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Transcript of Pocket protocols for ultrasound scanning 2rd
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Second Edition
Adapted from: Ultrasound Scanning: Principles and Protocols, Third edition
Betty Bates Tempkin, BA, RT(R), RDMSUltrasound Consultant
Formerly Clinical Director of the Diagnostic Medical Sonography ProgramHillsborough Community College, Tampa, Florida
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11830 Westline Industrial DriveSt. Louis, Missouri 63146
POCKET PROTOCOLS FOR ULTRASOUND SCANNING ISBN-13: 978-1-4160-3101-7ISBN-10: 1-4160-3101-4
Copyright © 2007, 1999 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writingfrom the publisher.Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1)215 239 3804, fax: (+1) 215 239 3805, e-mail: [email protected]. You may also complete your request on-line viathe Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’.
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Previous edition copyrighted in 1999.
ISBN-13: 978-1-4160-3101-7ISBN-10: 1-4160-3101-4
Acquisitions Editor: Jeanne WilkeDevelopmental Editor: Rebecca SwisherPublishing Services Manager: Pat JoinerProject Manager: Jennifer ClarkDesigner: Amy Buxton
Printed in the United States of America.
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Notice
Neither the Publisher nor the Author assumes any responsibility for any loss or injuryand/or damage to persons or property arising out of or related to any use of the materialcontained in this book. It is the responsibility of the treating practitioner, relying onindependent expertise and knowledge of the patient, to determine the best treatment andmethod of application for the patient.
The Publisher
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Contributors
v
Wayne C. Leonhardt, BA, RT(R), RVT, RDMSFacultyFoothill College School of UltrasoundLos Altos, California;Staff Sonographer, Technical Director, and
Continuing Education Director Summit Medical CenterOakland, California
Scrotum Scanning Protocol; Thyroid andParathyroid Glands Scanning Protocols
Maureen E. McDonald, BS, RDMS, RDCSStaff Echocardiographer Adult Echocardiography Instructor and LecturerThomas Jefferson University HospitalPhiladelphia, Pennsylvania
Adult Echocardiography Scanning Protocol;Pediatric Echocardiography Scanning Protocol
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Marsha M. Neumyer, BS, RVTAssistant Professor of General and Vascular
Surgery and Director of the Vascular StudiesSection
The Milton S. Hershey Medical CenterPennsylvania State University College of
MedicineHershey, Pennsylvania
Abdominal Doppler and Color Flow;Cerebrovascular Duplex Scanning Protocol;Peripheral Arterial and Venous Duplex ScanningProtocols
Betty Bates Tempkin, BA, RT(R), RDMSUltrasound ConsultantFormerly Clinical Director of the Diagnostic
Medical Sonography ProgramHillsborough Community CollegeTampa, Florida
Scanning Planes and Scanning Methods;Pathology; Scanning Protocol; Abdominal AortaScanning Protocol; Inferior Vena Cava ScanningProtocol; Liver Scanning Protocol; Gallbladderand Biliary Tract Scanning Protocol; PancreasScanning Protocol; Renal Scanning Protocol;Spleen Scanning Protocol; Scanning Protocols forFull and Limited Studies of the Abdomen; FemalePelvis Scanning Protocol; Obstetrical ScanningProtocol; Male Pelvis Scanning Protocol; ScrotumScanning Protocol; Thyroid and ParathyroidGlands Scanning Protocols; Breast ScanningProtocol; Female Pelvis Scanning Protocol
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Contents
PA R T IIntroduction: Purpose and Use . . . . . . . . . . . 1PA R T IIImage Protocol For Abnormal SonographicFindings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
PA R T IIIThe Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . 7
SECTION ONE
IMAGE PROTOCOLS FOR FULL SONOGRAPHICSTUDIES OF THE ABDOMEN 9
I. Liver Study with Full Abdomen 11II. Aorta Study with Full Abdomen 42III. Inferior Vena Cava Study with Full Abdomen
83IV. Gallbladder and Biliary Tract Study with Full
Abdomen 119V. Pancreas Study with Full Abdomen 157VI. Renal Study with Full Abdomen 192VII. Spleen Study with Full Abdomen 242
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SECTION TWO
IMAGE PROTOCOLS FOR LIMITEDSONOGRAPHIC STUDIES OF THE ABDOMEN276
I. Aorta Study 278II. Inferior Vena Cava Study 291III. Right Upper Quadrant Study 299IV. Gallbladder and Biliary Tract Study 330V. Pancreas Study 358VI. Renal Study 383VII. Spleen Study 407
PA R T IVThe Pelvis. . . . . . . . . . . . . . . . . . . . . . . . . . 415
SECTION ONE
IMAGE PROTOCOL FOR THETRANSABDOMINAL SONOGRAPHIC STUDY OFTHE FEMALE PELVIS 417
I. Transabdominal Female Pelvis Study 418
SECTION TWO
IMAGE PROTOCOL FOR THE TRANSVAGINALSONOGRAPHIC STUDY OF THE FEMALE PELVIS440
I. Transvaginal Female Pelvis Study 441
SECTION THREE
IMAGE PROTOCOLS FOR SONOGRAPHICSTUDIES OF THE MALE PELVIS 458
I. Transrectal Prostate Gland Study 459II. Scrotum Study 469III. Penis Study 516
PA R T VObstetrics . . . . . . . . . . . . . . . . . . . . . . . . . 521
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE EARLY FIRST TRIMESTER 523
I. Early First Trimester Study 524
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SECTION TWO
IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE LATE FIRST TRIMESTER 535
I. Late First Trimester Study 536
SECTION THREE
IMAGE PROTOCOL FOR SONOGRAPHICSTUDIES OF THE SECOND AND THIRDTRIMESTERS 545
I. Second and Third Trimesters Study 546
SECTION FOUR
IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF MULTIPLE GESTATIONS 591
I. Multiple Gestations Study 592II. The Biophysical Profile 595
PA R T VISmall Parts . . . . . . . . . . . . . . . . . . . . . . . . . 604
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE THYROID GLAND 606
SECTION TWO
IMAGE PROTOCOLS FOR THE SONOGRAPHICSTUDY OF THE BREAST 618
I. Breast Lesion Characterization 620II. Whole Breast Study 623
SECTION THREE
IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE NEONATAL BRAIN 625
PA R T VIIVascular System . . . . . . . . . . . . . . . . . . . . . 638
SECTION ONE
IMAGE PROTOCOLS FOR ABDOMINALDOPPLER AND COLOR FLOW STUDIES 639
I. Mesenteric Arterial Study 640II. Renal Arterial Study 644III. Image Examples of Various Studies 649
SECTION TWO
IMAGE PROTOCOL FOR CEREBROVASCULARDUPLEX SCANNING 655
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x
SECTION THREE
IMAGE PROTOCOLS FOR PERIPHERALARTERIAL AND VENOUS DUPLEX SCANNING665
I. Lower Extremity Venous Duplex Study 665II. Lower Extremity Peripheral Arterial Duplex
Study 675
PA R T VIIIEchocardiography . . . . . . . . . . . . . . . . . . . 687
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE ADULT HEART 688
I. Adult Heart Study 688
SECTION TWO
IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE PEDIATRIC HEART 721
I. Pediatric Heart Study 721
PA R T IXAbbreviation Glossary . . . . . . . . . . . . . . . . 746
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Introduction: Purpose andUse
Pocket Protocols is a response to the need for a practical imaging reference to use duringultrasound examinations. This flip-card presentation sits upright on the machine, making it easy to see and access.
The majority of the image protocols follow the American Institute of Ultrasound inMedicine’s (AIUM) imaging guidelines. Any other image protocols are patterned after theAIUM’s suggestions and the authors’ collective experiences.
Pocket Protocols is a reference devoted to documenting technically accurate andthorough ultrasound image studies for diagnostic interpretation by the physician. Thesecomprehensive imaging protocols include image and labeling examples for abdominal,pelvic, obstetrical, small parts, vascular, and echocardiography studies.
1
I
Images are presented in a logical manner and specify the scanning plane and area ofinterest. Every image is accompanied by a gray-scale, color-coded schematic to helpidentify anatomy.
These reference materials are just that. They do not include or endorse the exclusion of the necessary prerequisites for accomplished scanning skills.
I hope Pocket Protocols serve as a practical reference and imaging standard that helpssonographers obtain comprehensive, consistent, and technically accurate image represen-tations of ultrasound studies.
Betty Bates Tempkin
2
Image Protocol forAbnormal SonographicFindings
This section describes a universal imaging protocol for documenting pathology, regardless of the type. All pathology visualized by ultrasound in some way disrupts the normalsonographic pattern of the organ or structure involved and may alter its shape, size,contour, position, or textural appearance. Although familiarity with specific diseases andabnormalities is not necessary to document them accurately for physician interpretation,an understanding of pathological processes and the ways in which they affect interde-pendent body systems can be beneficial.
3
II
CRITERIA FOR DOCUMENTING ABNORMAL SONOGRAPHIC FINDINGS
a) Survey of the abnormality in at least two scanning planes following the survey of theprimary area(s) of interest. (This is not to say that the abnormality is not evaluatedas the area of interest is evaluated, but it ensures that a total evaluation is made of astructure, not just its abnormal part.)
b) Volume measurement of the abnormality.
c) High- and low-gain technical setting images of the abnormality in at least twoscanning planes.
4
REQUIRED IMAGES
1. Longitudinal image of the abnormality with measurement from the most superior tomost inferior margin.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”
2. Same image as Number 1, without measurement calipers.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”
3. Axial image of the abnormality with measurement from the most anterior to mostposterior margin and from the most lateral to lateral or lateral to medial margin.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”
5
SCANNING TIP: Required images of abnormal findings follow the study’s requiredimages of the area(s) of interest.
SCANNING TIP: In cases where the origin of an abnormality cannot be determined,adjacent structures must be noted for a site location. Look for bright, echogenicinterfaces where fat separates adjacent structures.
4. Same image as Number 3., without measurement calipers.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”
5. Longitudinal image of the abnormality with high-gain technique.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, HIGHGAIN
6. Axial image of the abnormality with high-gain technique.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, HIGHGAIN
7. Longitudinal image of the abnormality with low-gain technique.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, LOWGAIN
8. Axial image of the abnormality with low-gain technique.
L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, LOWGAIN
6
The Abdomen
SECTION ONE
IMAGE PROTOCOLS FOR FULL SONOGRAPHIC STUDIES OF THEABDOMEN
This section includes extensive images of the area(s) of interest accompanied by limitedviews of other major abdominal structures.
I. Liver Study with Full Abdomen
II. Aorta Study with Full Abdomen
7
III
III. Inferior Vena Cava Study with Full Abdomen
IV. Gallbladder and Biliary Tract Study with Full Abdomen
V. Pancreas Study with Full Abdomen
VI. Renal Study with Full Abdomen
VII. Spleen Study with Full Abdomen
SECTION TWO
IMAGE PROTOCOLS FOR L IMITED SONOGRAPHIC STUDIES OF THEABDOMEN
This section includes extensive images of the area(s) of interest.
I. Aorta Study
II. Inferior Vena Cava Study
8
III. Right Upper Quadrant Study
IV. Gallbladder and Biliary Tract Study
V. Pancreas Study
VI. Renal Study
VII. Spleen Study
SECTION ONE
IMAGE PROTOCOLS FOR FULL SONOGRAPHIC STUDIES OF THEABDOMEN
This section includes extensive images of the area(s) of interest accompanied by limitedviews of other major abdominal structures.
I. Liver Study with Full Abdomen
9
II. Aorta Study with Full Abdomen
III. Inferior Vena Cava Study with Full Abdomen
IV. Gallbladder and Biliary Tract Study with Full Abdomen
V. Pancreas Study with Full Abdomen
VI. Renal Study with Full Abdomen
VII. Spleen Study with Full Abdomen
• Criteria:— Begin studies with a survey of abdominal structures in at least two scanning
planes.— Do not share the results of the study with the patient. Legally, only physicians can
give diagnoses.
10
SECTION ONE
IMAGE PROTOCOLS FOR FULL SONOGRAPHIC STUDIES OF THEABDOMEN
I. Liver Study with Full Abdomen
Liver
LONGITUDINAL IMAGES
11
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
12
Posterior
Anterior
Splenic artery
InferiorSuperiorBowel
Pancreas bodyLeft lobe
Aorta
Spine
Splenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
13
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
14
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
15
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
16
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
17
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
18
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
19
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
20
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
21
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
22
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
23
SCANNING TIP: Routine measurements of the liver are not required.
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
Aorta
LONGITUDINAL IMAGE
13. Longitudinal image of the proximal and middle aorta.
24
Posterior
Anterior
Liver
Splenicartery
Superiormesenteric
artery
Pancreas InferiorSuperior
Stomach
Splenicvein
Proximal and Middle aorta
SCANNING TIP: The images of the aorta may be included with the liver images ifthe aorta is well visualized.
L A B E L E D : AORTA SAG MID
AXIAL IMAGE
14. Axial image of the middle aorta at the level of the renal arteries.
25
Posterior
Anterior
LeftRight
Spine
IVC Leftrenalvein
Liver
Superiormesentericartery
Leftrenal
artery
Pancreas
Middle aorta
Stomach
Splenic vein
L A B E L E D : AORTA TRV MID
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGE
15. Longitudinal image of the distal and middle inferior vena cava.
26
SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.
Posterior
Anterior Hepaticartery
InferiorSuperior
Distal and Middle IVC
Vertebrae
Smallbowel
shadow
Portalvein
Liver
L A B E L E D : IVC SAG DISTAL
AXIAL IMAGE
16. Axial image of the distal inferior vena cava to include the hepatic veins.
27
Posterior
Anterior
Distal IVC
Left hepaticvein
Middlehepaticvein
Right hepatic vein
LeftRight
Liver
L A B E L E D : IVC TRV DISTAL
Gallbladder and Biliary Tract
LONGITUDINAL GALLBLADDER IMAGE
17. Long axis image of the gallbladder.
28
Posterior
AnteriorGallbladder
InferiorSuperior
Small bowel
Throughtransmission
Portal vein
Diaphragm
IVC
Liver
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
18. Axial image of the gallbladder fundus.
29
Posterior
AnteriorGallbladderfundus
LeftRight
Sidewallshadow
IVC
Liver
L A B E L E D : GB TRV FUNDUS
LONGITUDINAL BILIARY TRACT IMAGES
19. Longitudinal image of the common hepatic duct.
30
Posterior
Anterior Gallbladder
InferiorSuperior
Hepatic artery
IVC
Liver
Commonhepatic duct
Portal vein
L A B E L E D : SAG CHD
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
20. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
31
Posterior
Anterior Duodenum
InferiorSuperior
Hepatic artery
Liver
Commonbile duct
Portal vein
L A B E L E D : SAG CBD
21. Same image as Number 20 without measurement calipers.
32
L A B E L E D : SAG CBD
Pancreas
LONGITUDINAL IMAGES
22. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
33
Pancreaticduct
Liver Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
TailSplenicvein
Aorta
Right renalartery
IVC
Head
Spine
Duodenum
Commonbile duct
Gastro-duodenalartery
Confluenceof superiormesenteric veinand splenic vein
Neck
L A B E L E D : PANC TRV LONG AXIS
23. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).
34
Superiormesentericartery
Liver
Splenic vein
Left renalartery
Anterior
LeftRight
Posterior
Neck
Rightkidney
Leftkidney
Aorta
IVC
Head
Spine
Uncinate process
Left renalvein
Liver
Superiormesenteric vein
Commonbile duct
Gallbladder
Duodenum
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
24. Axial image of the pancreas head to include the common bile duct (if bile-filled).
35
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
Anterior
Posterior
Liver
Superior Inferior
Head
Commonbile ductIVC
Bowel
Liver
Portal vein
Bowel
L A B E L E D : PANC SAG HEAD
Right Kidney
LONGITUDINAL IMAGE
25. Long axis image of the right kidney.
36
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
InferiorSuperior
Anterior
Posterior
Cortex
Sinus
Inferiorpole
Superior pole
Midportion
Liver
Diaphragm
L A B E L E D : RT KID SAG LONG AXIS
AXIAL IMAGE
26. Axial image of the right kidney midportion to include the hilum.
37
LeftRight
Anterior
Posterior
Cortex
Sinus
IVC
Rightrenal vein
Midportion
Liver
L A B E L E D : RT KID TRV MID
Left Kidney
LONGITUDINAL IMAGE
27. Long axis image of the left kidney.
38
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
InferiorSuperior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Superiorpole Midportion
Spleen Inferiorpole
L A B E L E D : LT KID COR LONG AXIS
AXIAL IMAGE
28. Axial image of the left kidney midportion to include the hilum.
39
PosteriorAnterior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
Spleen
LONGITUDINAL IMAGE
29. Long axis or longitudinal image of the spleen to include the adjacent pleural spacesuperiorly and portion of the left kidney inferiorly.
40
InferiorSuperior
Lateral
Medial
Left kidney
Long axisof spleen
Diaphragm
L A B E L E D : SPLEEN COR LONG AXIS or SPLEEN COR
AXIAL IMAGE
30. Axial image of the spleen to include the anterior and posterior margins.
41
PosteriorAnterior
Lateral
Medial
DiaphragmSplenichilum
L A B E L E D : SPLEEN LT TRV
II. Aorta Study with Full Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
42
Posterior
Anterior
Splenic artery
InferiorSuperior Bowel
Pancreas bodyLeft lobe
Aorta
Spine
Splenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
43
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
44
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
45
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
46
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
47
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
48
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
49
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
50
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
51
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
52
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
53
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
Aorta
LONGITUDINAL IMAGES
13. Longitudinal image of the proximal aorta (inferior to the diaphragm, superior to theceliac trunk).
54
Superior Inferior
Anterior
Posterior
Liver
Celiac artery
SuperiormesentericarteryProximal
aorta
L A B E L E D : AORTA SAG PROX
14. Longitudinal image of the middle aorta (inferior to the celiac trunk along the lengthof the superior mesenteric artery).
55
Anterior Pancreas body
Inferior
Posterior
Superior
Stomach
Superiormesentericartery
Middle aortaSplenic artery
Proximalaorta
Liver
Splenic vein
L A B E L E D : AORTA SAG MID
15. Longitudinal image of the distal aorta (inferior to the superior mesenteric artery,superior to the bifurcation).
56
Anterior
Inferior
Posterior
Superior
Stomach
Bowel
Distal aorta
Bowel
L A B E L E D : AORTA SAG DISTAL
16. Longitudinal image of the aorta bifurcation (common iliac arteries).
57
Medial
InferiorSuperiorDistal aorta
Left commoniliac artery
Aortabifurcation
Right commoniliac artery
Lateral
L A B E L E D : AORTA SAG BIF RT or LT OBL or AORTA LT COR BIF
AXIAL IMAGES
17. Axial image of the proximal aorta (inferior to the diaphragm, superior to the celiactrunk) with anterior to posterior measurement (calipers outside wall to outside wall).
58
Bowel
Liver
Proximalaorta
Posterior
Anterior
LeftRight
L A B E L E D : AORTA TRV PROX
18. Same image as Number 17 without measurement calipers.
59
L A B E L E D : AORTA TRV PROX
19. Axial image of the middle aorta (inferior to the celiac trunk along the length of thesuperior mesenteric artery) with anterior to posterior measurement (calipers outsidewall to outside wall).
60
Left renalvein
Liver
Posterior
Anterior
LeftRight
Pancreas Superiormesenteric
artery
Middle aorta
Splenicvein
Spine
IVC
L A B E L E D : AORTA TRV MID
20. Same image as Number 19, without measurement calipers.
61
SCANNING TIP: If the renal arteries were represented on Number 19, Numbers 21and/or 22 may be omitted.
L A B E L E D : AORTA TRV MID
21. Longitudinal image of the right renal artery.
62
Posterior
Anterior
LeftRight
Pancreas
Superiormesenteric
vein
Spine
IVC
Rightrenal
artery
Aorta
Gallbladder
L A B E L E D : RT RENAL ART TRV
22. Longitudinal image of the left renal artery.
63
Posterior
Anterior
LeftRight
Spine
IVC
Rightrenalartery Aorta
Left renal vein
Liver
Splenicvein
Superiormesenteric
artery
Left renal artery
Ligamentumteres
L A B E L E D : LT RENAL ART TRV
23. Axial image of the distal aorta (inferior to the superior mesenteric artery, superiorto the bifurcation) with anterior to posterior measurement (calipers outside wall tooutside wall).
64
Posterior
Anterior
LeftRight
Distal aorta
L A B E L E D : AORTA TRV DISTAL
24. Same image as Number 23, without measurement calipers.
65
L A B E L E D : AORTA TRV DISTAL
25. Axial image of aorta bifurcation (common iliac arteries).
66
Posterior
Anterior
LeftRight
Right commoniliac artery
Left commoniliac artery
L A B E L E D : AORTA TRV BIF
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGE
26. Longitudinal image of the distal and middle inferior vena cava.
67
SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.
Posterior
Anterior Hepaticartery
InferiorSuperior
Distal and Middle IVC
Vertebrae
Smallbowel
shadow
Portalvein
Liver
L A B E L E D : IVC SAG DISTAL
AXIAL IMAGE
27. Axial image of the distal inferior vena cava to include the hepatic veins.
68
Posterior
Anterior
Distal IVC
Left hepaticvein
Middlehepaticvein
Right hepatic vein
LeftRight
Liver
L A B E L E D : IVC TRV DISTAL
Gallbladder and Biliary Tract
LONGITUDINAL GALLBLADDER IMAGE
28. Long axis image of the gallbladder.
69
Posterior
Anterior
Body
IVC
Liver
Hepaticartery
InferiorSuperior
Neck Fundus
Gallbladder
Portal vein
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
29. Axial image of the gallbladder fundus.
70
Posterior
Anterior
Liver
LeftRight
Gallbladderfundus
Sidewallshadow
IVC
Right kidney
Sidewallshadow
L A B E L E D : GB TRV FUNDUS
LONGITUDINAL BILIARY TRACT IMAGES
30. Longitudinal image of the common hepatic duct.
71
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
Posterior
Anterior
Liver
InferiorSuperior
Gallbladder
IVC
Portal veinDiaphragm
Commonhepatic duct
Hepaticartery
L A B E L E D : SAG CHD
31. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
72
Posterior
Anterior
Bowel
Commonbile duct
Portal vein
Liver
Hepaticartery
InferiorSuperior
L A B E L E D : SAG CBD
32. Same image as Number 31 without measurement calipers.
73
L A B E L E D : SAG CBD
Pancreas
LONGITUDINAL IMAGES
33. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
74
Posterior
Anterior
Pancreaticduct
Commonbile duct
IVC
Liver
Head
LeftRight
NeckBody
Stomach
TailSplenicvein
Aorta
Left kidney
Spine
Right renalartery
Duodenum
Confluenceof superiormesenteric veinand splenic vein
Gastro-duodenalartery
L A B E L E D : PANC TRV LONG AXIS
34. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).
75
Superiormesentericartery
Liver
Splenic vein
Left renalartery
Anterior
LeftRight
Posterior
Neck
Rightkidney
Leftkidney
Aorta
IVC
Head
Spine
Uncinate process
Left renalvein
Liver
Superiormesenteric vein
Commonbile duct
Gallbladder
Duodenum
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
35. Axial image of the pancreas head to include the common bile duct (if bile-filled).
76
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
Anterior
Posterior
LiverRight
Left
Head
Portal veinIVC
Bowel
Commonbile duct
L A B E L E D : PANC SAG HEAD
Right Kidney
LONGITUDINAL IMAGE
36. Long axis image of the right kidney.
77
SCANNING TIP Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
InferiorSuperior
Anterior
Posterior
Cortex
Sinus
Inferiorpole
Superior pole
Midportion
Liver
Diaphragm
L A B E L E D : RT KID SAG LONG AXIS
AXIAL IMAGE
37. Axial image of the right kidney midportion to include the hilum.
78
Anterior
Posterior
Right Left
Rightrenal vein
Cortex
SinusMidportion
Medullarypyramids
Renalcapsule
LiverIVC
Morrison’spouch
L A B E L E D : RT KID TRV MID
Left Kidney
LONGITUDINAL IMAGE
38. Long axis image of the left kidney.
79
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
Lateral
Medial
Superior Inferior
Inferiorpole
Cortex
Sinus
MidportionSuperior
pole
Spleen
Medullarypyramids
Renalcapsule
L A B E L E D : LT KID COR LONG AXIS
AXIAL IMAGE
39. Axial image of the left kidney midportion to include the hilum.
80
PosteriorAnterior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
Spleen
LONGITUDINAL IMAGE
40. Long axis or longitudinal image of the spleen to include the adjacent pleural spacesuperiorly and portion of the left kidney inferiorly.
