010; image B reprinted with permission from Penny
SM, ed. Introduction to Sonography and Patient Care. Philadelphia, PA: Wolters Kluwer
Health; 2015.)
Figure 8-17. Hyperemia with pyloric stenosis. Long-axis color Doppler sonogram
shows increased vascularity of the thickened pyloric muscle and underlying
submucosa. (Reprinted with permission from Siegel MJ, ed. Pediatric Sonography. 5th ed.
An enlarged pyloric sphincter will yield the donut sign (Fig. 8-16B).
Additional images
A short cine loop of the fluid moving from the stomach through the pyloric sphincter
and into the duodenum can be most beneficial for establishing a definitive diagnosis.
Color Doppler can be employed and may yield hyperemia within the enlarged
sphincter muscle (Fig. 8-17).
Intussusception
Survey the abdomen in longitudinal and transverse
Place the patient in the supine position.
of pain.”
Utilize the graded compression technique in both longitudinal and transverse scan
planes and scan the entire abdomen, keeping in mind that the majority of
intussusceptions occur in the right lower quadrant in the area of the ileocecal valve.
A positive intussusception will be noncompressible and appear as a doughnut or
cinnamon bun in the transverse plane and have a reniform shape in the longitudinal
plane (Fig. 8-18).
Once identified, measure the intussusception in two orthogonal planes.
Utilize color Doppler to assess for evidence of compromised vascular supply or
signs of inflammation, the latter of which will increase Doppler signals, which is
verification of hyperemia (Fig. 8-19).
Additional images
A short cine loop of the area of interest with and without compression can be
beneficial.
Appendix
Survey the abdomen in longitudinal and transverse
Place the patient in the supine position.
of pain.”
Several cine loops with and without compression can be beneficial as well.
Utilize the graded compression technique in both longitudinal and transverse scan
planes and scan the region of interest, keeping in mind that the appendix is typically
located within the right lower quadrant.
Figure 8-18. Intussusception. A: T he gray scale transverse image of the right upper
quadrant shows a large donut-shaped structure (arrowheads) with concentric
hypoechoic and hyperechoic rings. B: T he flow seen on a color Doppler transverse
image suggests viable bowel. C, D: Transverse and longitudinal images from a
different patient demonstrating the donut sign in transverse plane and telescoping
bowel in longitudinal plane typical of intussusception. (A and B: Images courtesy of
Rechelle Nguyen, Columbus, OH; C and D: Reprinted with permission from Siegel MJ, ed.
Pediatric Sonography. 5th ed. Philadelphia, PA: Wolters Kluwer Health; 2018.)
Figure 8-19. Color Doppler of intussusception. Color Doppler sonogram shows flow
in the intussuscepted loop of bowel. (Reprinted with permission from Siegel MJ, ed.
Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams
& Wilkins; 2010.)
Identify the ascending colon and slowly manipulate the transducer throughout the
right lower quadrant from superior to inferior.
Measure the appendix when identified.
An enlarged appendix will appear as a noncompressible sausage-shaped, blind-
ended aperistaltic tube that measures more than 6 mm in diameter (Figs. 8-20
and 8-21).
An appendicolith may be identified within the abnormal appendix (Fig. 8-20E). An
appendicolith is an obstructive stone that often produces shadowing.
Patients often complain of rebound tenderness.
Use color Doppler to assess for the possibility of hyperemia within and/or around
the appendix (Fig. 8-20F).
Figure 8-20. Appendicitis. Longitudinal (A) and transverse (B) images of the appendix
demonstrate thickening of the wall (arrows) consistent with appendicitis. C and D:
Longitudinal images of two different patients with a dilated, inflamed appendix
(between arrows), with a thickened wall and dilatation of the appendiceal lumen. E:
Longitudinal image of an inflamed appendix containing an echogenic appendicolith
(arrows) . F: Longitudinal image demonstrates hyperemia within an inflamed appendix
consistent with appendicitis. (A–D and F: Images courtesy of Philips Healthcare, Bothell,
WA; E: Reprinted with permission from Kawamura D, Nolan T, eds.Abdomen and Superficial
Structures. 4th ed. Philadelphia, PA: Wolters Kluwer Health; 2017.)
Figure 8-21. A: Enlarged abnormal noncompressible appendix (between calipers). B:
Short axis view of an abnormal appendix (between calipers). (Image A reprinted with
permission from Britt LD, Peitzman A, Barie P, Jurkovich G, eds.Acute Care Surgery.
SCANNING TIPS
General bowel assessment8
A lower-frequency transducer may be required in patients with a large body habitus.
Minimal peristalsis may exist in the rectum, so manual external pressure applied to
the pelvis may assist in the imaging of this area.
IHPS
A good landmark to attempt to identify the pyloric sphincter is the area of the
transverse gallbladder. Typically, in the transverse plane to the abdomen, the pyloric
region and duodenum are located medial to the gallbladder and anterior to the
pancreatic head.
Overdistention of the stomach may cause the pyloric sphincter to curl underneath the
stomach, thus inhibiting effective visualization and accurate measuring.
If the infant becomes restless, an assistant should try to pacify the infant.
Intussusception
An intussusception may appear as a cinnamon bun in the abdomen in the axial plane
and have a reniform shape in the longitudinal plane.
Appendix
Posterior manual compression with the nonscanning hand combined with graded
compression scanning can be helpful. Perform this analysis with the patient placed in
the left lateral decubitus position.
Transvaginal sonography may be used to obtain a closer investigation of the appendix
in females.
MEASUREMENTS OF THE GI TRACT

General bowel assessment3,5
Normal duodenal and small bowel wall = between 2 and 3 mm
Normal colon wall nondistended = 4–9 mm
Normal colon wall distended = 2–4 mm (when the colon is distended beyond 5 cm)
Normal pyloric muscle5
Normal pyloric muscle wall thickness ≤3 mm
Normal pyloric channel ≤17 mm
Pyloric stenosis ≥3 mm in wall thickness and >17 mm in pyloric channel length
Intussusception5
Intussuscepted bowel diameter ≥3 cm
Appendix3
Normal appendix ≤6 mm in diameter
Appendicitis ≥6 mm in diameter
ESSENTIAL GI PATHOLOGY2
General GI pathology
Crohn disease (Fig. 8-22)—chronic autoimmune disease characterized by period of
bowel inflammation
Clinical findings
Diarrhea
Abdominal pain
Weight loss
Rectal bleeding
Sonographic findings
Bowel wall thickening
Focal areas of noncompressible bowel
Bowel wall hyperemia
Diverticulitis
Clinical findings
Constipation or diarrhea
Nausea and vomiting
Fever
Left lower quadrant pain or cramping
Inflamed diverticulum, which appears as an echogenic projection of tissue from the
bowel that may shadow or produce ring down artifact
Hyperemia within the wall of the affected bowel
Colitis
Clinical findings
Bloody or watery diarrhea
Fever
Abdominal pain
Previous antibiotic therapy
Thickened, hypoechoic colon wall
Hyperemia within the colon wall
Figure 8-22. Crohn disease. Longitudinal (A) and transverse (B) images
demonstrate hypoechoic thickening of the submucosal layer in the terminal ileum
in a patient with Crohn disease. (Images courtesy of Dr. Taco Geertsma, Hospital
Gelderse Vallei, Ede, The Netherlands.)
Bowel obstruction
Clinical findings
Abdominal distention
Intermittent abdominal pain
Constipation
Nausea and vomiting
Distended fluid-filled loops of bowel
Abrupt termination point of distended bowel
Increased peristaltic motion with a to-and-fro motion of intraluminal contents
IHPS (Video 8-1)
Clinical findings
Nonbilious, projective vomiting
First-born, white male patients between the ages of 2 and 6 wks
Weight loss
Constipation
Dehydration
Insatiable appetite
Palpable olive sign
Target- or doughnut-shaped enlarged pyloric sphincter
Cervix appearing enlarged pyloric sphincter
Wall of the pylorus measures >3 mm in thickness
Length of the pyloric channel measures ≥17 mm
Intussusception
Clinical findings
Intermittent, severe abdominal pain
Vomiting
Palpable abdominal mass
Red currant jelly stool
Leukocytosis
Noncompressible, target-shaped mass or pseudokidney-shaped mass
Altering rings of differing echogenicities (cinnamon bun sign)
Intussuscepted bowel diameter will exceed 3 cm
Appendicitis2,6 (Video 8-2)
Clinical findings
Abdominal pain preceded by vomiting
General abdominal pain that eventually is restricted to the right lower quadrant
Rebound tenderness
Possible leukocytosis
Fever
Noncompressible, blind-ended tube that measures more than 6 mm from outer wall
to outer wall
Evidence of an appendicolith
Hyperemic flow within the wall of the inflamed appendix
Periappendiceal fluid collection
Thyroid in the belly sign—hyperechoic edematous connective tissue around the
appendix
WHERE ELSE TO LOOK

IHPS
One differential for IHPS is midgut malrotation, which is a rotational abnormality of
the small bowel. Midgut malrotation results in bilious vomiting in the first month of
life.
Midgut malrotation is determined by identifying the relationship between the
superior mesenteric artery (SMA) and superior mesenteric vein (SMV). Normally,
the SMV is anterior and to the right of the SMA, but with malrotation, this
relationship is reversed (Fig. 8-23).5
Appendix
Other conditions may mimic appendicitis such as renal stones, pelvic inflammatory
disease, and diverticulitis.9
IMAGE CORRELATION
Pyloric stenosis (Fig. 8-24)
Intussusception on radiography and CT (Fig. 8-25)
Appendicitis on CT (Fig. 8-26)
Diverticulitis on CT (Fig. 8-27)
Figure 8-23. Midgut malrotation. Transverse color Doppler ultrasound image shows the
whirlpool sign, or swirling of bowel and vessels (arrows) around the SM A axis.
(Reprinted with permission from Lee E, ed. Pediatric Radiology: Practical Imaging Evaluation of
Infants and Children. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 8-24. A: Pyloric stenosis on radiography. B: UGI barium study reveals a pyloric
channel that is narrowed and elongated with a double-track appearance (arrow) with
hypertrophy of the pyloric muscle, consistent with pyloric stenosis. (Image A reprinted
with permission from Fleisher GR, Ludwig S, Baskin MN, eds.Atlas of Pediatric Emergency
Medicine. Philadelphia, PA: Lippincott W illiams & W ilkins; 2004; image B reprinted with
permission from Shaffner DH, Nichols DG, eds.Rogers’ Textbook of Pediatric Intensive Care.
Figure 8-25. Intussusception on CT. Axial contrast-enhanced CT image shows small

bowel–small bowel intussusception (I), with normal bowel wall enhancement. (Reprinted
with permission from Lee E, ed. Pediatric Radiology: Practical Imaging Evaluation of Infants
and Children. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 8-26. Appendicitis on CT. CT image shows a soft tissue inflammatory mass in the
right lower quadrant and a calcified fecalith within the thickened appendix (arrows).
(Reprinted with permission from Daffner RH, Hartman M, eds.Clinical Radiology. 4th ed.
Figure 8-27. Diverticulitis on CT. Diverticulitis with inflamed diverticulum (arrowhead).

(Reprinted with permission from Singh A, ed. Gastrointestinal Imaging: The Essentials.
Philadelphia, PA: Wolters Kluwer Health; 2016.)
REFERENCES
4. Curry RA, Tempkin BB. Sonography: Introduction to Normal Structure and Function.
4th ed. St. Louis, MO: Elsevier; 2016:307–330.
5. Seigel MJ. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer;
2011:339–383.
6. Penny SM. Imaging the vermiform appendix. Rad Tech. 2018;89(6):571–590.
7. Ahuja AT, et al. Diagnostic and Surgical Imaging Anatomy. Salt Lake City: Amirsys;
2007:IV140–IV155.
8. Sander RC, Hall-Terracciano BH.Clinical Sonography: A Practical Guide. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016:514–524.
9. Federle MP, Jeffrey RB, Woodward PJ.Diagnostic Imaging: Abdomen. 2nd ed.
Canada: Amirsys; 2010: II-6–26.
* Fluid ingestion may be contraindicated in the setting of some clinical situations.

CHAPTER 9
Male Pelvis
INTRODUCTION
This chapter provides an overview of the AIUM practice parameters for a sonogram
of the scrotum, including a proposed protocol, and the most common pathologies such
as epididymitis and testicular torsion. A brief introduction to sonography of the penis
is provided as well.
AIUM RECOMMENDATION FOR SONOGRAPHY OF THE

SCROTUM1
Assess the scrotum in the following manner:
Evaluate the scrotum because of scrotal pain, testicular trauma, ischemia/torsion, and
infectious or inflammatory disease.
Assess the scrotum for signs of inguinal, intrascrotal, or intratesticular masses.
Evaluate the scrotum for signs of hernias and varicoceles.
Assess for complications resulting in male infertility and for signs of disorders of
sexual development.
Examine the scrotum for the localization of nonpalpable testes.
Evaluate the scrotum for occult primary tumors associated with metastatic germ cell
tumors or retroperitoneal adenopathy.
Follow up on patients with sonography for pre-existing scrotal pathology and other
abnormalities noted on other imaging studies.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE MALE

PELVIS2
Anatomy and Physiology of the Male Pelvis
Scrotum and Testes:
The paired testicles initially develop within the upper abdomen and then descend
into the scrotum either before birth or shortly thereafter (Fig. 9-1). An undescended
testicle, a condition referred to as cryptorchidism, is one that is located outside of
the scrotum, most likely within the ipsilateral inguinal canal.
The scrotum is a sack of cutaneous tissue that contains the testicles. The purpose of
the scrotum is to attempt to regulate the temperature of the testicles.
The testicles are normally located within separate compartments by internal and
external bands of tissue.
The testicles function as both endocrine and exocrine glands. The endocrine function
is to produce testosterone, while the exocrine function is the production of sperm.
Spermatogenesis occurs in the seminiferous tubules. These tubules ultimately
converse at the rete testis, located within the mediastinum testis.
The spermatic cord is a structure that travels through the inguinal canal. It contains
the testicular veins and arteries, nerves, lymph nodes, and musculature.
The epididymides are paired structures located adjacent to the testicles that store
and transport sperm.
The epididymis has a head, body, and tail. The head is located more superiorly,
while the body travels posteriorly to meet with the tail at the base or the inferior
aspect of the testis (see Fig. 9-1).
There are several testicular appendages, including the appendix testis and the
appendix epididymis. These appendages are better visualized when a hydrocele, a
fluid collection around the testicle, is present (Fig. 9-2).
Penis:
The penis is a primary sex organ.
The penis consists of three cylindrical bands of tissue: one corpus spongiosum and
two corpus cavernosa (pleural for cavernosum) (Fig. 9-3).
The corpus spongiosum contains the male urethra and is located ventrally.
The corpus cavernosa contain the cavernosal arteries of the penis.
When sexual arousal occurs, the arteries in the penis dilate and restrict venous
drainage, ultimately resulting in an erection.
Figure 9-1. Anatomy of the testicle and epididymis. (Reprinted with permission from
Anatomical Chart Company. Understanding Erectile Dysfunction Anatomical Chart.
Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)
Figure 9-2. Hydrocele and the appendix epididymis. A large hydrocele (h) is noted
surrounded this testicle (T ). T he head of the epididymis (e) and the appendix
epididymis (arrow) can be seen as well. (Reprinted with permission from Brant W E, Helms
C, eds. Fundamentals of Diagnostic Radiology. 4th ed. Philadelphia, PA: Wolters Kluwer
Figure 9-3. Cross section of the penis. (Reprinted with permission from Anatomical Chart
Company. Male Reproductive System Anatomical Chart. Philadelphia, PA: Lippincott W illiams
& Wilkins; 2000.)

