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SITAL DIAGNOSTIC ULTRASOUND

Most common material zirconate titanate Quartz SELECTING A TRANSDUCER

is

lead

Human Hearing: 20 Hz- 20,000 Hz PROPAGATION VELOCITY The speed of which the pressure waves moves through the tissue. 1540 m/sec

A larger transducer is preferable for deep-lying structures. A small-diameter high-frequency transducer should be used for shallow Low-frequency large-diameter transducer for larger patients or harder to penetrate areas. ULTRASOUND COUPLING GEL: to allow efficient transfer of energy IMAGE DISPLAY 1. A-mode Displays the voltage produced across the transducer by the backscatter echo as vertical deflection on the face of oscilloscope determine solid vs. cystic nature of masses 2. M-mode Displays echo amplitude and show the position of moving reflectors. Use in assessing motion patterns of specific reflectors: Used for cardiac valves, cardiac chambers, vessel walls 3. B-mode, real-time, gray-scale Variations in display intensity or brightness are used to indicate reflected signals of different amplitude. produces a picture of a slice of tissue WHITEsignals of greatest intensity. BLACK- absence of signal

ATTENUATION: 1. The transfer of energy to the tissue (absorption) and removal of energy by reflection and scattering. 1. Absorption 2. Scattering 3. Reflection TRANSDUCER: any device that converts one form of energy to another Ultrasound transducers convert electric energy into ultrasonic energy

MAJOR COMPONENTS The crystal is the active portion of the transducer The backing block is used to dampen the crystal oscillations

Frequencies: 3.5 MHz, 5 Mhz, 7.0 Mhz, 7.5 Mhz 1. The lower the frequency, the better penetration but poorer resolution. 2. The higher the frequency , the lesser penetration but better resolution PIEZOELECTRIC CRYSTALS Materials used that change in physical dimension when electric field is applied.

GRAYintensity 4. Doppler PHYSICAL EFFECTS OF SOUND

intermediate

THYROID
High frequency sound waves (7.5-15 mhz) is used for HD images. Linear array is preferred Anatomy Made up of left and right lobes separated by isthmus whose diameter is 4-6mm. Length: 40-60 mm, AP diameter: 1318mm

1. Thermal: common experience of most medical professionals Attenuation is result of two processes: 1. Scattering: redirection of acoustic energy by the tissue encountered during propagation. 2. Absorption: is conversion of ultrasound energy into heat. 2. Non-Thermal Factors Controlling Tissue Heating: 1. Spatial Focusing 2. Temporal considerations: pulse-echo vs. continuous wave 3. Overall duration (dwell time): the longer the tissue is exposed, the greater the risk of bio effects. 4. Tissue type: Another important factor is the bodys ability to cool tissue via blood perfusion

Thyroid adenoma

Utrasound: Homogenous Medium to high-level echogenicity. By Doppler- rich vascularity is in Superior pole Inferior pole

INTRAHEPATIC BILE DUCTS NORMAL ANATOMY

1. INTRAHEPATIC BILIARY NEOPLASM occurs with middle-aged woman Chlolangiocarcinoma: primary bile duct carcinoma 2. INTRAHEPATIC BILIARY CALCULI Uncommon in patients with gallstones occurs in patients with recurrent pyogenic cholangitis (RPC) most common site: lateral segment of left lobe

Common bile duct Intrahepatic bile duct: less or 2 mm. in diameter. Not more than 40% of the accompanying portal vein

CAROLIS DISEASE: Congenital, autosomal recessive Characterized by saccular, communicating intrahepatic duct ectasia Complications include: Pyogenic cholangitis Hepatic abscess Intrahepatic biliary obstruction Calculi Cholangiocarcinoma- 7%

DILATED INTRAHEPATIC BILE DUCTS Alteration of the normal portal triad: most reliable differentiating feature Irregularity of the walls of the dilated bile ducts A central, stellate confluence of tubular structures Acoustic enhancement posterior to the dilated ducts

PITFALLS 23% of patients with biliary obstruction lacks intrahepatic bile duct dilatation Pneumobilia: also limit sonographic ability to evaluate the ductal system CAUSES: 1. Surgically created biliary-enteric anastomoses 2. Incompetence of spinchter of oddi

Pathology:

3. Wall erosion of gallstone or ulcer into common bile duct PARENCHYMAL CALCIFICATIONS Criteria suggesting intrahepatic duct calculi: Presence dilatation of bile duct

Chronic pancreatitis with stricture formation: 3rd most common cause

SUPRAPANCREATIC OBSTRUCTION between pancreas and porta hepatis Malignancy is cause Ultrasound: adenopathy the most common reveal mass or