81
InferiorSuperior
Lateral
Medial
Left kidney
Long axisof spleen
Diaphragm
L A B E L E D : SPLEEN COR LONG AXIS or SPLEEN COR
AXIAL IMAGE
41. Axial image of the spleen to include the anterior and posterior margins.
82
PosteriorAnterior
Lateral
Medial
DiaphragmSplenichilum
L A B E L E D : SPLEEN LT TRV
III. Inferior Vena Cava Study with Full Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
83
Posterior
Anterior
Splenic artery
InferiorSuperior Bowel
Pancreas bodyLeft lobe
Aorta
Spine
Splenicvein
Diaphragm
L A B E L E D : LIVER TRV LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
84
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
85
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
86
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
87
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
88
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
89
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
90
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
L A B E L E D : LIVER TRV RT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
91
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
92
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
93
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
94
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
Aorta
LONGITUDINAL IMAGE
13. Longitudinal image of the proximal and middle aorta.
95
SCANNING TIP: The images of the aorta may be included with the liver images ifthe aorta is well visualized.
Posterior
Anterior
Liver
Splenicartery
Superiormesentericartery
Pancreas InferiorSuperior
Stomach
Splenicvein
Proximal and Middle aorta
L A B E L E D : AORTA SAG MID
AXIAL IMAGE
14. Axial image of the middle aorta at the level of the renal arteries.
96
Posterior
Anterior
LeftRight
Spine
IVC Leftrenalvein
Liver
Superiormesentericartery
Leftrenal
artery
Pancreas
Middle aorta
Stomach
Splenic vein
L A B E L E D : AORTA TRV MID
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGES
15. Longitudinal image of the distal inferior vena cava to include the diaphragm andhepatic vein(s).
97
Posterior
Anterior
InferiorSuperior
Hepatic vein
Diaphragm Distal IVC
Portal vein
Liver
L A B E L E D : IVC SAG DISTAL
16. Longitudinal image of the middle inferior vena cava at the level of the head of thepancreas.
98
Posterior
Anterior
InferiorSuperior
Right renal artery
LiverPortalvein
Hepaticartery
Gallbladder neck fold shadow
Common bile duct Middle IVC
Pancreashead
Gastro-duodenal
arteryGallbladder
L A B E L E D : IVC SAG MID
17. Longitudinal image of the proximal inferior vena cava.
99
Posterior
Anterior
InferiorSuperior
BowelProximal IVC
L A B E L E D : IVC SAG PROX
18. Longitudinal image of the inferior vena cava bifurcation (common iliac veins).
100
Posterior
Anterior
InferiorSuperiorBowel
Proximal IVC
Left commoniliac vein
IVC bifurcation
Right commoniliac vein
L A B E L E D : IVC SAG BIF RT or LT OBL or IVC SAG RT COR BIF
AXIAL IMAGES
19. Axial image of the distal inferior vena cava to include the hepatic veins.
101
Posterior
Anterior
Distal IVC
LeftRight
Left hepaticvein
Middlehepaticvein
Right hepatic vein
L A B E L E D : IVC TRV DISTAL
20. Axial image of the inferior vena cava at the level of the renal veins.
102
Anterior
LeftRight
Posterior
Gallbladder
LiverMiddle IVC
Left renalvein
AortaSpine
Rightrenal vein
Rightrenal artery
L A B E L E D : IVC TRV MID
21. Axial image of the proximal inferior vena cava.
103
Posterior
Anterior
Proximal IVC
LeftRight
L A B E L E D : IVC TRV PROX
22. Axial image of the inferior vena cava bifurcation (common iliac veins).
104
Posterior
Anterior
Spine
LeftRight
Commoniliac vein Common
iliac vein
Commoniliac arteries
L A B E L E D : IVC TRV BIF
Gallbladder and Biliary Tract
LONGITUDINAL GALLBLADDER IMAGE
23. Long axis image of the gallbladder.
105
Posterior
Anterior
Body
IVC
Liver
Hepaticartery
InferiorSuperior
Neck Fundus
Gallbladder
Portal vein
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
24. Axial image of the gallbladder fundus.
106
Posterior
Anterior
Liver
LeftRight
Gallbladderfundus
Sidewallshadow
IVC
Right kidney
Sidewallshadow
L A B E L E D : GB TRV FUNDUS
LONGITUDINAL BILIARY TRACT IMAGES
25. Longitudinal image of the common hepatic duct.
107
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
Posterior
Anterior Gallbladder
InferiorSuperior
Hepatic artery
IVC
Liver
Commonhepatic duct
Portal vein
L A B E L E D : SAG CHD
26. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
108
Posterior
Anterior
Liver
InferiorSuperior
Portal vein
Bowel
Commonbile duct
Hepaticartery
L A B E L E D : SAG CBD
27. Same image as Number 26 without measurement calipers.
109
L A B E L E D : SAG CBD
Pancreas
LONGITUDINAL IMAGES
28. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
110
Pancreaticduct
Liver Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
TailSplenicvein
Aorta
Right renalartery
IVC
Head
Spine
Duodenum
Commonbile duct
Gastro-duodenalartery
Confluenceof superiormesenteric veinand splenic vein
Neck
L A B E L E D : PANC TRV LONG AXIS
29. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).
111
Superiormesentericartery
Liver
Splenic vein
Left renalartery
Anterior
LeftRight
Posterior
Neck
Rightkidney
Leftkidney
Aorta
IVC
Head
Spine
Uncinate process
Left renalvein
Liver
Superiormesenteric vein
Commonbile duct
Gallbladder
Duodenum
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
30. Axial image of the pancreas head to include the common bile duct (if bile-filled).
112
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
Anterior
Posterior
Bowel
IVC
Head
Portal vein
Liver
Commonbile duct
Liver
SuperiorInferior
L A B E L E D : PANC SAG HEAD
Right Kidney
LONGITUDINAL IMAGE
31. Long axis image of the right kidney.
113
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
Inferior
Superior
Anterior
Posterior
Cortex
Sinus
Inferiorpole
Superior pole
Midportion
Liver
Diaphragm
L A B E L E D : RT KID SAG LONG AXIS
AXIAL IMAGE
32. Axial image of the right kidney midportion to include the hilum.
114
LeftRight
Anterior
Posterior
Cortex
Sinus
IVC
Rightrenal vein
Midportion
Liver
L A B E L E D : RT KID TRV MID
Left Kidney
LONGITUDINAL IMAGE
33. Long axis image of the left kidney.
115
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
InferiorSuperior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Superiorpole Midportion
SpleenInferiorpole
L A B E L E D : LT KID COR LONG AXIS
AXIAL IMAGE
34. Axial image of the left kidney midportion to include the hilum.
116
PosteriorAnterior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
Spleen
LONGITUDINAL IMAGE
35. Long axis or longitudinal image of the spleen to include the adjacent pleural spacesuperiorly and portion of the left kidney inferiorly.
117
InferiorSuperior
Lateral
Medial
Left kidney
Long axisof spleen
Diaphragm
L A B E L E D : SPLEEN COR LONG AXIS or SPLEEN COR
AXIAL IMAGE
36. Axial image of the spleen to include the anterior and posterior margins.
118
PosteriorAnterior
Lateral
Medial
DiaphragmSplenichilum
L A B E L E D : SPLEEN LT TRV
IV. Gallbladder and Biliary Tract Study with Full Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
119
Posterior
Anterior
Splenic artery
InferiorSuperior Bowel
Pancreas bodyLeft lobe
Aorta
Spine
Splenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
120
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
121
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
Caudate lobe
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
122
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
123
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
124
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
125
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
126
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
127
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
128
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
129
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
130
SCANNING TIP: Routine measurements of the liver are not required.
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
Aorta
LONGITUDINAL IMAGE
13. Longitudinal image of the proximal and middle aorta.
131
Posterior
Anterior
Liver
Splenicartery
Superiormesenteric
artery
Pancreas InferiorSuperior
Stomach
Splenicvein
Proximal and Middle aorta
SCANNING TIP: The images of the aorta may be included with the liver images ifthe aorta is well visualized.
L A B E L E D : AORTA SAG MID
AXIAL IMAGE
14. Axial image of the middle aorta at the level of the renal arteries.
132
Posterior
Anterior
LeftRight
Spine
IVC Leftrenalvein
Liver
Superiormesentericartery
Leftrenal
artery
Pancreas
Middle aorta
Stomach
Splenic vein
L A B E L E D : AORTA TRV MID
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGE
15. Longitudinal image of the distal and middle inferior vena cava.
133
Posterior
Anterior Hepaticartery
InferiorSuperior
Distal and Middle IVC
Vertebrae
Smallbowel
shadow
Portalvein
Liver
SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.
L A B E L E D : IVC SAG DISTAL
AXIAL IMAGE
16. Axial image of the distal inferior vena cava to include the hepatic veins.
134
Posterior
Anterior
Distal IVC
Left hepaticvein
Middlehepaticvein
Right hepatic vein
LeftRight
Liver
L A B E L E D : IVC TRV DISTAL
Gallbladder and Biliary Tract
135
SCANNING TIP: When the gallbladder and biliary tract are the areas of interest,they are routinely surveyed in two different patient positions and the gallbladder isdocumented in both positions.
First Position
LONGITUDINAL GALLBLADDER IMAGES
17. Long axis image of the gallbladder.
136
Posterior
AnteriorGallbladder
InferiorSuperior
Small bowel
Throughtransmission
Portal vein
Diaphragm
IVC
Liver
L A B E L E D : GB SAG LONG AXIS
18. Longitudinal image of the gallbladder fundus and body.
137
Posterior
Anterior
Body
Liver
InferiorSuperior
Fundus
Gallbladder Bowel
L A B E L E D : GB SAG FUNDUS/BODY
19. Longitudinal image of the gallbladder neck.
138
Posterior
Anterior
Liver
InferiorSuperior
GallbladderCommon
hepatic duct
Body
Neck
Portal vein
IVCDiaphragm
L A B E L E D : GB SAG NECK
AXIAL GALLBLADDER IMAGES
20. Axial image of the gallbladder fundus.
139
Posterior
AnteriorGallbladderfundus
LeftRight
Sidewallshadow
IVC
Liver
L A B E L E D : GB TRV FUNDUS
21. Axial image of the gallbladder body.
140
Posterior
Anterior
Liver
LeftRight
GallbladderbodySidewall
shadow
IVC
Right kidney
Spine
L A B E L E D : GB TRV BODY
22. Axial image of the gallbladder neck.
141
Posterior
Anterior
LiverLeftRight
Gallbladderneck
Sidewallshadow
IVCRight kidney
Sidewallshadow
Aorta
L A B E L E D : GB TRV NECK
LONGITUDINAL BILIARY TRACT IMAGES
142
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
SCANNING TIP: Biliary tract images may be taken in the second patient position ifthey were better visualized there during the survey.
23. Longitudinal image of the common hepatic duct.
143
Posterior
Anterior
Liver
InferiorSuperior
Gallbladder
IVC
Portal veinDiaphragm
Commonhepatic duct
Hepaticartery
L A B E L E D : SAG CHD
24. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
144
Posterior
Anterior
Bowel
Commonbile duct
Portal vein
Liver
Hepaticartery
InferiorSuperior
L A B E L E D : SAG CBD
25. Same image as Number 24 without measurement calipers.
145
L A B E L E D : SAG CBD
Second Position
LONGITUDINAL GALLBLADDER IMAGE
26. Long axis image of the gallbladder.
146
Posterior
Anterior
Liver
InferiorSuperior
Portal vein Gallbladder
Diaphragm
IVC
Through transmission
Right renalartery
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
27. Axial image of the gallbladder fundus.
147
Posterior
AnteriorGallbladderfundus
LeftRight
Sidewallshadow
IVC
Liver
L A B E L E D : GB TRV FUNDUS
Pancreas
LONGITUDINAL IMAGES
28. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
148
Anterior
Posterior
Tail
Splenicvein
LiverRight Left
Left kidney
Superiormesenteric
artery
Stomach
Body
Aorta
Spine
Right renalartery
IVC
Uncinateprocess
Head
Neck
Duodenum
Ligamentumteres
Left renal vein
L A B E L E D : PANC TRV LONG AXIS
29. Longitudinal image of the pancreas head, to include the uncinate process andcommon bile duct (if bile-filled).
149
Anterior
Posterior
Tail
Splenicvein
Liver
Right Left
Leftkidney
Confluence ofsplenic vein
and superiormesenteric vein
Body
Aorta
Spine
Commonbile duct
IVC
Gallbladder
Head
Ligamentum teres
Superiormesenteric
artery
Liver
Gastroduodenalartery
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
30. Axial image of the pancreas head to include the common bile duct (if bile-filled).
150
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
Anterior
Posterior
LiverRight
Left
Head
Portal veinIVC
Bowel
Commonbile duct
L A B E L E D : PANC SAG HEAD
Right Kidney
LONGITUDINAL IMAGE
31. Long axis image of the right kidney.
151
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
InferiorSuperior
Anterior
Posterior
Cortex
Sinus
Inferiorpole
Superior pole
Midportion
Liver
Diaphragm
L A B E L E D : RT KID SAG LONG AXIS
AXIAL IMAGE
32. Axial image of the right kidney midportion to include the hilum.
152
LeftRight
Anterior
Posterior
Cortex
Sinus
IVC
Rightrenal vein
Midportion
Liver
L A B E L E D : RT KID TRV MID
Left Kidney
LONGITUDINAL IMAGE
33. Long axis image of the left kidney.
153
InferiorSuperior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Superiorpole Midportion
SpleenInferiorpole
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
L A B E L E D : LT KID COR LONG AXIS
AXIAL IMAGE
34. Axial image of the left kidney midportion to include the hilum.
154
PosteriorAnterior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
Spleen
LONGITUDINAL IMAGE
35. Long axis or longitudinal image of the spleen to include the adjacent pleural spacesuperiorly and portion of the left kidney inferiorly.
155
InferiorSuperior
Lateral
Medial
Left kidney
Long axisof spleen
Diaphragm
L A B E L E D : SPLEEN COR LONG AXIS or SPLEEN COR
AXIAL IMAGE
36. Axial image of the spleen to include the anterior and posterior margins.
156
PosteriorAnterior
Lateral
Medial
DiaphragmSplenichilum
L A B E L E D : SPLEEN LT TRV
V. Pancreas Study with Full Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
157
Posterior
Anterior
Splenic artery
InferiorSuperior
Bowel
Pancreas bodyLeft lobe
Aorta
Spine
Splenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
158
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
159
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
Caudate lobe
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
160
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
161
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
162
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
163
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
164
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
165
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
166
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
167
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
168
SCANNING TIP: Routine measurements of the liver are not required.
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
Aorta
LONGITUDINAL IMAGE
13. Longitudinal image of the proximal and middle aorta.
169
SCANNING TIP: The images of the aorta may be included with the liver images ifthe aorta is well visualized.
Posterior
Anterior
Liver
Splenicartery
Superiormesenteric
artery
PancreasInferior
Superior
Stomach
Splenicvein
Proximal and Middle aorta
L A B E L E D : AORTA SAG MID
AXIAL IMAGE
14. Axial image of the middle aorta at the level of the renal arteries.
170
Posterior
Anterior
LeftRight
Spine
IVC Leftrenalvein
Liver
Superiormesentericartery
Leftrenal
artery
Pancreas
Middle aorta
Stomach
Splenic vein
L A B E L E D : AORTA TRV MID
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGE
15. Longitudinal image of the distal and middle inferior vena cava.
171
Posterior
AnteriorHepaticartery
InferiorSuperior
Distal and Middle IVC
Vertebrae
Smallbowel
shadow
Portalvein
Liver
SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.
L A B E L E D : IVC SAG DISTAL
AXIAL IMAGE
16. Axial image of the distal inferior vena cava to include the hepatic veins.
172
Posterior
Anterior
Distal IVC
Left hepaticvein
Middlehepaticvein
Right hepatic vein
LeftRight
Liver
L A B E L E D : IVC TRV DISTAL
Gallbladder and Biliary Tract
LONGITUDINAL GALLBLADDER IMAGE
17. Long axis image of the gallbladder.
173
Posterior
AnteriorGallbladder
InferiorSuperior
Small bowel
Throughtransmission
Portal vein
Diaphragm
IVC
Liver
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
18. Axial image of the gallbladder fundus.
174
Posterior
AnteriorGallbladderfundus
LeftRight
Sidewallshadow
IVC
Liver
L A B E L E D : GB TRV FUNDUS
LONGITUDINAL BILIARY TRACT IMAGES
19. Longitudinal image of the common hepatic duct.
175
Posterior
Anterior Gallbladder
InferiorSuperior
Hepatic artery
IVC
Liver
Commonhepatic duct
Portal vein
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
L A B E L E D : SAG CHD
20. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
176
Posterior
Anterior Duodenum
InferiorSuperior
Hepatic artery
Liver
Commonbile duct
Portal vein
L A B E L E D : SAG CBD
21. Same image as Number 20 without measurement calipers.
177
L A B E L E D : SAG CBD
Pancreas
LONGITUDINAL IMAGES
22. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
178
Posterior
Anterior
Pancreaticduct
Commonbile duct
IVC
Liver
Head
LeftRight
NeckBody
Stomach
TailSplenicvein
Aorta
Left kidney
Spine
Right renalartery
Duodenum
Confluenceof superiormesenteric veinand splenic vein
Gastro-duodenalartery
L A B E L E D : PANC TRV LONG AXIS
23. Longitudinal image of the pancreas body and neck to include the splenic vein.
179
LigamentumteresLiver
Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
Tail
Splenicvein
AortaIVC
Head
Spine
Commonbile duct
Gastro-duodenalartery
Confluenceof superiormesentericvein andsplenic vein
Neck
L A B E L E D : PANC TRV BODY/NECK
24. Longitudinal image of the pancreas tail.
180
Superiormesentericartery
Liver Stomach
Leftkidney
Anterior
LeftRight
Posterior
Body
TailSplenicveinAorta
Left renalvein
Spine
IVC
Head
Uncinateprocess
L A B E L E D : PANC TRV TAIL
25. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).
181
Superiormesentericartery
Liver
Splenic vein
Left renalartery
Anterior
LeftRight
Posterior
Neck
Rightkidney
Leftkidney
Aorta
IVC
Head
Spine
Uncinate process
Left renalvein
Liver
Superiormesenteric vein
Commonbile duct
Gallbladder
Duodenum
L A B E L E D : PANC TRV HEAD
AXIAL IMAGES
26. Axial image of the pancreas head to include the common bile duct (if bile-filled).
182
Anterior
Posterior
Bowel
IVC
Head
Portal vein
Liver
Commonbile duct
Liver
Superior Inferior
L A B E L E D : PANC SAG HEAD
27. Axial image of the pancreas neck and uncinate process to include the superiormesenteric vein.
183
Anterior
Posterior
Bowel
IVC
Neck
Right renalartery
Uncinateprocess
Liver
Superior Inferior
Spine
Superiormesenteric vein
L A B E L E D : PANC SAG NECK/UNCINATE
28. Axial image of the pancreas body to include the splenic vein.
184
Anterior
Posterior
DiaphragmAorta
Body
Splenicartery
Splenic vein
LiverSuperior Inferior
Spine
Superiormesenteric
arteryEsophagealgastricjunction
L A B E L E D : PANC SAG BODY
29. Axial image of the pancreas tail.
185
Anterior
Posterior
Tail
Splenicvein
LiverSuperior Inferior
Left kidney
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
L A B E L E D : PANC SAG TAIL
Right Kidney
LONGITUDINAL IMAGE
30. Long axis image of the right kidney.
186
Inferior
Superior
Anterior
Posterior
Cortex
Sinus
Inferiorpole
Superior pole
Midportion
Liver
Diaphragm
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
L A B E L E D : RT KID SAG LONG AXIS
AXIAL IMAGE
31. Axial image of the right kidney midportion to include the hilum.
187
LeftRight
Anterior
Posterior
Cortex
Sinus
IVC
Rightrenal vein
Midportion
Liver
L A B E L E D : RT KID TRV MID
Left Kidney
LONGITUDINAL IMAGE
32. Long axis image of the left kidney.
188
InferiorSuperior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Superiorpole Midportion
Spleen Inferiorpole
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
L A B E L E D : LT KID COR LONG AXIS
AXIAL IMAGE
33. Axial image of the left kidney midportion to include the hilum.
189
PosteriorAnterior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
Spleen
LONGITUDINAL IMAGE
34. Long axis or longitudinal image of the spleen to include the adjacent pleural spacesuperiorly and portion of the left kidney inferiorly.
190
InferiorSuperior
Lateral
Medial
Left kidney
Long axisof spleen
Diaphragm
L A B E L E D : SPLEEN COR LONG AXIS or SPLEEN COR
AXIAL IMAGE
35. Axial image of the spleen to include the anterior and posterior margins.
191
PosteriorAnterior
Lateral
Medial
DiaphragmSplenichilum
L A B E L E D : SPLEEN LT TRV
VI. Renal Study with Full Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
192
Posterior
Anterior
Splenic artery
InferiorSuperior Bowel
Pancreas bodyLeft lobe
Aorta
SpineSplenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
193
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
194
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
195
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
196
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
197
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
198
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
199
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
200
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
201
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
202
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
203
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
SCANNING TIP: Routine measurements of the liver are not required.
L A B E L E D : LIVER TRV RT LOBE
Aorta
LONGITUDINAL IMAGE
13. Longitudinal image of the proximal and middle aorta.
204
Posterior
Anterior
Liver
Splenicartery
Superiormesenteric
artery
Pancreas InferiorSuperior
Stomach
Splenicvein
Proximal and Middle aorta
SCANNING TIP: The images of the aorta may be included with the liver images ifthe aorta is well visualized.
L A B E L E D : AORTA SAG MID
AXIAL IMAGE
14. Axial image of the middle aorta at the level of the renal arteries.
205
Posterior
Anterior
LeftRight
Spine
IVC Leftrenalvein
Liver
Superiormesentericartery
Leftrenal
artery
Pancreas
Middle aorta
Stomach
Splenic vein
L A B E L E D : AORTA TRV MID
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGE
15. Longitudinal image of the distal and middle inferior vena cava.
206
Posterior
Anterior Hepaticartery
InferiorSuperior
Distal and Middle IVC
Vertebrae
Smallbowel
shadow
Portalvein
Liver
SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.
L A B E L E D : IVC SAG DISTAL
AXIAL IMAGE
16. Axial image of the distal inferior vena cava to include the hepatic veins.
207
Posterior
Anterior
Distal IVC
Left hepaticvein
Middlehepaticvein
Right hepatic vein
LeftRight
Liver
L A B E L E D : IVC TRV DISTAL
Gallbladder and Biliary Tract
LONGITUDINAL GALLBLADDER IMAGE
17. Long axis image of the gallbladder.
208
Posterior
AnteriorGallbladder
InferiorSuperior
Small bowel
Throughtransmission
Portal vein
Diaphragm
IVC
Liver
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
18. Axial image of the gallbladder fundus.
209
Posterior
AnteriorGallbladderfundus
LeftRight
Sidewallshadow
IVC
Liver
L A B E L E D : GB TRV FUNDUS
LONGITUDINAL BILIARY TRACT IMAGES
19. Longitudinal image of the common hepatic duct.
210
Posterior
Anterior Gallbladder
Inferior
Superior
Hepatic artery
IVC
Liver
Commonhepatic duct
Portal vein
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
L A B E L E D : SAG CHD
20. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
211
Posterior
Anterior Duodenum
InferiorSuperior
Hepatic artery
Liver
Commonbile duct
Portal vein
L A B E L E D : SAG CBD
21. Same image as Number 20 without measurement calipers.
212
L A B E L E D : SAG CBD
Pancreas
LONGITUDINAL IMAGES
22. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
213
Pancreaticduct
Liver Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
TailSplenicvein
Aorta
Right renalartery
IVC
Head
Spine
Duodenum
Commonbile duct
Gastro-duodenalartery
Confluenceof superiormesenteric veinand splenic vein
Neck
L A B E L E D : PANC TRV LONG AXIS
23. Longitudinal image of the pancreas head, to include the uncinate process andcommon bile duct (if bile-filled).
214
Superiormesentericartery
Liver
Splenic vein
Left renalartery
Anterior
LeftRight
Posterior
Neck
Rightkidney
Leftkidney
Aorta
IVC
Head
Spine
Uncinate process
Left renalvein
Liver
Superiormesenteric vein
Commonbile duct
Gallbladder
Duodenum
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
24. Axial image of the pancreas head to include the common bile duct (if bile-filled).
215
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
Anterior
Posterior
Liver
Superior Inferior
Head
Commonbile ductIVC
Bowel
Liver
Portal vein
Bowel
L A B E L E D : PANC SAG HEAD
Right Kidney
LONGITUDINAL IMAGES
25. Long axis image of the right kidney with superior to inferior measurement.
216
Anterior
Posterior
Superior Inferior
Superiorpole
Cortex
Midportion
Sinus
InferiorpoleLiver
Diaphragm
L A B E L E D : RT KID SAG LONG AXIS
26. Same image as Number 25, without measurement calipers.
217
L A B E L E D : RT KID SAG LONG AXIS
27. Long axis image of the right kidney with superior to inferior measurement.
218
Anterior
Posterior
Superior Inferior
Superiorpole
Cortex
Midportion
Inferior pole
Liver
Diaphragm
Psoasmuscle
Sinus
L A B E L E D : RT KID SAG LONG AXIS
28. Same image as Number 27, without measurement calipers.
219
SCANNING TIP: If the superior and inferior poles were adequately demonstrated onthe long axis images, Numbers 29 and/or 30 may be omitted.