SCROTUM
No patient preparation is typically required for a sonogram of the male pelvis.
7-MHz or higher linear array transducer for the scrotum and/or penis
A curvilinear or vector transducer with lower frequencies may be warranted for
improved penetration and a larger field of view, especially in cases of large
hydroceles of the scrotum.
Doppler frequency settings should be optimized (typically between 5 and 10 MHz).
Towels are often required for patients’ positioning (Fig. 9-4).
Place one towel between the patient’s legs, elevating the scrotum and placing it on
the towel. This will prospectively demobilize the testicles.
Have the patient place his penis on his abdomen, and then drape another towel over
the patient’s penis in order to remove it from the field of view, tucking the ends of
that towel under the patient’s buttocks.
The patient may also assist by holding the towel in place with his hands next to his
hips.
Having the patient cross his legs may help to demobilize the testicles.
Figure 9-4. Draping technique for a scrotal sonogram. Place one towel between the
patient’s legs, elevating the scrotum and placing it on the towel. T his will prospectively
demobilize the testicles. Have the patient place his penis on his abdomen, and then
drape another towel over the patient’s penis in order to remove it from the field of
view, tucking the ends of that towel under the patient’s buttocks. T he patient could
also elevate his scrotum between his legs and cross his ankles in order to stabilize the
testes.
CLINICAL INVESTIGATION FOR SONOGRAPHY OF THE MALE

PELVIS
Laboratory values are listed in Table 9-1:
Critical clinical history questions related to the scrotum
How long have you been hurting? The extent of time in which pain has occurred is
relevant when examining the testicles because a sustained and nagging pain may be
associated with an ongoing infection, while a sudden extreme onset of pain may be
associated with testicular torsion. Unfortunately, the clinical features of these
abnormalities can overlap.
Table LAB FINDINGS AND POSSIBLE ASSOCIATED SCROTAL

9-1 PATHOLOGY
↑ WBC (leukocytosis) Epididymitis, orchitis, epididymo-orchitis
↑ AFP, hCG, LDH Used as tumor markers for testicular cancers
On which side is the pain? Some sonographers prefer to begin the examination with
the asymptomatic testis in order to establish a normal baseline.
Where is the pain? While some patients may claim to have general testicular pain,
occasionally testicular pain can be localized for some abnormalities. For example,
torsion of the appendix testis often presents with localized pain in the upper pole of
the testis.
Can you feel the mass and how was it discovered? It is important to appreciate the
initial discovery of the mass. For example, did the patient feel the mass or did his
doctor?
How long have you had the mass? This relates to determining if the condition is
chronic or acute.
Have you had a vasectomy? The epididymis in patients who have had a vasectomy
appears sonographically altered. Most often, the epididymis is often larger in size,
may be heterogeneous, and contain small cysts. Within the testes, there may be signs
of cysts within the mediastinum testes and granulomas.
NORMAL SONOGRAPHIC DESCRIPTION OF THE SCROTUM2,3

Testicles and scrotum
The normal testes are composed of medium- to low-level echoes, similar to that of
the thyroid gland.
Often the echogenic configuration of the mediastinum testis can be seen as a linear
structure in the longitudinal plane or a triangular or square-shaped structure in the
transverse plane (Fig. 9-5).
The parenchyma of both testicles should be isoechoic.
The epididymis may be isoechoic or slightly more echogenic compared to the normal
testicle.
A minimal amount of anechoic fluid may be noted around each testicle.
Figure 9-5. Sonographic appearance of the mediastinum testis. A,B: T he mediastinum
testis (M T ) in noted in figure A in the longitudinal plane, while it is demonstrated in
figure B in the transverse plane. (Reprinted with permission from Kawamura D, Lunsford
Figure 9-6. Transverse sonographic image of the penis. In this image, the two corpus
cavernosa are identified by the asterisks, while the spongiosum is indicated by the
hash. (Reprinted with permission from Penny S, ed. Examination Review for Ultrasound:
Abdomen and Obstetrics and Gynecology. 2nd ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Penis
The spongiosum is elliptical in shape and consists of medium- to low-level echoes,
whereas the paired cavernosa will appear similar to the spongiosum but be more
oval in shape (Fig. 9-6).

SCROTUM
The patient is asked to remove his clothing from the waist down and placed in the
supine position. Draping instructions are provided in Figure 9-4.
Scrotum
Image each testicle in both the longitudinal and transverse planes (Fig. 9-7). A brief
survey can be performed in either plane.
Obtain a brief cine loop of the scrotum (Video 9-1).
Transverse scrotum
Obtain an image of both testicles to compare the echogenicity, recalling that the testes
should be isoechoic and homogeneous in echotexture (Fig. 9-8).
Figure 9-7. A: Longitudinal scanning survey for the testes. 1, Spermatic cord; 2, Head
of epididymis; 3, Testis—superior; 4, Testis—mid; 5, Testis—inferior; 6, Tail of
epididymis. Note that the body of the epididymis is seen in sections 3–5. B:
Transverse scanning survey protocol for the testis. 1, Spermatic cord; 2, Head of
epididymis; 3, Testis—superior; 4, Testis—mid; 5, Testis—inferior; 6: Tail of
epididymis. T he body of the epididymis is seen in sections 3–5. (Reprinted with
Figure 9-8. Transverse of both testicles with and without color Doppler. A:
Transverse image of normal bilateral right (RT ) and left (LT ) testes (T ) demonstrating
similar homogeneous echogenicity. B: Transverse image of normal bilateral right
(RT ) and left (LT ) testes (T ) demonstrating normal flow bilaterally. (Reprinted with
Figure 9-9. Transverse epididymal head with measurement. T he epididymal head

(between calipers) is demonstrated in this image in transverse.
Transverse scrotum with color Doppler (see Fig. 9-8)

After obtaining an image of both testicles, apply color Doppler to both
simultaneously to assess for vascular symmetry. While comparatively an absent or
noticeable decreased flow may suggest torsion, excessive flow or hyperemia may
suggest infection.
Transverse (right or left) epididymal head (repeat on the contralateral side)
Obtain an image of the epididymal head (Fig. 9-9).
Measure the epididymal head if requested.
Color Doppler may also provide information regarding hyperemia of the epididymis
associated with epididymitis.
Transverse superior (right or left) testicle (repeat on the contralateral side)
Scanning from superior to inferior, obtain an image of the superior portion of the
testicle.
Transverse mid (right or left) testicle with and without measurement (repeat on the
contralateral side) (Fig. 9-10)
Obtain an image of the widest dimension of the testicle.
Transverse mid (right or left) testicle with color Doppler and pulsed-wave Doppler
(repeat on the contralateral side) (Fig. 9-11)
Obtain an image of the color Doppler signals within the testicle.
Obtain an image of the arterial, and if requested venous, pulsed-wave Doppler
signals within the testicle.
Utilize power Doppler if necessary.
Transverse inferior (right or left) testicle (repeat on the contralateral side)
Acquire an image of the inferior portion of the testicle.
Scan completely through the testicle.
At this time, the tail of the epididymis may be visualized.
Obtain a color Doppler image of the tail of the epididymis.
Figure 9-10. Transverse mid testicle with measurement. Transverse measurement of

the testis (between calipers). (Reprinted with permission from Kawamura D, Lunsford B,
Figure 9-11. Mid testicle with spectral and color Doppler. Normal spectral waveform
of intratesticular artery with low-resistance flow. (Reprinted with permission from
Kawamura D, Lunsford B, eds.Abdomen and Superficial Structures. 3rd ed. Philadelphia,
Longitudinal (right or left) epididymal head (repeat on the contralateral side) (Fig. 9-
12)
Obtain an image of the epididymal head in longitudinal.
Measure the head of epididymis.
Obtain a color Doppler image of the epididymal head.
Longitudinal (right or left) testicle with and without measurements (repeat on the
contralateral side) (Fig. 9-13)
Obtain the longest dimension of the testicle and measure the length and
anteroposterior dimensions.
Do not include any part of the epididymis in these measurements.
Longitudinal (right or left) testicle with color Doppler and pulsed-wave Doppler
(repeat on the contralateral side)
If not obtained in transverse, obtain an image of the color Doppler signals within the
testicle.
Obtain an image of the arterial, and if requested venous, pulsed-wave Doppler
signals within the testicle.
Utilize power Doppler if necessary.
Figure 9-12. Longitudinal epididymus. A: Longitudinal image of normal testis (T ) and
epididymal head (E). B: Longitudinal image of normal testis (T ) with the body of
epididymis (B). C: Longitudinal image of normal testis (T ) and tail of epididymis (E).D:
Longitudinal color image of testis (T ) with normal flow in the epididymis (E). (Reprinted
with permission from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th
Figure 9-13. Longitudinal testicle with measurement. Longitudinal measurement of
the testis (between calipers). (Reprinted with permission from Kawamura D, Lunsford B,
Longitudinal (right or left) testicle medial (repeat on the contralateral side)

Scan through the testicle medially, obtaining several images.
Longitudinal (right or left) testicle lateral (repeat on the contralateral side)
Scan through the testicle laterally, obtaining several images.
Additional images:
Palpable scrotal masses may be best demonstrated by having the patient point with
his finger, or if possible, hold the mass between two of his fingers while you scan.
Inguinal canal images can be obtained to analyze and demonstrate the spermatic cord.
SCANNING TIPS3
Extended field of view images may be helpful to demonstrate the entire length of the
testicles.
For comparison purposes, dual images may be utilized to best demonstrate the
echogenicity of both testicles.
When anechoic vascular tubes are noted adjacent to the testicle (varicocele), the
patient should perform the Valsalva maneuver. To do this, have him tighten his
abdominal muscles. This will increase intrabdominal pressure. Obtain color Doppler
images with and without the Valsalva maneuver.
Upright scanning may be performed when a varicocele is suspected.
It is important to assess the thickness of the scrotal wall. Thickening may be indicative
of an infectious process.
Utilize a curved transducer for large hydroceles in order to demonstrate the pathology
and identify the testicles.
Utilize a stand-off device or a large mound of gel to demonstrate superficial
abnormalities.
NORMAL MEASUREMENTS OF THE SCROTUM1–3

Adult testicle:
3–5 cm in length
2–4 cm in width
3 cm in thickness
Epididymal head:
10–12 mm
Scrotal wall:
2–8 mm in thickness
Testicular volume:
Length × width × height × 0.52 (ellipsoid formula)
Length × width × height × 0.71
ESSENTIAL SCROTAL PATHOLOGY2

Testicular torsion—twisting of the testicle on its vascular pedicle that causes
compromised vascular supply and venous drainage (Fig. 9-14)
Clinical findings:
Acute testicular pain often at rest
Swollen testis/scrotum
Nausea and vomiting
Painful testes positioned higher and horizontally
Enlargement of the spermatic cord, epididymis, and testis
Thickened scrotal wall
Hypoechoic or heterogeneous testis
Reactive hydrocele
Figure 9-14. Testicular torsion. Longitudinal color Doppler sonogram of the right
(A) and left (B) testicles demonstrates right testicular enlargement and
heterogeneity (asterisk) as well as absent blood flow, consistent with testicular
torsion. The left testicle is normal. (Reprinted with permission from Lee E, ed. Pediatric
Radiology: Practical Imaging Evaluation of Infants and Children. 1st ed. Philadelphia, PA:
Absent intratesticular flow with color Doppler

Decreased intratesticular flow with color Doppler compared to the asymptomatic
testes
Epididymitis (epididymo-orchitis)—inflammation of the epididymis and/or testicle
(Fig. 9-15)
Clinical findings:
Acute testicular pain
Leukocytosis
Fever
Dysuria
Urethral discharge
Scrotal wall edema (erythema)
Enlargement of the affected portion of the epididymis
Hypoechoic testis (orchitis)
Hyperemia within the epididymis and/or testis
Thickened scrotal wall
Reactive hydrocele
Varicocele—dilated veins within the scrotum (most likely on the left) (Fig. 9-16)
Clinical findings:
Often asymptomatic but may cause discomfort
Fullness within the scrotum
Possible infertility
Figure 9-15. Epididymitis and orchitis. A: Sagittal color Doppler image of a hyperemic
epididymal head (EH). B: Sagittal power Doppler image of a hyperemic epididymal
tail (ET ). C: Sagittal color Doppler image a hyperemic epididymal body (EB).D, E:
Power Doppler images of a hyperemic testicle, indicating orchitis. (Reprinted with
Figure 9-16. Varicocele. A: Sonographic demonstration of multiple anechoic tubular
structures representing veins within the scrotum adjacent to the testicle are noted.
B: Increased vascular flow is demonstrated within the dilated veins when color
Doppler is applied. (Reprinted with permission from Kawamura D, Nolan T, eds.
Tubular vascular anechoic structures adjacent to the testis
Dilated veins within the scrotum that measure greater than 2 mm
Distention of the veins occurs with the Valsalva maneuver
Seminoma (testicular malignancy)
Clinical findings:
Painless enlargement of the testis
Elevated human chorionic gonadotropin
Solid hypoechoic or heterogeneous mass within the testicle
Penile trauma
Clinical findings:
History of hearing an audible popping sound during intercourse
Penile erythema (redness) denoting a subcutaneous bleeding area
Irregular hypoechoic or hyperechoic defect at the site of penile rupture
Notable hematoma in the area of erythema
WHERE ELSE TO LOOK

It may be prudent to briefly survey the retroperitoneum on the ipsilateral side of a
varicocele because varicoceles may be associated with retroperitoneal pathology,
especially on the right side.
Assess the inguinal canal of the ipsilateral side for evidence of an undescended
testicle if it is absent from the scrotum. The testicle may also be located within the
abdomen or pelvis.
Be sure to analyze the scrotal wall for signs of thickening.
In cases of suspected hernia, watch the incarcerated bowel for signs of peristalsis.
IMAGE CORRELATION
Scrotal mass on CT (Fig. 9-17)
Figure 9-17. Scrotal mass on CT. Axial contrast-enhanced CT image demonstrates an
enhancing left extratesticular scrotal mass (arrows). (Reprinted with permission from Lee
E, ed. Pediatric Radiology: Practical Imaging Evaluation of Infants and Children. 1st ed.
REFERENCES
1. AIUM Practice Parameters for the Performance of the Scrotal Ultrasound
E xami nati ons. https://www.aium.org/resources/guidelines/scrotal.pdf. Accessed
October 18, 2018.
3. Sanders RC, Hall-Terracciano B, eds. Clinical Sonography: A Practical Guide. 5th
ed. Philadelphia, PA: Wolters Kluwer; 2016:735–746.
CHAPTER 10
Neck and Face

INTRODUCTION
Sonography of the thyroid gland and surrounding area, including an assessment for
parathyroid pathology and lymphadenopathy of the neck, is exceedingly common and
useful. Sonography can also aid in the guidance of fine-needle aspiration of thyroid
lesions. Since sonography can provide a noninvasive analysis of the face, it may be
utilized to characterize pathology in this region as well. This chapter will provide
protocols for thyroid and parathyroid sonographic analysis, as well as the salivary
glands and general neck lymph node locations.
AIUM RECOMMENDATION FOR SONOGRAPHY OF THE NECK

AND FACE1
Assess the thyroid and parathyroid in the following manner:
Determine the location and characteristics of palpable neck masses.
Evaluate for abnormalities identified on another imaging study or assess for evidence
of pathology associated with abnormal laboratory findings.
Assess the size and location of the thyroid gland.
Evaluate the thyroid in patients who have a high risk for thyroid malignancy.
Provide follow-up analysis of previously discovered thyroid nodules.
Evaluate for signs of recurrent disease or regional nodal metastases.
Assess for the location of parathyroid abnormalities in patients with suspected
primary or secondary hyperparathyroidism.
Assess for the number and size of enlarged parathyroid glands in patients who have
undergone previous parathyroid surgery or ablative therapy with recurrent symptoms
of hyperparathyroidism.
Locate thyroid/parathyroid abnormalities or adjacent cervical lymph nodes for
biopsy, ablation, or other interventional procedures.
Identify unsuspected thyroid pathology after parathyroid localization with a nuclear
medicine exam (sestamibi scan) and the localization of autologous parathyroid gland
implants.
Assess the salivary glands in the following manner:
Evaluate for enlargement and tenderness of the glands, which may indicate
sialadenitis.
Assess for signs of abscess formation.
Evaluate for swelling and signs of SjÖgren disorder.
Identify signs of obstructive salivary gland calculus, solitary salivary gland masses
or cysts, and oral lesions.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE NECK AND

FACE2,3
Anatomy and physiology of the thyroid gland
The thyroid is located in the anterior neck (Fig. 10-1).
The thyroid consists of a right and left lobe.
The thyroid lobes are connected by a bridge of tissue located anterior to the trachea
referred to as the isthmus.
Some patients may have a pyramidal lobe, which is a superior extension of the
isthmus.
The anterior pituitary gland produces thyroid hormone (TSH), which controls the
release of hormones by the thyroid.
Thyroxine (T4), triiodothyronine (T3), and calcitonin are hormones released by the
thyroid gland, and they all work together to help regulate metabolism, growth, and
development.
A surplus of thyroid hormones is referred to as hyperthyroidism and a reduction is
referred to as hypothyroidism.
Anatomy and physiology of the parathyroid glands
Most individuals have two pairs of parathyroid glands.
The parathyroid glands are often located near the posterior aspect of the midportion
of each lobe, and one is often located inferior to each lobe. But there can be some
aberrant locations (Fig. 10-2).
Figure 10-1. Location of the thyroid and common locations for parathyroid glands. A:
T he thyroid is located anterior to the trachea. B: T here are typically two pairs of
parathyroid glands. (Reprinted with permission from McConnell TH, Hull KL, eds.Human
Form, Human Function. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams
& Wilkins; 2011.)
The parathyroid glands serve the purpose of calcium regulation in the blood.
An elevation in the serum calcium level is referred to as hypercalcemia, while a
reduction in calcium is referred to as hypocalcemia.
Anatomy and physiology of the lymph nodes of the neck
Lymph nodes are important for the functioning of the immune system by acting as
filters of foreign materials and abnormal cells.
They are small islands of tissue that contain B and T lymphocytes and other white
blood cells.
Each lymph node consists of an outer cortex and an inner medulla.
There exists within the lateral neck a chain of small lymph nodes.
The lymph nodes of the neck may be evaluated during a sonogram of the thyroid and
may be evaluated sonographically using a numbered region or level method (Fig.
10-3).
Figure 10-2. Possible locations of the parathyroid glands. (Reprinted with permission
from Moore KL, Dalley AF II, Agur AMR, eds.Clinically Oriented Anatomy. 8th ed.
Anatomy and physiology of the salivary glands

The face contains three sets of paired salivary glands: the sublingual glands, the
submandibular glands, and the parotid glands (Fig. 10-4).
The bilateral parotid glands are the largest of the salivary glands and they are located
anterior to the ears on each side of the face.
The submandibular glands are located under the mandible bilaterally. They are
bordered laterally by the mandibular body and superiorly and medially by the
mylohyoid muscle.
The sublingual glands are located under the tongue.
Figure 10-3. Lymph node regions of the neck. (Reprinted with permission from Myers J,
Hanna E, eds. Cancer of the Head and Neck. 5th ed. Philadelphia, PA: Wolters Kluwer;
2016.)
Figure 10-4. Location of the salivary glands. (Reprinted with permission from McConnell
TH, Hull KL, eds.Human Form, Human Function. 1st ed. Philadelphia, PA: Wolters Kluwer
The primary function of the salivary glands is to produce saliva, which aids in
digestion by containing amylase.
Saliva is transported to the mouth via the salivary ducts.
PATIENT PREPARATION FOR SONOGRAPHY OF THE NECK

