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present any acoustic interfaces, theirultrasound appearance is black(assuming no possible interferingartefacts). The plane of sectionnecessary to visualize the liver hilumbest may vary considerably from caseto case. As a rule, slim (and tall)

patients have a more or lesslongitudinal course to the hilarstructures running in the hepato-duodenal ligament, whereas moreobese (and small) patients show arather transverse course; again,adapting to these individualcircumstances by variations in thescanning plane will give the best

information. In the first group ofpatients, more longitudinal sections (inthe supine position) will be sufficient,whilst right lateral (maybe evenintercostal) sections in left obliqueposition may be needed in the secondgroup.

The course of the portal vein is alwaysdorsal to the course of the commonbile duct, with the hepatic artery (orone of its main branches) crossing inbetween. Lymphatic vessels are notvisible on ultrasound either in the liverhilum or elsewhere.

General view of the porta hepatis andliver:1 inferior vena cava, 2 liver veins, 3portal vein, 4 splenic vein, 5 commonbile duct, 6 superior mesenteric vein;liver segments

Porta hepatis:1 common bile duct,2 portal vein, 3 hepatic artery (note itsintercrossing right branch between 1and 2)

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The tubular structures of vesselscontaining blood and bile can beinfluenced by- FKDQJHV in liquid pressure

(resulting in a more or lesspronounced increase in vesseldiameter),

- FKDQJHV in the wall structure(e.g.,sclerosis, partial thrombosis,or inflammation,

- RFFOXVLRQ (complete thrombosis,tumor, concretions), or by

- FRPSUHVVLRQ (tumor, lymphoma,

inflammation).

1

2

1 Infrarenal aneurysma,2 normal aorta (longitudinal scan)

1

2

3

1 Thoracoabdominal aneurysma,2 liver, 3 right ventricle (longitudinalscan)

1

2

1 Lumen of a giant infrarenalaneurysma, 2 thrombotic portions(transverse ! scan)

1

1 Single arteriosclerotic plaque,infrarenal abdominal aorta(longitudinal scan)

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1

1 Multiple plaques, abdominal aorta(longitudinal scan)

1

2

Right heart failure with 1 dilated cavainferior and 2 dilated hepatic veins(right subcostal scan)

12

3

1 cava inferior with 2 tumor spread(thrombus-like) in renal adenocarcinoma3 caudate lobe (longitudinal scan)

Membranous dissection of abdominalaorta with 1a, 1b lumen portions and2 dissection membrane (transversescan)

1

2

1 thrombosis of superior mesentericvein (no colour flow), 2 aorta(longitudinal scan)

1

2

1 thrombosis of left iliacal vein (nocolour flow), 2 iliacal artery (left lowerabdominal scan)

1a2

1b

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With the advent of more sophisticatedultrasound devices even normalparavascular lymphnodes in theabdomen may be visible in slimpatients. Routinely however only

enlarged lymphnodes (either benign or

malignant) can be detected, usuallyadjacent to the great vessels (aorta,celiac axis, inferior vena cava). Theyare less pronounced in the liver hilum.The spleen - as a specifically biglymphnode - deserves special attention(see 3.7.).

1

2

3

4

56 71

1

1

1 multiple lymphnodes, 2 liver, 3 aorta,4 vertebral body, 5 celiac axis with 6hepatic and 7 splenic artery(transverse scan)

1

2

3

4

5

1, 2 lymhnodes adjacent to 3 head ofpancreas, 4 splenic vein, 5 superiormesenteric artery (transverse scan)

1

2

1 multiple lymphnodes anterior andposterior to 2 aorta (longitudinalscan)

arrow: retroaortal lymphnodeenlargement (metastatic), 1 abdominalaorta, 2 celiac axis, 3 superiormesenteric artery, 4 liver, arrowhead:left kidney vein (longitudinal section)

2

3

4

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The pancreas appears as a more orless carrot-shaped organ without a

capsule lying transversely across theaorta and the spinal column. Its mainportion - the head - is generally to theright of the second lumbar vertebra.The junction of the head and the bodyis curved around the vertebral columnand the abdominal aorta and the taillies in the left upper abdomen touchingthe splenic hilum.The uncinate process as a part of thepancreatic head surrounds the superior

mesenteric vein. The head of thepancreas itself is surrounded by theduodenal C-loop, and penetrated bythe intrapancreatic portion of thecommon bile duct.The pancreas is covered by intestinalstructures (stomach, small and largeintestine) and the left lobe of the liver.The latter serves in deep inspiration -as an acoustic window.