L A B E L E D : RT KID SAG LONG AXIS
29. Longitudinal image of the right kidney superior pole.
220
Anterior
Posterior
Superior Inferior
Superiorpole
Cortex
Liver
Diaphragm
Sinus
L A B E L E D : RT KID SAG SUP POLE
30. Longitudinal image of the right kidney inferior pole.
221
Anterior
Posterior
Superior InferiorInferiorpole
Cortex
Liver
Sinus
L A B E L E D : RT KID SAG INF POLE
31. Longitudinal image of the right kidney just medial to the long axis.
222
Anterior
Posterior
Superior Inferior
Medialportion
Cortex
Liver
Spine
Psoasmuscle
Medullary pyramids
Diaphragm
L A B E L E D : RT KID SAG MED
32. Longitudinal image of the right kidney just lateral to the long axis to include part ofthe liver for parenchyma comparison.
223
Anterior
Posterior
Superior Inferior
Lateralportion
Cortex
Liver
Sinus
Quadratuslumborummuscle
Medullarypyramids
Diaphragm
L A B E L E D : RT KID SAG LAT
AXIAL IMAGES
33. Axial image of the right kidney superior pole.
224
Anterior
Posterior
Right Left
Cortex
Liver
SinusIVC
Medullary pyramids
Superiorpole
L A B E L E D : RT KID TRV SUP POLE
34. Axial image of the right kidney midportion to include the hilum and anterior toposterior measurement.
225
Anterior
Posterior
Right Left
Cortex
Liver
Sinus
IVC
Renal vein
Midportion
L A B E L E D : RT KID TRV MID
35. Same image as Number 34, without measurement calipers.
226
L A B E L E D : RT KID TRV MID
36. Axial image of the right kidney inferior pole.
227
Anterior
Posterior
Right Left
CortexLiver
Sinus
IVC
Psoasmuscle
Inferiorpole
Quadratuslumborum
muscle
Bowel
L A B E L E D : RT KID TRV INF POLE
Left Kidney
LONGITUDINAL IMAGES
37. Long axis image of the left kidney with superior to inferior measurement.
228
Lateral
Medial
Superior Inferior
Cortex
Spleen
Sinus
MidportionSuperiorpole
Inferiorpole
Medullarypyramids
Diaphragm
L A B E L E D : LT KID COR LONG AXIS
38. Same image as Number 37, without measurement calipers.
229
L A B E L E D : LT KID COR LONG AXIS
39. Long axis image of the left kidney with superior to inferior measurement.
230
Lateral
Medial
Superior Inferior
Cortex
Spleen
Sinus
MidportionSuperiorpole
Inferiorpole
Medullarypyramids
DiaphragmDiaphragm
Pleuralspace
L A B E L E D : LT KID COR LONG AXIS
40. Same image as Number 39, without measurement calipers.
231
SCANNING TIP: If the superior and inferior poles were adequately demonstrated onthe long axis images, Numbers 41 and/or 42 may be omitted.
L A B E L E D : LT KID COR LONG AXIS
41. Longitudinal image of the left kidney superior pole with part of the spleen forparenchyma comparison.
232
Lateral
Medial
Superior Inferior
Cortex
Spleen
Sinus
Superiorpole
AortaDiaphragm
Psoasmuscle
L A B E L E D : LT KID COR SUP POLE
42. Longitudinal image of the left kidney inferior pole.
233
Lateral
Medial
Superior Inferior
Cortex
Bowel
Sinus
Inferiorpole
Aorta
L A B E L E D : LT KID COR INF POLE
43. Longitudinal image of the left kidney just anterior to the long axis.
234
Lateral
Medial
Superior Inferior
Cortex
Sinus
Anteriorportion
L A B E L E D : LT KID COR ANT
44. Longitudinal image of the left kidney just posterior to the long axis.
235
Lateral
Medial
Superior Inferior
Cortex
Sinus
Posteriorportion
L A B E L E D : LT KID COR POST
AXIAL IMAGES
45. Axial image of the left kidney superior pole.
236
Lateral
Medial
Anterior Posterior
Cortex
Sinus
Superiorpole
L A B E L E D : LT KID LT TRV SUP POLE
46. Axial image of the left kidney midportion to include the hilum and anterior toposterior measurement.
237
Lateral
Medial
Anterior Posterior
Cortex
Sinus
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
47. Same image as Number 46, without measurement calipers.
238
L A B E L E D : RT KID TRV MID
48. Axial image of the left kidney inferior pole.
239
Lateral
Medial
Anterior Posterior
Cortex
Sinus
Inferiorpole
Medullarypyramids
L A B E L E D : LT KID LT TRV INF POLE
Spleen
LONGITUDINAL IMAGE
49. Long axis or longitudinal image of the spleen to include the adjacent pleural spacesuperiorly and portion of the left kidney inferiorly.
240
InferiorSuperior
Lateral
Medial
Left kidney
Long axisof spleen
Diaphragm
L A B E L E D : SPLEEN COR LONG AXIS or SPLEEN COR
AXIAL IMAGE
50. Axial image of the spleen to include the anterior and posterior margins.
241
PosteriorAnterior
Lateral
Medial
DiaphragmSplenichilum
L A B E L E D : SPLEEN LT TRV
VII. Spleen Study with Full Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
242
Posterior
Anterior
Splenic artery
InferiorSuperior
Bowel
Pancreas bodyLeft lobe
Aorta
Spine
Splenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
243
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
244
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
245
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
246
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
247
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
248
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
249
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
250
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
251
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
252
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
253
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
SCANNING TIP: Routine measurements of the liver are not required.
L A B E L E D : LIVER TRV RT LOBE
Aorta
LONGITUDINAL IMAGE
13. Longitudinal image of the proximal and middle aorta.
254
SCANNING TIP: The images of the aorta may be included with the liver images ifthe aorta is well visualized.
Posterior
Anterior
Liver
Splenicartery
Superiormesenteric
artery
Pancreas InferiorSuperior
Stomach
Splenicvein
Proximal and Middle aorta
L A B E L E D : AORTA SAG MID
AXIAL IMAGE
14. Axial image of the middle aorta at the level of the renal arteries.
255
Posterior
Anterior
LeftRight
Spine
IVC Leftrenalvein
Liver
Superiormesentericartery
Leftrenal
artery
Pancreas
Middle aorta
Stomach
Splenic vein
L A B E L E D : AORTA TRV MID
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGE
15. Longitudinal image of the distal and middle inferior vena cava.
256
Posterior
Anterior Hepaticartery
InferiorSuperior
Distal and Middle IVC
Vertebrae
Smallbowel
shadow
Portalvein
Liver
SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.
L A B E L E D : IVC SAG DISTAL
AXIAL IMAGE
16. Axial image of the distal inferior vena cava to include the hepatic veins.
257
Posterior
Anterior
Distal IVC
Left hepaticvein
Middlehepaticvein
Right hepatic vein
LeftRight
Liver
L A B E L E D : IVC TRV DISTAL
Gallbladder and Biliary Tract
LONGITUDINAL GALLBLADDER IMAGE
17. Long axis image of the gallbladder.
258
Posterior
AnteriorGallbladder
InferiorSuperior
Small bowel
Throughtransmission
Portal vein
Diaphragm
IVC
Liver
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
18. Axial image of the gallbladder fundus.
259
Posterior
AnteriorGallbladderfundus
LeftRight
Sidewallshadow
IVC
Liver
L A B E L E D : GB TRV FUNDUS
LONGITUDINAL BILIARY TRACT IMAGES
19. Longitudinal image of the common hepatic duct.
260
Posterior
Anterior Gallbladder
InferiorSuperior
Hepatic artery
IVC
Liver
Commonhepatic duct
Portal vein
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
L A B E L E D : SAG CHD
20. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
261
Posterior
Anterior Duodenum
InferiorSuperior
Hepatic artery
Liver
Commonbile duct
Portal vein
L A B E L E D : SAG CBD
21. Same image as Number 20 without measurement calipers.
262
L A B E L E D : SAG CBD
Pancreas
LONGITUDINAL IMAGES
22. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
263
Pancreaticduct
Liver Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
TailSplenicvein
Aorta
Right renalartery
IVC
Head
Spine
Duodenum
Commonbile duct
Gastro-duodenalartery
Confluenceof superiormesenteric veinand splenic vein
Neck
L A B E L E D : PANC TRV LONG AXIS
23. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).
264
Superiormesentericartery
Liver
Splenic vein
Left renalartery
Anterior
LeftRight
Posterior
Neck
Rightkidney
Leftkidney
Aorta
IVC
Head
Spine
Uncinate process
Left renalvein
Liver
Superiormesenteric vein
Commonbile duct
Gallbladder
Duodenum
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
24. Axial image of the pancreas head to include the common bile duct (if bile-filled).
265
Anterior
Posterior
Liver
SuperiorInferior
Head
Commonbile ductIVC
Liver
Portal vein
Bowel
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
L A B E L E D : PANC SAG HEAD
Right Kidney
LONGITUDINAL IMAGE
25. Long axis image of the right kidney.
266
Inferior
Superior
Anterior
Posterior
Cortex
Sinus
Inferiorpole
Superior pole
Midportion
Liver
Diaphragm
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
L A B E L E D : RT KID SAG LONG AXIS
AXIAL IMAGE
26. Axial image of the right kidney midportion to include the hilum.
267
LeftRight
Anterior
Posterior
Cortex
Sinus
IVC
Rightrenal vein
Midportion
Liver
L A B E L E D : RT KID TRV MID
Left Kidney
LONGITUDINAL IMAGE
27. Long axis image of the left kidney.
268
InferiorSuperior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Superiorpole Midportion
SpleenInferiorpole
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
L A B E L E D : LT KID COR LONG AXIS
AXIAL IMAGE
28. Axial image of the left kidney midportion to include the hilum.
269
PosteriorAnterior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
Spleen
LONGITUDINAL IMAGES
29. Long axis image of the spleen.
270
Lateral
Medial
InferiorSuperior
Long axisof spleen
Diaphragm Left kidney
SCANNING TIP: If the adjacent pleural space and a portion of the left kidney wereadequately demonstrated on Number 29, Numbers 30 and/or 31 may be omitted.
L A B E L E D : SPLEEN COR LONG AXIS
30. Superior longitudinal image of the spleen to include the adjacent pleural space.
271
Lateral
Medial
InferiorSuperior
Spleen
Diaphragm
Rib shadows
Pleuralspace
L A B E L E D : SPLEEN COR SUP
31. Inferior longitudinal image of the spleen to include part of the left kidney forparenchyma comparison.
272
Lateral
Medial
InferiorSuperior
Spleen
Leftkidney
Pleuralspace
L A B E L E D : SPLEEN COR INF
AXIAL IMAGES
32. Axial image of the spleen to include both anterior and posterior margins.
273
Lateral
Medial
PosteriorAnterior
Splenichilum
Diaphragm
SCANNING TIP: If the anterior and posterior margins were adequatelydemonstrated on Number 32, Numbers 33 and/or 34 may be omitted.
L A B E L E D : SPLEEN LT TRV
33. Axial image of the spleen to include both anterior margin and splenic hilum.
274
Lateral
Medial
PosteriorAnterior
Splenichilum
Diaphragm
Spleen Rib shadow
L A B E L E D : SPLEEN LT TRV ANT
34. Axial image of the spleen to include the posterior margin.
275
Lateral
Medial
PosteriorAnterior
Splenichilum Diaphragm
Spleen
L A B E L E D : SPLEEN LT TRV POST
SECTION TWO
IMAGE PROTOCOLS FOR L IMITED SONOGRAPHIC STUDIES OF THEABDOMEN
• Extensive images of the area(s) of interest.
I. Aorta Study
II. Inferior Vena Cava Study
III. Right Upper Quadrant Study
IV. Gallbladder and Biliary Tract Study
V. Pancreas Study
VI. Renal Study
VII. Spleen Study
276276
277
• Criteria:— Begin studies with a survey of the area(s) of interest in at least two scanning
planes.— Do not share the results of the study with the patient. Legally, only physicians can
give a diagnosis.
I. Aorta Study/Limited Abdomen
Aorta
LONGITUDINAL IMAGES
1. Longitudinal image of the proximal aorta (inferior to the diaphragm, superior to theceliac trunk).
278
Superior Inferior
Anterior
Posterior
Liver
Celiac artery
SuperiormesentericarteryProximal
aorta
L A B E L E D : AORTA SAG PROX
2. Longitudinal image of the middle aorta (inferior to the celiac trunk along the lengthof the superior mesenteric artery).
279
Anterior Pancreas body
Inferior
Posterior
Superior
Stomach
Superiormesentericartery
Middle aortaSplenic artery
Proximalaorta
Liver
Splenic vein
L A B E L E D : AORTA SAG MID
3. Longitudinal image of the distal aorta (inferior to the superior mesenteric artery,superior to the bifurcation).
280
Anterior
Inferior
Posterior
Superior
Stomach
Bowel
Distal aorta
Bowel
L A B E L E D : AORTA SAG DISTAL
4. Longitudinal image of the aorta bifurcation (common iliac arteries).
281
Medial
InferiorSuperiorDistal aorta
Left commoniliac artery
Aortabifurcation
Right commoniliac artery
Lateral
L A B E L E D : AORTA SAG BIF RT or LT OBL or AORTA LT COR BIF
AXIAL IMAGES
5. Axial image of the proximal aorta (inferior to the diaphragm, superior to the celiactrunk) with anterior to posterior measurement (calipers outside wall to outside wall).
282
Bowel
Liver
Proximalaorta
Posterior
Anterior
LeftRight
L A B E L E D : AORTA TRV PROX
6. Same image as Number 5, without measurement calipers.
283
L A B E L E D : AORTA TRV PROX
7. Axial image of the middle aorta (inferior to the celiac trunk along the length of thesuperior mesenteric artery) with anterior to posterior measurement (calipers outsidewall to outside wall).
284
Left renalvein
Liver
Posterior
Anterior
LeftRight
Pancreas Superiormesenteric
artery
Middle aorta
Splenicvein
Spine
IVC
L A B E L E D : AORTA TRV MID
8. Same image as Number 7, without measurement calipers.
285
SCANNING TIP: If the renal arteries were represented on Number 7, Numbers 9and/or 10 may be omitted.
L A B E L E D : AORTA TRV MID
9. Longitudinal image of the right renal artery.
286
Posterior
Anterior
LeftRight
Pancreas
Superiormesenteric
vein
Spine
IVC
Rightrenal
artery
Aorta
Gallbladder
L A B E L E D : RT RENAL ART TRV
10. Longitudinal image of the left renal artery.
287
Posterior
Anterior
LeftRight
Spine
IVC
Rightrenalartery Aorta
Left renal vein
Liver
Splenicvein
Superiormesenteric
artery
Left renal artery
Ligamentumteres
L A B E L E D : LT RENAL ART TRV
11. Axial image of the distal aorta (inferior to the superior mesenteric artery, superiorto the bifurcation) with anterior to posterior measurement (calipers outside wall tooutside wall).
288
Posterior
Anterior
LeftRight
Distal aorta
L A B E L E D : AORTA TRV DISTAL
12. Same image as Number 11, without measurement calipers.
289
L A B E L E D : AORTA TRV DISTAL
13. Axial image of aorta bifurcation (common iliac arteries).
290
Posterior
Anterior
LeftRight
Right commoniliac artery
Left commoniliac artery
L A B E L E D : AORTA TRV BIF
II. Inferior Vena Cava Study/Limited Abdomen
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGES
1. Longitudinal image of the distal inferior vena cava to include the diaphragm andhepatic vein(s).
291
Posterior
Anterior
InferiorSuperior
Hepatic vein
Diaphragm Distal IVC
Portal vein
Liver
L A B E L E D : IVC SAG DISTAL
2. Longitudinal image of the middle inferior vena cava at the level of the head of thepancreas.
292
Posterior
Anterior
InferiorSuperior
Right renal artery
LiverPortalvein
Hepaticartery
Gallbladder neck fold shadow
Common bile duct Middle IVC
Pancreashead
Gastro-duodenal
arteryGallbladder
L A B E L E D : IVC SAG MID
3. Longitudinal image of the proximal inferior vena cava.
293
Posterior
Anterior
InferiorSuperior
BowelProximal IVC
L A B E L E D : IVC SAG PROX
4. Longitudinal image of the inferior vena cava bifurcation (common iliac veins).
294
Posterior
Anterior
InferiorSuperiorBowel
Proximal IVC
Left commoniliac vein
IVC bifurcation
Right commoniliac vein
L A B E L E D : IVC SAG BIF RT or LT OBL or IVC RT COR BIF
AXIAL IMAGES
5. Axial image of the distal inferior vena cava to include the hepatic veins.
295
Posterior
Anterior
Distal IVC
LeftRight
Left hepaticvein
Middlehepaticvein
Right hepatic vein
L A B E L E D : IVC TRV DISTAL
6. Axial image of the inferior vena cava at the level of the renal veins.
296
Anterior
LeftRight
Posterior
Gallbladder
LiverMiddle IVC
Left renalvein
AortaSpine
Rightrenal vein
Rightrenal artery
L A B E L E D : IVC TRV MID
7. Axial image of the proximal inferior vena cava.
297
Posterior
Anterior
Proximal IVC
LeftRight
L A B E L E D : IVC TRV PROX
8. Axial image of the inferior vena cava bifurcation (common iliac veins).
298
Posterior
Anterior
Spine
LeftRight
Commoniliac vein Common
iliac vein
Commoniliac arteries
L A B E L E D : IVC TRV BIF
III. Right Upper Quadrant Study/Limited Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
299
Posterior
Anterior
Splenic artery
InferiorSuperior Bowel
Pancreas bodyLeft lobe
Aorta
Spine
Splenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
300
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
301
Hepaticvein
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
302
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
303
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
304
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
305
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
306
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
307
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
308
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
309
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
310
SCANNING TIP: Routine measurements of the liver are not required.
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
Inferior Vena Cava (IVC)
LONGITUDINAL IMAGE
13. Longitudinal image of the distal and middle inferior vena cava.
311
Posterior
Anterior Hepaticartery
InferiorSuperior
Distal and Middle IVC
Vertebrae
Smallbowel
shadow
Portalvein
Liver
SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.
L A B E L E D : IVC SAG DISTAL
AXIAL IMAGE
14. Axial image of the distal inferior vena cava to include the hepatic veins.
312
Posterior
Anterior
Distal IVC
Left hepaticvein
Middlehepaticvein
Right hepatic vein
LeftRight
Liver
L A B E L E D : IVC TRV DISTAL
Gallbladder and Biliary TractFirst Position
LONGITUDINAL GALLBLADDER IMAGES
15. Long axis image of the gallbladder.
313
Posterior
Anterior
Body
IVC
Liver
Hepaticartery
InferiorSuperior
Neck Fundus
Gallbladder
Portal vein
L A B E L E D : GB SAG LONG AXIS
16. Longitudinal image of the gallbladder fundus and body.
314
Posterior
Anterior
Body
Liver
InferiorSuperior
Fundus
Gallbladder Bowel
L A B E L E D : GB SAG FUNDUS/BODY
17. Longitudinal image of the gallbladder neck.
315
Posterior
Anterior
Liver
InferiorSuperior
GallbladderCommon
hepatic duct
Body
Neck
Portal vein
IVCDiaphragm
L A B E L E D : GB SAG NECK
AXIAL GALLBLADDER IMAGES
18. Axial image of the gallbladder fundus.
316
Posterior
Anterior
Liver
LeftRight
Gallbladderfundus
Sidewallshadow
IVC
Right kidney
Sidewallshadow
L A B E L E D : GB TRV FUNDUS
19. Axial image of the gallbladder body.
317
Posterior
Anterior
Liver
LeftRight
GallbladderbodySidewall
shadow
IVC
Right kidney
Spine
L A B E L E D : GB TRV BODY
20. Axial image of the gallbladder neck.
318
Posterior
Anterior
LiverLeftRight
Gallbladderneck
Sidewallshadow
IVCRight kidney
Sidewallshadow
Aorta
L A B E L E D : GB TRV NECK
LONGITUDINAL BILIARY TRACT IMAGES
319
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
SCANNING TIP: Biliary tract images may be taken in the second patient position ifthey were better visualized there during the survey.
21. Longitudinal image of the common hepatic duct.
320
Posterior
Anterior
Liver
InferiorSuperior
Gallbladder
IVC
Portal veinDiaphragm
Commonhepatic duct
Hepaticartery
L A B E L E D : SAG CHD
22. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
321
Posterior
Anterior
Liver
InferiorSuperior
Portal vein
Bowel
Commonbile duct
Hepaticartery
L A B E L E D : SAG CBD
23. Same image as Number 22 without measurement calipers.
322
L A B E L E D : SAG CBD
Second Position
LONGITUDINAL GALLBLADDER IMAGE
24. Long axis image of the gallbladder.
323
Posterior
Anterior
Liver
InferiorSuperior
Portal vein Gallbladder
Diaphragm
IVC
Through transmission
Right renalartery
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
25. Axial image of the gallbladder fundus.
324
Posterior
Anterior
Liver
LeftRight
Gallbladderfundus
Right kidney
IVC
Through transmission
Spine
L A B E L E D : GB TRV FUNDUS
Pancreas
LONGITUDINAL IMAGES
26. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
325
Anterior
Posterior
Tail
Splenicvein
LiverRight Left
Left kidney
Superiormesenteric
artery
Stomach
Body
Aorta
Spine
Right renalartery
IVC
Uncinateprocess
Head
Neck
Duodenum
Ligamentumteres
Left renal vein
L A B E L E D : PANC TRV LONG AXIS
27. Longitudinal image of the pancreas head, to include the uncinate process andcommon bile duct (if bile-filled).
326
Anterior
Posterior
Tail
Splenicvein
Liver
Right Left
Leftkidney
Confluence ofsplenic vein
and superiormesenteric vein
Body
Aorta
Spine
Commonbile duct
IVC
Gallbladder
Head
Ligamentum teres
Superiormesenteric
artery
Liver
Gastroduodenalartery
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
28. Axial image of the pancreas head to include the common bile duct (if bile-filled).
327
Anterior
Posterior
LiverRight
Left
Head
Portal veinIVC
Bowel
Commonbile duct
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
L A B E L E D : PANC SAG HEAD
Right Kidney
LONGITUDINAL IMAGE
29. Long axis image of the right kidney.
328
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
InferiorSuperior
Anterior
Posterior
Cortex
Sinus
Inferiorpole
Superior pole
Midportion
Liver
Diaphragm
L A B E L E D : RT KID SAG LONG AXIS
AXIAL IMAGE
30. Axial image of the right kidney midportion to include the hilum.
329
LeftRight
Anterior
Posterior
Cortex
Sinus
IVC
Rightrenal vein
Midportion
Liver
L A B E L E D : RT KID TRV MID
IV. Gallbladder and Biliary Tract Study/Limited Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
330
Posterior
Anterior
Splenic artery
InferiorSuperior Bowel
Pancreas bodyLeft lobe
Aorta
SpineSplenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
331
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
332
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
333
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
334
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
335
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
336
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
337
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
338
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
339
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
340
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
341
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
SCANNING TIP: Routine measurements of the liver are not required.