AND FACE
No patient preparation is typically required for a sonogram of the neck and face.
8–12 MHz linear transducer.
Lower frequencies may be warranted in some situations where more penetration is
required.
A stand-off pad or mounded gel is useful for the investigation of superficial
pathologies.
CLINICAL INVESTIGATION FOR SONOGRAPHY OF THE NECK

AND FACE2
Evaluate prior imaging reports and images including nuclear medicine, CT, MRI,
radiography, and any other appropriate tests.
Table LAB FINDINGS AND POSSIBLE ASSOCIATED NECK

10-1 PATHOLOGY

↑ WBC (leukocytosis) Infection within the neck or face; lymphadenopathy;
sialadenitis
↑ Thyroid stimulating Hyperthyroidism (Graves disease)
hormone (TSH),T3, T4
↓ Thyroid stimulating Hypothyroidism (Hashimoto thyroiditis)
hormone (TSH),T3, T4
↑ Serum calcium Hyperparathyroidism or parathyroid adenoma
↑ Parathyroid Hyperparathyroidism
hormone (PTH)
Critical clinical history questions related to the neck and face

Thyroid and parathyroid glands
Have you had any neck surgeries? Patients with a history of neck surgeries may have
a history of previous thyroid cancer, and thus may only have one lobe or none at all.
In this situation, if any exists, residual tissue should be assessed, and the entire neck
should be evaluated for possible metastasis to the cervical lymph nodes.
Have you been diagnosed with hyperthyroidism or hypothyroidism? Both
hyperthyroidism and hypothyroidism can alter the sonographic appearance of the
thyroid gland.
Do you have a mass in your neck that you can feel? If so, have the patient indicate
the area that is palpable to him or her.
Do you have difficulty breathing or swallowing? Dyspnea and dysphagia could be
caused by an enlarged thyroid gland.
Are you taking any thyroid-related medications? Levothyroxine sodium (Synthroid)
is a commonly prescribed medication used to treat hypothyroidism.
Cervical lymph nodes
Have you had any neck surgeries? Patients with a history of neck surgeries may have
a history of previous thyroid cancer, and thus may only have one lobe or none at all.
In this situation, if any exists, residual tissue should be assessed, and the entire neck
should be evaluated for possible metastasis to the cervical lymph nodes.
Do you have a mass in your neck that you can feel? If so, have the patient indicate
the area that is palpable to him or her.
Salivary glands
Do you have a mass in your face that you can feel? If so, have the patient indicate the
area that is palpable to him or her.
Do you have a history of salivary stones or salivary gland surgery? Past stones or
surgery indicates a history of salivary gland issues. Inquire as to when and what
treatment was received for the ailment.
NORMAL SONOGRAPHIC DESCRIPTION OF THE NECK AND

FACE4
Thyroid gland
The normal tissue of the thyroid gland is homogeneous and consists of medium- to
high-level echogenicities similar to that of the testes (Fig. 10-5).
Parathyroid glands
Normal parathyroid glands are often oval or bean shaped and are isoechoic to the
adjacent thyroid tissue.
Normal parathyroid glands may not be clearly delineated with sonography.
Normal cervical lymph nodes
Normal cervical lymph nodes tend to measure <1 cm, are oval in shape, hypoechoic,
and have an echogenic hilum (Fig. 10-6).
Salivary glands4
The normal salivary glands are homogeneous and hyperechoic compared to the
adjacent musculature.
The parotid gland is round in transverse and elliptical on coronal images.
Often, there are several intraparotid lymph nodes (Fig. 10-7).
Figure 10-5. Normal sonographic appearance of the thyroid gland. Transverse
sonographic image of the right thyroid lobe (white asterisk) demonstrates
homogeneous echotexture. T he isthmus (yellow asterisk) is normal in thickness.
Lateral to the thyroid lobe, the common carotid artery (red asterisk) and internal jugular
vein (blue asterisk) are noted. Overlying the gland are strap muscles (white arrows),
with the sternocleidomastoid muscle (orange asterisk) seen more laterally. T he trachea
(T ) is seen in the midline. (Reprinted with permission from Sanelli P, Schaefer P, Loevner L,
eds. Neuroimaging: The Essentials. 1st ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Figure 10-6. Normal lymph node. T his image depicts the normal sonographic
appearance of a lymph node (between arrows) . Note the fatty hilum and oval shape.
(Image courtesy of Philips Medical Systems, Bothell, WA.)
Figure 10-7. Normal parotid gland. Longitudinal scan parallel to the earlobe. In this
plane, the gland has an elliptical shape (arrows) . Note also normal hypoechoic
intraparotid lymph nodes (N). T he retromandibular vein (V) divides the gland into the
superficial lobe anteriorly and deep lobe posteriorly. (Reprinted with permission from
Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott
SUGGESTED PROTOCOL FOR SONOGRAPHY OF THE NECK

AND FACE
Thyroid gland
Survey the thyroid gland
Perform the examination with the neck in extension and the patient either supine or
semirecumbent.
Remove the patient’s pillow and place a rolled towel under the patient’s neck to
assist in neck extension.
Survey the thyroid in either the transverse or longitudinal planes.
Scan completely through both lobes for a brief assessment of the parenchyma.
Scan from superior to inferior in the transverse plane and obtain a short video
(Video 10-1).
Transverse isthmus
The thickness (anteroposterior measurement) of the isthmus on the transverse view
should be recorded (Fig. 10-8).
Figure 10-8. Transverse thyroid isthmus. A, B: Transverse of the isthmus with
anteroposterior thickness measurement (between calipers).
Transverse right and left thyroid lobes

Have the patient turn his or her face slightly to the opposite direction that you are
examining, if needed.
Obtain several images of the superior aspect of each lobe (Fig. 10-9).
Obtain an image of the midportion of each lobe with and without a transverse
measurement (Fig. 10-10). An anteroposterior measurement can be obtained in the
transverse plane as well.
Obtain several images of the inferior aspect of each lobe (Fig. 10-11).
Longitudinal right and left thyroid lobes
Lengthening the complete lobe, obtain an image of the midportion of each lobe.
Measure the length, and if not obtained in transverse, obtain the anteroposterior
dimension of the right lobe (Fig. 10-12).
An extended-field-of-view or dual image may be warranted to obtain the full length
of enlarged thyroid lobes.
Longitudinal right and left thyroid lobes with color Doppler
Image each lobe with color Doppler (Fig. 10-13).
Evaluate for hypervascularity, which can be an indicator of thyroid pathology.
Longitudinal medial right and left thyroid lobes
From the midportion of the lobe scan medially and obtain several images of each
lobe’s medial aspect (Fig. 10-14).
Tracheal rings may be visualized medially.
Longitudinal lateral right and left thyroid lobes
From the midportion of the lobe scan laterally and obtain several images of the right
lobe’s lateral aspect (Fig. 10-15).
The carotid artery will often mark the lateral border of the thyroid gland.
Bilateral neck assessment
Evaluate the neck for signs of lymphadenopathy in association with thyroid disease.
Beginning just below the mandible, scan from superior to inferior in transverse
along the bilateral internal jugular veins and carotid arteries. Regions of the neck
can be assessed and labeled accordingly (see Fig. 10-3).
Figure 10-9. Transverse superior right lobe. A, B: Superior right thyroid lobe (RT
SUP) with adjacent anatomy, including the common carotid artery (CCA), strap
muscles (STRAP), and the sternocleidomastoid muscle (SCM).
Figure 10-10. Transverse mid right lobe. A, B: Transverse image of the mid right
thyroid lobe with measurement of the thyroid width. In this image, the common
carotid artery (CCA) can be seen laterally and the sternocleidomastoid muscle and
strap muscles anteriorly. The trachea and thyroid isthmus are also noted.
Figure 10-11. Transverse inferior right lobe. A, B: Transverse image of the right
inferior thyroid (RT LOBE INF) including the isthmus, trachea, common carotid
artery (CCA), and the sternocleidomastoid muscle (SCM).
Figure 10-12. Longitudinal mid right lobe. A, B: Longitudinal right thyroid lobe
(between calipers) with measurements.
Figure 10-13. Longitudinal mid right lobe with color Doppler.
Document and measure any abnormal-appearing cervical lymph nodes in two

orthogonal planes (see Essential Face and Neck Pathology in this chapter).
Documentation of abnormalities1
Visualized thyroid abnormalities should be documented.
The location, size, number, and character of significant abnormalities should be
documented, and measurements should be made in three dimensions.
In patients with numerous nodules in each lobe, measurements of all nodules are not
necessary. The largest nodules or those with the most worrisome features should be
selectively measured when multiple nodules are present.
Doppler analysis of lesions may be helpful.
Other abnormalities, such as venous thrombosis, should be documented.
Additional images
Dual thyroid image
An image of both thyroid lobes can be used to assess the overall echogenicity of
the thyroid and, in part, to compare the size of each lobe.
Figure 10-14. Longitudinal right lobe medial. A, B: Medial aspect of the right lobe.
Figure 10-15. Longitudinal right lobe lateral. A, B: Medial aspect of the right lobe.
Figure 10-16. Elastogram of a thyroid nodule. A: Representative grayscale image of a
hypoechoic indeterminate nodule (arrows) . B: Elastogram image shows the
periphery of the nodule (arrows), which has a red hue and constitutes the stiffer or
harder (nonelastic) component of the nodule. T his mass was highly suspicious for
malignancy. (Reprinted with permission from Siegel MJ, ed.Pediatric Sonography. 4th ed.
Thyroid volume2
Some ultrasound machines contain capabilities of storing thyroid volume.
Thyroid volume = L × W × H × 0.529
Elastography2
Elastograms can be performed on thyroid lesions to assess for the presence of
abnormal tissue stiffness (Fig. 10-16).
In theory, the stiffer the tissue, the more likely the mass is malignant.
Fine-needle aspiration remains the gold standard for the tissue characterization of
thyroid lesions.
Thyroidectomy patients:
Scan the entire neck, from just under the mandible to the clavicle bilaterally,
especially in those patients with a history of thyroid cancer because there may be
lingering lymphadenopathy.
Parathyroid glands
Perform an assessment of the neck with Figure 10-2 in mind.
If visualized, measure each parathyroid gland in two orthogonal planes.
Cervical lymph nodes
Perform an assessment of the cervical lymph node chains with Figure 10-3 in mind.
If visualized, measure any abnormal-appearing cervical lymph nodes.
Label the regional lymph nodes, if warranted.
Salivary glands4
Parotid glands
Transverse views are obtained by placing the transducer perpendicular and inferior
to the earlobe.
Longitudinal views are obtained by placing the transducer anterior and parallel to
the ear.
Color Doppler may be utilized to differentiate dilated ducts from vascular
structures.
Hyperemia may indicate sialadenitis.
Sialolithiasis (salivary stones) will appear hyperechoic and may shadow.
Submandibular glands
The submandibular glands are evaluated by placing the transducer just under the
mentum and angling the transducer coronally and sagittally.
Color Doppler may be utilized to differentiate dilated ducts from vascular
structures.
Hyperemia may indicate sialadenitis.
Sialolithiasis (salivary stones) will appear hyperechoic and may shadow.
Sublingual glands
The sublingual glands are imaged with the transducer placed perpendicular and
parallel to the submental mandible.
SCANNING TIPS
When prominent, the esophagus may suggest the presence of a mass within the neck. It
is often located posterior to the left thyroid lobe. Have the patient swallow to confirm
the esophagus. Saliva will be seen passing through the esophagus.
The bilateral longus colli muscles can be noted posterior to each thyroid lobe and may
simulate a mass (Fig. 10-17).
A stand-off device or mounded gel may be warranted for superficial masses and for
the assessment of the salivary glands.
Figure 10-17. Longus colli muscle. A transverse section of the thyroid gland
demonstrating the sternocleidomastoid muscle (SCM) beneath the subcutaneous fat
(white arrowhead). T he infrahyoid strap muscles lie deep to the fat and medial to the
sternocleidomastoid muscle (white arrows). T he jugular vein (J) and carotid artery (C)
are prominent lateral boundaries defining the position of the thyroid gland (T G). T he
longus colli muscle (LC) is seen deep to the gland, and the trachea (T ) is the midline
landmark. (Reprinted with permission from Mancuso AA, ed. Head and Neck Radiology. 1st ed.
NORMAL MEASUREMENTS OF THE NECK AND FACE2

Thyroid
Lobes
Length = 4–6 cm
Anteroposterior = 1–2 cm
Transverse dimension = 2–3 cm
Isthmus = between 2 and 6 mm in thickness
Thyroid volume = L × W × H × 0.529
Parathyroid
Parathyroid glands typically measure <5 mm in length.
Normal lymph nodes
Normal nodes measure <5 or 6 mm in the longest dimension, though they may
measure up to 1 cm.
ESSENTIAL NECK AND FACE PATHOLOGY2

Thyroid gland
Thyroid imaging, reporting, and data system (TI-RADS) calculator link:
http://tiradscalculator.com/
The American College of Radiology released a white paper in 2018 on the use of
TI-RADS in the clinical setting as a means of characterizing thyroid lesions detected
with sonography and in order to prevent unnecessary biopsies.
Characteristics of benign thyroid nodules:
Extensive cystic components
Cysts <5 mm
Hyperechoic mass
“Eggshell” calcification surrounding the mass
Characteristics of malignant thyroid nodules:
Hypoechoic mass (possibly solitary)
Taller-than-wide shape
Solid mass with internal microcalcifications
Irregular margins
Graves disease (hyperthyroidism)
Clinical findings:
Bulging eyes
Heat intolerance
Nervousness
Weight loss
Hair loss
Enlarged gland
Heterogeneous or diffusely hypoechoic echotexture (Fig. 10-18)
Thyroid inferno (increased vascularity)
Hashimoto thyroiditis (hypothyroidism)
Clinical findings:
Depression
Increased cold sensitivity
Elevated blood cholesterol levels
Slight weight gain
Puffy face and puffiness under the eyes
Figure 10-18. Graves disease. Transverse image of the thyroid demonstrating
increased vascularity. T he patient had clinical symptoms consistent with
hyperthyroidism. (Reprinted with permission from Siegel MJ, ed.Pediatric Sonography.
Mild enlargement of the gland initially
Heterogeneous echotexture (Fig. 10-19)
Numerous, ill-defined hypoechoic regions separated by fibrous bands
Increased vascularity
Parathyroid glands
Parathyroid adenoma
Clinical findings:
Elevated serum calcium and PTH
Possible palpable mass
Hypoechoic mass adjacent to the thyroid
Other neck masses
Thyroglossal duct cyst
Clinical findings:
Palpable midline mass superior to the thyroid
Anechoic or complex cyst within the midline of the neck superior to the thyroid
Figure 10-19. Hashimoto thyroiditis. A: Longitudinal image of a heterogeneous
thyroid gland. B: Increased vascularity is depicted with color Doppler. (Reprinted with
Branchial cleft cyst

Clinical findings:
Palpable lateral neck mass
Anechoic mass
Cervical lymphadenopathy
Clinical findings:
Node that measure >1 cm
Rounded shape or has irregular margins (Fig. 10-20)
Loss of echogenic hilum
Calcifications
Hyperemia may be present
Salivary gland
Pleomorphic adenoma
Clinical findings:
Enlargement of the parotid gland
Hypoechoic mass
WHERE ELSE TO LOOK

Thyroid gland
Don’t forget to scan the lateral neck for irregular-appearing lymph nodes.
Parathyroid glands
Remember, there can be ectopic locations for parathyroid glands (see Fig. 10-2).
Cervical lymphadenopathy
When a suspicious thyroid nodule is discovered, look carefully throughout the neck
for enlarged or irregular-appearing lymph nodes.
IMAGE CORRELATION
Malignant thyroid mass on CT (Fig. 10-21)
Figure 10-20. Abnormal appearing lymph node. Ultrasound examination of the right
lateral cervical lymph nodes shows an abnormal right level III lymph node in the
longitudinal (A) and transverse (B) images. T he arrows denote the abnormal lymph
node. (Reprinted with permission from Dimick JB, Upchurch GR, Sonnenday CJ, eds.Clinical
Scenarios in Surgery. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams &
Wilkins; 2012.)
Figure 10-21. Follicular carcinoma. A: T he computed tomography (CT ) with contrast

image demonstrates the sectional neck anatomy and a heterogeneous area beginning
in the isthmus and extending throughout the left thyroid lobe arrow. B: T he transverse
sonogram of the left thyroid mass shows a diagonal line (white arrows) entering the
image from the right, which is the biopsy needle used during a sonography-guided fine-
needle aspiration biopsy. T he cytology report diagnosed follicular carcinoma. (Reprinted
REFERENCES
1. AIUM practice parameters for the performance of ultrasound examinations of the
head and neck. https://www.aium.org/resources/guidelines/headNeck.pdf. Accessed
September 4, 2018.
4. Seigel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer;
2011:118–163.
CHAPTER 11
Breast
INTRODUCTION
Sonography is an outstanding adjunct to mammography in the characterization of
breast lesions. Oftentimes, sonography immediately follows the mammographic
detection of a worrisome lesion or suspicious finding. Sonography can also be used
as an initial imaging tool for young women prior to receiving their earliest screening
mammogram. This chapter will provide a brief overview of breast imaging. The
sonographer should have a thorough understanding of the benefits and limitations of
sonography. Protocols for breast sonography may vary among institutions. Guidelines
that have been established for breast imaging in each institution must be carefully
followed in order to provide each patient with standardized, and yet case-specific
optimal sonographic imaging.
AIUM AND ACR RECOMMENDATION FOR SONOGRAPHY OF

