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Ultrasound of normal abdominal organs

Geir Folvik, MD

Division of Gastroenterology

Department of Medicine, Haukeland University Hospital

Bergen, Norway

30.11. 2015

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Basic ultrasound imaging

ultrasound frequencies: from 3,5 to 5 MHz (up to 15 MHz)

high-frequency ultrasound gives a high spatial resolution, but reduced

penetration in depth

air, gas and bones: high reflection factor

attenuation of the ultrasound wave is caused by

– absorption, reflection, refraction and scattering

– fatty tissue gives a high absorption

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Helping techniques

familiar with technical scanning variables

knobology

overnight fasting

full urinary bladder

oral water intake

respiration/ Valsalva

examination in both supine, sitting and standing positions

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Systematic approach (6+)

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Organ evaluation

size and shape

structure/ echogenicity

surface

ducts

blood vessels

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Liver

– smooth surface

– fine structure and homogenous echogenicity » slightly hyperechogenic compared to renal cortex

– no focal lesions

– wedge shaped edges

– size blunt edges

liver below right costal margins/arc

size can be measured a.m. Kratzer

– segments

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Liver

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Liver

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Liver –size a.m Kratzer

overnight fasting, supine and right arm behind head

max inspiration

largest craniocaudal diameter i right MCL

88,5% in a large cohort had a diameter <16 cm

– BMI

– hight

– sex

Kratzer et al. J Ultrasound Med 2003

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Segments

2 lobes – right and left

8 segments: – lobus caudatus 1

– left lobe 2,3

– right lobe 4-8

ligamentum teres

ligamentum venosum

ligamentum falciforme

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Segments

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7

8

4

3

2

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Liver

vv. hepaticae – run a dominantly straight course and divides in sharp angles

– anechoic walls

– typical flow pattern on Doppler (atrial contraction/ respiration)

v. porta – highly echogenic vessel walls

– divides in less sharp angles

– <13-15 mm?

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Vv. hepaticae

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Vv. hepaticae

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Hepatic veins -flow

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V. porta

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V. porta

Normal portal and splenic vein

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Gallbladder

Gallbladder (inter- and subcostal view) – after a night`s fast

– supine/ left lateral position/ sitting/ standing/ deep inspiration

– anechoic

– wall thickness normally <2-3 mm

– no wall layers

– diameter <4-5 cm

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Gallebladder

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Bile ducts Bile ducts

– ductus hepaticus communis/ choledochus <5-6 mm

– normally up to 8-9 mm after cholecystectomy?

– intrahepatic bile ducts follow v. porta

– dilated when: ”parallell sign”/ to many ductal structures

– colour-Doppler

– ”drei-spϋrige autobahn”

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Bile ducts

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Bile ducts – intrahepatic cholestasis

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Intrahepatic cholestasis

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Pancreas

» transversal-/ longitudinal access in the mid-line

» characteristic imaging picture with transversal access

» eventually by drinking 300-400 ml water

» great variation in size and form

» focal lesions?/ calcifications?/ cysts?

» ductus pancreaticus 1-2mm (dilated when >5mm)

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Pancreas

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Pancreas

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Pancreatic duct Doppler

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Cauda pancreatis – access from the spleen

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Kidney

subcostal/ intercostal/ lumbal scan

longitudinal/ transversal scan

deep inspiration

parenchyma slightly hypoechoic compared to liver(1/3 x 2) » pyramids hypoechoic (cyst-like)

sinus is 1/3 (collecting system/ vessels/ fat/ connective tissue)

length 10-13 cm

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Nyre

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Kidney -hydronephrosis

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Spleen

supine

intercostal, posterior access

echogenicity like liver

max size 12 x 8 x 4cm

accessory spleen in 2-3% of population

– 1-3 cm/ circular/ hilar location

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Spleen Accessory spleen

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Urinary tract/ genitals

ureteres normally not seen

urinary bladder – transversal/ longitudinel scan

– full bladder

– volume: h x b x l x 0,5

prostata – transducer behind symphysis

– full bladder

– volume: h x b x l x 0,5

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Urinary bladder

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Genitals

– uterus » longitudinal/transversal scan with full bladder in supine position

» hyperechogenic

– ascites in fossa Douglasi?

– ovaris » scan with full bladder on each side of uterus

» difficult because of intestinal loops

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Uterus

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Lymph nodes/adrenals/ascites/pleural fluid

lymph nodes – paraaortal in supine position

– most often hypoechoic

adrenals – difficult to visualise unless pathology

ascites: Morrisons pocket/ fossa Douglasi

pleural fluid

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Stomach/ intestine – air/gas

– gastric imaging » after oral water intake

» normal wall thickness 2-5 mm

– intestine » small intestine: <2 mm (<4 cm)

» large bowel: <2-3 mm (<6 cm)

» ”target lesions”

» ”high frequency ultrasound”

wall layers

– hydrocolon sonography/ ”hydrosonography of the small bowel”

Target lesion cancer coli

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Ileum terminale

Folvik et al. Scand J Gastroenterol. 1999 Dec;34(12):1247-52.

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Large vessels

vena cava inferior – compressible/ Valsalva/ caliber variation

aorta – AAA (diameter>3 cm/ thrombus?)

coeliac trunk

superior mesenteric artery

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Vena Cava Inferior

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Aorta/ truncus coeliacus/ AMS

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Truncus coeliacus

AAA with thrombosis

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