L A B E L E D : LIVER TRV RT LOBE
Gallbladder and Biliary Tract
342
SCANNING TIP: When the gallbladder and biliary tract are the areas of interest,they are routinely surveyed in two different patient positions and the gallbladder isdocumented in both positions.
First Position
LONGITUDINAL GALLBLADDER IMAGES
13. Long axis image of the gallbladder.
343
Posterior
Anterior
Body
IVC
Liver
Hepaticartery
InferiorSuperior
Neck Fundus
Gallbladder
Portal vein
L A B E L E D : GB SAG LONG AXIS
14. Longitudinal image of the gallbladder fundus and body.
344
Posterior
Anterior
Body
Liver
InferiorSuperior
Fundus
Gallbladder Bowel
L A B E L E D : GB SAG FUNDUS/BODY
15. Longitudinal image of the gallbladder neck.
345
Posterior
Anterior
Liver
InferiorSuperior
GallbladderCommon
hepatic duct
Body
Neck
Portal vein
IVCDiaphragm
L A B E L E D : GB SAG NECK
AXIAL GALLBLADDER IMAGES
16. Axial image of the gallbladder fundus.
346
Posterior
Anterior
Liver
LeftRight
Gallbladderfundus
Sidewallshadow
IVC
Right kidney
Sidewallshadow
L A B E L E D : GB TRV FUNDUS
17. Axial image of the gallbladder body.
347
Posterior
Anterior
Liver
LeftRight
GallbladderbodySidewall
shadow
IVC
Right kidney
Spine
L A B E L E D : GB TRV BODY
18. Axial image of the gallbladder neck.
348
Posterior
Anterior
LiverLeftRight
Gallbladderneck
Sidewallshadow
IVCRight kidney
Sidewallshadow
Aorta
L A B E L E D : GB TRV NECK
LONGITUDINAL BILIARY TRACT IMAGES
349
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
SCANNING TIP: Biliary tract images may be taken in the second patient position ifthey were better visualized there during the survey.
19. Longitudinal image of the common hepatic duct.
350
Posterior
Anterior
Liver
InferiorSuperior
Gallbladder
IVC
Portal veinDiaphragm
Commonhepatic duct
Hepaticartery
L A B E L E D : SAG CHD
20. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
351
Posterior
Anterior
Liver
InferiorSuperior
Portal vein
Bowel
Commonbile duct
Hepaticartery
L A B E L E D : SAG CBD
21. Same image as Number 20 without measurement calipers.
352
L A B E L E D : SAG CBD
Second Position
LONGITUDINAL GALLBLADDER IMAGE
22. Long axis image of the gallbladder.
353
Posterior
Anterior
Liver
InferiorSuperior
Portal vein Gallbladder
Diaphragm
IVC
Through transmission
Right renalartery
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
23. Axial image of the gallbladder fundus.
354
Posterior
Anterior
Liver
LeftRight
Gallbladderfundus
Right kidney
IVC
Through transmission
Spine
L A B E L E D : GB TRV FUNDUS
Pancreas
LONGITUDINAL IMAGES
24. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
355
Anterior
Posterior
Tail
Splenicvein
LiverRight Left
Left kidney
Superiormesenteric
artery
Stomach
Body
Aorta
Spine
Right renalartery
IVC
Uncinateprocess
Head
Neck
Duodenum
Ligamentumteres
Left renal vein
L A B E L E D : PANC TRV LONG AXIS
25. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).
356
Anterior
Posterior
Tail
Splenicvein
Liver
Right Left
Leftkidney
Confluence ofsplenic vein
and superiormesenteric vein
Body
Aorta
Spine
Commonbile duct
IVC
Gallbladder
Head
Ligamentum teres
Superiormesenteric
artery
Liver
Gastroduodenalartery
L A B E L E D : PANC TRV HEAD
AXIAL IMAGE
26. Axial image of the pancreas head to include the common bile duct (if bile-filled).
357
Anterior
Posterior
Liver
Right
Left
Head
Portal veinIVC
Bowel
Commonbile duct
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
L A B E L E D : PANC SAG HEAD
V. Pancreas Study/Limited Abdomen
Liver
LONGITUDINAL IMAGES
1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.
358
Posterior
Anterior
Splenic artery
InferiorSuperiorBowel
Pancreas bodyLeft lobe
Aorta
SpineSplenicvein
Diaphragm
L A B E L E D : LIVER SAG LT LOBE
2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.
359
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior Left lobe
Splenicvein
Diaphragm
Inferiorvenacava
Ligamentumvenosum
L A B E L E D : LIVER SAG LT LOBE
3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.
360
Caudate lobe
Hepaticvein
Posterior
Anterior
InferiorSuperior
IVC
Bowel
Right lobe
Right lobe
Right renal artery
Hepaticvein
Portal vein
Stomach
Diaphragm
L A B E L E D : LIVER SAG RT LOBE
4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.
361
Posterior
Anterior
InferiorSuperior
Right lobe
Portalvein
Bowel
Gallbladder
Diaphragm
Main lobarfissure
Throughtransmission
L A B E L E D : LIVER SAG RT LOBE
5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.
362
Posterior
Anterior
InferiorSuperior
Right lobe
DiaphragmRightkidney
L A B E L E D : LIVER SAG RT LOBE
6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.
363
Posterior
Anterior
InferiorSuperior
Right lobe
Diaphragm
Diaphragmaticmotion
DomePleuralspace
L A B E L E D : LIVER SAG RT LOBE
AXIAL IMAGES
7. Axial image of the left lobe of the liver to include its lateral margin.
364
Posterior
Anterior
LeftRight
Ligamentumvenosum
Left lobe
Caudate lobe
AortaIVC
L A B E L E D : LIVER TRV LT LOBE
8. Axial image of the left lobe of the liver to include the ligamentum teres.
365
Posterior
Anterior
LeftRight
Ligamentum teres
Aorta
IVC
Bowel
Portal splenicconfluence
Portalvein
Sidewall shadow
Spine
Splenicvein
Pancreas
Left lobe
Left renalvein
Superiormesenteric
artery
SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE
L A B E L E D : LIVER TRV LT LOBE
9. Axial image of the right lobe of the liver to include the hepatic veins.
366
Posterior
Anterior
LeftRight
IVC
Left hepaticvein
Right lobeMiddlehepatic vein
Righthepatic vein
Diaphragm
L A B E L E D : LIVER TRV RT LOBE
10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.
367
Posterior
Anterior
LeftRight
Left portalvein
IVCAorta
Right lobe
Rightportal vein
Right kidney
Spine
L A B E L E D : LIVER TRV RT LOBE
11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.
368
Posterior
Anterior
LeftRight
Right lobe
Right kidney
Gallbladder
Bowel
L A B E L E D : LIVER TRV RT LOBE
12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.
369
Posterior
Anterior
LeftRight
Right lobe
Pleuralspace
Diaphragm
SCANNING TIP: Routine measurements of the liver are not required.
L A B E L E D : LIVER TRV RT LOBE
Gallbladder and Biliary Tract
LONGITUDINAL GALLBLADDER IMAGE
13. Long axis image of the gallbladder.
370
Posterior
AnteriorGallbladder
InferiorSuperior
Small bowel
Throughtransmission
Portal vein
Diaphragm
IVC
Liver
L A B E L E D : GB SAG LONG AXIS
AXIAL GALLBLADDER IMAGE
14. Axial image of the gallbladder fundus.
371
Posterior
AnteriorGallbladderfundus
LeftRight
Sidewallshadow
IVC
Liver
L A B E L E D : GB TRV FUNDUS
LONGITUDINAL BILIARY TRACT IMAGES
15. Longitudinal image of the common hepatic duct.
372
SCANNING TIP: Biliary tract images may be magnified to aid interpretation.
SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.
Posterior
Anterior Gallbladder
InferiorSuperior
Hepatic artery
IVC
Liver
Commonhepatic duct
Portal vein
L A B E L E D : SAG CHD
16. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.
373
Posterior
Anterior Duodenum
InferiorSuperior
Hepatic artery
Liver
Commonbile duct
Portal vein
L A B E L E D : SAG CBD
17. Same image as Number 16 without measurement calipers.
374
L A B E L E D : SAG CBD
Pancreas
LONGITUDINAL IMAGES
18. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.
375
Pancreaticduct
Liver Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
TailSplenicvein
Aorta
Right renalartery
IVC
Head
Spine
Duodenum
Commonbile duct
Gastro-duodenalartery
Confluenceof superiormesenteric veinand splenic vein
Neck
L A B E L E D : PANC TRV LONG AXIS
19. Longitudinal image of the pancreas body and neck to include the splenic vein.
376
LigamentumteresLiver
Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
Tail
Splenicvein
AortaIVC
Head
Spine
Commonbile duct
Gastro-duodenalartery
Confluenceof superiormesentericvein andsplenic vein
Neck
L A B E L E D : PANC TRV BODY/NECK
20. Longitudinal image of the pancreas tail.
377
Superiormesentericartery
Liver Stomach
Left kidney
Anterior
LeftRight
Posterior
Body
TailSplenicveinAorta
IVC
Head
Spine
Uncinateprocess
Left renalvein
L A B E L E D : PANC TRV TAIL
21. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).
378
Superiormesentericartery
Liver
Splenic vein
Left renalartery
Anterior
LeftRight
Posterior
Neck
Rightkidney
Leftkidney
Aorta
IVC
Head
Spine
Uncinate process
Left renalvein
Liver
Superiormesenteric vein
Commonbile duct
Gallbladder
Duodenum
L A B E L E D : PANC TRV HEAD
AXIAL IMAGES
22. Axial image of the pancreas head to include the common bile duct (if bile-filled).
379
Anterior
Posterior
Bowel
IVC
Head
Portal vein
Liver
Commonbile duct
Liver
Superior Inferior
L A B E L E D : PANC SAG HEAD
23. Axial image of the pancreas neck and uncinate process to include the superiormesenteric vein.
380
Anterior
Posterior
Bowel
IVC
Neck
Right renalartery
Uncinateprocess
Liver
Superior Inferior
Spine
Superiormesenteric vein
L A B E L E D : PANC SAG NECK/UNCINATE
24. Axial image of the pancreas body to include the splenic vein.
381
Anterior
Posterior
DiaphragmAorta
Body
Splenicartery
Splenic vein
LiverSuperior Inferior
Spine
Superiormesenteric
arteryEsophagealgastricjunction
L A B E L E D : PANC SAG BODY
25. Axial image of the pancreas tail.
382
Anterior
Posterior
Tail
Splenicvein
Liver
Superior Inferior
Left kidney
SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.
L A B E L E D : PANC SAG TAIL
VI. Renal Study/Limited Abdomen
Right Kidney
LONGITUDINAL IMAGES
1. Long axis image of the right kidney with superior to inferior measurement.
383
Anterior
Posterior
Superior Inferior
Superiorpole
Cortex
Midportion
Sinus
Inferiorpole
Liver
Diaphragm
L A B E L E D : RT KID SAG LONG AXIS
2. Same image as Number 1 without measurement calipers.
384
L A B E L E D : RT KID SAG LONG AXIS
3. Long axis image of the right kidney with superior to inferior measurement.
385
Anterior
Posterior
Superior Inferior
Superiorpole
Cortex
Midportion
Inferior pole
Liver
Diaphragm
Psoasmuscle
Sinus
L A B E L E D : RT KID SAG LONG AXIS
4. Same image as Number 3 without measurement calipers.
386
SCANNING TIP: If the superior and inferior poles were adequately demonstrated onthe long axis images, Numbers 5 and/or 6 may be omitted.
L A B E L E D : RT KID SAG LONG AXIS
5. Longitudinal image of the right kidney superior pole.
387
Anterior
Posterior
Superior Inferior
Superiorpole
Cortex
Liver
Diaphragm
Sinus
L A B E L E D : RT KID SAG SUP POLE
6. Longitudinal image of the right kidney inferior pole.
388
Anterior
Posterior
Superior InferiorInferiorpole
Cortex
Liver
Sinus
L A B E L E D : RT KID SAG INF POLE
7. Longitudinal image of the right kidney just medial to the long axis.
389
Anterior
Posterior
Superior Inferior
Medialportion
Cortex
Liver
Spine
Psoasmuscle
Medullary pyramids
Diaphragm
L A B E L E D : RT KID SAG MED
8. Longitudinal image of the right kidney just lateral to the long axis to include part ofthe liver for parenchyma comparison.
390
Anterior
Posterior
Superior Inferior
Lateralportion
Cortex
Liver
Sinus
Quadratuslumborummuscle
Medullarypyramids
Diaphragm
L A B E L E D : RT KID SAG LAT
AXIAL IMAGES
9. Axial image of the right kidney superior pole.
391
Anterior
Posterior
Right Left
Cortex
Liver
SinusIVC
Medullary pyramids
Superiorpole
L A B E L E D : RT KID TRV SUP POLE
10. Axial image of the right kidney midportion to include the hilum and anterior toposterior measurement.
392
Anterior
Posterior
Right Left
Cortex
Liver
Sinus
IVC
Renal vein
Midportion
L A B E L E D : RT KID TRV MID
11. Same image as Number 10 without measurement calipers.
393
L A B E L E D : RT KID TRV MID
12. Axial image of the right kidney inferior pole.
394
Anterior
Posterior
Right Left
CortexLiver
Sinus
IVC
Psoasmuscle
Inferiorpole
Quadratuslumborum
muscle
Bowel
L A B E L E D : RT KID TRV INF POLE
Left Kidney
LONGITUDINAL IMAGES
13. Long axis image of the left kidney with superior to inferior measurement.
395
Lateral
Medial
Superior Inferior
Cortex
Spleen
Sinus
MidportionSuperiorpole
Inferiorpole
Medullarypyramids
Diaphragm
L A B E L E D : LT KID COR LONG AXIS
14. Same image as Number 13 without measurement calipers.
396
L A B E L E D : LT KID COR LONG AXIS
15. Long axis image of the left kidney with superior to inferior measurement.
397
Lateral
Medial
Superior Inferior
Cortex
Spleen
Sinus
MidportionSuperiorpole
Inferiorpole
Medullarypyramids
DiaphragmDiaphragm
Pleuralspace
L A B E L E D : LT KID COR LONG AXIS
16. Same image as Number 15 without measurement calipers.
398
SCANNING TIP: If the superior and inferior poles were adequately demonstrated onthe long axis images, Numbers 17 and/or 18 may be omitted.
L A B E L E D : LT KID COR LONG AXIS
17. Longitudinal image of the left kidney superior pole with part of the spleen forparenchyma comparison.
399
Lateral
Medial
Superior Inferior
Cortex
Spleen
Sinus
Superiorpole
AortaDiaphragm
Psoasmuscle
L A B E L E D : LT KID COR SUP POLE
18. Longitudinal image of the left kidney inferior pole.
400
Lateral
Medial
Superior Inferior
Cortex
Bowel
Sinus
Inferiorpole
Aorta
L A B E L E D : LT KID COR INF POLE
19. Longitudinal image of the left kidney just anterior to the long axis.
401
Lateral
Medial
Superior Inferior
Cortex
Sinus
Anteriorportion
L A B E L E D : LT KID COR ANT
20. Longitudinal image of the left kidney just posterior to the long axis.
402
Lateral
Medial
Superior Inferior
Cortex
Sinus
Posteriorportion
L A B E L E D : LT KID COR POST
AXIAL IMAGES
21. Axial image of the left kidney superior pole.
403
Lateral
Medial
Anterior Posterior
Cortex
Sinus
Superiorpole
L A B E L E D : LT KID LT TRV SUP POLE
22. Axial image of the left kidney midportion to include the hilum and anterior toposterior measurement.
404
Lateral
Medial
Anterior Posterior
Cortex
Sinus
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
23. Same image as Number 22 without measurement calipers.
405
L A B E L E D : RT KID TRV MID
24. Axial image of the left kidney inferior pole.
406
Lateral
Medial
Anterior Posterior
Cortex
Sinus
Inferiorpole
Medullarypyramids
L A B E L E D : LT KID LT TRV INF POLE
VII. Spleen Study/Limited Abdomen
Spleen
LONGITUDINAL IMAGES
1. Long axis image of the spleen.
407
SCANNING TIP: If the adjacent pleural space and a portion of the left kidney wereadequately demonstrated on Number 1, Numbers 2 and/or 3 may be omitted.
Lateral
Medial
InferiorSuperior
Long axisof spleen
Diaphragm Left kidney
L A B E L E D : SPLEEN COR LONG AXIS
2. Superior longitudinal image of the spleen to include the adjacent pleural space.
408
Lateral
Medial
InferiorSuperior
Spleen
Diaphragm
Rib shadows
Pleuralspace
L A B E L E D : SPLEEN COR SUP
3. Inferior longitudinal image of the spleen to include part of the left kidney forparenchyma comparison.
409
Lateral
Medial
InferiorSuperior
Spleen
Leftkidney
Pleuralspace
L A B E L E D : SPLEEN COR INF
AXIAL IMAGES
4. Axial image of the spleen to include both anterior and posterior margins.
410
Lateral
Medial
PosteriorAnterior
Splenichilum
Diaphragm
SCANNING TIP: If the anterior and posterior margins were adequatelydemonstrated on Number 4, Numbers 5 and/or 6 may be omitted.
L A B E L E D : SPLEEN LT TRV
5. Axial image of the spleen to include both anterior margin and splenic hilum.
411
Lateral
Medial
PosteriorAnterior
Splenichilum
Diaphragm
Spleen Rib shadow
L A B E L E D : SPLEEN LT TRV ANT
6. Axial image of the spleen to include the posterior margin.
412
SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.
Lateral
Medial
PosteriorAnterior
Splenichilum Diaphragm
Spleen
L A B E L E D : SPLEEN LT TRV POST
Left Kidney
LONGITUDINAL IMAGE
7. Long axis image of the left kidney.
413
Lateral
Medial
Superior Inferior
Inferiorpole
Cortex
Sinus
MidportionSuperior
pole
Spleen
Medullarypyramids
Renalcapsule
L A B E L E D : LT KID SAG LONG AXIS
AXIAL IMAGE
8. Axial image of the left kidney midportion to include the hilum.
414
PosteriorAnterior
Lateral
Medial
Cortex
Sinus
Medullarypyramids
Midportion
Renalvasculature
L A B E L E D : LT KID LT TRV MID
IV
415
The Pelvis
SECTION ONE
IMAGE PROTOCOL FOR THE TRANSABDOMINAL SONOGRAPHICSTUDY OF THE FEMALE PELV IS
SECTION TWO
IMAGE PROTOCOL FOR THE TRANSVAGINAL SONOGRAPHIC STUDYOF THE FEMALE PELV IS
SECTION THREE
IMAGE PROTOCOLS FOR SONOGRAPHIC STUDIES OF THE FEMALEPELV IS
I. Transrectal Prostate Gland Study
II. Scrotum Study
II. Penis Study
416
SECTION ONE
IMAGE PROTOCOL FOR THE TRANSABDOMINAL SONOGRAPHICSTUDY OF THE FEMALE PELV IS
• Criteria:— Begin studies with a survey of pelvic structures in at least two scanning planes.— No single organ examinations are performed.— Do not share the results of the study with the patient. Legally, only physicians can
give a diagnosis.
417
418
I. Transabdominal Female Pelvis Study
Vagina • Uterus • Pelvic Cavity
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach
SCANNING TIP: Longitudinal images begin with representative images of thepelvic cavity followed by a long axis image of the uterus.
1. Longitudinal image of the midline of the pelvic cavity just superior to the symphysispubis.
419
Anterior
Inferior
Posterior
Superior
Vagina
Uterine cervix
Uterine body
Endometrium
Uterinefundus
Urinarybladder
L A B E L E D : PELVIS SAG MIDLINE
2. Longitudinal image of the right adnexa that may include part of the uterusdepending on its position.
420
Anterior
Inferior
Posterior
Superior
Section ofendometrium
Urinarybladder
Lateral margin ofuterine body
L A B E L E D : PELVIS SAG R1
3. Longitudinal image to include the right lateral wall of the bladder and pelvicsidewall.
421
Anterior
Inferior
Posterior
SuperiorUrinarybladder
Lateral margin ofuterine body
L A B E L E D : PELVIS SAG R2
4. Longitudinal image of the left adnexa that may include part of the uterus dependingon its position.
422
Anterior
Inferior
Posterior
SuperiorUrinarybladder
Bowel
Left ovaryMusculature
L A B E L E D : PELVIS SAG L1
5. Longitudinal image to include the left lateral wall of the bladder and pelvicsidewall.
423
Anterior
Inferior
Posterior
SuperiorUrinarybladder
BowelMusculature
L A B E L E D : PELVIS SAG L2
6. Long axis image of the uterus to include as much endometrial cavity as possiblewith uterine length (superior to inferior) and height (anterior to posterior)measurements.
424
Anterior
Inferior
Posterior
SuperiorUrinarybladder
L A B E L E D : UTERUS SAG LONG AXIS
7. Same image as Number 6 without measurement calipers.
425
SCANNING TIP: It may be necessary to take an additional image demonstratingthe long axis of the endometrial, endocervical, and vaginal canals. If so, label asfollows: UT SAG
L A B E L E D : UTERUS SAG LONG AXIS
Vagina • Uterus • Pelvic Cavity
AXIAL IMAGES
Transverse Plane • Anterior Approach8. Axial image of the vagina.
426
Anterior
Posterior
VaginaUrinarybladder
Rectum
Patient's right Patient's left
Coccygeusmuscle
Vaginalcanal
Gluteusmaximus muscle
Coccygeusmuscle
L A B E L E D : TRV VAG
9. Axial image of the cervix.
427
Anterior
Posterior
Urinarybladder
Cervix
Patient's right Patient's left
Shadowingfrom vaginal
fornices
Musculatureof pelvic floor
Obturatorinternusmuscle
L A B E L E D : TRV CERX
10. Axial image of the uterus body.
428
Anterior
Posterior
Uterine body
Urinarybladder
Bowel
Leftovary
Musculature
Endometrium
Patient's right Patient's left
Portion ofright ovary
Pelvicmusculature
L A B E L E D : TRV UT BODY
11. Axial image of the uterus fundus measuring uterine width (right to left).
429
Anterior
Posterior
Urinarybladder
Patient'sright
Patient'sleft
L A B E L E D : TRV UT FUNDUS
12. Same image as Number 11 without measurement calipers.
430
L A B E L E D : TRV UT FUNDUS
431
Right Ovary
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach13. Long axis image of the right ovary measuring length (superior to inferior) and height
(anterior to posterior).
SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: RT OV SAG OBL LONG AXIS
Anterior
Inferior
Posterior
SuperiorUrinarybladder
L A B E L E D : RT OV SAG LONG AXIS
432
14. Same image as Number 13 without measurement calipers.
L A B E L E D : RT OV SAG LONG AXIS
433
Right Ovary
AXIAL IMAGES
Transverse Plane • Anterior Approach15. Axial image of the right ovary with width (right to left) measurement.
Anterior
Posterior
Urinarybladder
Patient'sright
Patient's left
SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: RT OV TRV OBL
L A B E L E D : RT OV TRV
434
16. Same image as Number 15 without calipers.
L A B E L E D : RT OV TRV
435
Left Ovary
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach
17. Long axis image of the left ovary measuring length (superior to inferior) and height(anterior to posterior).
436
Anterior
Inferior
Posterior
Superior
Urinarybladder
L A B E L E D : LT OV SAG LONG AXIS
SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: LT OV SAG QBL LONG AXIS
437
18. Same image as Number 17 without measurement calipers.
L A B E L E D : LT OV SAG LONG AXIS
438
AXIAL IMAGES
Transverse Plane • Anterior Approach19. Axial image of the left ovary with width (right to left) measurement.