THE BREAST 1
Assess the breast in the following manner:
Evaluate and sonographically characterize palpable masses and other breast-related
signs and/or symptoms.
Evaluate abnormalities identified on other imaging modalities, including
mammography and breast magnetic resonance imaging (MRI).
Initially assess palpable breast masses in patients <30 yrs of age and in lactating
women.
Evaluate for breast implant complications.
Assist in the sonographic guidance of breast biopsies and axillary lymph nodes,
interventional procedures, and treatment planning for radiation therapy.
Provide a screening tool, in conjunction with mammography, for occult cancers in
certain populations.
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE BREAST 2–4

Anatomy and physiology of the breast
The breast is an exocrine organ, with the primary function of producing milk
following childbirth.
The breast has three major portions: the skin, the subcutaneous fat, and the glandular
parenchyma of the breast, which is the functional component and the location of most
cancers (Fig. 11-1). The breast may also be divided into three zones: premammary,
mammary, and retromammary.
The tail of the breast, or its axillary process, extends toward the axilla.
The glandular breast consists of 15–20 segments or lobes that are separated by
connective tissue. These lobes can be divided further into lobules.
Five to ten major collecting milk or lactiferous ducts radiate from the nipple into the
lobules and work to drain the breast of milk in the direction of the nipple.
The functional, glandular unit of the breast is the terminal duct lobular unit.
Cooper suspensory ligaments provide support to the breast.
Developmental changes of the breast occur during a woman’s life:
In the young girl, with the production of estrogen by the ovaries, the glandular
portion of the breast increases.
The glandular portion of the breast is thick in a young woman compared to the fat
component.
An increase of fatty components and more functional tissue occurs during pregnancy
and lactation.
As the female advances in age, fatty components increase.
Fibrocystic breasts are composed of scattered fibrotic and cystic areas and are a
common variant in childbearing ages.
Atrophy of the breast during and after menopause results in an increase in fatty
components, while the functional component decreases in size, a variant that may be
referred to as fatty breast.
Figure 11-1. Anatomy of the breast. A: Sagittal schematic of the breast. B: Sonogram of
the breast demonstrates the skin layer, the subcutaneous fat (SCF), and Copper
ligament (CL) within the premammary zone; fibroglandular tissue (FGT ) within the
mammary zone; retromammary fat (RM F) within the retromammary zone; and the
pectoralis major muscle (PM). T he mammary zone is encased within the anterior and
posterior mammary fascial planes. (Image A reprinted with permission from Jensen S, ed.
Nursing Health Assessment. 1st ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott
W illiams & W ilkins; 2010; Image B reprinted with permission from Kawamura D, Nolan T, eds.
PATIENT PREPARATION FOR SONOGRAPHY OF THE BREAST
No patient preparation is typically required for a sonogram of the breast.
Equipment includes a linear array transducer with a center frequency of at least 12
MHz or higher with electronically adjustable focal zones.
A stand-off device or mounded gel may be required for imaging of superficial lesions.

BREAST
Evaluate prior imaging reports and images including previous sonograms,
mammography, CT, MRI, radiography, and any other appropriate tests.
The BI-RADS US categories are provided in Table 11-2 as a basic overview.
Critical clinical history questions related to the breast
Is there any family history of breast cancers or tumors? When appropriate, this is a
helpful initial question to be asked before you begin scanning. If so, further inquire
about when, and if found in a relative, which relative (e.g., mother, aunt, etc.).
Do you have a mass that you can feel? The patient may be able to palpate the mass
herself. If so, have her indicate the location with her finger or her hand.
How long has the mass been there? This is an important question with regard to aging
the mass.
Is the mass mobile or stationary? In theory, a mobile mass, or one that can be pushed
around in the breast, is likely benign. A mass that is nonmobile or stiff is likely
malignant.
Table LAB FINDINGS AND POSSIBLE ASSOCIATED BREAST

11-1 PATHOLOGY

↑ WBC (leukocytosis) Mastitis
Table 11-2 BI-RADS US Categories and Basic Overview5
CATEGORY BASIC OVERVIEW

Category 0: Patient requires additional imaging
Incomplete
Category 1: Negative Essentially 0% likelihood of malignancy
Category 2: Benign Essentially 0% likelihood of malignancy
Category 3: Probably <0% but ≤2% likelihood of malignancy
benign
Category 4: >2% but <95% likelihood of malignancy
Suspicious
Category 4A: Low
suspicion
Category 4B:
Moderate suspicion
Category 4C: High
suspicion
Category 5: Highly ≥95% likelihood of malignancy
suggestive of
malignancy
Category 6: Known N/A
biopsy-proven
malignancy
In what position do you feel the mass the best? A mass may only be felt by the patient
in the upright position, and thus scanning in that position may be helpful.
Are you having any nipple discharge? Any nipple discharge and the color of the
discharge should be reported to the radiologist.
Is there discoloration of the skin? Discoloration or dimpling of the skin is a possible
finding with infection and/or cancer, and should be reported to the radiologist.
Are there any lumps in the armpit? A palpable mass in the armpit may be a sign of
metastasis to an axillary lymph node.
Are you breastfeeding? Breastfeeding can significantly improve the visualization of
the ducts. Also, some breast masses are more common during lactation.
NORMAL SONOGRAPHIC DESCRIPTION OF THE BREAST 1,6

Subcutaneous fat typically consists of medium gray echoes and is more hypoechoic
than fibroglandular tissue, which is light gray.
Dense glandular tissue is often defined sonographically as round, oval, or elongated
hypoechoic regions surrounded by an echogenic background (Fig. 11-2).
Fatty tissue appears as hypoechoic tissue surrounded and delineated by echogenic
ligaments (Fig. 11-3).
Heterogeneous breast tissue demonstrates a mixture of hypoechoic and echogenic
areas.
Lactiferous ducts may be seen as linear, branching tubular channels within the breast
tissue.
The nipple may simulate a mass or produce a significant shadow.
Ribs will be equally spaced round structures in the far field in the cross section and
will produce a shadow (Fig. 11-4).
Figure 11-2. Dense breast tissue. A: Dense breast tissue often appears as round, oval,
or elongated hypoechoic areas in an echogenic background. B: A fibrous ridge of
tissue is noted in this image. (Reprinted with permission from Cardenosa G, ed. Breast
Imaging Companion. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 11-3. Fatty breast tissue. A, B: Two images of fatty tissue, which is depicted
sonographically as hypoechoic tissue surrounded and delineated by echogenic
ligaments. (Reprinted with permission from Cardenosa G, ed. Breast Imaging Companion. 4th
Figure 11-4. Pectoralis muscles and ribs. A: T he pectoral muscle is hypoechoic. In this
orientation of the transducer, parallel echogenic striations are noted in the substance
of the muscle. T he deep pectoral fascia (arrows) serves to delineate the pectoral
muscle from overlying breast tissue. T he pleura is seen as an echogenic line (double-
headed arrows) deep to the pectoral muscle. B: T he pectoral muscle is hypoechoic.
T he deep pectoral fascia (arrows) serves to delineate the pectoral muscle from
overlying breast tissue. T he rib is associated with shadowing that interrupts
visualization of the pleura (double-headed arrows). (Reprinted with permission from
Cardenosa G, ed. Breast Imaging Companion. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)

BREAST 1,6
The patient should be placed in a position that minimizes the thickness of the portion
of the breast being evaluated, which often is in a slight posterior contralateral oblique
position (Fig. 11-5). Positioning may also be correlated to mammographic images
(Fig. 11-6).
The ipsilateral arm should be raised and placed behind the patient’s head.
The requested region should be imaged in at least two perpendicular projections—that
is to say, either transverse and longitudinal or radial and antiradial (Fig. 11-7).
Clock-face notation should be provided, as well as distance from the nipple. Do not
measure from the areola (Fig. 11-8).
A quadrant location and 1-2-3 and A-B-C annotation may be required by some
institutions (Fig. 11-9).
The time gain compensation should be adjusted in order to differentiate fatty tissue
from glandular tissue and the focal zone should be placed at the depth of identifiable
lesions.
Figure 11-5. Supine-oblique patient positioning. T he side to be examined is elevated

by a foam support and the patient’s arm is positioned near the head. T his
contralateral oblique position helps flatten the breast tissue over the chest.
2012.)
Figure 11-6. Positioning for sonography of the breast. A: Upright positioning can be
used to compare the sonography location of a mass to the mammographic
craniocaudal view. B: Decubital positioning, in this case, is used to access the medial
breast to compare relative mass location with the M LO or 90° lateral mammographic
views. T he patient can be rolled to better access the lateral breast. (Reprinted with
permission from Kawamura D, Lunsford B, eds. Abdomen and Superficial Structures. 3rd ed.
Figure 11-7. Perpendicular scan planes. A: Schematic of traditional sagittal (SAG) and
transverse (T V) scan planes. B: Radial (RAD) and antiradial (ARAD) scan planes.
2012.)
Figure 11-8. Quadrant and clock-face annotation. Some institutions will require clock-
face and/or quadrant annotation. (Reprinted with permission from Kawamura D, Lunsford
Figure 11-9. 1-2-3-A-B-C annotation. Some institutions may require this format of
labeling. 1 depicts the inner third of the breast, 2 is the mid third of the breast, while
3 is the outer third of the breast. A is the anterior third of the breast, B is the middle
third of the breast, while C is the posterior third of the breast. (Reprinted with
permission from Kawamura D, Lunsford B, eds. Abdomen and Superficial Structures. 3rd ed.
The depth should be deep enough in order to include the pectoralis muscle.
If possible, the transducer should be manipulated with one hand, while the fingers of
the other hand are simultaneously moved back and forth at the leading edge of the
transducer in order to correlate what is being imaged with what is being felt.
If a suspected abnormality is identified in one plane, the transducer should be rotated
90 degrees in order to confirm the presence of the abnormality in two planes (Fig.
11-10).
The sonographer should scan completely through a mass, noting the borders carefully
for signs of irregular margins.
A measureable abnormality should be documented in images that are obtained with
measurements and without measurements in two perpendicular projections.
Masses behind the nipple may require the peripheral compression technique or the
rolled-nipple technique (Figs. 11-11 and 11-12).
Color Doppler should be employed to provide an analysis of the vascularity of the
lesion.
Elastography, which essentially characterizes a mass based on tissue stiffness, can
also be utilized. In theory, the stiffer the tissue, the more likely the mass is malignant
(Fig. 11-13). However, manufacturer guidelines and settings vary, and thus training
in the use of elastography and interpretation of elastograms in the clinical setting is
warranted to provide optimal patient care.
Figure 11-10. Rotating the transducer correctly. A: If a potential lesion is identified, it is
important to rotate the transducer over the area. A true lesion remains discrete (oval,
round, or irregular) as the transducer is rotated. B: Oblong breast tissue bundles are
intercalated within the skeleton provided by Cooper ligaments. If a bundle is imaged in
cross section it may appear mass-like; however, as the transducer is rotated over this
area the pseudomass elongates, becomes less apparent, and often fuses with the
surrounding tissue. (Reprinted with permission from Cardenosa G, ed. Breast Imaging
Companion. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 11-11. Peripheral compression technique for subareolar duct evaluation. T he
transducer is oriented in a radial plane along the axis of the duct to be examined. T he
nonscanning hand is placed on the opposite side of the breast to provide counter
pressure. T he transducer is angled by applying pressure to the peripheral edge of the
transducer. T his maneuver brings the subareolar duct into a scan plane more parallel
to the transducer. Sliding the transducer toward the nipple follows the duct. (Reprinted
Figure 11-12. Rolled-nipple technique. A: T he transducer is placed along the nipple and
breast in a radial plane parallel to the long axis of the excretory and subareolar duct.
T he index finger of the sonographer’s nonscanning hand is placed on the opposite
side of the nipple. Light transducer pressure is applied to roll the nipple over the index
finger. T his maneuver allows a subareolar duct to be imaged as it passes through the
nipple to evaluate for an intraductal mass. B: T he sonogram shows a nipple adenoma
within a dilated excretory duct using the rolled-nipple technique. (Reprinted with
Figure 11-13. Shear-wave elastograms. A: 2D image (lower image) and elastogram of a
benign mass. B: T his multilobulated lesion displays hard (stiff) elastic features, typical
of a malignant mass. (Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen
SCANNING TIPS3
The sonographer should learn more about mammography and how to correctly view
mammograms so that he or she can better understand the location of masses (Figs.
11-14 and 11-15).
The patient should indicate the area of a palpable lesion with her finger or hand.
Upright imaging may be helpful, especially if that is the position in which a palpable
mass is best felt by the patient.
Transducer pressure that is too light can cause simulated shadowing, while scanning
with too much pressure can result in obscuring underlying lesions.
A stand-off pad should be used to improve the visualization of superficial masses.
Mounded gel can also be utilized.
Microcalcifications demonstrated on a mammogram may not be seen sonographically.
Vocal fremitus may be utilized as well. To do this, have the patient hum “eee” while
scanning with color Doppler or power Doppler (Fig. 11-16). Certain abnormal
tissues and masses will be devoid of Doppler signals.
Figure 11-14. Mammographic projections. A: Mediolateral projection (M LO).B:
Craniocaudal projection (CC). (Reprinted with permission from Smith W L, ed.Radiology
101. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013.)
Figure 11-15. Normal mammogram. A: Left breast mediolateral oblique (M LO) digital
mammogram. Normal. B: Left breast craniocaudal (CC) digital mammogram. Normal.
(Reprinted with permission from Smith W L, ed.Radiology 101. 4th ed. Philadelphia, PA:
Figure 11-16. Vocal fremitus. Conventional two-dimensional sonogram on the left and
on the right, power Doppler reveals an area devoid of color, which purportedly depicts
this tissue as being more dense and thus increases the likelihood of an area of
abnormal tissue. (Reprinted with permission from Kawamura D, Lunsford B, eds.Abdomen
and Superficial Structures. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams
& Wilkins; 2012.)
NORMAL MEASUREMENTS OF THE BREAST

Skin covering the breast typically measures not more than 2 mm
ESSENTIAL BREAST PATHOLOGY3,6

Benign features of solid breast masses:
Hyperechoic mass
Well-circumscribed margins
Wider than tall
Bilobulated or trilobulated
Thin echogenic pseudocapsule
Malignant feature of solid breast masses:
Markedly hypoechoic
Speculated borders
Taller than wide
Angular or indistinct margins
Irregular echogenic rim around the mass
Posterior shadowing
Microlobulations
Duct extension
Branch pattern
Calcifications within the mass
Possible posterior enhancement
Breast cyst (Fig. 11-17)
Clinical findings:
Anechoic mass
Posterior enhancement
Well-circumscribed mass
Thin, echogenic capsule
Fibroadenoma—a common solid benign breast mass (Fig. 11-18)
Clinical findings:
Hypoechoic mass
Well-circumscribed margins
Wider than tall
Bilobulated or trilobulated
Thin, echogenic pseudocapsule
Infiltrative ductal carcinoma (Fig. 11-19)
Clinical findings:
Skin dimpling
Nipple discharge
Red, swollen breast with skin edema (“peau d’orange”)
Possible family history
Markedly hypoechoic
Speculated borders
Taller than wide
Angular or indistinct margins
Irregular echogenic rim around the mass
Posterior shadowing
Microlobulations
Duct extension
Branch pattern
Calcifications within the mass
Possible posterior enhancement
Figure 11-17. Breast cyst. A, B: Orthogonal ultrasound images of an anechoic mass with
circumscribed margins and posterior acoustic enhancement in a fibrous ridge (arrows)
of breast tissue. (Reprinted with permission from Cardenosa G, ed. Breast Imaging
Companion. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 11-18. Fibroadenoma. A well-circumscribed hypoechoic solid mass

corresponding with a palpable mass (arrows). (Reprinted with permission from Smith W L,
e d . Radiology 101. 4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott W illiams &
Wilkins; 2013.)
Figure 11-19. Ductal carcinoma. A: Mammogram image of a ductal carcinoma. B:
Corresponding mass demonstrated with sonography. (Reprinted with permission from
Cardenosa G, ed. Breast Imaging Companion. 4th ed. Philadelphia, PA: Wolters Kluwer; 2017.)
WHERE ELSE TO LOOK
The associated axilla should also be examined if a suspicious lesion is identified for
associated lymphadenopathy, as well as the remaining breast tissue.
The axilla should also be examined in cases of ruptured implants.
IMAGE CORRELATION
MRI of the breast (Fig. 11-20)
Figure 11-20. M RI, axial T 1-weighted image, postcontrast. Two masses with
heterogeneous enhancement are imaged at this level. T he medial lesion is further
characterized by spiculated margins and correlates with the site of the patient’s known,
screen-detected invasive ductal carcinoma. T he lateral lesion at this level is the more
anterior of the two masses seen laterally in the M IP image and demonstrates rim
enhancement. (Reprinted with permission from Cardenosa G, ed. Clinical Breast Imaging:
The Essentials. 1st ed. Philadelphia, PA: Wolters Kluwer; 2014.)
REFERENCES
1. ACR practice parameters for the performance of a breast ultrasound examination.
https://www.acr.org/∼/media/ACR/Files/Practice-Parameters/US-Breast.pdf.
2. Gibbs R, Karlan BY, Haney AF, Nygaard IE, eds.Danforth’s Obstetrics and
Gynecology. 10th ed. Philadelphia: Wolters Kluwer; 2008:932–958.
3. Sanders R, Hall-Terracciano B, eds. Clinical Sonography: A Practical Guide. 5th ed.
Philadelphia: Wolters Kluwer; 2016:713–733.
4. Curry RA, Tempkin BB, eds. Sonography: Introduction to Normal Structure and
Function. 4th ed. St. Louis, Missouri: Elsevier; 2015:519–528.
5. ACR BI-RADS ATLAS—breast ultrasound.
https://www.acr.org/media/ACR/Files/RADS/BI-RADS/US-Reporting.pdf.
6. Cardenosa G, ed. Breast Imaging Companion. 4th ed. Philadelphia: Wolters Kluwer;
2017:103–129.
CHAPTER 12
Infant Hips, Neonatal Brain, and Neonatal