([DPLQDWLRQWHFKQLTXHDQGXOWUDVRXQGVHFWLRQDODQDWRP\

With the scanning probe in atransverse position high up in theepigastrium, a deep inspiration willmove the liver downwards for some 3-

5 cm, which in turn will deflectinterfering gas-containing intestinalstructures. The main anatomicallandmarks used for visualising thepancreas are the mesenteric vascularstructures which adhere to it, the

splenic and mesenteric vein and their junction ( the confluens), forming theportal vein. In gross anatomy, there areno fixed demarcations between thethree portions of the pancreas (head,body and tail), and the same is true ofcourse on ultrasound scanning.

The visualisation of the non-distendedmain pancreatic duct as it passesalong the body of the pancreas serves

as a marker of ultrasound machineswhich have high resolution capabilties.The normal organ shows soft passivemovements caused by aortic andvenous pulsations.

The head and body of the pancreasare detectable in nearly all patients.The tail region (usually less important)is somewhat more difficult for theultrasonographer due to its small size,

angulated course (with a highvariability ) and sometimes hiddenposition behind the gas filled gastricfundus. If necessary, filling the gastricfundus with non-sparkling water cancreate a good acoustic window forvisualisation of the pancreatic tail.

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As in all parenchymatous organs, anultrasound examination of thepancreas gives information relating tochanges in its- SRVLWLRQ, VKDSH, and VL]H,- overall UHIOH[LELOLW\and

- YDVFXODUDUFKLWHFWXUH (with respectto the main pancreatic duct, thecommon bile duct, the splenic andmesenteric vein and their junction,the confluens),

- IRFDOOHVLRQV, and adjacentstructures (e.g.lymphnodes).

11

23

4

5

6

7

8

Acute pancreatits with 1 spotted headof pancreas and 2 too good visibility oflumen and * of wall layers of duodena C(transverse scan)

Acute pancreatitis with 1 swollen headof pancreas obstructing, 2 commonbile duct (note 3 distended cystic duct)and 4 fluid filled duodenum, 5 hepaticartery, 6 portal vein, 7 liver, 8 rightrenal artery,inferior vena cava

Ventral view of the extrahepatic bileduct: 1 portal vein, 2 common bile duct,3 pancreatic duct, 4 duodenum

Dorsal view of the extrahepatic bileduct: 1 portal vein, 2 common bile duct,3 pancreatic duct, 4 duodenum

2

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1

2 3

4

5

1

2

1p

1 acute pancreatitis with2 pseudocyst and 3 splenic vein,4 liver, 5 aorta (longitudinal scan)

1 huge pseudocyst with 1p penetrationinto the 2 spleen (left lateral scan)

1

2

3

4

5

6

7

1

2

3

4

5

6

1 pseudocyst (color-artifact, nobleeding), 2 confluens, 3 gastro-duodenal artery, 4 reduced panreasparenchyma, 5 inferior cava, 6duodenal C, 7 liver (2nd scans)

Highly reflexible spots (probablycalcifications in chronical pancreatitis)in 1 head and body of pancreas,2 gastroduodenal and 3 superiormesenteric artery, 4 aorta, 5 cavainferior, 6 liver

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1

2

3

4

2

3

4

5

1

6

1

1

1 chronical calcifying panreatitis(confirmed by ERCP) with slightcompression of 2 portal vein/superiormesenteric vein, 3 gastroduodenal artery,4 liver (modified longitudinal scan)

1 multiple pseudocysts, 2 aorta,3 hepatic artery, 4 cava inferior, 5 liver,6 confluens (transverse scans)

1 reduced pancreas parenchyma inchronic inflammation with 2 marked ductdilatation, 3 splenic vein/confluens,4 superior mesenteric artery, 5 hepatic,6 gastroduodenal and 7 renal artery,8 aorta, 9 left renal vein, 10 liver(transverse scan)

1 marked dilatation of main pancreaticduct in chronical inflammation with 2reduced parenchyma, 3 confluens, 4superior mesenteric artery, 5 aorta,6 duodenal C, 7 gastric corpus

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E

+,* slightly dilated main pancreatic duct1 confluens, 2 posterior antrum wall,3 gastric lumen (with highly reflexibleingested material), 4 uncinate process

(transverse scan)

1 pancreas tumour with 2 splenicvein, 3h head, 3b body of pancreas,4 superior mesenteric artery,5 aorta (transverse scan)

1 tumour of pancreas head with 2 tipof fine needle for aspiration cytology;3 gastroduodenal artery 4 liver(transverse scan)

1 stent in the stenotic mainpancreatic duct in chronicpancreatitis (note the reducedparenchyma) 2 superior mesentericartery 3 confluens (transverse scan)

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