Anterior
Posterior
Urinarybladder
Patient'sright
Patient's left
SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: LT OV TRV OBL
L A B E L E D : LT OV TRV
439
20. Same image as Number 19 without measurement calipers.
L A B E L E D : LT OV TRV
440
SECTION TWO
IMAGE PROTOCOL FOR THE TRANSVAGINAL SONOGRAPHIC STUDYOF THE FEMALE PELV IS
• Criteria:— In most cases, “trans” or “endo” vaginal sonography is used in conjunction with
transabdominal sonography when pelvic contents require further evaluation.— Verbal or written consent is required from the patient. Explain the details of the
exam; inform the patient that the exam is virtually painless, that the insertedtransducer feels like a tampon, and that the exam is necessary for the interpretingphysician to make an accurate diagnosis.
— The exam should be chaperoned by a female healthcare professional. The initials ofthe witness should be included as part of the film labeling.
— Begin studies with a survey of pelvic structures in at least two scanning planes.— Do not share the results of the study with the patient. Legally, only physicians can
give a diagnosis.
441
I. Transvaginal Female Pelvis Study
Uterus • Adnexa
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach
442
1. Longitudinal midline image. If the long axis of the uterus is visualized here, theninclude measurements of uterine length and height.
Uterus
Endometrium
SCANNING TIP: If the long axis is not imaged at midline, it should be takenfollowing Number 1 and be labeled as follows: TV SAG UT LONG AXIS
L A B E L E D : TV SAG ML or TV SAG ML UT LONG AXIS(“TV” indicates transvaginal)
443
2. Same image as Number 1 without measurement calipers.
L A B E L E D : TV SAG ML or TV SAG ML UT LONG AXIS
444
3. Longitudinal image of the uterus fundus to include the endometrial cavity.
Endometrium
Uterine fundus
L A B E L E D : TV SAG FUNDUS
445
4. Longitudinal image of the uterus body and cervix to include the endometrial cavity.
Endometrium
Uterinebody
Uterinecervix
Endocervicalcanal
L A B E L E D : TV SAG BODY/CERX
446
AXIAL IMAGES
Coronal Plane • Inferior Approach5. Axial image of the uterine fundus measuring uterine width.
EndometriumUterine fundus
L A B E L E D : TV COR FUNDUS
447
6. Same image as Number 5 without measurement calipers.
L A B E L E D : TV COR FUNDUS
448
7. Axial image of the uterine body.
Endometrium
Uterine body
L A B E L E D : TV COR BODY
449
8. Axial image of the cervix.
Endocervicalcanal
Uterine cervix Sidewall shadow
L A B E L E D : TV COR CERX
450
Right Ovary
AXIAL IMAGES
Coronal Plane • Inferior Approach
9. Axial image of the right ovary measuring ovarian width (right to left).
SCANNING TIP: For the sake of instruction, this assumes that the ovary long axisis visualized in a sagittal plane.
Follicles
Follicles
Follicles
Right ovary
L A B E L E D : TV COR RT OV
451
10. Same image as Number 9 without measurement calipers.
L A B E L E D : TV COR RT OV
452
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach
11. Long axis image of the right ovary measuring ovarian length and height.
SCANNING TIP: For the sake of instruction, this assumes that the ovary long axisis visualized in a sagittal plane.
Follicles
FollicleRight ovary
L A B E L E D : TV SAG RT OV LONG AXIS
453
12. Same image as Number 11 without measurement calipers.
L A B E L E D : TV SAG RT OV LONG AXIS
454
Left Ovary
AXIAL IMAGES
Coronal Plane • Inferior Approach
13. Axial image of the left ovary measuring ovarian width (right to left).
SCANNING TIP: For the sake of instruction, this assumes that the ovary long axisis visualized in a sagittal plane.
L A B E L E D : TV COR LT OV
Follicle
Follicle
Follicles
Left ovary
455
14. Same image as Number 13 without measurement calipers.
L A B E L E D : TV COR LT OV
456
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach
15. Long axis image of the left ovary measuring ovarian length and height.
SCANNING TIP: For the sake of instruction, this assumes that the ovary long axisis visualized in a sagittal plane.
L A B E L E D : TV SAG LT OV LONG AXIS
Follicles
Left ovary
457
16. Same image as Number 15 without measurement calipers.
L A B E L E D : TV SAG LT OV LONG AXIS
458
SECTION THREE
IMAGE PROTOCOLS FOR SONOGRAPHIC STUDIES OF THE MALEPELV IS
I. Transrectal Prostate Gland Study
II. Scrotum Study
III. Penis Study
• Criteria:— These exams should be witnessed by another healthcare professional, whose
initials should be part of the lm labeling. For transrectal or endorectal prostateevaluations, the patient’s verbal or written consent is also required.
— Begin studies with a survey of pelvic structures in at least two scanning planes.— Do not share the results of the study with the patient. Legally, only physicians can
give a diagnosis.
459
I. Transrectal Prostate Gland Study
Prostate Gland
* Images in this section are by courtesy of the Ultrasound Department of the Methodist Hospital, Houston, Texas.
460
Prostate Gland
AXIAL IMAGES
Transverse Plane • Rectal Approach1. Axial image of the seminal vesicles.
Anterior
Right Left
Seminalvesicle
Posterior(rectum)
Urinarybladder
SCANNING TIP: Because of the limited field of view, both seminal vesicles may notbe entirely visible on a single view. If so, take the following additional images.
L A B E L E D : ER TRV SEM V
461
2. Axial image of the right seminal vesicle to include its right lateral margin.
Anterior
Right Left
Right seminalvesicle
Posterior(rectum)
Urinarybladder
L A B E L E D : ER TRV SEM V RT
462
3. Axial image of the left seminal vesicle to include its left lateral margin.
462
Right Left
vesicleLeft seminal
Anterior
Urinarybladder
Posterior(rectum)
L A B E L E D : ER TRV SEM V LT
463
4. Axial image of the base of the prostate.
Anterior
Right Left
Base of prostate
Posterior(rectum)
L A B E L E D : ER TRV BASE
464
5. Axial image of the midprostate.
Anterior
Right Left
Posterior(rectum)
Midprostate
L A B E L E D : ER TRV MID
465
6. Axial image of the apex of the prostate.
Anterior
Right Left
Apex ofprostate
Posterior(rectum)
L A B E L E D : ER TRV APEX
466
LONGITUDINAL IMAGES
Transverse Plane • Rectal Approach7. Longitudinal midline image of the prostate.
Anterior
Right Left
Apex ofprostate
Posterior(rectum)
L A B E L E D : ER SAG ML
467
8. Longitudinal image of the right lateral portion of the prostate gland and seminalvesicle.
Anterior
Urinarybladder
Urethra
Prostate
Superior InferiorPosterior (rectum)
Anterior
Urinary bladder
Urethra
Prostate
SuperiorPosterior (rectum)
Inferior
L A B E L E D : ER SAG RT
468
9. Longitudinal image of the left lateral portion of the prostate gland and seminalvesicle.
Superior
Right seminalvesicle
Anterior
ProstateInferior
Posterior (rectum)
L A B E L E D : ER SAG LT
469
II. Scrotum Study
Right Hemiscrotum
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach1. Long axis image of the spermatic cord at normal respiration or rest with anterior to
posterior measurement.
Spermatic cord
L A B E L E D : RT CORD SAG REST
470
2. Same image as Number 1 without measurement calipers.
L A B E L E D : RT CORD SAG REST
471
3. Long axis image of the spermatic cord at valsalva with anterior to posteriormeasurement.
Spermatic cord
L A B E L E D : RT CORD SAG VAL
472
4. Same image as Number 3 without measurement calipers.
L A B E L E D : RT CORD SAG VAL
473
5. Longitudinal image of the head of the epididymis.
Head of epididymis
L A B E L E D : RT EPI HEAD SAG
474
6. Longitudinal image of the right testis at its most superior margin.
Testi superior border
L A B E L E D : RT TESTIS SAG SUP
475
7. Longitudinal image of the midportion of the right testis.
Testis mid portion
L A B E L E D : RT TESTIS SAG MID
476
8. Long axis image of the right testis with superior to inferior measurement.
Testis long axis
SCANNING TIP: If necessary, use dual imaging to obtain the entire long axis of thetestis on the image.
L A B E L E D : RT TESTIS SAG LONG AXIS
477
9. Same image as Number 8 without measurement calipers.
L A B E L E D : RT TESTIS SAG LONG AXIS
478
10. Longitudinal image of the medial portion of the right testis.
Testis medial portion
L A B E L E D : RT TESTIS SAG MED
479
11. Longitudinal image of the lateral portion of the right testis.
Testis lateral portion
L A B E L E D : RT TESTIS SAG LAT
480
12. Longitudinal image of the right testis at its most inferior margin.
Testis inferior border
L A B E L E D : RT TESTIS SAG INF
481
13. Longitudinal image of the tail of the epididymis (if visualized).
Tail of epididymis
L A B E L E D : RT EPI TAIL SAG
482
Right Hemiscrotum
AXIAL IMAGES
Transverse Plane • Anterior Approach14. Axial image of the spermatic cord at normal respiration or rest with anterior to
posterior measurement.
Spermatic cord
L A B E L E D : RT CORD TRV REST
483
15. Same image as Number 14 without measurement calipers.
L A B E L E D : RT CORD TRV REST
484
16. Axial image of the spermatic cord at valsalva with anterior to posteriormeasurement.
Spermatic cord
L A B E L E D : RT CORD TRV VAL
485
17. Same image as Number 16 without measurement calipers.
L A B E L E D : RT CORD TRV VAL
486
18. Axial image of the epididymal head.
Head of epididymis
L A B E L E D : RT EPI HEAD TRV
487
19. Axial image of the superior portion of the right testis.
Testis superiorportion
L A B E L E D : RT TESTIS TRV SUP
488
20. Axial image of the midportion of the right testis with medial to lateralmeasurement.
Testis midportion
L A B E L E D : RT TESTIS TRV MID
489
21. Same image as Number 20 without measurement calipers.
L A B E L E D : RT TESTIS TRV MID
490
22. Axial image of the inferior portion of the right testis.
Testis inferiorportion
L A B E L E D : RT TESTIS TRV INF
491
23. Axial image of the tail of the epididymis (if visualized).
Tail of epididymis
L A B E L E D : RT TESTIS TRV INF / EPI TAIL
492
Left Hemiscrotum
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach24. Long axis image of the spermatic cord at normal respiration or rest with anterior to
posterior measurement.
Spermatic cord
L A B E L E D : LT CORD SAG REST
493
25. Same image as Number 24 without measurement calipers.
L A B E L E D : LT CORD SAG REST
494
26. Long axis image of the spermatic cord at valsalva with anterior to posteriormeasurement.
Spermatic cord
L A B E L E D : LT CORD SAG VAL
495
27. Same image as Number 26 without measurement calipers.
L A B E L E D : LT CORD SAG VAL
496
28. Longitudinal image of the head of the epididymis.
Head of epididymis
L A B E L E D : LT EPI HEAD SAG
497
29. Longitudinal image of the left testis at its most superior margin.
Testis superior border
L A B E L E D : LT TESTIS SAG SUP
498
30. Longitudinal image of the midportion of the left testis.
Testis mid portion
L A B E L E D : LT TESTIS SAG MID
499
31. Long axis image of the left testis with superior to inferior measurement.
Testis long axis
SCANNING TIP: If necessary, use dual imaging to obtain the entire long axis of thetestis on the image.
L A B E L E D : LT TESTIS SAG LONG AXIS
500
32. Same image as Number 31 without measurement calipers.
L A B E L E D : LT TESTIS SAG LONG AXIS
501
33. Longitudinal image of the medial portion of the left testis.
Testis medial portion
L A B E L E D : LT TESTIS SAG MED
502
34. Longitudinal image of the lateral portion of the left testis.
Testis lateral portion
L A B E L E D : LT TESTIS SAG LAT
503
35. Longitudinal image of the left testis at its most inferior margin.
Testis inferior border
L A B E L E D : LT TESTIS SAG INF
504
36. Longitudinal image of the tail of the epididymis (if visualized).
Tail of epididymis
L A B E L E D : LT EPI TAIL SAG
505
Left Hemiscrotum
AXIAL IMAGES:
Transverse Plane • Anterior Approach37. Axial image of the spermatic cord at normal respiration or rest with anterior to
posterior measurement.
Spermatic cord
L A B E L E D : LT CORD TRV REST
506
38. Same image as Number 37 without measurement calipers.
L A B E L E D : LT CORD TRV REST
507
39. Axial image of the spermatic cord at valsalva with anterior to posteriormeasurement.
Spermatic cord
L A B E L E D : LT CORD TRV VAL
508
40. Same image as Number 39 without measurement calipers.
L A B E L E D : LT CORD TRV VAL
509
41. Axial image of the epididymal head.
Head of epididymis
L A B E L E D : LT EPI HEAD TRV
510
42. Axial image of the superior portion of the left testis.
Testis superior portion
L A B E L E D : LT TESTIS TRV SUP
511
43. Axial image of the midportion of the left testis with medial to lateral measurement.
Testis mid portion
L A B E L E D : LT TESTIS TRV MID
512
44. Same image as Number 43 without measurement calipers.
L A B E L E D : LT TESTIS TRV MID
513
45. Axial image of the inferior portion of the left testis.
Testis inferior portion
L A B E L E D : LT TESTIS TRV INF
514
46. Axial image of the tail of the epididymis (if visualized).
Tail of epididymis
L A B E L E D : LT TESTIS TRV INF / EPI TAIL
515
47. Axial image of the midportion of both testes.
RT testis LT testis
L A B E L E D : BILAT TESTES TRV
516
III. Penis Study
Penis1. Axial section of the penis.
Corpuscavernosum
Corpusspongiosum
Urethra
Deep artery
517
2. Longitudinal section of the penis.
Corpuscavernosum
Deep artery
Corpusspongiosum
Buck’sfascia
Tunicaalbuginea
Tunicaalbuginea
518
Penis
LONGITUDINAL IMAGES
Sagittal Plane • Anterior Approach1. Longitudinal image of the left lateral, superior portion of the penis to include the
corpus spongiosum, corpus cavernosum, and cavernosal artery.
L A B E L E D : SAG PENIS LT SUP
2. Longitudinal image of the left lateral, midportion of the penis to include the corpusspongiosum, corpus cavernosum, and cavernosal artery.
L A B E L E D : SAG PENIS LT MID
3. Longitudinal image of the left lateral, inferior portion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.
L A B E L E D : SAG PENIS LT INF
519
4. Longitudinal image of the left lateral glans penis.
L A B E L E D : SAG PENIS LT GLANS
5. Longitudinal image of the right lateral, superior portion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.
L A B E L E D : SAG PENIS RT SUP
6. Longitudinal image of the right lateral, midportion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.
L A B E L E D : SAG PENIS RT MID
7. Longitudinal image of the right lateral, inferior portion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.
L A B E L E D : SAG PENIS RT INF
8. Longitudinal image of the right lateral glans penis.
L A B E L E D : SAG PENIS RT GLANS
520
Penis
AXIAL IMAGES
Sagittal Plane • Anterior Approach
9. Axial image of the superior portion of the penis to include the corpus spongiosum,corpus cavernosum, and cavernosal arteries.
L A B E L E D : TRV PENIS SUP
10. Axial image of the midportion of the penis to include the corpus spongiosum, corpuscavernosum, and cavernosal arteries.
L A B E L E D : TRV PENIS MID
11. Axial image of the inferior portion of the penis to include the corpus spongiosum,corpus cavernosum, and cavernosal arteries.
L A B E L E D : TRV PENIS INF
12. Axial image of the glans penis.
L A B E L E D : TRV PENIS GLANS
521
VObstetrics
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE EARLYF IRST TR IMESTER
SECTION TWO
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE LATEF IRST TR IMESTER
SECTION THREE
IMAGE PROTOCOL FOR SONOGRAPHIC STUDIES OF THE SECONDAND TH IRD TR IMESTERS
I. Second and Third Trimester Study
SECTION FOUR
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF MULT IPLEGESTAT IONS
I. Multiple Gestations Study
II. The Biophysical ProfileMultiple Gestations
522
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE EARLYF IRST TR IMESTER
• Criteria:— No limited studies.— Before the examination, a patient history should be taken to include the date of the
first day of the patient’s last period, gravidity, parity, and history of any pelvicsurgery.
— Begin early first trimester studies with a survey of the uterus and adnexa followedby the pregnancy if present.
— When transvaginal sonography is used in conjunction with the routinetransabdominal study, the patient’s verbal or written consent is required. Also, theexam should be chaperoned by a female healthcare professional, whose initialsshould be included as part of the film labeling.
— Do not share the results of the study with the patient. Legally, only physicians cangive a diagnosis.
523
I. Early First Trimester Study
Early First Trimester
UTERUS LONG AXIS
Gestational Sac Location
Sagittal Plane • Transabdominal Approach
524
1. Long axis image of the uterus showing the location of the gestational sac.
525
Gestationalsac
Superior Inferior
Amnioticcavity/fluid
Uterus
Vaginalcanal
Vagina
Urinary bladderAnterior
Posterior
L A B E L E D : UT LONG AX SAG
GESTATIONAL SAC
Sagittal/Transverse Plane • Transabdominal Approach
526
SCANNING TIP: Gestational sac images are taken whether an embryo is identifiedor not. Depending on the earliness of gestation, it may be helpful to magnify the fieldof view for these images.
SCANNING TIP: Scanning plane is dictated by the position of the anatomy.
2. Longitudinal image of the gestational sac with length (superior to inferior) anddepth (anterior to posterior) measurements (calipers inside wall to inside wall).
527
Gestationalsac
Superior Inferior
Urinary bladderAnterior
Posterior
Endometrialspace
Uterus
Decidual reaction
Trophoblasticring
L A B E L E D : GS SAG or TRV
3. Same image as Number 2 without measurement calipers.
528
L A B E L E D : GS SAG or TRV
4. Axial image of the gestational sac with greatest width (right to left) measurement(calipers inside wall to inside wall).
529
Right
Anterior
Posterior
Uterus
Decidualreaction
Embryo
Left
Width measurement
L A B E L E D : GS SAG or TRV
5. Same image as Number 4 without measurement calipers.
530
SCANNING TIP: If the yolk sac or embryo is present and has not been clearlydemonstrated with the gestational sac measurement images, an additional image of theyolk sac or embryo (or both) should be taken and labeled accordingly.
L A B E L E D : GS SAG or TRV
YOLK SAC AND/OR EMBRYO
Sagittal/Transverse Plane • Transabdominal Approach6. Image demonstrating the yolk sac and/or embryo.
531
Uterus
Amnioticcavity
Embryo
Yolk sac
Amnion
Chorioniccavity
L A B E L E D : YOLK SAC / EMBRYO SAG or TRV
7. Long axis image of embryo with length (superior to inferior) or crown rump (CR)length measurement.
532
UterusDecidual reaction
Head (“crown”)
Gestational sac
Rump
L A B E L E D : EMBRYO LONG AXIS or CR
8. Same image as Number 7 without measurement calipers.
533
L A B E L E D : CR
9. Doppler documentation of viability.
534
.40
m/s
.40Fetal heart Doppler signal
Doppler gate
Trophoblasticring
Yolk sacGestationalsac
L A B E L E D : DOP VIAB
535
SECTION TWO
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE LATEF IRST TR IMESTER
• Criteria:— No limited studies.— Before the examination, a patient history should be taken to include the date of the
first day of the patient’s last period, gravidity, parity, and history of any pelvicsurgery.
— Begin late first trimester studies with a survey of the uterus and adnexa followedby the pregnancy.
— When transvaginal sonography is used in conjunction with the routinetransabdominal study, the patient’s verbal or written consent is required. Also, theexam should be chaperoned by a female healthcare professional, whose initialsshould be included as part of the film labeling.
— Do not share the results of the study with the patient. Legally, only physicians cangive a diagnosis.
I. Late First Trimester Study
Late First Trimester
UTERUS LONG AXIS
Gestational Sac Location
Sagittal Plane • Transabdominal Approach
536
1. Long axis image of the uterus showing the location of the gestational sac.
537
Uterus
Anterior
Posterior
InferiorSuperior
Amnioticcavity/fluid
Gestationalsac
Vagina
Maternal urinarybladder
L A B E L E D : UT LONG AX SAG
GESTATIONAL SAC
Sagittal/Transverse Plane • Transabdominal Approach
538
SCANNING TIP: Assuming an embryo is identified, the crown rump (CR) lengthmeasurement is taken in the scanning plane where its long axis appears.
SCANNING TIP: For the following images, the scanning plane is determined by theposition of the anatomy.
2. Longitudinal image of the gestational sac to include the embryo (if visualized) withmeasurement from crown to rump (if applicable) and placenta location (ifdistinguishable).
539
UterusEmbryo
Posterior
InferiorSuperior
Amnioticcavity/fluid
Gestationalsac
AnteriorPlacenta
Foleyballoon
Urinarybladder
L A B E L E D : GS SAG or TRV
3. Same image as Number 2 without measurement calipers (if applicable).
L A B E L E D : GS SAG or TRV
4. Axial image of the gestational sac to include the embryo (if visualized) withmeasurement from crown to rump (if applicable) and placenta location (ifdistinguishable).
540
Uterus
Embryo
Amnioticcavity/fluid
Gestationalsac
Anterior
Posterior
LeftRight
Placenta
L A B E L E D : GS SAG or TRV
5. Same image as Number 4 without measurement calipers (if applicable).
L A B E L E D : GS SAG or TRV
541
SCANNING TIP: In this case, the longest axis of the embryo was not visualized onthe previous images; therefore an additional image demonstrating the longest axis ofthe embryo with crown rump length measurement follows on the next page.
6. Long axis image of the embryo with measurement from crown to rump.
542
Limb bud
Calipers forcrown rump
length
Calipers forcrown rumplength
Amnioticcavity/fluid
Head
Body
L A B E L E D : CR
7. Same image as Number 6 without calipers.
543
SCANNING TIP: In addition to the crown rump length measurement, someinstitutions require biparietal diameter, abdominal circumference, and femur lengthmeasurements of the embryo during the later part of the first trimester. Many expertsbelieve that these additional measurements are not necessary because they do not addany new information to the study and they are not as accurate as the crown rumplength measurement for determining gestational age.
L A B E L E D : CR
8. An optional view(s) of the embryo demonstrating limbs.
544
SCANNING TIP: It may be helpful to magnify the field of view for the limbimage(s).
Uterus
Gestationalsac
Arm buds
Head“Tail”
Leg buds
L A B E L E D : LIMBS
545
SECTION THREE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE SECONDAND TH IRD TR IMESTERS
• Criteria:— No limited studies.— Before the examination, a patient history should be taken to include the date of the
first day of the patient’s last period, gravidity, parity, and history of any pelvicsurgery.
— Begin second and third trimester studies with a survey of the uterus and adnexafollowed by the pregnancy.
— When transvaginal or translabial sonography is used in conjunction with theroutine transabdominal study, the patient’s verbal or written consent is required.Also, the exam should be chaperoned by a female healthcare professional, whoseinitials should be included as part of the film labeling.
— Do not share the results of the study with the patient. Legally, only physicians cangive a diagnosis.
I. Second and Third Trimesters Study
Second and Third Trimesters
UTERUS LONG AXIS
Sagittal Plane • Transabdominal Approach
546
1. When the trimester allows, long axis image of the uterus and contents or bestoverall longitudinal presentation.
547
L A B E L E D : UT SAG
SCANNING TIP: In this case, the trimester was too advanced to image the entireuterus on a single view.
Amnioticfluid
Fetalcranium
PLACENTA
Scanning Plane Determined by Position of Placenta • TransabdominalApproach
2. Longitudinal image of the placenta
548
Placenta
Portion offetal chest
and abdomen
Fetal limbsMyometrium
Amnioticfluid
Lacunae
L A B E L E D : PLACENTA SAG or TRV
PLACENTA
Scanning Plane Determined by Position of Placenta • TransabdominalApproach
3. Axial image of the placenta.
549
Lamina
PlacentaCentrum
Amnioticfluid
L A B E L E D : PLACENTA SAG or TRV
CERVIX
Sagittal Plane • Transabdominal Approach
4. Longitudinal image of the cervix to include the internal os.
550
Placenta
Cervical canal
Internal os
Uterus
Body
Inferior
Anterior
Superior
Posterior
Cervix
Urinarybladder
Amnioticfluid/cavity
L A B E L E D : CERVIX SAG
Longitudinal translabial image of the lower uterine segment.