Spine
INTRODUCTION
Abdominal sonographers may occasionally be required to perform additional
sonographic examinations such as infant hip sonograms, neonatal brain sonograms,
and sonograms of the neonatal spine. This chapter provides a summary of these
examinations, including a suggested protocol, images, and an abbreviated overview
of the most common pathologies one might encounter.
AIUM AND ACR RECOMMENDATION FOR SONOGRAPHY OF

INFANT HIPS, NEONATAL BRAIN, AND NEONATAL SPINE
Infant hips1:
A sonogram of the infant hip is often indicated when developmental dysplasia of the
hip (DDH) is strongly suspected, especially when the following risk factors are
present:
Frank breech presentation
History of a parent and/or sibling with DDH
Hip instability is present on physical examination
The infant has a neuromuscular condition that predisposes him or her to DDH
Oligohydramnios or other intrauterine causes of abnormal posturing
Neonatal brain2:
Indications for a neonatal and infant brain sonogram include, but are not limited to,
the following:
Evaluation for hemorrhage or parenchymal abnormalities
Evaluation for hydrocephalus
Evaluation for signs of vascular disorders
Evaluation for possible or suspected hypoxic–ischemic encephalopathy
Follow-up of patients on hypothermia, extracorporeal membrane oxygenation, and
other support machines
Evaluation for signs/symptoms of central nervous disorders
Evaluation of trauma
Evaluation for craniosynostosis
Follow-up or assessment of previously documented abnormalities, including those
identified during a prenatal sonogram
Screening before a surgical procedure
Neonatal spine3:
Indications for a neonatal spine sonogram include, but are not limited to, the
following:
External spinal signs suggestive of a spinal dysraphism or spinal cord tethering such
as:
Midline or paramedian masses
Midline skin discoloration
Skin tags
Hair tuffs
Hemangiomas
Sacral dimples (small or deep)
– Higher suspicion for occult lesions occurs with sacral dimples in which
the base of dimple is not visualized, if it is located >2.5 cm above the
anus, or is seen in combination with the above listed skin
abnormalities.
Presence of caudal regression syndrome and anal atresia or stenosis
Evaluation of other suspected cord abnormalities including diastematomyelia,
hydromyelia, and syringomyelia
Detection of hematoma following trauma, infection, or hemorrhage following prior
instrumentation such as a lumbar puncture, or posttraumatic cerebrospinal fluid
(CSF) leakage
Visualization of blood products within the spinal canal in patients with intracranial
hemorrhage
Postoperative follow-up assessment of spinal surgeries
ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE INFANT HIP,

NEONATAL BRAIN, AND NEONATAL SPINE
Anatomy and physiology of the infant hip4:
The hip bone is composed of the ilium, ischium, and pubis.
The infant hip joint is a ball-and-socket joint, with the femoral head normally resting
within the acetabulum of the pelvic bone (Fig. 12-1).
The newborn hip is mostly cartilaginous, which allows for the sonographic
assessment of the relationship between the femoral head and the acetabulum.
DDH is a congenital anomaly in which the newborn suffers from a shallow hip
socket.
As a result of DDH, the newborn hip can be referred to as subluxed, which is defined
as partially dislocated. It can also be completely dislocated or dislocatable upon
physical examination (Fig. 12-2).
It is thought that perhaps circulating maternal hormones influence the laxity of fetal
ligaments, thus possibly predisposing some newborns to hips that are either
subluxable or dislocatable.
Fetal malposition, such as breech, and oligohydramnios greatly increase the
likelihood of an infant suffering from DDH.
Anatomy and physiology of the neonatal brain:
Anatomy:
Fontanelles:
Sonography utilizes the fontanelles to evaluate the infant brain:
– The most common fontanelle utilized is the anterior fontanelle (Fig.
12-3).
– Other fontanelles include posterior, mastoidal, and sphenoidal.
The two main portions of the brain are the cerebrum and the cerebellum, which are
separated by a fold of dura mater referred to as the tentorium.
Figure 12-1. Basic anatomy of the hip joint. (Reprinted with permission from Flynn JM,
Sankar W N, W iesel SW, eds.Operative Techniques in Pediatric Orthapaedic Surgery.
2nd ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Cerebrum:
– The cerebrum is the largest superiorly positioned portion of the brain.
– It can be separated into right and left hemispheres by the falx cerebri.
– It is composed of an anterior frontal lobe, superior and laterally located
paired parietal lobes, paired temporal lobes that are located inferior
and lateral, and an occipital lobe that is posterior in location.
Figure 12-2. Developmental dysplasia of the hip. In developmental dysplasia of
the hip, flattening of the acetabulum prevents the head of the femur from rotating
adequately. T he child’s hip may be unstable, subluxated (partially dislocated), or
completely dislocated. (Reprinted with permission from Penny S, ed. Examination
Review for Ultrasound: Abdomen and Obstetrics and Gynecology. 2nd ed. Philadelphia,
Figure 12-3. Sonographic windows for sonography of the infant brain. T he
anterior fontanelle (AF) is the most commonly utilized window, while the posterior
fontanelle (PF) and mastoid fontanelle (M F) can also provide additional views.
(Adapted with permission of American Society of Neuroradiology, from Correa F,
Enriquez G, Rossello J, et al. Posterior fontanelle sonography: An acoustics window into
the neonatal brain. AJNR Am J Neuroradiol. 2004;25(7):1274–1282. Permission
conveyed through Copyright Clearance Center, Inc.)
– The right and left cerebral hemispheres are connected by a band of

tissue referred to as the corpus callosum.
– The right and left lateral ventricles are located within the hemispheres
respectively.
– The cerebrum of the premature newborn may lack the normally
demonstrated sulci and gyri of the full-term newborn.
Cerebellum:
– The cerebellum is the smaller posterior and inferiorly positioned part of
the brain.
– It consists of a right and left hemisphere, connected in the midline by a
structure referred to as the cerebellar vermis.
Figure 12-4. Lateral or sagittal anatomy of the ventricles of the brain. (A) Lateral
ventricle: 1-Anterior horn; 2-Inferior horn; 3-Posterior horn, (B) Interventricular
foramen (Monro), (C) T hird ventricle, (D) Cerebral aqueduct, (E) Fourth ventricle,
(F) Lateral foramen (Luschka), (G) Medial foramen (Magendie). (Reprinted with
permission from Anatomical Chart Company. Rapid Review Anatomy Reference Guide.
3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.)
The ventricular system:

– The ventricles of the brain contain CSF, which is produced by choroid
plexus that is mostly located in the bilateral lateral ventricles (Fig. 12-
4). There are two lateral ventricles, one third ventricle, and one fourth
ventricle.
– Lateral ventricles
The lateral ventricles are located within the right or left hemisphere, and each
consists of a frontal horn, body, trigone or atrium, temporal or inferior horn, and
occipital horn.
They contain the majority of choroid plexus, which is located in the atrium or
trigone.
– Third ventricle:
The third ventricle is located in the midline of the brain and linked to each
lateral ventricle by the foramina of Monro.
The interthalamic adhesion travels through the third ventricle and may be readily
noted when the third ventricle is distended with CSF.
– Fourth ventricle:
The fourth ventricle is connected to the third ventricle via the cerebral aqueduct
(aqueduct of Sylvius).
It is located in the midline anterior to the cerebellar vermis.
Cisterna magna:
– The cisterna magna is the largest cistern of the brain.
– It is located posterior to the cerebellum.
Cavum septum pellucidum (CSP):
– The CSP is a normal midline cystic brain structure that appears much
more prominent in the neonatal brain.
– The CSP is located between the frontal horns of the lateral ventricles,
superior to the third ventricle and inferior to the corpus callosum (Fig.
12-5).
– The posterior extension of the CSP within the premature brain is
referred to as the cavum vergae.
– The CSP closes from posterior to anterior as the brain matures.
Thalamus:
– The lobes of the thalamus are located below each cerebral lobe and
form the lateral borders of the third ventricle.
– The lobes are connected by a band of tissue, the interthalamic
adhesion, which travels through the third ventricle.
– Both lobes help to form the caudothalamic groove inferior to the lateral
ventricles bilaterally.
Caudate nucleus:
– The caudate nucleus helps to form the caudothalamic groove and it is
located in each cerebral hemisphere.
– The caudate nucleus consists of a head, body, and tail.
Figure 12-5. Anatomy of the cavum septum pellucidum. T he cavum septum
pellucidum (CSP) is a normal midline structure often noted within the premature
brain. T he cavum vergae (CV) and even the cavum velum interpositum (CVI) may
also be noted, especially if the brain is exceedingly immature. 3, third ventricle; 4,
fourth ventricle. (Reprinted with permission from Kline-Fath B, Bahado-Singh R, Bulas
D, eds. Fundamental and Advanced Fetal Imaging. 1st ed. Philadelphia, PA: Wolters
Kluwer; 2015.)
Caudothalamic groove:
– The caudothalamic groove is the bilateral groove created by the
caudate nucleus and thalamus.
– The caudothalamic groove contains the germinal matrix and is the
most common location for cerebral hemorrhage to occur within the
premature brain (Fig. 12-6).
Germinal matrix:
– The germinal matrix is a group of thin-walled blood vessels that are
highly prone to rupture when a compromise to cerebral blood pressure
occurs.
– The bilateral germinal matrix is larger in preterm infants, but ultimately
regresses in size to be located at the head of the caudate nucleus in
the caudothalamic groove.
– The germinal matrix is the most common location for intracranial
hemorrhage to occur in the premature infant brain.
Figure 12-6. Caudothalamic groove. Magnified sonographic parasagittal scan at
the level of the caudothalamic groove. Head of the caudate nucleus (C) is seen
anterior to the thalamus (T ). Between these two structures is the caudothalamic
groove (arrow), which contains the anterior extent of the choroid plexus.
Physiology:
The premature infant lacks the ability to autoregulate cerebral blood pressure, and
thus the brain may suffer from a lack of oxygen.
Lack of oxygen to the brain can result in a hypoxic–ischemic event, leading to
hemorrhage and death of the affected tissue.
Sonography provides a noninvasive imaging modality that can assess the infant brain
for signs of hemorrhage, congenital brain malformations, and other pathology.
Figure 12-7. Malformation of the distal spine. (Reprinted with permission from Bowden
V, Greenberg CS, eds. Children and Their Families. 3rd ed. Philadelphia, PA: Wolters
Anatomy and physiology of the neonatal spine4,5:

When clinical findings are worrisome for spinal dysraphisms, the distal neonatal
spine can be well demonstrated with sonography in the newborn up until around 3
mo.
Open spinal defects are typically visually demonstrated, while occult (hidden)
lesions often require imaging (Fig. 12-7).
Overlying skin abnormalities suggestive of occult abnormalities include a sacral
dimple, tuft of hair or skin tags, dorsal dermal sinus, or skin lesion such as a
hemangioma located over the distal spine region.
Of main concern is the location of the distal spinal cord, a structure referred to as the
conus medullaris (Fig. 12-8).
The conus medullaris is the tapering of the spinal cord and it should normally
terminate between L1 and L2.
The conus medullaris gives rise to the filum terminale, which is surrounded by the
cauda equine.
Tethering of the cord can be demonstrated with sonography when the conus
medullaris is located at or below the L3 vertebral level.
Tethering of the cord can lead to nerve damage, and if surgical intervention is not
performed, possible complications include bladder, bowel, and lower limb
dysfunction.
Figure 12-8. Normal longitudinal anatomy of the spinal cord. Longitudinal scan through
the distal cord shows a normal smoothly tapering conus medullaris (C), nerve roots
(arrowheads), and the filum terminale (f). T he second lumbar vertebral body is labeled
(L2). T he conus medullaris is in a normal position at L2 to L3. (Reprinted with permission
from Siegel MJ, ed. Pediatric Sonography. 5th ed. Philadelphia, PA: Wolters Kluwer; 2018.)
PATIENT PREPARATION FOR SONOGRAPHY OF THE INFANT

HIP, NEONATAL BRAIN, AND NEONATAL SPINE1–6
Infant hips:
A hip ultrasound is not typically performed on patients younger than 6 wks of age
unless indicated based on abnormal findings on physical exam. Also, sonography is
most useful for infants younger than 6 mo secondary to the increased ossification of
the bones in older infants.
The optimal time to assess the infant’s hips is immediately following feeding when
the infant is relaxed and cooperative.
Rolled towels or perhaps a small-angled sponge may be needed in order to stabilize
the infant when decubitus imaging is warranted.
Clothing should be removed from the waist down, though the diaper should remain in
place.
Keeping the infant warm is beneficial, as well as the aid that a parent or assistant can
provide during the examination.
A physical examination can be conducted by a qualified examiner prior to the
sonographic examination (Fig. 12-9). There are two tests that are often utilized:
Figure 12-9. A: T he Ortolani maneuver. From a flexed and adduced position, the hip
is abducted; the examiner feels a clunk as the femoral head moves into the socket.
T he examiner’s other hand stabilizes the infant’s pelvis. B: T he Barlow test. T he
examiner holds the infant’s hip in flexion and slight abduction. T he infant’s hip is
adduced while applying pressure in a posterior direction. Dislocation of the femoral
head with pressure indicates an unstable hip. (Reprinted with permission from Penny
S, ed. Examination Review for Ultrasound: Abdomen and Obstetrics and Gynecology. 2nd
Barlow test—assesses the hip for dislocation:

The infant is placed in the supine position and the leg is flexed 90 degrees.
The examiner then grasps the symphysis pubis and sacrum with one hand, while the
other hand adducts the hip by manipulating the knee.
Slight outward pressure is then exerted over the knee and distal thigh.
If the hip is dislocatable, a palpable sensation referred to as a clunk, will be felt as
the femoral head exits the acetabulum.
Ortolani test—the examiner attempts to reduce a recently dislocated hip:
The infant is placed in the supine position.
The index and middle fingers are placed along the outer femur at the level of the
greater trochanter and the thumb is placed along the inner thigh.
The hip is then flexed 90 degrees and is then abducted while simultaneously lifting
the leg anteriorly.
A palpable clunk is felt as the hip is reduced into the acetabulum.
An audible click may also be heard as well.
A basic visual assessment can be conducted as well (Fig. 12-10):
Assess for signs of asymmetry in the lengths of the legs. DDH can be suspected
when the knees are flexed, and one knee is notably lower than the other, thus
demonstrating a leg length discrepancy.
Assess for signs of asymmetry in the thigh skin folds. The affected side will have
both asymmetric thigh and gluteal folds.
Neonatal brain:
Premature infants are often analyzed in the neonatal intensive care unit:
Make sure the ultrasound machine and all equipment are thoroughly cleaned.
Be aware that units will most likely require surgical hand asepsis before entering
and providing patient care to premature infants.
Figure 12-10. DDH physical findings. A: Asymmetric skin folds. B: Leg length
discrepancy. (Reprinted with permission from Sanders RC, ed.Clinical Sonography: A
Practical Guide. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Work to maintain a clean environment and to not disrupt the infants environment too
much, including maintaining a warm atmosphere.
Obtain necessary information regarding the birth weight and current weight of the
infant. Also, obtain the age of gestation at the time of birth and current age prior to
the examination. This information may be provided on the sonographic images.
Evaluation of inpatient and outpatient term infants and follow-up examinations are
typically performed in the sonography department:
An assistant may be helpful to pacify the infant.
Neonatal spine:
No preparation is required for a neonatal spine sonogram.
A bottle or pacifier can be helpful to calm the patient during the exam.
SUGGESTED EQUIPMENT 1–5

Infant hips:
Birth to 3 mo = 7.5 MHz high-frequency linear transducer or higher
Older infants = 5 MHz linear transducer may be warranted
An assistant would be helpful for stabilizing the infant or manipulating the machine
controls
Neonatal brain:
Newborns = 7.5 MHz phased array vector, sector, or curved linear transducer that
can fit within and image through the anterior fontanelle
Older infants = 5 MHz phased array vector, sector, or curved linear transducer may
be warranted
Linear transducer may be warranted for the assessment of the superior sagittal sinus
The Doppler power output should be as low as reasonably achievable
Neonatal spine:
Neonates = 9–12 MHz high-frequency linear array transducer
Older infants = 5–9 MHz high-frequency linear array transducer:
3–9 MHz curvilinear transducer with a larger field of view may be helpful in larger
infants
Transducers settings that can provide a panoramic view or a split or dual screen can
be helpful
A towel may be warranted to elevate the abdomen in order to decrease the natural
curvature of the distal spine