551
SCANNING TIP: An image of the lower uterine segment to include the internal os isrequired to rule out placenta previa and to document the cervix. When the head of thefetus or the mother’s body habitus inhibits imaging of the lower uterine segment, eithera transvaginal or translabial image must be obtained. The translabial image isobtained with an empty or nearly empty bladder. The transducer is covered with asheath, condom, or glove and placed between the labia. The transducer is angled sothat the cervix is nearly perpendicular to the ultrasound beam.
Placenta
Bowel
Inferio
r
Anterior
Su
per
ior
Posterior
Cervix
Vagina
Prominentuterine
veins
Amnioticfluid
Empty maternalbladder
L A B E L E D : CERVIX TRANSLAB
AMNIOTIC FLUID
Scanning Plane Determined by Position of Anatomy • TransabdominalApproach
5. Depending on the stage of gestation, an overall longitudinal image of amniotic fluidor the largest pocket with superior to inferior measurement.
552
Placenta
Inferior
Anterior
Superior
Posterior
Amnioticcavity/fluid
L A B E L E D : FLUID SAG or TRV
AMNIOTIC FLUID
Scanning Plane Determined by Position of Anatomy • TransabdominalApproach
6. Depending on the stage of gestation, an overall axial image of amniotic fluid or thelargest pocket with anterior to posterior and right to left measurements.
553
Placenta
Left
Anterior
Right
Posterior
Amnioticcavity/fluid
L A B E L E D : FLUID SAG or TRV
FETAL ANATOMY
Transabdominal Approach
554
SCANNING TIP: At times, a quantitative measurement of amniotic fluid isrequired. Anteroposterior (AP) measurements are obtained for the right and left upperand lower quadrants. The sum of these AP measurements is called the amniotic fluidindex (AFI). Fluid pockets that contain primarily cord or fetal parts are not includedin the measurement.
SCANNING TIP: Because of the variability of fetal position and movement, thefollowing fetal anatomy images may be taken in any sequence.
SCANNING TIP: An ultrasound examination during the second and thirdtrimesters requires the documentation of a large number of anatomic structures;therefore two or more structures can be documented on a single image if they are wellrepresented.
SCANNING TIP: Because of the variability of fetal position and movement, thescanning plane is not included as part of the film labeling for the following images:
7. Longitudinal image of the cervical spine.
555
Amnioticfluid
Anteriorspinal
processes
Posteriorspinal
processes
Occipitalbone of
skull
Cervicalspine
L A B E L E D : C SPINE
8. Longitudinal image of the thoracic spine.
556
Amnioticfluid
Anteriorspinal
processes
Posteriorspinal
processes
Thoracicspine
L A B E L E D : T SPINE
9. Longitudinal image of the lumbar spine.
557
Anteriorspinal
processes
Posterior spinal processes
Fetal bladder
Fetal skin
CoccyxSpinal cord
L A B E L E D : L SPINE
10. Longitudinal image of the sacral spine.
558
Placenta
Anteriorelement
Posteriorelement Coccyx
Acoustic shadows
Sacralspine
SCANNING TIP: In some cases the long axis of the spine can be visualized on asingle image. If so, take the image, and label it as follows: SPINE LONG AX
L A B E L E D : S SPINE
11. Axial image of the cervical spine.
559
Placenta
Anteriorspinalprocessesof cervicalvertebra
Posterior spinalprocessesof cervicalvertebra
Amnioticcavity/fluid
Clavicles
Clavicles
L A B E L E D : C SPINE
12. Axial image of the thoracic spine.
560
Placenta
LimbShoulder
Amnioticcavity/fluid
Throracicvertebrae
Posteriorspinal
processes
Scapulae Anteriorspinal
processes
L A B E L E D : T SPINE
13. Axial image of the lumbar spine.
561
Placenta
Limb
Kidney
Amnioticcavity/fluid
Lumbarvertebrae
Stomach
Limb
Kidney
L A B E L E D : L SPINE
14. Four-chamber view of the fetal heart to include its location within the thorax.
562
Right ventricle
Rib
Rightatrium
Apex ofthe heart
Leftventricularseptum
Left atriumSpine
Left
Descendingaorta
Tricuspid valve
Atrialseptum
Mitralvalve
LeftventricleForamen
ovalae
Right
Anterior
Posterior
L A B E L E D : HEART
15. An optional image showing the normal right ventricular outflow tract.
563
Pulmonaryvalve leaflet
Placenta
Right ventricularoutflow tract
Right atrium
Hand
Mainpulmonaryartery
Rightpulmonaryartery
Thorax
Aorta
Amnioticfluid
Pulmonaryvalve leaflet
Leftpulmonaryartery
Descendingaorta
Left atrium
L A B E L E D : RVOT
16. An optional image showing the normal left ventricular outflow tract.
564
Liver
AortaSpleenDescending
aorta
Rightventricle
Heart muscle
Diaphragm
Left ventricularoutflow tract
LimbInterventricularseptum
Stomach
Leftventricle
L A B E L E D : LVOT
17. Axial image of fetal kidneys together.
565
Right kidney Vertebra
Amnioticfluid
Acoustic shadow from spine
Portal vein
Liver
Left kidney
SCANNING TIP: When the kidneys cannot be imaged together because of fetalposition or movement, take separate axial images of each kidney and label accordingly.
L A B E L E D : KIDNEYS
18. Longitudinal image of the right kidney.
566
Uterus
Placenta
Amnioticcavity/fluid
Amnioticcavity/fluid
Rightkidney
Spine
L A B E L E D : RT KID
19. Longitudinal image of the left kidney.
567
Uterus
Stomach
Amnioticcavity/fluid
Leftkidney
Spine
L A B E L E D : LT KID
20. Image of the urinary bladder.
568
Uterus
Stomach
Amnioticfluid
Limbs
Placenta
Uterus
Urinary bladder
Amnioticfluid
Muscle
L A B E L E D : UR BLADDER
21. Image of the umbilical cord insertion site on the anterior abdominal wall.
569
Amnioticcavity/fluid
Placenta
Umbilicalcord
insertion
VeinArtery
SCANNING TIP: If the insertion site image does not distinguish the three vessels ofthe cord, take an additional image of the cord to demonstrate the three vessels and labelaccordingly.
L A B E L E D : CORD
22. A magnified view of an axial section of the three-vessel umbilical cord.
570
Amnioticcavity/fluid
Placenta
Umbilicalcord
Umbilicalarteries
Umbilicalvein
Limb
Wharton’sjelly
L A B E L E D : CORD
23. Image of the stomach if visualized.
571
Placenta
Stomach
Vertebrae
Umbilicalportion ofleft portalvein
SCANNING TIP: The image of the stomach is not necessary if the stomach wasdocumented on any other image.
L A B E L E D : STOMACH
24. Image of genitalia.
A. Image of male genitalia.
572
Scrotum
Testicle
Limb
Foreskin
Glans
Thigh
Penis
L A B E L E D : GENITALIA
B. Image of female genitalia.
573
Placenta
Myometrium
Amnioticfluid
Minorlabium
Thighs
Vaginalcleft
Majorlabium
L A B E L E D : GENITALIA
25. Longitudinal image of the fetus to include the diaphragm.
574
Placenta
Spine
Fetal profile
Diaphragm
Abdomen
Aorta
Thorax
Heart
L A B E L E D : DIAPHRAGM
26. Biparietal diameter (BPD) image at the level of the thalamus and the cavumseptum pellucidi. Measurement is from the outside of the near cranium to the insideof the far cranium (leading edge to leading edge).
575
Placenta
Amnioticfluid
Thalamus
Lateralventricle
Myometrium
Thirdventricle
Lateral fissure
Frontalhorns
Cavum septumpellucidum
SCANNING TIP: Because of the obvious nature of the fetal measurements, specificsare not included as part of the film labeling.
27. Cerebellum with measurement.
576
Placenta
Parietal bone
Hemispheres ofthe cerebellum
Vermis ofthe cerebellum
Calipers forcerebellar
measurement
Occipitalbone
28. Cisterna magnum with measurement.
577
Placenta Cerebellum
Calipers formeasurement ofcisternamagnum
Cisternamagnum
Cerebralpeduncles
Occipitalbone
Amniotic fluid
29. Nuchal fold (done between 16 and 24 weeks) with measurement.
578
Placenta
Cerebellum
Calipers formeasurement ofnuchal fold
Cisterna magnumOccipitalbone
Amniotic fluid
Nuchalfold
Thalamus
SCANNING TIP: The measurement of the nuchal fold is not always routinelyperformed but should be considered for the fetus of patients over 35 or when a lower-than-normal serum alpha fetal protein (AFP) level has been detected in the mother.
30. Head circumference image at the same level as the BPD, or use the BPD image.Measurement is around the outline of the cranium. Up-to-date ultrasound equipmentprovides tracking balls to trace the cranium or calipers that open to outline thecranium.
579
Placenta
Amnioticfluid
Thalamus
Lateralventricle
Myometrium
Thirdventricle
Lateral fissure
Frontalhorns
Cavum septumpellucidum
Tentorium
31. Image of the choroid plexus.
580
Placenta
Choroid plexus
Amniotic fluid
Falxcerebrei
Occipital-parietal sutureof the calvarium
Medial wallof the lateralventricle
32. Lateral ventricle with measurement.
581
Thalamus
Choroidplexus
Lateral wall of thelateral ventricle
Falxcerebrei
Calipers formeasurementof lateralventricle
Medial wall ofthe lateral
ventricle(near the atrium)
Occipitalbone
Amnioticfluid
33. Abdominal circumference image at the level of the junction of the umbilical vein andportal vein sinus. Measurement is around the outline of the abdomen. The abdomenshould appear round.
582
Portion ofuncoiledumbilical
cord
Cross-sectionfetal abdomen
Aorta
Right portalvein
Femur
Inferiorvena cava
Vertebra
Stomach
Umbilical portionof portal vein
(left portal vein)
34. Long axis image of the femur with measurement from one ossified end of the femurto the other ossified end.
583
Femur
Placenta
Bladder
SCANNING TIP: For long bone measurements, cursors are placed at the bone-cartilage interface. The cartilaginous ends of the bones are not included in themeasurement.
35. Long axis image of the humerus with measurement from one ossified end of thefemur to the other ossified end.
584
Placenta
Humerus
Rib portions/shadow
Amnioticfluid
Soft tissue and musclesurrounding humerus
Extremitycross section
Portion of spineand spinal canal
Myometrium
Blood vessel
36. Image of the lower portion of the leg.
585
PlacentaPortionof foot
Lowerleg
Tibia
Fibula
Patella
Amniotic fluid
37. Image of the radius and ulna.
586
Placenta
Radius
Lowerarm
Hand
Amnioticfluid
Ulna
Elbow
Other arm
38. Image of a hand.
587
Placenta
HandLimb
39. Another image of the hand.
588
Open fetalhand
Wrist
Thumb
Radius
Ulna
Small(5th finger)
Bent finger(out of plane)
SCANNING TIP: Most physicians require images only of one hand, foot, arm, andleg based on the assumption that both were evaluated during the survey.
40. Image of facial profile.
589
590
41. Coronal image of the nostrils and lips.
Nostrils
Placenta
Lips
Filtrum (between& below nostrils)
Acousticshadow
Amnioticfluid
Amnioticfluid
Chin
Limb
591
SECTION FOUR
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF MULT IPLEGESTAT IONS
• Criteria:— In addition to the required images for multiple gestations, each fetus of a multiple
gestation should be imaged as previously described for singleton pregnancies.— No limited studies.— Before the examination, a patient history should be taken to include the date of the
first day of the patient’s last period, gravidity, parity, and history of any pelvicsurgery.
— Begin multiple gestation studies with a survey of the uterus and adnexa followedby the pregnancies.
— When transvaginal or translabial sonography is used in conjunction with theroutine transabdominal study, the patient’s verbal or written consent is required.Also, the exam should be chaperoned by a female healthcare professional, whoseinitials should be included as part of the film labeling.
— Do not share the results of the study with the patient. Legally, only physicians cangive a diagnosis.
592
I. Multiple Gestations StudyMultiple Gestations
Multiple Gestations
GESTATIONAL SACS
Scanning Plane Determined by Position of Anatomy • TransabdominalApproach
1. Image of a twin pregnancy demonstrating separate sacs.
Uterus
Placenta A
Placenta B
Sac A with embryo
Sac B with embryo
B
A
L A B E L E D : TWINS / SEP SACS
593
2. Image of second trimester twins demonstrating the presence of a separatingmembrane.
Thin membrane
Placenta
Cord B
Sac A
Sac B
Head B
Cord A
L A B E L E D : TWINS / MEMBRANE
594
3. Image of triplets.
SCANNING TIP: It is important to demonstrate the position of the presenting fetus.This is the fetus that is lower in the uterus, closer to the cervix, and will be deliveredfirst. This fetus should be labeled “a” and the other fetus(es) labeled “b,” “c,” “d,” etc.This labeling allows individual growth rates to be determined. If possible, determine thegender of each fetus. This information may help determine whether they are fraternal oridentical.
L A B E L E D : TRIPLETS
Thickmembranes
Uterus
Sac A
Sac B(embryo not inthe scanning plane)
Cord A
Sac C
Embryo C Embryo A
II. The Biophysical Profile
An examination that is often performed during the late third trimester is the biophysicalprofile (BPP). This test measures fetal well-being and consists of five parameters. The first part of the test involves a nonstress test. This test is performed in the delivery room or in an obstetrician’s office and measures spontaneous heart rate accelerations. The remaining four parameters of the BPP are measured by sonography: (1) amniotic fluid, (2) fetalrespiration, (3) fetal tone, and (4) gross body motion. These parameters and scoring of this test are described in Table 5-1, which follows the described required images.
595
Biophysical Profile
AMNIOTIC FLUID
Scanning Plane Determined by Position of Anatomy • TransabdominalApproach
1. Demonstration of a pocket of amniotic fluid.
596L A B E L E D : FLUID
Fluid pocket
Venons lake
Cord A
Placenta
597
2. Demonstration of fetal respiration.
Fetalheart
Fetal bladder
Respiratorymotion
Amniotic fluid
Fetal diaphragm
L A B E L E D : DIAPHRAGM / RESP
3. Demonstration of fetal tone.
598
Fetal head
Open hand
L A B E L E D : HAND
4. Demonstration of fetal gross body motion.
599
Head
Twistingof torso
Spine
Arching ofneck or back
L A B E L E D : MOTION
5. Umbilical artery Doppler measurements and determination of the SD ratio.
600
Doppler gate
Doppler calipers.60
m/s
.60
L A B E L E D : DOP / UMB ART
SCANNING TIP: Occasionally, it is necessary to measure the resistance to bloodflow within the umbilical arteries. This measurement is obtained by interrogating theumbilical cord artery with low power Doppler. The ratio of the peak systolic flow to theend diastolic flow is calculated (SD ratio). This number varies with the age of thefetus, and charts are available to determine whether blood flow through the cord isadequate.
601
Doppler gate
Doppler calipers.30
m/s
.30
Umbilicalcord
Fetalabdomen
Spectral doppler tracing ofumbilical artery blood flow
Fetal limb
L A B E L E D : DOP / UMB ART
6. Uterine artery Doppler measurement and determination of the SD ratio.
602
Doppler gate
.30
m/s
.30
Uterus
Placenta
Spectral doppler tracing ofmaternal uterine (arcuate) artery
Fetal abdomen
Amniotic fluid
L A B E L E D : DOP / UT ART
SCANNING TIP: In some cases, the physician may also want to determine whetherthe blood flow to the placenta from the mother’s circulation is adequate, so anotherDoppler measurement is made at the interface between the placenta and uterus or inthe uterine artery if possible. The SD ratio for the Doppler waveform is calculated andchecked against a chart value for the appropriate gestational age.
603
TABLE 5-1 Biophysical Profile Scoring
CRITERION SCORE (PTS)
Part INonstress test Two accelerations of 15 beats per minute 2
in 30-min test
Part IIUltrasound examinationGross movement Three separate flexions and extensions in 2
30-min examinationTone One episode of fetal opening and closing 2
of hand or clenching of foot in 30-minexamination
Respiration At least 60 seconds of fetal breathing in 230-min examination
Fluid At least 1 pocket of amniotic fluid of at 2least 1 cm in 2 dimensions
Unqualified pass 8 or moreMaximum total 10
Data from Manning EA, Platt LD, Sipos L (1980). Antenatal fetal evaluation: development of a fetal biophysicalprofile. Am J Obstet Gynecol 136: 787-795.
Small Parts
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THETHYROID GLAND
SECTION TWO
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE BREAST
I. Breast Lesion Characterization
604
VI
605
II. Whole Breast Study
SECTION THREE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THENEONATAL BRA IN
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THETHYROID GLAND
• Criteria:— Begin studies with a survey of the thyroid gland and associated structures in at
least two scanning planes.— As a general rule, the parathyroid glands are not appreciated sonographically
unless they are abnormal.— Do not share the results of the study with the patient. Legally, only physicians can
give a diagnoses.
Thyroid Gland Study
Thyroid Gland
RIGHT LOBE
606
Transverse Plane • Anterior Approach
LONGITUDINAL IMAGES
1. Longitudinal image of the inferior portion of the right lobe.
607
Anterior
Posterior
Right Left
Sternohyoid muscleIsthmus
Trachea
Inferiorlobe
Sternocleidomastoidmuscle
Internaljugular vein
Sternothyroidmuscle
Inferiorthyroid vessel
Commoncarotid artery
Longuscolli muscle
L A B E L E D : RT LOBE TRV INF
2. Longitudinal image of the midportion of the right lobe.
608
Anterior
Posterior
Right Left
Sternohyoid muscleIsthmus
Trachea
Midlobe
Sternocleidomastoidmuscle
Internaljugular vein
Sternothyroidmuscle
Commoncarotid artery
Longuscolli muscle
L A B E L E D : RT LOBE TRV MID
3. Longitudinal image of the superior portion of the right lobe.
609
Anterior
Posterior
Right Left
Sternohyoid muscle
Trachea
Superiorlobe
Sternocleidomastoidmuscle
Internaljugularvein
Sternothyroidmuscle
Commoncarotidartery
Longuscolli muscle
Venousstructures
L A B E L E D : RT LOBE TRV SUP
4. Long axis image of the thyroid to include the isthmus and both right and left lobeattachments.
610
Anterior
Posterior
Right Left
Sternohyoid muscle
TracheaRightlobe
Sternocleidomastoidmuscle
Sterno-thyroidmuscle
Left commoncarotid artery
Longuscolli muscle
Isthmus
Longuscolli muscle
Right commoncarotid artery
Sterno-thyroidmuscleLeft
lobe
Sternocleido-mastoidmuscle
L A B E L E D : ISTHMUS TRV
RIGHT LOBE
Sagittal Plane • Anterior Approach
AXIAL IMAGES
5. Axial image of the medial portion of the right lobe.
611
Anterior
Posterior
SuperiorInferior
Platysmamuscle
Trachea
Sternothyroidmuscle
Venousstructures
Mediallobe
Sterno-hyoidmuscle
Skin
Thyroidcartilage
L A B E L E D : RT LOBE SAG MED
6. Axial image of the lateral portion of the right lobe.
612
Anterior
Posterior
Superior Inferior
SternothyroidmuscleLateral
lobe
Sterno-hyoidmuscle
Skin
L A B E L E D : RT LOBE SAG LAT
LEFT LOBE
Transverse Plane • Anterior Approach
LONGITUDINAL IMAGES
7. Longitudinal image of the inferior portion of the left lobe.
613
Anterior
Posterior
Right Left
Commoncarotidartery
Inferiorlobe
Omohyoidmuscle
Sternohyoidmuscle
Sternocleidomastoidmuscle
Internaljugular
vein
Inferiorthyroidvessels
Longuscolli
muscle
Esophagus
Sterno-thyroidmuscle
Trachea
Isthmus
L A B E L E D : LT LOBE TRV INF
8. Longitudinal image of the midportion of the left lobe.
614
Anterior
Posterior
Right Left
Commoncarotidartery
Midlobe
Omohyoidmuscle
Sternohyoidmuscle
Sternocleidomastoidmuscle
Internaljugular
vein
Longus collimuscle
Esophagus
Isthmus
Trachea
Sterno-thyroidmuscle
L A B E L E D : LT LOBE TRV MID
9. Longitudinal image of the superior portion of the left lobe.
615
Anterior
Posterior
Right Left
Commoncarotid artery
Superiorlobe
Sterno-thyroidmuscle
Sternohyoidmuscle
Sternocleidomastoidmuscle
Internaljugular veinLongus
collimuscle
Esophagus
Trachea
L A B E L E D : LT LOBE TRV SUP
LEFT LOBE
Sagittal Plane • Anterior Approach
AXIAL IMAGES
10. Axial image of the medial portion of the left lobe.
616
Anterior
Posterior
Superior Inferior
Longus collimuscle
Mediallobe
Sterno-hyoidmuscle
SternocleidomastoidmuscleSkin
Sternothyroidmuscle
L A B E L E D : LT LOBE SAG MED
11. Axial image of the lateral portion of the left lobe.
617
Anterior
Posterior
Superior Inferior
Lateral lobe
Sternohyoid muscle
Sternothyroidmuscle
L A B E L E D : LT LOBE SAG LAT
618
SECTION TWO
IMAGE PROTOCOLS FOR THE SONOGRAPHIC STUDY OF THEBREAST
• Criteria:— In most cases, for women under 30 and lactating and pregnant women, breast
sonography has become the first phase of imaging for evaluating palpable masses.Breast sonography, however, is not recognized as a screening study formicrocalcifications.
— Breast sonography is generally performed to determine the composition orcharacterization of a localized lesion or lesions (that may or may not be palpable)and to further evaluate mammographic and clinical findings.
— Additional indications for breast sonography include guidance of biopsies,treatment plan for radiation therapy, and evaluating complications associated withbreast implants.
— In some cases, whole breast scanning may be recommended for diffuse diseasessuch as fibrocystic disease.
— Begin studies with a survey of the structure(s) in at least two scanning planes.
— Do not share the results of the study with the patient. Legally, only physicians cangive diagnoses.
— Use the following image of normal breast tissue as a technical guideline. Rememberthat the thickness of the sonographically distinct layers of the breast varies withage.
619
Skin line
Subcutaneouslayer
Mammarylayer
Pectoralis majormuscle
Retromammarylayer
620
I. Breast Lesion Characterization
Breast Lesion
SCANNING TIP: The location of the lesion must be recorded to accompany therequired images.
The location of the lesion can be indicated by one of the following methods:- Shown on a diagram of the breast- Specifying the quadrant- Using clock notation and distance from the nipple
SCANNING TIP: Image labeling should include right or left breast, location of thelesion, and transducer orientation with regard to the breast (axial or longitudinal,radial or anti-radial).
621
RIGHT OR LEFT BREAST
Scanning Plane Determined by Lesion Shape and Location • ApproachDetermined By Lesion Location
LONGITUDINAL AND AXIAL IMAGES
1. Longitudinal image of the lesion with measurement from the most superior to themost inferior margin.
L A B E L E D : SITE LOCATION and SCANNING PLANE
2. Same image as Number 1, without measurement calipers.
3. Axial image of the lesion with measurements from the most anterior to the mostposterior margin and from the most lateral to lateral or lateral to medial margin.
L A B E L E D : SITE LOCATION and SCANNING PLANE
4. Same image as Number 3, without measurement calipers.
L A B E L E D : SITE LOCATION and SCANNING PLANE
622
5. Longitudinal image of the lesion with high gain technique.
L A B E L E D : SITE LOCATION, SCANNING PLANE, HIGH GAIN
6. Axial image of the lesion with high gain technique.
L A B E L E D : SITE LOCATION, SCANNING PLANE, HIGH GAIN
7. Longitudinal image of the lesion with low gain technique.
L A B E L E D : SITE LOCATION, SCANNING PLANE, LOW GAIN
8. Axial image of the lesion with low gain technique.
L A B E L E D : SITE LOCATION, SCANNING PLANE, LOW GAIN
SCANNING TIP: Depending on the size and complexity of the lesion, additionalimages (in at least two scanning planes) may be necessary to document the extent ofthe lesion.
623
II. Whole Breast Study
Whole Breast
RIGHT OR LEFT BREAST
1. 12 o’clock image of breast tissue with the base of the transducer toward the nippleand the end of the transducer facing outward so that the nipple area is closest to thetop of the imaging screen.
L A B E L E D : 12 O’CLOCK RT or LT
2. 3 o’clock image (same orientation as Number 1).
L A B E L E D : 3 O’CLOCK RT or LT
3. 6 o’clock image.
L A B E L E D : 6 O’CLOCK RT or LT
4. 9 o’clock image.
L A B E L E D : 9 O’CLOCK RT or LT
624
5. Axial image through the nipple.
L A B E L E D : NIP TRV RT or LT
6. Longitudinal image through the nipple.
L A B E L E D : NIP SAG RT or LT
7. Longitudinal image of the axillary region.
L A B E L E D : AXILLARY SAG RT or LT
8. Axial image of the axillary region.
L A B E L E D : AXILLARY TRV RT or LT
9. to 16. The same corresponding images of the other breast.
SCANNING TIP: Sometimes, whole breast scanning includes images from 12o’clock, 1 o’clock, 2 o’clock, 3 o’clock, and so on. If this is the case, label accordinglyand include nipple and axillary images.
625
SECTION THREE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THENEONATAL BRA IN
• Criteria:— Begin studies with a survey of the brain in at least two scanning planes.— Infants should be kept warm and disturbed as little as possible.— Do not share the results of the study with the patient. Legally, only physicians can
give diagnoses.
Neonatal Brain Study
Neonatal BrainAnterior Fontanelle Approach
CORONAL IMAGES
1. Coronal image of the frontal lobes of the brain with the interhemispheric fissure.Include the orbital cones and ethmoid sinus.
626
Interhemisphericfissure
Left frontallobe of
brain
Right frontallobe ofbrain
Orbital cones Ethmoid sinus
Right Left
L A B E L E D : CORONAL
2. Coronal image of the frontal horns of the ventricles encompassing the caudatenucleus. Include the germinal matrix adjacent to the ventricles and corpus callosum.
627
Corpus callosum
Caudatenucleus
Cavum septumpellucidum
Frontalhorn
lateralventricleGerminal matrix
ThalamusTemporal
lobe
Right Left
L A B E L E D : CORONAL
3. Coronal image of the frontal horns and thalami. Include the sylvian fissures, septumpellucidum, third ventricle, and foramen of Monro.
628
InterhemisphericfissureLateralventricle
Cavum septumpellucidum
Caudatenucleus
Sylvianfissure
with middlecerebral artery
Thirdventricle
Temporallobe
Foramenof Monro Thalamus
Right Left
L A B E L E D : CORONAL
4. Coronal image of the bodies of the lateral ventricles, thalami, sylvian fissures,choroidal fissures, and temporal horns.
629
Cavum vergae
Caudatenucleus bodySylvianfissure
Body lateralventricle
Thirdventricle
Temporalhorn
lateralventricle
Thalamus
ChoroidalfissureCerebellarhemisphere
Cerebralpeduncle Pons
Right Left
Tentorium
L A B E L E D : CORONAL
5. Coronal image of the tentorium cerebelli. Include the sylvian fissures and thecisterna magna.
630
QuadrigeminalplateTemporalhornlateralventricle
Body lateralventricle
Thalamus
Sylvianfissure
Choroidalfissure
Cisterna magna Cerebellum
Right Left
Tentorium
L A B E L E D : CORONAL
6. Coronal image of the choroid plexus in the atrium or trigone region.
631
Choroidplexus
Right Left
Lateralventricle
L A B E L E D : CORONAL
7. Coronal image of the occipital lobes of the brain.
632
Right occipitalbrain lobe
Interhemisphericfissure
Right Left
L A B E L E D : CORONAL
SAGITTAL IMAGES
8. Sagittal midline image of the cavum septum pellucidum, corpus callosum, thirdventricle, fourth ventricle, and cerebellum, including the massa intermedia (seen intwo thirds of infants).
633SCANNING TIP: This image should be perpendicular at the midline.
Cavum septumpellucidumThirdventricle
Massaintermedia
Sulci
Occipitallobe
Cerebellarvermis
Frontallobe
Corpuscallosum
Aqueduct of SylviusFourth ventricle
Medulla
Midline
L A B E L E D : SAG ML
9. Sagittal image of the right ventricle, germinal matrix, caudate nucleus, thalamus,and choroids plexus.
634
Germinal matrix
Anterior hornlateralventricle
Body lateralventricle
Trigone
Occipitallobe
Occipitalhorn
lateral ventricle
Caudatenucleus
Temporal hornlateral ventricle
Choroid plexus
Cerebellar vermis
Right lateral
Thalamus
L A B E L E D : SAG RT LAT
SCANNING TIP: In some cases the frontal horn, body, temporal horn, and occipitalhorn cannot be imaged in the same plane. Therefore an additional image (oradditional images) may be necessary. LABELED: SAG RT LAT
10. Sagittal image of the right temporal lobe of the brain at the level of the sylvianfissure.
635
Temporallobe
Sylvianfissure
Right lateral
L A B E L E D : SAG RT LAT
11. Sagittal image of the left ventricle, germinal matrix, caudate nucleus, thalamus, andchoroid plexus.
636
SCANNING TIP: In some cases the frontal horn, body, temporal horn, and occipitalhorn cannot be imaged in the same plane. Therefore an additional image (or images)may be necessary. LABELED: SAG RT LAT
Germinal matrix
Anterior hornlateralventricle
Body lateralventricle
Trigone
Occipitalhorn
lateral ventricle
Occipitallobe
Caudatenucleus
Temporal hornlateral ventricle
Choroid plexus
Cerebellar vermis
Left lateral
Thalamus
L A B E L E D : SAG LT LAT
12. Sagittal image of the left temporal lobe of the brain at the level of the sylvianfissure.
637
SCANNING TIP: Alternative axial views through the temporal recess or posteriorfontanelle are options to further evaluate the lateral ventricular walls and the occipitalhorns, respectively.
Temporallobe
Sylvianfissure
Left lateral
L A B E L E D : SAG LT LAT
638
Vascular System
SECTION ONE
IMAGE PROTOCOLS FOR ABDOMINAL DOPPLER AND COLOR FLOWSTUDIES
I. Mesentric Arterial Study
II. Renal Arterial Study
III. Image Example of Various Studies
VII
SECTION TWO
IMAGE PROTOCOLS FOR CEREBROVASCULAR DUPLEX SCANNING
SECTION THREE
IMAGE PROTOCOLS FOR PER IPHERAL , ARTER IAL , AND VENOUSDUPLEX SCANNING
I. Lower Extremity Venous Duplex Study
II. Lower Extremity Peripheral Arterial Study
SECTION ONE
IMAGE PROTOCOLS FOR ABDOMINAL DOPPLER AND COLOR FLOWSTUDIES
639
I. Mesenteric Arterial Study
1. Locate the celiac trunk as it arises from the anterior abdominal aortic wall justinferior to the diaphragm.
I M A G E : LONGITUDINAL AORTA-CELIAC ORIGIN
L A B E L E D : AORTA-CELIAC ORIGIN
2. Sample with Doppler throughout the celiac trunk.
I M A G E : DOPPLER SPECTRAL WAVEFORM FROM THE ORIGIN OF THE CELIAC
L A B E L E D : CELIAC ORIGIN
I M A G E : DOPPLER SPECTRAL WAVEFORM FROM THE DISTAL CELIAC TRUNK
L A B E L E D : CELIAC DIST
3. Return to a transverse image of the aorta at the level of the celiac origin. Locate theartery and its bifurcation into the common hepatic and splenic arteries.
I M A G E : LONGITUDINAL VIEW CELIAC ARTERY, COMMON HEPATIC AND SPLENIC ARTERIESAT THE BIFURCATION
640
L A B E L E D : CELIAC BIFURCATION
4. Sample with Doppler throughout the length of the celiac trunk and the proximalcommon hepatic and splenic arteries.
I M A G E : SPECTRAL WAVEFORMS FROM THE CELIAC, COMMON HEPATIC AND SPLENICARTERIES
L A B E L E D : CELIAC ART or COMMON HEP ART or SPLENIC ART
641
SCANNING TIP: The hepatic artery may be followed from the celiac bifurcation tothe level of its entry into the liver at the porta hepatis. Images and Doppler spectralwaveforms should be documented throughout the proximal, middle, and distalsegments of the vessel.
SCANNING TIP: In a similar manner, the splenic artery may be examined from itsorigin at the celiac bifurcation to the level of the splenic hilum. Images and Dopplerspectral waveforms are documented throughout the proximal, middle, and distalsegments of the vessel. The splenic artery is frequently quite tortuous, and color flowmay facilitate examination of this vessel.
642
Black and white version of a color Doppler image demonstrating flow in the region of the portahepatic.
5. Return to the longitudinal image of the aorta just inferior to the origin of the celiacartery. Locate the origin of the superior mesenteric artery, which is usually 1 to 2 cminferior to the celiac. The celiac and superior mesenteric artery (SMA) may share acommon origin.
I M A G E : LONGITUDINAL VIEW OF THE SMA FROM ITS ORIGIN TO THE MIDSECTION OF THEVESSEL
L A B E L E D : PROX-MID SMA
6. Sample with Doppler throughout the visualized segments of the SMA beginning atits origin.
I M A G E : SPECTRAL WAVEFORMS FROM THE PROXIMAL TO THE MID SMA
L A B E L E D : PROX SMA or MID SMA
643
SCANNING TIP: The inferior mesenteric artery (IMA) is not routinely examined. Ifthe celiac or SMA is critically stenosed or occluded, the IMA would be evaluated in amanner similar to the study of the SMA.
644
II. Renal Arterial Study
1. Longitudinal view of the abdominal aorta.
I M A G E : LONGITUDINAL VIEW OF THE AORTA
L A B E L E D : LONG AO
2. Transversely scan the aorta. Locate the left renal vein as it crosses anterior to theaorta just inferior to the SMA origin. Locate the right and left renal arteriesimmediately posterior to the renal veins.
I M A G E : TRANSVERSE VIEW OF THE AORTA AT THE LEVEL OF THE LEFT RENAL VEIN ANDORIGIN OF THE RIGHT OR LEFT RENAL ARTERY
L A B E L E D : ORIGIN RT or LT REN ART
3. Continuously sample with Doppler from within the lumen of the aorta through therenal artery orifice by moving the Doppler sample volume slowly along this course.
I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE ORIGIN OF THE RIGHT OR LEFT RENALARTERY
L A B E L E D : ORIGIN RT or LT REN ART
4. Using gray-scale or color flow imaging, follow the course of the renal artery from theproximal to the midsegment of the vessel.
I M A G E : LONGITUDINAL VIEW OF THE RIGHT OR LEFT RENAL ARTERY FROM ITS ORIGINFROM THE POSTEROLATERAL WALL OF THE AORTA AS FAR DISTALLY AS POSSIBLE
645
L A B E L E D : PROX or MID RT / LT REN ART
646
5. Sample continuously with Doppler throughout the visualized length of the renalartery.
I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE PROXIMAL THROUGH THEMIDSEGMENTS OF THE RENAL ARTERY
L A B E L E D : PROX or MID RT/LT REN ART
6. Transverse image of the renal artery from the hilum of the kidney as far proximalas possible.
I M A G E : TRANSVERSE VIEW OF THE KIDNEY AND THE DISTAL TO MIDRENAL ARTERY FROMTHE LEVEL OF THE HILUM
L A B E L E D : DIST RT/LT REN ART
7. Sample continuously with Doppler from the level of the renal hilum throughout thedistal to midrenal artery.
I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE DISTAL TO MIDRENAL ARTERY
L A B E L E D : DIST RT/LT REN ART
8. Obtain a long axis measurement of the kidney. You may use color flow imaging todemonstrate the arterial and venous perfusion of the organ.
I M A G E : LONGITUDINAL VIEW OF THE RIGHT KIDNEY SHOWING MEASURED LENGTH ANDPERFUSION
647
L A B E L E D : RT or LT KIDNEY
9. Sample with Doppler throughout the intersegmental arteries of the renal medullaand the arcuate arteries of the renal cortex. You will obtain both arterial and venoussignals at the cortical level because of the small size of the vessels and thearteriovenous shunting that occurs at this level.
I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE RENAL MEDULLA AND CORTEX
L A B E L E D : RT or LT REN MED COR
648
SCANNING TIP: Approximately 20% of patients have more than one renal arteryon each side. These accessory or multiple renal arteries may be detected using severalstrategies:
• Power Doppler (Doppler power angio) may be useful because this technique relies onthe intensity of the signal and is less affected by the angle of insonation than colorDoppler imaging.
• Accessory renal arteries usually course to the surface of the lower pole of the kidney. Asa consequence, the Doppler signals from the renal pole with the additional artery mayhave higher amplitude than the signal from the other region of the organ.
• Enlarge the Doppler sample volume, and listen along the wall of the aorta foradditional low resistance renal artery signals. Multiple renal arteries may ariseanywhere along the aortic wall to the level of the common iliac arteries.
III. Image Examples Of Various Studies
649
Abdominal Venous Flow Study. Black and white version of color flow Doppler in hepatic veins.
650
Abdominal Venous Flow Study. Black and white version of color Doppler flow in the portal vein.
651
Obstetrical Study. Black and white version of color Doppler in the three vessel umbilical cord.
652
Obstetrical Study. Black and white version of color Doppler flow in the four chamber fetal heart.
653
Gynecological Study. Black and white version of a color Doppler spectral display of blood in anactive ovary.
654654
Scrotal Study. Black and white version of color Doppler flow in a testicular artery.
SECTION TWO
IMAGE PROTOCOL FOR CEREBROVASCULAR DUPLEX SCANNING
• Criteria:— No limited studies.— Use the following five images (beginning on the following page) of normal
cerebrovascular structures as a technical guideline.
655
656
Longitudinal section of the common carotid artery.
657
Axial sections of the common carotid artery (CCA) and internal jugular vein (IJV).
658
Longitudinal section of the carotid artery bulb.
659
Axial section of the carotid artery bulb.
660
Internal and external carotid artery origins.
661
CEREBROVASCULAR DUPLEX STUDY
1. Longitudinal image of the right proximal common carotid artery.
L A B E L E D : SAG RT PCCA
2. Spectral waveform from the right proximal common carotid artery with peaksystolic and end diastolic velocities measured.
L A B E L E D : RT PCCA
3. Longitudinal image of the right distal common carotid artery.
L A B E L E D : SAG RT DCCA
4. Spectral waveform from the right distal common carotid artery with peak systolicand end diastolic velocities measured.
L A B E L E D : RT DCCA
5. Longitudinal image of the proximal internal carotid artery showing its origin fromthe bulb.
L A B E L E D : SAG RT PCCA
6. Spectral waveform from the proximal internal common carotid artery with peaksystolic and end diastolic velocities measured.
L A B E L E D : DIST RT ICA
7. Longitudinal image of the right middle internal carotid artery.
L A B E L E D : SAG RT MICA
8. Spectral waveform from the middle internal carotid artery with peak systolic andend diastolic velocities measured.
L A B E L E D : RT MICA
9. Longitudinal image of the right distal internal carotid artery.
L A B E L E D : SAG RT DICA
10. Spectral waveform from the distal internal carotid artery with peak systolic and enddiastolic velocities measured.
L A B E L E D : RT DICA
662
663
11. Longitudinal image of the right external carotid artery.
L A B E L E D : SAG RT ECA
12. Spectral waveform from the external carotid artery with peak systolic and enddiastolic velocities measured.
L A B E L E D : RT ECA
13. Optional longitudinal image of the right vertebral artery.
L A B E L E D : SAG RT VERT
14. Spectral waveform from the right vertebral artery with peak systolic and enddiastolic velocities measured.
L A B E L E D : RT VERT
15. Transverse image of the carotid bulb just prior to vessel bifurcation.
L A B E L E D : TRV RT BULB
SCANNING TIP: The spectral image of this vessel is often not satisfactory becauseof the depth of the vertebral vessels.
664
SCANNING TIP: The image and spectral data from the vertebral arteries and thesubclavian are required to bill for a complete carotid examination and receive vascularlaboratory accreditation.
SCANNING TIP: Even in the absence of pathology, it is important to carefullyimage the bulb. It is thought that this area is most prone to atherosclerosis because ofthe shear forces imposed on the vessel wall by the blood flow patterns and the vesselgeometry. Stenotic lesions are often asymptomatic until they reduce the diameter of thevessel lumen by more than 60%. Lesser lesions may occasionally be detected only withcareful, thorough scanning in the transverse plane.
SCANNING TIP: Stenotic plaque may be measured in the transverse plane to ensureaccuracy.
SCANNING TIP: Additional images of plaque may be necessary. It is important tolook for irregularities along the borders of the plaque, which may indicate ulcerations.
SCANNING TIP: Repeat the required images on the left side, beginning with athorough survey.
SECTION THREE
IMAGE PROTOCOLS FOR PER IPHERAL ARTER IAL AND VENOUSDUPLEX SCANNING
I. Lower Extremity Venous Duplex Study
665
SCANNING TIP: Examination of veins is easiest in a transverse plane, butlongitudinal imaging should also be performed to help ensure adequate venousmapping (so that no small thrombosis is missed) and assessment of the venous valves,especially with color flow Doppler.
SCANNING TIP: Because a venous duplex examination requires a thoroughmapping of the veins, it is unnecessary to perform a survey and then a more detailedexam to obtain images. Images may be obtained as you go. A diagnosis is rarely madefrom hard copy alone in this exam.
SCANNING TIP: Always examine both legs for comparative purposes. It may behelpful to examine the asymptomatic leg first.
666
• Begin transversely high on the thigh at or above the level of the groin crease. Locatethe common femoral vein (CFV) and common femoral artery (CFA). To confirm thatyou are in the CFV, identify the insertion of the saphenous vein and the bifurcationinto the superficial femoral vein (SFV) and the profunda femoris vein (PFV).
• Assess the entire length of the CFV for compressibility by compressing every 1 to2 cm. The walls of the CFA should not deform with adequate compression of the vein.
1. Images of noncompressed and compressed common femoral vein (on split screen ifavailable).
L A B E L E D : LT or RT CFV
• Still at the level of the CFV, turn on the Doppler and place the cursor toward flow.Spontaneous, phasic flow should be present throughout the CFV.
2. Duplex image of Doppler spectral CFV waveform demonstrating respiratory changesand augmentation.
L A B E L E D : RT or LT CFV
SCANNING TIP: For split screen imaging, use the left side for noncompressed viewsand the right side for compressed.
667
• Return to a gray scale image. Move inferiorly and locate the insertion of thesaphenous vein medially. Assess the proximal portion of the saphenous vein forcompressibility.
3. Images of noncompressed and compressed saphenous vein (split screen).
L A B E L E D : RT or LT SAPH V
• Investigate the saphenous vein with Doppler to confirm normal flow characteristics.
4. Duplex image of a Doppler spectral waveform from the saphenous veindemonstrating augmentation and respiratory changes.
L A B E L E D : RT or LT SAPH V
• Return to gray scale imaging, and return to the level of the CFV. Move inferiorly tolocate the insertion of the profunda vein. This lies posterior and lateral to the SFV.Follow this vein as inferiorly as possible, assessing compressibility.
SCANNING TIP: A complete exam requires assessment of the entire length of thegreater saphenous vein.
5. Images of noncompressed and compressed profunda vein (split screen).
L A B E L E D : RT or LT PROF V
• Return superiorly to the deep vein insertion, and begin sampling with Doppler. Assessfor normal characteristics. Follow as inferiorly as possible.
6. Duplex image of a Doppler spectral waveform from the profunda vein demonstratingaugmentation and respiratory changes.
L A B E L E D : RT or LT PROF V
• Return to a gray scale image, and move superior to the level of the SFV insertion.Begin following that vein inferiorly compressing every 1 to 2 cm at a level near itsinsertion.
7. Images of noncompressed and compressed SFV near its insertion (split screen).
L A B E L E D : RT or LT SFV SUP668
SCANNING TIP: Compressibility may be difficult to assess in vessels lying deep ortangent to the skin.
• Sample the same segment of vein with Doppler. Assess for normal characteristics.
8. Duplex image of a Doppler spectral waveform from the SFV near its insertiondemonstrating augmentation and respiratory changes.
L A B E L E D : RT or LT SFV
• Return to a gray scale image, and continue to follow the SFV inferiorly, assessing forcompressibility.
9. Images of noncompressed and compressed superficial femoral vein at approximatelymidthigh (split screen).
L A B E L E D : RT or LT SFV MID
• Sample SFV at a midthigh level with Doppler. Assess for normal characteristics.
10. Duplex image of a Doppler spectral waveform from the SFV at midthigh leveldemonstrating augmentation and respiratory changes.
669
SCANNING TIP: Make very careful note of vein compressibility because that is themost important indicator of venous thrombosis.
670
L A B E L E D : RT or LT SFV MID
• Return to a gray scale image, and investigate the remaining segment of SFV,compressing at regular intervals.
11. Images of noncompressed and compressed SFV as inferiorly as possible (splitscreen).
L A B E L E D : RT or LT SFV INF
• Doppler in the SFV just superior to the knee: The vein will have passed medially andnow lies posterior to the artery. Augmentation is especially important here becausecompression is often less than adequate.
12. Duplex image of a Doppler spectral waveform from the SFV just superior to theknee demonstrating augmentation.
L A B E L E D : RT or LT SFV INF
SCANNING TIP: As you approach Hunter’s canal just superior to the knee,compression is often very difficult, if possible at all. This is due to the tendons presenthere.
• The popliteal veins can be examined either with the patient prone or with the kneebent and relaxed away from the patient to the side.
• Locate the popliteal vein posterior to the artery and assess for normal characteristics.— Follow the vein as far superiorly behind the thigh as possible. Continue to assess
compression.— Begin to move inferiorly, following the popliteal vein to the level of its bifurcation
into the anterior tibial trunk and the tibioperoneal trunk. Follow the tibioperonealtrunk to the level where it bifurcates into the posterior tibial and peroneal trunks.
— Once the entire length of the popliteal vein has been adequately assessed forcompressibility, return to a midpopliteal level.
13. Images of noncompressed and compressed popliteal vein at its midpoint (splitscreen).
L A B E L E D : RT or LT POP V MID
• Sample with Doppler throughout the entire length of the popliteal vessels atmidpopliteal level.
671
SCANNING TIP: Document any vessel duplication, which is fairly common at thislevel. If there is more than one popliteal vessel, they must both be carefully examined.
14. Duplex image of a Doppler spectral waveform from the midpopliteal veindemonstrating augmentation.
L A B E L E D : RT or LT POP V MID
672
Black and white version of color Doppler image of popliteal vein and artery.
• Color Doppler may be used to rescan the entire leg in a longitudinal plane. ColorDoppler provides a visual means of assessing spontaneous flow, augmentation, andvalve competence.
• To assess valve competence, rescan quickly to locate a venous valve (this may be donewithin the scanning protocol of that particular venous segment) and scan to a leveljust inferior to the valve.— While observing color flow Doppler (or a spectral waveform), squeeze the patient’s
leg superior to the valve. If the valve is too superior to the scanning site, have thepatient take in a deep breath, hold it, bear down hard, and release (Valsalvamaneuver).
— There should be no remarkable amount of retrograde (inferior) venous blood flowthrough the valve. Significant retrograde flow indicates the presence of anincompetent valve.
— Any valve can be examined in this manner.• Examine only the deep veins of the thigh.
— It has been shown that the majority of life-threatening pulmonary emboli originatein the proximal deep veins of the leg. Although pulmonary emboli may originate
673
SCANNING TIP: It may be awkward to squeeze a patient’s thigh and maintaintransducer location at the same time. Having the patient quickly flex the ipsilateralfoot will have a similar effect.
674
from the smaller veins of the calf, these emboli are usually not clinically significant.The importance of detecting and treating isolated calf vein thrombi remainscontroversial.
• Repeat on the affected leg.
675
II. Lower Extremity Peripheral Arterial Duplex Study
• Beginning with the patient in a supine position, obtain bilateral brachial bloodpressures. Record on worksheet (see section on blood pressures).
• With the patient in supine position, palpate the following pulses:— Groin (iliac/common femoral artery)— Popliteal— Posterior tibial— Dorsalis pedis
• Using a low frequency probe (2.25 to 3.0 MHz), the distal aorta and proximal iliacarteries may be examined in both longitudinal and transverse planes.