INFANT HIPS, NEONATAL BRAIN, AND NEONATAL SPINE
Infant hips:
Evaluate prior imaging reports and images including previous perinatal sonogram
reports for evidence of predisposing conditions such as breech position or
oligohydramnios.
Evaluate previous radiography examinations of the hip.
Critical clinical history questions related to infant hips:
Was the baby in a breech position at the time of delivery? A breech delivery
increases the chances for the infant to suffer from DDH.
Was there evidence of abnormal fetal position or oligohydramnios?
Oligohydramnios increases the chances for the infant to suffer from DDH.
Any family history of DDH? Family history increases the chances for the infant to
suffer from DDH.
Did the physician hear a click or pop on physical exam? Physician examination of
infants suffering from DDH could reveal an audible pop or click emanating from the
abnormal hip joint.
Does the infant have signs of asymmetry in the lengths of the legs? Asymmetry in the
legs can be a physical sign of DDH.
Does the infant have signs of asymmetry in the thigh skin folds? Asymmetry of the
skin folds can be a physical sign of DDH.
Neonatal brain:
Evaluate prior imaging reports and images including previous perinatal sonogram
reports for evidence of congenital brain abnormalities or complicated perinatal
conditions.
Critical clinical history questions related to the neonatal brain:
Premature neonatal brain:
What was the gestational age at the time of birth? Preterm infants who are born less
than 32 wks of gestational age are at high-risk for suffering from intracranial
hemorrhage.
What was the birth weight? Preterm infants who are born weighing <1,500 g are at
high risk for suffering from intracranial hemorrhage.
What is the current age of the infant? Oftentimes, intracranial hemorrhage may not
be visualized with sonography until 3–4 d after birth.
Mature infant brain:
Was the infant born prematurely? A history of prematurity increases the risk for
intracranial hemorrhage.
Is the infant feeding normally? Hydrocephalus and congenital brain anomalies can
cause associated feeding issues in infants.
Is the head enlarged? Pediatricians measure the head circumference in the neonatal
period to assess for signs of hydrocephalus.
Neonatal spine:
Evaluate prior imaging reports and images including previous postnatal radiography
exams.
Critical clinical history questions related to the neonatal spine:
Does the infant have any skin features or external defects suggestive of a spinal
dysraphism? Overlying skin abnormalities suggestive of occult abnormalities
include a sacral dimple, tuft of hair or skin tags, dorsal dermal sinus, or skin lesion
such as a hemangioma located over the distal spine region.
Are there any perinatal sonographic findings suggestive of spina bifida? Open
neural tube defects may be discovered in utero and thus obstetric sonogram reports
should be obtained if possible.
NORMAL SONOGRAPHIC DESCRIPTION OF INFANT HIPS,
NEONATAL BRAIN, AND NEONATAL SPINE1–4
Infant hips:
The femoral head appears as a hypoechoic well-circumscribed circle containing
hyperechoic dots (Fig. 12-11).
The femoral neck is hyperechoic and extends medially, superiorly, and anteriorly as
it tapers toward the head of the femur.
Figure 12-11. Normal neonatal hip in coronal. T he femoral head (H) is clearly
distinguishable as a hypoechoic round structure containing multiple hyperechoic
foci. It is noted within the curved hyperechoic cup-shaped acetabulum (A). (Reprinted
with permission from Chew FS, ed. Skeletal Radiology. 3rd ed. Philadelphia, PA: Wolters
The acetabulum is a cup-shaped hyperechoic fossa that should contain the femoral
head.
The labrum is best seen in coronal as a triangular hypoechoic structure adjacent to
the ileum and superolateral to the femoral head.
The ileum is hyperechoic and produces an acoustic shadow.
Neonatal brain:
The mid-low level echoes that comprise the brain parenchyma in the premature infant
may appear exceedingly smooth, lacking sulci and gyri. As the infant brain matures
more sulci and gyri can be noted (Fig. 12-12).
Sulci and gyri appear as hyperechoic curvilinear structures that course throughout the
mature brain parenchyma.
The normal lateral ventricles appear as slit-like structures in the mature infant brain,
while in the premature brain the ventricles are much more prominent and slightly
distended with anechoic CSF.
Figure 12-12. Normal neonatal brain and mature brain sonographic features.
Parasagittal US images of normal 26-wk (A), normal 35-wk (B), and normal term (C)
infants. Head sonography is the most frequent means of neonatal brain imaging.
Note how sulcation (arrows) evolves from a smooth cortical mantle at 26 wk (A), into
a highly organized adult pattern by term (C) (arrows). (Reprinted with permission from
Brant W E, Helms C, eds.Fundamentals of Diagnostic Radiology. 4th ed. Philadelphia, PA:
Figure 12-13. Normal infant spine, extended field of view. Longitudinal extended
field-of-view image in a newborn infant shows the entire lower spinal cord and its
relationship to the spine. S5 is the first ossified vertebral segment, the coccyx
(arrow) is unossified, and the conus (C) ends normally at L1–L2. (Reprinted with
permission from Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters
The CSP can be noted in the midline of the brain. In the premature infant, a posterior
extension of the CSP referred to as the cavum vergae, can be identified as well.
Occasionally, the cavum interpositum can be seen as an anechoic structure inferior to
the cavum vergae.
The bilateral caudothalamic grooves can be noted as hyperechoic curvilinear
structures located between the caudate nuclei and lobes of the thalamus.
Bilateral sylvian fissure can also be noted laterally as echogenic curvilinear
structures.
Neonatal spine:
In longitudinal, the spinal cord appears as a hypoechoic tubular structure with
anterior and posterior borders that should ultimately taper at the conus medullaris,
typically at the level of the first or second lumbar vertebral body (Fig. 12-13).
The echogenic central complex can be noted within the spinal cord.
Anechoic CSF is located within the anterior subarachnoid space and should be seen
adjacent to the spinal cord.
The echogenic vertebral bodies can be noted anterior to the spinal cord, while the
echogenic posterior elements of the spine are noted posteriorly.
The spinal cord is bordered posteriorly by the hypoechoic cartilaginous spinous
processes, hyperechoic dura mater, and CSF-filled posterior subarachnoid space.
The conus medullaris gives rise to the fibrous filum terminale, which should extend
into the distal sacral canal.
Upon real-time investigation, the spinal cord should be noted freely moving within
the spinal canal.
In transverse, the spinal cord appears as a hypoechoic oval or round structure with an
echogenic central complex.
Nerve fibers that extend from the spinal cord can be noted as hyperechoic linear
structures coursing away from the cord and filum terminale.
SUGGESTED PROTOCOL FOR SONOGRAPHY OF INFANT

HIPS, NEONATAL BRAIN, AND NEONATAL SPINE1–6
Infant hips:
Both hips should be examined with sonography.
If possible, some type of pacification for the infant should be provided, including
feeding the infant during the exam to minimize irritability.
Each hip can be examined in the supine or related decubitus positions.
Each hip is examined in coronal at rest and transverse with and without stress.
Careful labeling should be maintained to include “stress” and/or “neutral.”
Coronal view (Fig. 12-14) (Video 12-1)
The anatomic coronal image is obtained by manipulating the superior edge of the
transducer 10–15 degrees into an oblique coronal image in order for the ilium to
appear straight. This will provide a longitudinal image of the hip.
The iliac line will be noted superiorly and the femoral neck will be noted inferiorly
in the image.
In the coronal/neutral scan plane, the leg can be extended or remain in the neutral
position.
Both alpha and beta angle can be obtained in the coronal plane (Fig. 12-15).
Graf technique—measurement of the relationship between the acetabulum and the
femoral head.
Three lines and two angles are drawn around the acetabulum.
Figure 12-14. Coronal infant hip. A: Probe placement on an infant hip for the
coronal flexion view. Please note the infant’s knee is bent at approximately 90
degrees. B: Anatomic drawing of the infant hip in coronal. C: Normal coronal
sonogram of the infant hip in the coronal plane. (Reprinted with permission from
Sanders RC, ed. Clinical Sonography: A Practical Guide. 5th ed. Philadelphia, PA:
Figure 12-15. T he Graf technique. Drawing of the coronal view of the hip (A) and
coronal sonogram (B) delineate the femoral head, bony acetabulum, and labrum. A
horizontal baseline is drawn along the ilium (1), along with lines along the labrum
(2) and bony acetabulum (3). T he alpha angle measures the acetabulum and is
equal to greater than 60 degrees in infants with seated hips and less than 50
degrees in patients with dysplasia. (Panel A adapted by permission from the Springer:
Graf R. Classification of hip joint dysplasia by means of sonography. Arch Orthop
Trauma Surg. 1984;102(4);248–255. Copyright © 1984 Springer Nature; Panel B
reprinted with permission from Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia,
– Alpha angle:
Obtained by drawing one line along the straight edge of the iliac bone and a
second line along the bony acetabular roof.
– Beta angle:
Obtained by drawing one line through the straight edge of the iliac bone and a
line through the echogenic fibrocartilaginous labrum.
Coverage of the femoral head by the acetabulum should also be assessed.
Validation by angle and femoral head coverage measurement is optional.
Performance of stress in this plane is also optional.
Transverse:
The correct transverse plane is the anatomic transverse or axial plane with respect
to the body (Fig. 12-16).
Flexion position is adequate, though some may prefer to include a neutral position
also.
Transverse flexion is made from a transverse plane with the femur flexed 90
degrees.
The femoral shaft and ischium should form a U or V configuration with the femoral
head.
Stress maneuvers can be performed in real time to assess the seating position of the
femoral head into the acetabulum (Video 12-2).
Stress maneuvers are not performed when the hips are being examined in a Pavlik
harness or split device unless otherwise specified.
Neonatal brain:
The brain should be examined with the infant in the supine position, though it may be
in the prone position if needed.
Transducer orientation is critical, so ensure that in coronal the index or notch is
located on the right side of the head, while in sagittal the notch should be positioned
anteriorly.
Coronal images should include (Figs. 12-17 and 12-18) (Video 12-3):
Frontal lobes anterior to the frontal horns of the lateral ventricles with orbits
visualized deep to the skull base.
Frontal horns or bodies of the lateral ventricles and interhemispheric fissure.
Figure 12-16. Transverse infant hip. A: Transducer placement for flexion
transverse imaging of the infant hip. B: Drawing of the infant hip anatomy in the
transverse flexion view. C: Sonogram of the normal infant hip in transverse.
(Reprinted with permission from Sanders RC, ed.Clinical Sonography: A Practical
Guide. 5th ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Figure 12-17. Transducer placement and manipulation for coronal imaging of the
neonatal brain. Note that the transducer notch or index is placed on the patient’s
right side. (Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and
Lateral ventricles at the level of the lateral and third ventricles.

Include interhemispheric fissure, cingulate sulcus (if developed), corpus callosum,
septum pellucidum or cavum septi pellucidi, caudate nuclei, putamina, globi
pallidi, and sylvian fissures. The foramina of Monro should also be depicted,
outlining the course of the choroid plexus from the lateral into the third ventricle.
Figure 12-18. Coronal neonatal brain sonographic images from anterior to
posterior. A: Image of the frontal lobes includes the interhemispheric fissure
(white arrow). T he orbital ridges (O) are also noted. B: T he frontal horns (f)
appear as triangular-shaped, fluid-filled spaces separated by the cavum septum
pellucidum (cp). T he head of the caudate nuclei (N) lie adjacent to the lateral
walls of the ventricles. T he hypoechoic corpus callosum (cc) forms the roof of the
cavum. T he echogenic Y-shaped sylvian fissures (arrows) are seen laterally. C:
Magnified coronal image at the level of the normal third ventricle. Slight off-axis
scan shows the normal size third ventricle (arrow) at the level of the foramen of
M onro. D: T he echogenic choroid plexus is seen in the floor of the lateral
ventricles (arrows) and the roof of the third ventricle (arrowhead). T he Y-shaped
sylvian fissures (SF) are seen laterally. Also visible are the echogenic tentorium
(asterisk), the cerebellar hemispheres (CB), and the cisterna magna (CM).E:
Coronal image taken at the level of the quadrigeminal cistern. T he star-shaped
echogenic quadrigeminal cistern (Q) is seen inferior to the thalami (T ). T he
cerebellum (CB) and the echogenic choroid plexus (arrowhead) in the floor of the
lateral ventricles are also visualized on this image. F: Coronal scan at the level of
the trigones of the lateral ventricles. T he largest part of the choroid plexus (CP),
the glomus, can be seen occupying most of the lateral ventricles. T he
periventricular matter is located lateral to the ventricles (arrows) . G: Coronal
image taken posterior to the occipital horns of lateral ventricles shows the normal
echogenic periventricular white matter (arrows) and the occipital cortex.
Lateral ventricles slightly posterior to the foramina of Monro where the lateral and
third ventricles communicate. Include the pons and medulla, thalami, and choroid
plexus in the roof of the third ventricle and in the caudothalamic grooves.
Level of the quadrigeminal cistern and cerebellum. Include the cerebellar vermis,
cisterna magna posteriorly and inferiorly, bodies of the lateral ventricles bordered
by caudate nuclei and thalami, and temporal horns.
Echogenic glomi of choroid plexuses at the posterior aspect of the lateral
ventricles at the level of trigones. Include the splenium of the corpus callosum at
divergence of the lateral ventricle, periventricular white matter lateral to posterior
horns of the lateral ventricles.
Area posterior to the occipital horns. Include parietal and occipital lobes and the
posterior interhemispheric fissure.
Additional coronal image:
– Extra-axial fluid spaces as needed. Use linear high-frequency (≥9 MHz)
transducers to obtain a coronal magnification view of the extra-axial
fluid space, including only peripheral brain structures (superior sagittal
sinus at the level of the frontal horns; measure the sinocortical
distance, craniocortical distance, and width of the interhemispheric
fissure).
Sagittal images should include (Figs. 12-19 and 12-20) (Video 12-4):
Midline sagittal view to include the corpus callosum, cavum septum pellucidi, and
cavum vergae if present, third and fourth ventricles, cerebral aqueduct, brain stem,
cerebellar vermis, cisterna magna, and sulci.
Bilateral parasagittal images to include all parts of the lateral ventricles, the
choroid plexus, caudothalamic grooves, insula, periventricular white matter, and
sylvian fissures.
Additional views and images:
Mastoid views and posterior views may be utilized to demonstrate the cerebellum
and posterior elements of the brain.
Pulsed Doppler assessment of the resistive index of the midline anterior cerebral
artery may be obtained.
A color Doppler linear image of the anterior surface of the brain may be obtained
to evaluate for subdural hemorrhage. Normal subarachnoid fluid has crossing
vessels (cortical vein sign), whereas abnormal subdural fluid does not.
Neonatal spine:
The examination is usually performed with the infant lying in the prone position,
although the study can also be done with the patient in the decubitus position.
A small bolster may be placed under the lower abdomen or pelvis to mildly flex the
back, which may improve imaging.
The knees may be flexed to improve visualization of the spinal canal.
The infant should be kept warm and pacified.
Images are typically obtained in the longitudinal and transverse scan planes.
Extended field-of view images or landscape views are highly beneficial.
Cine clips can be used to demonstrate cord motion and provide an overall view of
the spine (Video 12-5).
Figure 12-19. Transducer placement for imaging of the neonatal brain in the sagittal
and parasagittal plane. Note that the transducer notch or index is placed toward the
patient’s face. (Reprinted with permission from Kawamura D, Nolan T, eds. Abdomen and
Longitudinal spine
Studies may be limited to the lumbosacral region in specific cases, as in those
patients being evaluated for a sacrococcygeal dimple and tethered cord.
Normal cord morphology and the level of termination of the conus should be
assessed and documented, which requires accurate identification of vertebral body
level.
Figure 12-20. Sagittal and parasagittal neonatal brain sonographic images. A:
Sagittal midline. Normal midline sagittal image on a term infant. T he hypoechoic
corpus callosum (cc) is seen anterior to the cavum septum pellucidum. T he third
(3) and fourth (4) ventricles are visible in this plane. Posterior to the fourth
ventricle is the echogenic vermis of the cerebellum (v) and the cisterna magna
(arrow). Anterior to the fourth ventricle is the pons (p) and medulla (m). B:
Parasagittal scan through the area of the lateral ventricle. T he highly echogenic
choroid plexus (CP) is seen within the body of the lateral ventricle (V) and tapers
to a point at the caudothalamic groove. T he caudate nucleus (C) anterior to the
thalamus (T ) is again noted. T his is the location of the germinal matrix in
premature infants. C: Parasagittal scan through the body of the lateral ventricle.
T he echogenic choroid plexus (CP) is seen within the trigone of the ventricle. D:
Parasagittal scan lateral to the ventricle. T he sylvian fissure (arrow) is seen in
this scan, and on real-time scanning, the branches of the middle cerebral arteries
can be seen pulsating within this fissure. Normal periventricular white matter
(arrowheads) lateral to the ventricle. (Reprinted with permission from Kawamura D,
Nolan T, eds. Abdomen and Superficial Structures. 4th ed. Philadelphia, PA: Wolters
Kluwer; 2017.)
Figure 12-21. Lumbosacral junction. T his longitudinal image of the distal infant
spine depicts the vertebral column and the lumbosacral junction, which is a
crucial landmark used to help count the vertebral bodies and to determine the
location of the conus. (Reprinted with permission from Kawamura D, Lunsford B, eds.
– Method 1:
Identification of the normal lumbosacral curvature to locate the lumbosacral
junction and thus the location of L5 is a means to determine the location of the
conus (Fig. 12-21).
The vertebral level of the conus medullaris is then determined by counting
cephalad from L5.
Extended field-of-view (panoramic) imaging can often aid in identification of a
longer segment of the spine and facilitate identification of the vertebral level.
The first coccygeal segment may or may not be ossified at birth, though it can be
differentiated by its rounder shape compared to the rectangular shape of the
sacral bodies.
– Method 2:
The last rib-bearing vertebra can be presumed to be T12, and the lumbar level
of the conus can then be determined by counting from superior to inferior of the
successive vertebral bodies.
The conus is normally located at or above the L2 to L3 disk space. However, a
normal conus located at the mid-L3 level may be identified, especially in preterm
infants; this position is considered the lower limits of normal.
Figure 12-22. Longitudinal view of lower spinal canal showing echogenic roots of
cauda equina (arrowheads). Distal cord tapers into conus (white arrow). Filum
terminale (black arrow) extends from conus to distal thecal sac. (Reprinted with
permission from Iyer R, Chapman T, eds. Pediatric Imaging: The Essentials. 1st ed.
Cord motion should be noted with respiration and the cord should rest anteriorly in
the spinal canal when the patient is in the prone position. A motionless spinal cord
may be suggestive of a tethered cord.
The filum of the cord and its thickness should be noted (Fig. 12-22).
Abnormal fluid collections in and around the cord should be noted.
Tracts extending from the skin surface should be assessed for connection into the
spinal canal.
A stand-off pad or a thick layer of coupling gel may be used, if needed, to evaluate
the superficial soft tissues and skin line for the presence of a tract.
Transverse spine (Fig. 12-23):
Transverse images are essential to identify and document diastematomyelia (split
spinal cord).
Open posterior elements in skin-covered dysraphic defects can be documented on
transverse views.
The filum of the cord and its thickness should be noted.
Figure 12-23. Normal transverse spinal cord. A: T he hypoechoic spinal cord (c) is
surrounded by the echogenic nerve roots of the cauda equina (arrows). Cerebrospinal
fluid surrounds the cord that is contained by the echogenic dura (arrowheads)
encompassing the canal. Echogenic vertebral arches (*) are noted posterior and
laterally joining with the hypoechoic spinous process (p) posteriorly. B: A slightly more
prominent echogenic round filum terminale (arrow) floats among echogenic nerve
roots (arrowheads). C: Nerve roots can appear as small echogenic dots (arrowheads)
or clump together, sometimes obscuring the filum terminale. (Reprinted with permission
from Kawamura D, Nolan T, eds. Abdomen and Superficial Structures. 4th ed. Philadelphia,
SCANNING TIPS4
Infant hips:
False-positive results for DDH can result from improper transducer orientation of the
acetabulum with the femoral head and triradiate cartilage. To correct improper
orientation in the coronal view, ensure that the beam is centered over the acetabulum
and that the ilium is parallel to the transducer face.
Scanning at 6 wks may not always be helpful because the immature acetabulum may
be underdeveloped. Thus, inconclusive or indeterminate exams should be followed
up.
Acoustic shadowing produced by the femoral head or acetabulum can prohibit the
complete visualization of the hip joint. Thus, a radiographic examination may be
warranted.
Neonatal brain:
Asymmetry between the lateral ventricles may be noted. In most cases, the larger
ventricle is the side that the infant is lying on and this is secondary to that ventricle
becoming distended with more CSF due to gravity.
The “three dot sign” is the sonographic sign of choroid plexus located in the roof of
the third ventricle and the floor of both lateral ventricles. This sign can simulate
bilateral germinal matrix hemorrhages.
The normal periventricular halo can appear similar to periventricular leukomalacia.
However, the tissue containing the normal halo should not appear brighter than the
choroid plexus.
Neonatal spine:
Two other methods exist for determining the location of the conus:
The thecal sac usually ends at S2. This level can then be used to count cephalad to
determine the location of the conus.
When the level of the conus cannot be definitively assessed as normal or abnormal,
correlation with previous plain radiographs, if available, is helpful. A radiopaque
marker can be placed on the skin at the level of the conus determined
sonographically, followed by an anterior–posterior spine radiograph.
NORMAL MEASUREMENTS OF INFANT HIPS, NEONATAL