1. Longitudinal view of the distal aorta.
L A B E L E D : SAG AORTA DIS
2. Longitudinal view of the right iliac artery.
L A B E L E D : SAG RT ILIAC
3. Longitudinal view of the left iliac artery.
L A B E L E D : SAG LT ILIAC
4. Transverse view of the distal aorta.
L A B E L E D : TRV AORTA DIS
5. Transverse view of the right and left iliac arteries.
L A B E L E D : TRV RT/LT ILIAC
• Begin scanning with a 5.0- or 7.0-MHz transducer. You will need to start superior tothe groin crease in a sagittal plane. Locate the common femoral artery (CFA).
• Sample with Doppler thoroughly to assess blood flow velocity and waveformmorphology throughout the length of the CFA.— Use simultaneous imaging for duplex studies if available. Although this may
slightly decrease image resolution on some ultrasound systems, it will makescanning much quicker.
676
SCANNING TIP: The iliac arteries may be examined simultaneously from a coronalplane with the patient in a right lateral decubitus position.
SCANNING TIP: If one leg is significantly more symptomatic than the other, beginwith the less symptomatic leg.
677
Systolicpeak
“O”Diastolic
flow
Base line
Systolicrise
Seconds
Flowreversal
Vel
ocity
cm
/sec
or
KH
Z�
Normal triphasic arterial signal from a high-resistance system.
678
6. Longitudinal gray scale view of the common femoral artery.
L A B E L E D : SAG RT or LT CFA
7. Doppler spectral waveform of the CFA.
L A B E L E D : RTOR LT CFA
• The CFA will bifurcate into the superficial femoral artery (SFA) and the deep femoralor profunda femoris artery.
• Follow the profunda femoris artery as inferiorly as possible with duplex sampling.
8. Longitudinal view of the profunda femoris artery origin.
L A B E L E D : SAG RT or LT PROF ART
9. Doppler spectral waveform of the profunda femoris artery near its insertion.
L A B E L E D : SAGRT or LT PROF ART
SCANNING TIP: If simultaneous imaging is not available, you will have to B-scanfor a short segment, freeze an image, then move a Doppler cursor thoroughly over thatfrozen image, and continue on to the next segment through the entire vessel.
679
• Return superiorly to the level of the bifurcation, and locate the SFA. Follow thisartery inferiorly to just above the knee.
10. Longitudinal view of the SFA origin.
L A B E L E D : SAGRT or LT PROX SFA
11. Doppler spectral waveform of the SFA near its origin.
L A B E L E D : SAGRT or LT PROX SFA
12. Longitudinal view of the SFA at approximately midthigh.
L A B E L E D : SAGRT or LT MID SFA
13. Duplex spectral waveform at midthigh.
L A B E L E D : SAGRT or LT MID SFA
SCANNING TIP: It may be difficult to follow the profunda for more than a fewcentimeters because the vessel usually courses deep into the leg. If you are able to followthe profunda artery for a longer length, another set of images should be documentedmore inferiorly along the vessel.
680
14. Longitudinal view of the SFA just superior to the knee.
L A B E L E D : SAGRT or LT DIST SFA
15. Duplex spectral waveform just superior to knee SFA
L A B E L E D : SAGRT or LT DIST SFA
• Next, the popliteal artery is to be examined. This may be done in a number of ways.The patient may be placed in a prone position with the knee slightly flexed, the legmay be bent slightly and positioned out to the side away from the patient, or thepatient may be placed in a lateral decubitus position with the knee slightly flexed.— Placing the patient in a prone position will allow for a more direct, easier approach,
but it may be difficult or time-consuming to have the patient roll over.• Locate the popliteal artery posterior and slightly lateral to the vein.
— Follow the artery as superiorly as possible into the thigh while gray scale imaging.— Begin duplex scanning and follow the artery inferiorly to the superior aspect of the
calf to the level of the vessel trifurcation into the anterior tibial, posterior tibial,and peroneal arteries.
681
Black and white version of color Doppler image of popliteal artery.
682
16. Longitudinal view of the popliteal artery.
L A B E L E D : SAGRT or LT POP ART
17. Doppler spectral waveform of the popliteal artery.
L A B E L E D : SAGRT or LT POP ART
• The tibial arteries may be evaluated using color Doppler.— It may be helpful to follow the arteries up the left from the ankle if there is any
difficulty following them down the calf.• After examining the popliteal artery, move down to the patient’s ankle to examine the
posterior tibial artery (PT) and dorsalis pedis artery (DP).— All three tibial arteries should be sampled with Doppler using a high frequency
transducer
18. Doppler spectral waveform of the posterior tibial artery.
L A B E L E D : SAG RT or LT PT
SCANNING TIP: Gray scale images may be taken to demonstrate pathology.
19. Doppler spectral waveform of the dosalis pedis artery.
L A B E L E D : SAG RT or LT DP
683
Spectral analysis of the posterior artery demonstrating normal triphasic flow. Courtesy of ATL,Bothell, Washington.
684
Black and white version of color Doppler image of the posterior tibial artery and vein.
• Cuff placement depends on whether a 3-cuff or 4-cuff method is to be used. If the 4-cuff procedure is used, appropriately sized cuffs are to be placed as follows:a) As high as possible on the thighb) Just above the kneec) Just below the kneed) Just above the ankle
— If the 3-cuff technique is used, a wide thigh cuff is placed snugly over the thigh andbelow knee and above ankle cuffs are used.
— Inaccurate blood pressures will be measured if inappropriate cuff sizes are used. Itis necessary to use only cuffs that are at least 20% wider than the diameter of the
685
SCANNING TIP: Determine the strongest and most easily accessible artery to use forpressure monitoring.Duplex ultrasonography is used to complement arterial assessment using indirectnoninvasive physiologic studies. Ankle brachial indices, segmental systolic pressuremeasurements, pulse volume recording photoplethysmography, and constant-loadexercise testing are among the more common procedures employed for primaryevaluation. The scope of this chapter does not permit detailed discussion of each ofthese physiologic test modalities. A brief description of the protocol for segmental systolicpressure measurements follows. The reader is referred to the references listed at the endof this section for additional information.
limb at that segment.• Start at ankle level and measure the pressure at each cuff level, moving superiorly.
The popliteal artery signal may be used, if necessary, to measure the thigh pressures.• Repeat on the contralateral leg.
686
SCANNING TIP: If the high thigh pressure is reduced, the Doppler spectralwaveform from the common femoral artery will indicate the likelihood of more proximaldisease.Normally, the waveform will be triphasic.If the CFA Doppler signal demonstrates loss of the reverse diastolic flow component,occlusive disease of the common or external iliac artery is suggested. If the CFA signalis abnormal bilaterally, aorto-iliac disease is indicated.
SCANNING TIP: It may be difficult to obtain a high thigh pressure on obesepatients. When the arterial wall is calcified (i.e., with diabetic patients), pressures maybe falsely elevated.
687
VIIIEchocardiography
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE ADULTHEART
SECTION TWO
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THEPED IATR IC HEART
SECTION ONE
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE ADULTHEART
I. Adult Heart Study
REQUIRED IMAGES
688
SCANNING TIP: The study is videotaped, allowing for real-time assessment ofstructures. At least 6 to 10 beats of each view should be recorded, with additionalimages of any pathology.
689
1. Parasternal long axis.
SCANNING TIP: The anterior portion of the aortic root and the interventricularseptum should be continuous and as perpendicular to the ultrasound beam as possible.The posterior portion of the aortic root runs continuous with the anterior mitral valveleaflet.
Interventricularseptum
Left ventricle
Posterior wall
Mitral valve
Descending thoracic aorta
Right ventricle
Aortic root
Aortic valve
690
2. Right ventricular inflow view.
Right ventricle
Right atrium
Tricuspid valve
3. Right ventricular outflow view.
691
Right ventricle
Main pulmonary artery
Pulmonic valve
4. Parasternal short axis at the level of the aortic valve.
692
Right ventricle
Mainpulmonary
artery
Pulmonic valve
Leftatrium
Descending thoracic aortaInteratrial septum
Right atrium
Tricuspidvalve
Noncoronarycusp
Right coronarycusp
Left coronarycusp
Aortic valve
5. Parasternal short axis at the level of the mitral valve.
693
Right ventricle Interventricularseptum
Anterior mitralvalve leaflet
Posterior mitralvalve leaflet
6. Parasternal short axis at the level of the papillary muscles.
694
Right ventricle Anterior wall
Left ventricle
Anterolateralpapillary
muscle
Lateral wall
Posterior wallPosteromedial
papillary muscle
Inferior wall
Interventricularseptum
7. Apical four-chamber view.
695
Rightventricle
Left ventricle
Lateral wall
Leftatrium
Mitral valve
Interventricularseptum
Rightatrium
Tricuspidvalve
Interatrial septum
8. Apical five-chamber view.
696
Rightventricle
Left ventricle
Left ventricularoutflow tract
Leftatrium
Rightatrium
Aorticvalve
9. Apical two-chamber view.
697
Left ventricle
Inferior wall
Left atrium
Descending aorta
Anterior wall
698
Left ventricle
Left atrium
Descending aorta
SCANNING TIP: When questions involving the aorta arise, a portion of thedescending thoracic aorta can be visualized posterior to the two-chamber view andshould be evaluated for pathology.
10. Apical long axis.
699
Left ventricle
Left atrium
Interventricularseptum
Right ventricle
Aortic valve
Aorta
Mitral valve
Posterior wall
11. Subxiphoid four chamber.
700
Left ventricle
Left atrium
Interventricularseptum
Right ventricleTricuspid valve
Rightatrium
Mitral valve
Lateral wall
Liver
12. Subxiphoid short axis papillary muscle level.
701
Leftventricle
Right ventricle
Papillary muscles
Liver
13. Subxiphoid short axis at the level of the mitral valve.
702
Right ventricle
Mitral valve
Liver
14. Subxiphoid short axis at the level of the aortic valve.
703
Right ventricle
Aortic valve
Liver
Left atrium
Pulmonaryartery
Right atrium
15. Subxiphoid short axis viewing the inferior vena cava (IVC) entering the rightatrium (RA).
704
Inferior vena cava
LiverRight atrium
16. Suprasternal notch viewing the long axis of the aorta.
705
Leftsubclavian artery
Left commoncarotid artery
Innominate artery
Aortic arch
Right pulmonaryartery
Descending aorta
SCANNING TIP: This view should be used when questions involving the aortaarise, such as dissection or Marfan’s syndrome. A short axis of the aorta should also beevaluated in these cases.
706
SCANNING TIP: A minimum of six beats should be recorded at each level todemonstrate both systolic and diastolic motion.
SCANNING TIP: The M-mode may be documented on either videotape or strip chartrecorder. If the strip chart is used, begin with a frozen image of the parasternal longaxis view to demonstrate the orientation of the heart.
SCANNING TIP: The 2D image must be as perpendicular to the ultrasound beamas possible, lessening the chance for inaccurate measurements. (A tipped ventricle willyield exaggerated numbers.) If you are unsure of a dimension when measuring, omit it.
M-Mode EvaluationAortic Valve Level
• The cursor is placed so that it transects the right ventricle (RV), aorta, and leftatrium (LA) in either the parasternal long or short axis view.
707
Left atrium
Right ventricle
Aorticcusps
Aorticroot
• Measurements taken1:
(a) Aortic root: from the anterior wall of the root to the posterior wall of the root, atthe level of the Q wave on the electrocardiogram (EKG); normally 1.9 to 4 cm.
(b) Aortic valve cusp separation: normally has the shape of a box when open with theright coronary cusp more anterior and the noncoronary cusp posterior; measuredat the onset of systole (when the valve first opens); normally 1.5 to 2.6 cm.
1Normal values used in the lab at Thomas Jefferson University, Philadelphia, Pennsylvania.
708
(c) Left atrium: measured at the largest dimension (end systole); normally 1.9 to 4 cm.
709
Left atrialdimension
Aortic cuspseparation
Aortic rootdimension
SCANNING TIP: Always measure structures from leading edge to leading edge.
Mitral Valve Level
• Slowly sweep the cursor through the left ventricular outflow tract (LVOT) region tothe tip of the mitral valve leaflets. This sweep will demonstrate structural continuity.The biphasic opening of both mitral leaflets should then be documented.
710
Posterior mitral leaflet
Anterior mitral leaflet
Interventricularseptum
Right ventricle
A
CF
E
D
711
SCANNING TIP: The mitral valve is labeled to describe the different phases of itsmotion.D: beginning of diastole.E: maximal excursion of the valve.F: point to which the valve had closed following the passive filling phase.A: atrial contraction (P wave on the EKG).B: extra bump between A and C (occurs only when pathology, such as diastolic
dysfunction, is present).C: closure of the valve and the beginning of systole.
• Measurements2:
(a) D to E excursion; normally greater than 1.6 cm.(b) E to F slope over the period of one second (expressed in mm/sec); normally greater
than 70 mm/sec.(c) E point to septal separation; normally no greater than 1 cm.
2Normal values used in the lab at Thomas Jefferson University, Philadelphia, Pennsylvania.
712
E point to septalseparation
Velocity(mm/sec)
D to Eexcursion
1 second
E
F
E
Left Ventricular Level
• Slowly sweep the cursor just beyond the mitral leaflets but stopping before thepapillary muscles. Both systolic and diastolic dimensions of the LV should bedocumented.
713
Right ventricle
Left ventricle
Posterior wallInterventricularseptum
Chordaetendineae
• Measurements3:
(a) All of the following are measured at the level of the Q wave on the EKG: RV (nogreater than 2.7 cm); interventricular septum (IVS), posterior LV wall (bothnormally between .6 and 1.2 cm); and LV end diastolic dimension (LVEDD)(normal range 3.5 to 5.7 cm).
3Normal values used in the lab at Thomas Jefferson University, Philadelphia, Pennsylvania.
714
Tricuspid valve
(b) LV end systolic dimension (LVESD): Measure at the smallest dimension.
715
SCANNING TIP: Often, the free wall of the RV is not visualized because of its closeproximity to the transducer, which makes it difficult to determine the true size of thechamber. The measurement is therefore taken from the point where motion is firstobserved, to the leading edge of the interventricular septum. Then subtract .5 cm fromthe total to compensate for the RV wall thickness.
SCANNING TIP: The LVEDD and the LVESD should be measured on the samebeat.
SCANNING TIP: Be careful not to include chordae tendinea in the thickness of theLV walls.
Tricuspid and Pulmonic Valves
• An M-mode of the tricuspid or pulmonic valve is used to demonstrate thickness andmotion and is not necessarily a routine part of the exam. There are no standardmeasurements obtained.
716
Tricuspid valve
717
Pulmonic valve
Doppler EvaluationValve Survey
Color Doppler Survey
• The color sector should be placed so that the valve or area being assessed is in thecenter of the sample. Normally, mitral and tricuspid flow appear red, and pulmonicand aortic flow are blue. When the valves are closed, no color (regurgitation) should beseen below them. Mitral and tricuspid regurgitation appear blue; aortic and pulmonic
718
SCANNING TIP: The following sequence should be used in the evaluation of eachvalve: color Doppler, continuous wave (CW) Doppler, then pulse-wave (PW) Doppler.Assess each value separately beginning with the mitral valve. Repeat this process on theaortic, tricuspid, and pulmonic valves and the left ventricular outflow tract (LVOT) ifnecessary.
SCANNING TIP: Flow moving toward the transducer appears as various shades ofred. Flow moving away is blue. A lower velocity would be deeper in color and graduallylighten as the velocity increases to almost yellow or white. At times, a variance map isused. This is usually a green color tagged on the end of the color spectrum. The greenmakes the higher velocities or turbulent flows stand out.
719
regurgitation are usually red.• Slowly angle the transducer back and forth across the valve plane to locate any
eccentric areas of turbulence. Demonstrate the size and location of any regurgitationor turbulent flow.
• Color can also be used to locate the peak flow velocity across the valve, allowing foreasy placement of the continuous wave (CW) Doppler cursor.
Continuous-Wave Doppler Survey
• CW is best for determining peak flow velocities. Place the cursor so that it bisects theopening of the valve that is to be sampled. If the peak velocity across a valve exceedsits normal velocity, the peak should then be measured. Three profiles are measuredand averaged. Do not measure post PVC beats. If the patient is in atrial fibrillation,average at least five or six beats.
• The peak velocity of tricuspid regurgitation is also measured to help with theevaluation of pulmonary hypertension.
SCANNING TIP: Regurgitation or any pathology should be demonstrated in morethan one view.
Pulsed-Wave Doppler Survey
• Pulsed Doppler demonstrates exactly where a flow disturbance occurs and is thenused to map out the direction and size of the disturbance. Place the cursor or Doppler“gate” slightly above the valve opening. Slowly move below the valve, then across thevalve plane in both directions. If regurgitation is detected, follow the flow into thechamber as far back as it goes, mapping the length and also the width of theturbulent area.
720
SCANNING TIP: If you are unable to find a peak velocity on any valve, tricuspid,or aortic regurgitation, a nonimaging, stand-alone CW probe should be used. Becauseof the smaller footprint of the transducer and the lower frequency, the peak velocity canbe easily found.
SCANNING TIP: If any additional flow disturbances (e.g., ASD, VSD) arevisualized, they too should be evaluated with color, CW, and PW Doppler.
SECTION TWO
IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THEPED IATR IC HEART
I. Pediatric Heart Study
REQUIRED IMAGES
721
SCANNING TIP: The following views are all recorded on videotape, allowing forreal-time assessment of cardiac structures. At least 8 to 10 beats of each view isrecorded with additional images for color, PW, and CW Doppler.
1. Subcostal view demonstrating the orientation of the aorta and IVC.
722
Spine
Aorta
Hepaticvein
Inferiorvena cava
Liver
2. Subcostal four-chamber view.
723
Left atriumMitral valve
Pulmonaryvein
Tricuspidvalve
Rightatrium
Right ventricle
Liver
Interventricularseptum
Pulmonary veins
Left ventricle
3. Subcostal five-chamber view showing the aorta and the LVOT.
724
Aortic valve
Aortic root
Rightventricle
Liver
Left ventricle
Interventricularseptum
4. Subcostal long axis angled anteriorly to demonstrate the RV outflow tract, pulmonicvalve, and the pulmonary artery.
725
Pulmonic valve Main pulmonaryartery
Rightventricle
Liver
5. Short axis subcostal showing the IVC and superior vena cava (SVC) entering theright atrium.
726
Liver
Superiorvena cava
Right atrium
Inferiorvena cava
6. Short axis subcostal demonstrating the aortic valve, pulmonary artery, andinteratrial septum.
727
SCANNING TIP: A small angulation may be needed to fully visualize theinteratrial septum.
Aortic valve
Interatrialseptum
Left atrium
Right atrium
Tricuspidvalve
Liver
Pulmonicvalve
Main pulmonaryartery
Right ventricle
7. Short axis subcostal of the mitral valve.
728
Interventricularseptum
Mitral valve
Right ventricle
8. Short axis subcostal of the left and right ventricles.
729
Left ventricle
Interventricularseptum
Papillary muscles
Right ventricle
9. Apical four-chamber view.
730
Interatrialseptum
Right atrium
Tricuspidvalve
Right ventricleInterventricular
septum
Left ventricle
Mitral valve
Left atrium
Pulmonary veins
10. Apical long axis documenting the LVOT.
731
Aortic root
Left atrium
Left ventricularoutflow tract
Left ventricleInterventricularseptum
Right ventricle
Aorticvalve
11. Parasternal long axis.
732
Interventricularseptum
Left ventricularoutflow tract
Leftventricle
Posterior leftventricular wall
Mitral valve
Right ventricle
Aortic root
Aorticvalve
Left atrium
Descendingaorta
12. Right ventricular inflow view.
733
Tricuspid valveRight ventricle
Right atrium
13. Right ventricular outflow view.
734
Pulmonicvalve
Right ventricle
Left atriumMain pulmonary
artery
14. Parasternal short axis at the level of the aortic valve to document the orientation ofthe great vessels.
735
Pulmonicvalve
Right ventricle
Left atrium
Mainpulmonary
artery
Left coronarycusp aortic valve
Noncoronarycusp aortic valve
Interatrialseptum
Rightatrium
Tricuspidvalve
Right coronarycusp aortic valve
15. Parasternal short axis documenting the left coronary artery.
736
SCANNING TIP: Angle slightly above the aortic valve leaflets and zoom in on theregion to simplify coronary evaluation.
Right ventricle
Left atrium
Left anteriordescending
(LAD)coronary
artery
Leftcircumflexcoronary
artery
Left maincoronaryartery
Aorta
16. Parasternal short axis documenting the right coronary artery.
737
Left atrium
Right coronaryartery
Aorta
17. Parasternal short axis to document the right and left pulmonary branches and thepresence or absence of a patent ductus arteriosus.
738
SCANNING TIP: If a ductus is present, demonstrate its connection to the aorta.
Main pulmonaryartery
Descending aorta
Aorta
Left atrium
Patent ductusarteriosus
Left pulmonary artery
Right pulmonary artery
18. Parasternal short axis at the level of the mitral valve to document thickness andmotion of the leaflets.
739
Right ventricle
Interventricularseptum Anterior mitral
valve leaflet
Posterior mitralvalve leaflet
19. Parasternal short axis at the level of the papillary muscles.
740
Right ventricleInterventricularseptum
Anterolateralpapillary muscle
Posteromedialpapillary muscle
Left ventricle
20. Suprasternal notch documenting the aortic arch and its branches.
741
Descending aorta
Aortic arch
Left subclavianartery
Right pulmonaryartery
Left commoncorotid artery
Brachiocephalic(innominate) artery
Ascendingaorta
Left atrium
21. Suprasternal notch documenting the branch pulmonary arteries and short axis ofthe aorta.
742
Aorta
Left pulmonaryartery
Right pulmonaryartery
Main pulmonaryartery
M-Mode EvaluationAortic Valve Level
743
Aortic leafletsRight ventricle
Aorticroot
Left atrium Aortic root
Right ventricle
Aortic valve
Left atrium
Mitral Valve Level
744
Right ventricle
Right ventricle
Mitral valve
Anterior mitral leaflet
Posterior mitral leaflet
Left Ventricular Level
745
SCANNING TIP: Sweep speed of the M-Mode is increased to 100% to accommodatethe increased heart rate of neonates.
Right ventricle
Rightventricle
Interventricularseptum
Posteriorventricular wall
Left ventricle
Posteriorventricular wall
Left ventricle
Interventricularseptum
Abbreviation Glossary
746
IXAIUM: American Institute of Ultrasoundin MedicineALARA: As low as reasonably acceptableANT: AnteriorART: ArteryAV: AtrioventricularAV: Atrioventricular valvesBIF: BifurcationCBD: Common bile ductcc: Cubic centimeterCD: Common ductCERX: Cervix
CFA: Common femoral arteryCFV: Common femoral veinCHD: Common hepatic ductcm: CentimeterCOR: CoronalCR: Crown rumpC-SPINE: Cervical spineCW: Continuous wave DopplerDECUB: DecubitusDP: Dorsalis pedis arteryEKG: ElectrocardiogramER: Endorectal
747
EV: EndovaginalFd: Doppler shift frequencyFo: Operating frequencyGB: GallbladderGS: Gestational sacHz: HertzIN: InchesINF: InferiorIVC: Inferior vena cavaIVS: Interventricular septumkHz: KilohertzKID: KidneyLA: Left atriumLAD: Left anterior descendingLAT: LateralLLD: Left lateral decubitusLPO: Left posterior obliqueL-SPINE: Lumbar spineLT: LeftLV: Left ventricularLVOT: Left ventricular outflow tract
MED: MedicalMHz: MegahertzML: Midlinemm: MillimeterMV: Mitral valveNIP: NippleOBL: ObliqueOV: OvaryPA: Pulmonary arteryPDA: Patent ductus arteriosusPFV: Profunda femoris veinPOP: Popliteal arteryPOST: PosteriorPRF: Time and depth limitationsPROX: ProximalPT: Posterior tibial arteryPV: Pulmonic valvePW: Pulsed wave DopplerRA: Right atriumRCA: Right coronary arteryRI: Resistive indices
748
RLD: Right lateral decubitusRPO: Right posterior obliqueRT: RightRV: Right ventricleSA: Sinoatrial nodeSAG: SagittalSEM V: Seminal vesiclesSFA: Superficial femoral arterySFV: Superficial femoral vein
SMA: Superior mesenteric arterySUP: SuperiorSVC: Superior vena cavaTGC: Time-gain compensationTRV: TransverseT-SPINE: Thoracic spineTV: Tricuspid valveUT: UterusVAG: Vagina