BRAIN, AND NEONATAL SPINE4,5
Infant hips:
Graf technique:
Alpha angle is normally ≥60 degrees:
The smaller the alpha angle, the more likely DDH is present.
Beta angle is normally ≤50 degrees:
The greater the beta angle, the more likely DDH is present.
Coverage of the femoral head by the acetabulum of greater than 55% or less is
normal, while less than 50% is said to be shallow, and less than 45% is said to be
very shallow.
Neonatal brain:
Lateral ventricles: Term infants should have slit-like lateral ventricles that measure
<3 mm in diameter.
Neonatal spine:
Normal conus medullaris is nearly always located above the L2–L3 disc space.
Filum terminale thickness ≤2 mm.
Lumbar portion of the cord = 5.8 ± 0.66 mm.
ESSENTIAL PATHOLOGY OF INFANT HIPS, NEONATAL BRAIN,

AND NEONATAL SPINE5–7
Infant hips:
Developmental dysplasia of the infant hip:
Clinical findings:
History of breech birth
Family history of DDH
Asymmetric skin folds on the legs
Leg length discrepancy
Limited limb abduction
Positive Barlow or Ortolani test
Complete dislocation: femoral head located completely outside of the acetabulum
(Fig. 12-24)
Subluxation: partial coverage of the femoral head by the acetabulum (Fig. 12-25)
Evidence of a shallow acetabulum demonstrating <50% coverage of the femoral
head
Small alpha angle
Large beta angle
Infant hip joint effusion (transient synovitis):
Clinical findings:
Leg and knee pain
Reluctance to walk
Irritability
Low-grade fever
Mild leukocytosis
An anechoic or hypoechoic fluid collection that elevates the anterior capsule of the
joint
Width of the abnormal hip joint capsule typically exceeds 5 mm
Neonatal brain:
Intracranial/intraventricular hemorrhage grades:
Grade I = Germinal matrix hemorrhage (subependymal hemorrhage) (Fig. 12-26)
Grade II = Germinal matrix hemorrhage + Intraventricular hemorrhage (Fig. 12-27)
Figure 12-24. Coronal image of partial dislocation and severe acetabular dysplasia
of the infant hip (A, B). (Reprinted with permission from Sanders RC, ed.Clinical
Figure 12-25. Subluxation. A: Coronal flexion views of the left hip. T he femoral
head (H) is positioned laterally but maintains contact with the bony acetabulum
(arrowhead) and the labrum (arrow). Note the echogenic pulvinar (P) deep to the
femoral head. B: Transverse flexion view. T he femoral head (H) is subluxed
posteriorly in relationship to the ischium (I) and acetabular roof cartilage (arrow).
(Reprinted with permission from Siegel MJ, Coley B, eds.Core Curriculum: Pediatric
Imaging. 1st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.)
Figure 12-26. Germinal matrix hemorrhage (grade I). A: Coronal sonogram shows a
focus of increased echogenicity (arrow) in the right subependymal area. B: Right
parasagittal image shows increased echogenicity in the caudothalamic groove
(arrow). (Reprinted with permission from Siegel MJ, ed.Pediatric Sonography. 5th ed.
Figure 12-27. Intraventricular (grade II) hemorrhage. Coronal cranial image shows
an intraventricular ovoid hemorrhage (arrow) within the left lateral ventricle. Note
absence of ventricular dilatation. (Reprinted with permission from Iyer R, Chapman T,
eds. Pediatric Imaging: The Essentials. 1st ed. Philadelphia, PA: Wolters Kluwer; 2015.)
Grade III = Intraventricular hemorrhage + Ventriculomegally (Fig. 12-28)

Grade IV = Intraparenchymal hemorrhage (Fig. 12-29)
Periventricular leukomalacia:
Stage I = Increased echogenicity of the periventricular white matter (Fig. 12-30)
Stage II = Cystic spaces form adjacent to both lateral ventricles (Fig. 12-30)
Figure 12-28. Neonatal brain with intraventricular hemorrhage with ventriculomegaly
(grade III). A: Coronal scan shows clot in both lateral ventricles with hydrocephalus
(arrow). B: Parasagittal scan shows some retraction of the intraventricular clot.
Figure 12-29. Neonatal brain with intraparenchymal hemorrhage (grade IV). An

echogenic hemorrhage (arrow) is noted within the left lateral aspect of this neonatal
brain. (Reprinted with permission from W hite AJ, ed. The Washington Manual of Pediatrics.
2nd ed. Philadelphia, PA: Wolters Kluwer; 2016.)
Neonatal spine:
Tethering of the spinal cord:
Clinical findings:
Overlying skin abnormalities suggestive of occult abnormalities include a sacral
dimple, tuft of hair or skin tags, dorsal dermal sinus, or skin lesion such as a
hemangioma located over the distal spine region.
Obvious spinal external defect such as a meningomyelocele.
Absence of the normal motion of the spinal cord.
Conus medullaris located at or below the L3 vertebral level (Fig. 12-31).
Figure 12-30. Stages of periventricular leukomalacia. A: A right parasagittal image
demonstrates the echogenic pattern of periventricular leukomalacia (arrows) in its
early stage. B: Follow-up examination reveals the later stage of periventricular
leukomalacia. (Reprinted with permission from Siegel MJ, ed.Pediatric Sonography. 5th ed.
Figure 12-31. Tethering of the spinal cord. Longitudinal extended field-of-view image
shows an elongated spinal cord (C) that is dorsally displaced within the thecal sac. T he
tip of the conus (arrow) is elongated and low lying at L4, indicating a tethered cord.
T here was no appreciable thickening of the filum and no other abnormality to account
for the cord tethering. (Reprinted with permission from Siegel MJ, ed.Pediatric Sonography.
4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.)
WHERE ELSE TO LOOK

Infant Hips:
Obtaining a thorough clinical obstetric history is vital. If prenatal reports are
available, evaluate for DDH- predisposing conditions.
Always sonographically evaluate both hips for comparison and assess the external
physical signs mentioned earlier in this chapter before beginning the exam.
Neonatal brain:
Note the cerebellar hemispheres for signs of asymmetry. This could be a sign of
cerebellar hemorrhage.
Evaluate the internal components of the lateral ventricles for signs of choroid plexus
bleeds and for intraventricular hemorrhage.
Neonatal spine:
Urinary tract anomalies may accompany spinal dysraphisms. An assessment of the
kidneys and bladder may be warranted in some cases, especially if clinical
suspicions abound.
IMAGE CORRELATION
Infant hips radiograph of DDH (Fig. 12-32)
Neonatal spine MRI with tethering of the cord (Fig. 12-33)
Figure 12-32. Frontal radiograph of the pelvis in a 7-mo-old girl with left DDH. (Reprinted
with permission from Lee E, ed. Pediatric Radiology: Practical Imaging Evaluation of Infants
and Children. 1st ed. Philadelphia, PA: Wolters Kluwer; 2017.)
Figure 12-33. Tethering of the spinal cord on M RI. Tethering of the cord to the L5–S1
level. T he spinal cord should not extend below the inferior endplate of L2. Significant
spinal dysraphism with an associated 1.3-cm intraspinal lipoma (red arrow) is causing
tethering of the cord. (Reprinted with permission from Salimpour RR, Salimpour P,
Salimpour P, eds. Photographic Atlas of Pediatric Disorders and Diagnosis. 1st ed.
REFERENCES
1. AIUM-ACR-SPR-SRU Practice parameter for the performance of an ultrasound
examination for detection and assessment of developmental dysplasia of the hip.
https://www.aium.org/resources/guidelines/hip.pdf. Accessed December 16, 2018.
2. AIUM Practice parameter for the performance of neurosonography in neonates and
infants. https://www.aium.org/resources/guidelines/neurosonography.pdf. Accessed
December 16, 2018.
3. AIUM Practice parameter for the performance of an ultrasound examination of the
neonatal and infant spine.
https://www.aium.org/resources/guidelines/neonatalSpine.pdf. Accessed December
16, 2018.
4. Sanders R, Hall-Terracciano B, eds. Clinical Sonography: A Practical Guide. 5th ed.
Philadelphia, PA: Wolters Kluwer; 2016:Hips 670–690;Head 626–656;Spine 657–
669.
5. Siegel MJ, ed. Pediatric Sonography. 4th ed. Philadelphia, PA: Wolters Kluwer;
2011:Hips 607–616;Head 43–117;Spine 647–674.
INDEX
NOTE: Page numbers followed by f indicate figures; t indicate tables.
A
Abdomen imaging
AIUM indications, 1–2
Doppler sonography for, 14
patient positioning, 22, 22f
transducers for, 2, 3f
Abdominal aorta, anatomy and physiology of, 173–174, 174f
Abdominal aorta, sonography of
AIUM recommendations, 173
clinical investigation
critical clinical history questions, 176
laboratory values, 176t
CT and MRI of, 195f–196f
equipment, 175–176
normal measurements, 191
normal sonographic description, 177
pathologies
abdominal aortic dissection, 191, 193, 193f
enlargement of aorta, 191, 192f
patient preparation, 175
protocol, 177, 178f, 179, 180f–185f, 184
iliac arteries, 185, 186f–187f
scanning tips, 191
Abdominal aortic dissection, 191, 193, 193f
Abdominal pathologies, 20t–21t
Acoustic shadowing, 6t, 7f
Acute pancreatitis, sonographic findings of, 47, 48f, 52f
AIUM indications
for abdomen, 1–2
breast, 292
gallbladder and biliary tract, 86–87
gastrointestinal (GI) tract, 198
infant hips, 319
inferior vena cava (IVC), 173
liver, 55–56
neck and face, 263–264
neonatal brain, 319–320
neonatal spine, 320–321
pancreas, 30
pancreas, sonography of, 30
scrotum, 239
spleen, 154
urinary tract, 122–123
Alanine aminotransferase (ALT), 20t, 35t, 62t, 90t
ALARA (as low as reasonably achievable) principle, 4
Albumin, 21t, 62t
Alkaline phosphatase (ALP), 20t–21t, 35t, 62t, 90t
Alpha-fetoprotein (AFP), 62t, 245t
Amylase, 20t, 35t, 90t
Anterior cul-de-sac, 26
Appendix, sonography of
of appendicitis, 234
CI and MRI of, 237f
conditions mimicking, 234
clinical investigation, 209–210
equipment, 208
measurements, 231
normal sonographic description, 210, 216f
protocol, 222, 225, 226f–229f
scanning tips, 230
Area of pain, for abdominal complaints, 19f
Ascites, 24, 25f, 26
Aspartate aminotransferase (AST), 20t, 62t, 90t
B
Bacteria (bacteriuria), 134t
Barlow test, 332
Benign thyroid nodules, 285
Best sonographic practices, 29
Bile ducts, 88–89, 88f
Bilirubin, 20t, 35t, 90t
Blood urea nitrogen (BUN), 20t
in urinary tract pathology, 134t
Bowel obstruction, 233
Branchial cleft cyst, 288
Breast, anatomy and physiology of, 293, 294f
Breast, sonography of
BI-RADS US categories, 296t
critical clinical history questions, 295–296
laboratory findings, 295t
equipment, 295
mammographic projections, 310f
MRI image, 317f
normal sonographic description, 297, 298f–300f
pathologies
breast cyst, 313, 314f
breast masses, 312–313
fibroadenoma, 313, 315f
infiltrative ductal carcinoma, 313, 316f
protocol, 301, 301f–304f, 304, 305f–308f, 306
scanning tips, 309, 310f–312f
vocal fremitus, 312f
Breast cyst, 313, 314f
Breast masses, 312–313
C
Calcitonin, 20t
Caudate nucleus, 326
Caudothalamic groove, 327, 328f
Cavum septum pellucidum (CSP), 326, 327f
Cerebellum, 324
Cerebrum, 322
Cervical lymphadenopathy, 288, 289f
Cholecystectomy, 89, 90f
Chronic pancreatitis, sonographic findings of, 48, 49f, 53f
Chronic renal failure, 149–151, 150f
Cisterna magna, 326
Clinical history querie, 19–20
Colitis, 231
Color Doppler (CD), 14, 15f
Comet tail artifact, 6t, 8f
Complete abdominal sonogram protocol, 23
Continuous-wave Doppler (CW Doppler), 16
Creatinine, 20t
Crohn disease, 231, 232f
Cystitis, 151
D
Developmental dysplasia, 359, 360f–361f
Dirty shadowing, 6t, 9f
Diverticulitis, 231
Diverticulitis, sonography of
CT of, 238f
pathology, 231
Dromedary hump, 128t, 130f
Duplex collecting system, 128f, 128t
E
Ectopic kidney, 128t
Edge shadowing, 6t, 10f
Enlargement of aorta, 191, 192f
Epididymitis (epididymo-orchitis), 257, 258f–259f
Ergonomics, 28–29
Extrarenal pelvis, 128t, 131f
F
FAST examination, 26–28, 27f
Fibroadenoma, 313, 315f
Fluid recognition using sonography
abdominal fluid collection points, 24, 26
pleural effusions, 24, 25f
Fontanelles, 321
G
Gallbladder and biliary tract, anatomy and physiology of, 87–89, 88f
Gallbladder and biliary tract, sonography of, 23–24
AIUM recommendations, 86–87
clinical investigation, 89, 90t
clinical history questions, 89
essential pathology, 108–112, 116
acute cholecystitis, 111–112, 113f–114f
adenomyomatosis, 110–111, 112f
cholangitis, 116, 117f
choledocholithiasis, 112, 115f–116f, 116
cholelithiasis, 108, 109f
gallbladder polyps, 110, 111f
gallbladder sludge, 108, 110f
important signs, 117
protocol
bile ducts, 99, 102f
gallbladder wall measurement, 92, 97f–98f
left lateral decubitus images, 99
long common duct, 99, 100f–104f
longitudinal gallbladder, 92, 94f–95f
main lobar fissure, 91, 93f
transverse gallbladder, 92, 96f
scanning tips, 105
junctional fold, 105, 107f
Phrygian cap, 105, 106f
suggested equipment, 89
Gamma-glutamyltransferase (GGT), 20t, 62t, 90t
Gastrointestinal (GI) tract, anatomy and physiology of, 198, 199f
appendix, 203, 205f–206f
gut signature, 201f
infantile hypertrophic pyloric stenosis (IHPS), 200
intestinal wall layers, 201f
intussusception, 200, 203, 204f
McBurney point, 205f
pyloric stenosis, 202f
stomach, 202f
Gastrointestinal (GI) tract, sonography of
CI and MRI of, 235f–238f
clinical investigation, 208–210, 208t
measurements, 230–231
pathologies
bowel obstruction, 233
colitis, 231
Crohn disease, 231, 232f
diverticulitis, 231
protocol, 216–217, 218f–229f, 221–222, 225
scanning tips, 230
General bowel assessment, sonography of
equipment, 207
measurement, 230–231
protocol, 216–217
scanning tips, 230
Germinal matrix, 327
Glomerular filtration rate (GFR), 134t
Graf technique, 340, 342f, 343, 358
Graves disease (hyperthyroidism), 285, 286f
H
Hashimoto thyroiditis (hypothyroidism), 285–286, 287f
Hemangioma, 169, 169f
Hematocrit, 21t
abdominal aorta and IVC, 176t
in spleenic pathology, 156t
Hematuria, 134t
Hip effusion (transient synovitis), 359
Horseshoe kidneys, 128t, 131f
Hydronephrosis, 23–24, 144–146, 145f
I
Iliac arteries, 185, 186f–187f
Infant hips, anatomy and physiology of, 321, 322f–323f
Infant hips, sonography of
clinical investigation, 335
equipment, 334
normal sonographic description, 336–337, 337f
pathologies
developmental dysplasia, 359, 360f–361f
hip effusion (transient synovitis), 359
patient preparation, 330, 331f, 333f
protocol, 340, 341f–342f, 343, 344f
radiograph of DDH, 368f
scanning tips, 357
Infantile hypertrophic pyloric stenosis (IHPS), sonography of
CI and MRI of, 236f
determining midgut malrotation, 234
equipment, 208
normal sonographic description, 210, 215f
pathology, 233
protocol, 217, 218f–221f, 221
scanning tips, 230
Inferior vena cava (IVC), anatomy and physiology of, 175, 175f
Inferior vena cava (IVC), sonography of
protocol, 177, 186, 188f–190f
scanning tips, 191
of thrombosis, 193–194, 194f
Infiltrative ductal carcinoma, 313, 316f
Intracranial/intraventricular hemorrhage grades, 359, 362f–365f, 363
Intussusception, sonography of
CI and MRI of, 237f
equipment, 198
measurements, 231
pathology, 233
protocol, 221–222, 223f–225f
scanning tips, 230
L
Labeling of sonographic examinations, 23
Lactate dehydrogenase (LDH), 62t
in scrotal pathology, 245t
Lesser sac, 24
Lipase, 20t, 35t, 90t
Liver
anatomy and physiology of, 56–57
anterior views, 58f
caudate lobe, 56
left lobe, 56
left portal vein, 57
main portal vein, 56
porta hepatis (liver hilum), 56, 60f
posterior views, 59f
right lobe, 56
right portal vein, 57
functions, 57
surgical sections, 56, 59f
Liver, sonography of
of cavernous hemangioma, 76, 78f
of cirrhotic liver, 80, 82f, 83
laboratory values and possible pathologies, 62t, 76, 80, 83
equipments, 61–62
of fatty liver, 76, 81f
of hepatic cysts, 76, 79f, 83
liver–kidney interface, 67f
of liver metastasis, 80, 83f
normal measurements, 76, 77f
normal sonographic description of liver, 63
protocol for, 63–64, 70, 72
Doppler assessment of hepatic vasculature, 70, 72, 73f–74f
liver surface, 72, 75f
longitudinal liver, 63–64, 65f–66f, 68f
transverse liver, 64, 69f–71f
scanning tips, 76
signs of biliary obstruction, 83
Lymph nodes of neck, anatomy and physiology of, 265, 267f
M
Male pelvis, anatomy and physiology of, 239–240, 241f–243f, 243
Male pelvis, sonography of
draping technique for a scrotal sonogram, 244f
equipment for, 243–244
normal scrotum description, 245–247, 246f–247f
protocol, 247, 248f–255f, 250–252, 255
scanning tips, 255–256
scrotal pathologies, 256–257, 261
epididymitis (epididymo-orchitis), 257, 258f–259f
penile trauma, 261
seminoma, 261
testicular torsion, 256–257, 257f
varicocele, 257, 260f, 261
scrotum, AIUM recommendation, 239
Malignant thyroid nodules, 285
Mean frequencies of ultrasound machines, 2
Murphy sign, 86, 87f
N
Neck and face, anatomy and physiology of, 264–268
Neck and face, sonography of
of bilateral longus colli muscles, 283, 284f
CT scan of malignant thyroid mass, 290f
equipment for, 268
important signs of, 288
normal measurements, 284–285
pathologies
benign thyroid nodules, 285
branchial cleft cyst, 288
cervical lymphadenopathy, 288, 289f
Graves disease (hyperthyroidism), 285, 286f
Hashimoto thyroiditis (hypothyroidism), 285–286, 287f
malignant thyroid nodules, 285
parathyroid adenoma, 286
pleomorphic adenoma, 288
thyroglossal duct cyst, 286
protocol
abnormalities, 279
bilateral neck assessment, 274, 279
cervical lymph nodes, 283
dual thyroid image, 279
elastogram of thyroid nodule, 282, 282f
longitudinal right and left thyroid lobes, 274, 278f–281f
parathyroid glands, 282–283
parotid glands, 283
sublingual glands, 283
submandibular glands, 283
thyroidectomy patients, 282
thyroid gland, 272
transverse isthmus, 272, 273f
transverse right and left thyroid lobes, 274, 275f–277f
Neonatal brain, anatomy and physiology of, 321–322, 324–328, 324f
caudate nucleus, 326
caudothalamic groove, 327, 328f
cavum septum pellucidum (CSP), 326, 327f
cerebellum, 324
cerebrum, 322
cisterna magna, 326
fontanelles, 321
germinal matrix, 327
thalamus, 326
ventricular system, 325–326, 325f
Neonatal brain, sonography of
equipment, 334
intracranial/intraventricular hemorrhage grades, 359, 362f–365f, 363
normal measurements, 357–358
patient preparation, 332–334
periventricular leukomalacia, 363, 366f
protocol, 343, 345, 345f–349f, 349–350, 351f–353f
Neonatal spine, anatomy and physiology of, 329, 329f–330f
Neonatal spine, sonography of
equipment, 334
protocol, 350–351, 354–355, 354f–357f
scanning tips, 358
tethering of the spinal cord, 365, 367f
MRI image of, 369f
O
Optimal CD imaging, 14
Ortolani test, 332
P
Pancreas, anatomy and physiology of, 31, 31f–32f
endocrine function of, 31
exocrine function of, 31
main pancreatic duct, 31
normal measurements, 46, 47f, 51f
pancreatic body, 32
pancreatic head, 32
pancreatic neck, 32
pancreatic tail, 32
vasculature of, 33f
Pancreas, sonography of, 23–24
anechoic structures, 36
clinical investigation and findings, 34, 35t
image correlations, 50, 51f–53f
longitudinal image, 40, 43f
normal sonographic description, 35–36
pancreatic tail, 40
protocol, 36
right lateral decubitus pancreatic tail, 40, 44f–45f
scanning tips, 46
suggested equipment for, 34
transverse pancreas, 36, 37f–39f, 40
transverse upright pancreas, 40
vascular landmarks, 36
Pancreatic carcinoma, sonographic findings of, 49, 50f
Paracolic gutters, 26
Parathyroid adenoma, 286
Parathyroid glands, anatomy and physiology of, 264–265, 266f, 282–283
Parathyroid hormone (PTH), 269t
Partial thromboplastin time (PTT), 21t
Patient preparation and positioning in sonography
abdominal aorta imaging, 175
abdominal sonographic imaging, 22, 22f
appendix imaging, 207
gallbladder and biliary tract imaging, 89
gastrointestinal (GI) tract imaging, 207
general bowel assessment, 207
infant hips imaging, 330, 331f, 333f
infantile hypertrophic pyloric stenosis (IHPS) imaging, 207
inferior vena cava (IVC) imaging, 175
intussusception imaging, 207
liver imaging, 61
neonatal brain imaging, 332–334
neonatal spine imaging, 334
pancreas imaging, 34
urinary tract imaging, 132
Penile trauma, 261
Periventricular leukomalacia, 363, 366f
Pleomorphic adenoma, 288
Posterior cul-de-sac, 26
Posterior enhancement, 6t, 11f
Power Doppler (PD), 14, 15f, 16
Protein (proteinuria), 134t
Prothrombin time (PT), 62t
Pulsed-wave Doppler (PW), 16
Pyuria, 134t
R
Refraction artifact, 6t, 12f
Renal cell carcinoma, 147–149, 149f
Renal cysts, 146–147, 148f
Resistive patterns
high, 16, 18f
low, 16, 17f
Retroperitoneum sonogram, 1–2
Reverberation, 6t, 13f
Right subhepatic space, 24, 25f
Right upper quadrant protocol, 24
Ring-down artifact, 6t, 14f
S
Salivary glands, anatomy and physiology of, 266, 268, 268f
Scanning tips
abdominal aorta, 191
appendix, 230
breast, 309, 310f–312f
gallbladder and biliary tract, 105
gastrointestinal (GI) tract, 230
general bowel assessment, 230
infant hips, 357
infantile hypertrophic pyloric stenosis (IHPS), 230
inferior vena cava (IVC), 191
intussusception, 230
liver, 76
male pelvis, 255–256
neck and face, 283–284
neonatal brain, 357–358
neonatal spine, 358
pancreas, 46
spleen, 164–166
urinary tract, 143
Scrotum, sonography of
AIUM recommendation, 239
CT image of, 262f
draping technique for a scrotal sonogram, 244f
normal description, 245–247, 246f–247f
normal measurements of, 256
scrotal pathologies, 256–257, 261
epididymitis (epididymo-orchitis), 257, 258f–259f
penile trauma, 261
seminoma, 261
testicular torsion, 256–257, 257f
varicocele, 257, 260f, 261
Seminoma, 261
Serum bilirubin, 62t
Serum calcium, 21t
in neck pathology, 269t
Sonographic terminology, 4, 5t
Specific gravity, in urinary tract pathology, 134t
Spleen, anatomy and physiology of, 154–155, 155f
location, 155f
splenic artery, 154
splenic vein, 154–155
vascularity, 155f
Spleen, sonography of
of accessory spleen, 165f
Doppler image of splenic hilum, 163, 164f
equipment, 156
normal description, 157
normal measurements of spleen, 166
protocol
longitudinal spleen, 157–160, 158f–161f
transducer placement, 157
transverse spleen, 160–163, 162f–163f
splenic pathologies
hemangioma, 169, 169f
splenic infarct, 169, 170f
splenic trauma, 166, 168f
splenomegaly, 166, 167f
Splenic infarct, 169, 170f
Splenic trauma, 166, 168f
Splenomegaly, 166, 167f
Sublingual glands, 283
Submandibular glands, 283
Subphrenic spaces, 24
T
Testicular torsion, 256–257, 257f
Thalamus, 326
Thrombosis, IVC, 193–194, 194f
Thyroglossal duct cyst, 286
Thyroidectomy, 282
Thyroid gland, anatomy and physiology of, 264, 265f, 272
Thyroid-stimulating hormone (TSH), 21t
Thyroxine (T4), 21t
Transducers
for abdominal imaging, 2, 3f
infection control and machine maintenance, 28
Transverse isthmus, 272, 273f
Transverse right and left thyroid lobes, 274, 275f–277f
Transverse sonogram of pancreas, 36, 37f–39f, 40
pancreatic body measurement, 41f
pancreatic head measurement, 41f
pancreatic tail measurement, 42f
upright pancreas, 40
Triiodothyronine (T3), 21t
U
Ultrasound artifacts, 6t
acoustic shadowing, 6t, 7f
comet tail artifact, 6t, 8f
dirty shadowing, 6t, 9f
edge shadowing, 6t, 10f
posterior enhancement, 6t, 11f
refraction artifact, 6t, 12f
reverberation, 6t, 13f
ring-down artifact, 6t, 14f
Ultrasound equipment
infection control and machine maintenance, 28
selection and quality control, 2–4, 3f
Ureterocele, 151
Urinary tract, anatomy and physiology of, 123–124, 132
basic, 132f
normal measurements, 144, 144f
renal variants and description
dromedary hump, 128t, 130f
duplex collecting system, 128f, 128t
ectopic kidney, 128t
extrarenal pelvis, 128t, 131f
horseshoe kidneys, 128t, 131f
junctional line, 128t, 129f
Urinary tract, sonography of
normal appearance and description, 134–135
protocol, 135–136
CT and MRI of, 151, 152f–153f
equipments, 133
pathologies
chronic renal failure, 149–151, 150f
cystitis, 151
hydronephrosis, 144–146, 145f
renal cell carcinoma, 147–149, 149f
renal cysts, 146–147, 148f
ureterocele, 151
urolithiasis, 146, 147f
protocol
longitudinal kidney, 135–136, 137f
survey of kidney, 135
transverse bladder, 142, 143f
transverse kidney, 136, 138f–141f
urinary bladder, 141–142, 142f
scanning tips, 143
Urobilirubin, 90t
Urolithiasis, 146, 147f
V
Varicocele, 257, 260f, 261
Ventricular system, 325–326, 325f
W
White blood cell (WBC), 21t, 35t, 90t
abdominal aorta and IVC, 176t
in breast pathology, 295t
in GI tract pathology, 208t
in scrotal pathology, 245t
in spleenic pathology, 156t

Pocket Anatomy & Protocols For Abdominal Ultrasound 1ed

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Pocket Anatomy

& Protocols for

Steven M. Penny, MA, RT (R), RDMS (AB, PS, OB/GYN)

Copyright © 2020 Wolters Kluwer.

To Lisa, Devin, and Reagan:

Sandra Broadhead, RDMS, RT(R)

Krista Downey, ARDMS, ARRT

Traci B. Fox, EdD, RT(R), RDMS, RVT

Martie Grant, MEd

Jennifer Myers, RDMS, RT(R)

Danika Ashley Washington, BS, AAS

Diagnostic medical sonography has become an imaging modality that is utilized

HOW TO USE THIS POCKET BOOK

STEP #1: POCKET IT!

STEP #2: REVIEW NORMAL ANATOMY AND PHYSIOLOGY

STEP #3: REVIEW PATIENT PREPARATION AND SUGGESTED

STEP #4: REVIEW NORMAL SONOGRAPHIC ANATOMY

STEP #5: REVIEW THE SUGGESTED PROTOCOL

STEP #6: CLINICAL INVESTIGATION

STEP #8: ESSENTIAL PATHOLOGY FOCUS

REVIEWERS • PREFACE • ACKNOWLEDGMENTS

1: Abdominal Sonography Overview

4: Gallbladder and Biliary Tract

7: Abdominal Aorta and Inferior Vena Cava

10: Neck and Face

12: Infant Hips, Neonatal Brain, and Neonatal Spine

Abdominal Sonography Overview

AIUM INDICATIONS FOR AN ABDOMEN AND/OR

EQUIPMENT SELECTION AND QUALITY CONTROL1

THE ALARA PRINCIPLE1

Table 1-1 SONOGRAPHIC TERMS AND A BRIEF EXPLANATION

Table 1-2 COMMON ULTRASOUND ARTIFACTS

BASICS OF DOPPLER SONOGRAPHY3

SUMMARY OF RELEVANT LABORATORY VALUES AND KEY

Table POSSIBLE LABORATORY FINDINGS AND POTENTIAL

LABORATORY FINDING KEY ABDOMINAL FINDINGS

PATIENT POSITIONING FOR ABDOMINAL SONOGRAPHY

LABELING OF SONOGRAPHIC EXAMINATIONS

COMPLETE ABDOMEN AND RIGHT UPPER QUADRANT

FOCUSED ASSESSMENT WITH SONOGRAPHY FOR TRAUMA

Left upper quadrant view

INFECTION CONTROL AND MACHINE MAINTENANCE

AIUM RECOMMENDATIONS FOR SONOGRAPHY OF THE

ESSENTIAL ANATOMY AND PHYSIOLOGY OF THE

Surrounding vasculature (Fig. 2-3):

PATIENT PREPARATION FOR SONOGRAPHY OF THE

CLINICAL INVESTIGATION FOR SONOGRAPHY OF THE

Table LAB FINDINGS AND POSSIBLE ASSOCIATED PANCREAS

LAB FINDING Potential Pancreas Pathology2,4

NORMAL SONOGRAPHIC DESCRIPTION OF THE PANCREAS

SUGGESTED PROTOCOL FOR SONOGRAPHY OF THE

Figure 2-9. Pancreatic body measurement. In the transverse plane, a measurement of

NORMAL MEASUREMENTS OF THE PANCREAS3,5,6

ESSENTIAL PANCREATIC PATHOLOGY2

Chronic pancreatitis—chronic inflammation of the pancreas with atrophic changes

Figure 2-15. Chronic pancreatitis. Transverse image of the pancreas in a patient

Pancreatic carcinoma—most likely in the head of the pancreas (Fig. 2-16)

WHERE ELSE TO LOOK

AIUM RECOMMENDATIONS FOR SONOGRAPHY OF THE