Multiple lesions Left lobe involvement] Elevated alkaline phospatase

PORTA HEPATIS OBSTRUCTION due to neoplasm ultrasound: lack uniformity

EXTRAHEPATIC BILE DUCTS

UNUSUAL CAUSES FOR BILE OBSTRUCTION 1. Cholangiocarcinoma: bile duct carcinoma, rare, accounting for fewer than 1% 2. Klatskin tumor: a specific type of cholangiocarcinoma, occur in 10%25% of cases COMMON BILE DUCT 5 mm: normal 6mm-7mm: equivocal 8mm: dilated 3. Mirizzi syndrome: due to impacted stone in the cystic duct creating extrinsic mechanical compression of the common hepatic duct

Pathology: DIAGNOSING OBSTRUCTION Bile ducts expands centrifugally from the point of obstruction In patients with fibrosed or infiltrated livers, intrahepatic dilatation cannot occur because of lack of compliance of the hepatic parenchyma Extrahepatic dilatation occurs before intrahepatic dilatation

INTRAPANCREATIC OBSTRUCTION: Conditions caused by: Pancreatic carcinoma Choledocholithiasis- most common

Klatskin

tumor

4. Speed, safety, portability and flexibility 5. Independence of gastrointestinal, hepatic and biliary functions 6. Multiple organ examination. NORMAL ANATOMY

Mirizzi syndrome 4. Choledochal cyst: focal dilatation of CBD Types: Type I- Fusiform dilatation of the CBD, often with an anomalous junction of the pancreaticobiliary ductal system (the most common form) Type II- A diverticulum protruding from the wall of the CBD (rare) Type III- Choledochocele or herniation of the CBD into the duodenum (rare) JUNCTIONAL FOLD Fold between the body and infundibulum of the gallbladder Can produce high amplitude echoes PHYRIGIAN CAP Folding or kinking Gallbladder fundus appears to be folded on the body Seen in 4% of patients

Classic triad: Pain, Jaundice, Abdominal mass 5. BILIARY PARASITES Ascaris lumbricoides: the most common parasite Ultrasound: non-shadowing tubelike structure, straight or coiled macerated roundworm

GALLBLADDER AND BILIARY TREE ADVANTAGES OF SONOGRAPHY 1. High sensitivity and accuracy 2. Lack of ionizing radiation 3. No contrast material

GALLBLADDER WALL

Visible as pencil-thin echogenic line, less than 3mm thick

SCANNING TECHNIQUES Overnight fast of 8-12 hours 3.5-MHz transducer Thin patients: 5.0-MHz transducer Scan is performed by lower intercostal or preferably by subcostal approach with the patient supine or in left posterior oblique position PATHOLOGY CHOLELITHIASIS Most: cholesterol stones 3x higher in women than in men The net sonographic effect is: 1. Highly reflective echo originating from the anterior surface of the calculus 2. Posterior acoustic shadow CAUSES OF WALL THICKENING Hepatic dysfunction Alcoholism Hypoalbuminemia Ascites Hepatitis Congestive heart failure Renal disease AIDS

GALLBLADDER CARCINOMA

GALLBLADDER STONES WITH CHOLECYSTITIS

WALL-ECHO SHADOW (WES) TRIAD (DOUBLE ARC SHADOW SIGN) sign consists of 2 parallel, curved, echogenic lines separated by a thin anechoic space with distal acoustic sonic shadowing

Adenomyomatosis BILE SLUDGE: used to describe the presence of particulate material (specifically calcium bilirubinate and/or cholesterol crystals in the bile Bile stasis: most predisposing factor common

PERICHOLECYSTIC FLUID attributable to acute cholecystitis with gallbladder perforation and abscess formation Ultrasound: anechoic or complex fluid collection THE SPLEEN Embryologically, spleen arises from a mass of mesenchymal cells located between layers of dorsal mesentery rotates 90on its longitudinal axis Long axis lies in the 10th rib Diaphragmatic surface is convex and is usually situated between 9th and 11th rib ACUTE CHOLECYSTITIS Occurs in of gallbladder stone patients with Average spleen weights: grams (average:150 grams ) Functions: Phagocytosis Fetal hematopoesis Adult lymphopoesis Immune response Erythrocyte storage 80-300

Caused by persistent obstruction of the gallbladder neck or cystic duct inflammation necrosis and infection Sonographic Murphys sign: present when maximal tenderness is elicited over the sonographically localized gallbladder Primary signs: Gallstone, Sonographic Murphys sign, Impacted gallstone Secondary dilatation, thickening COMPILICATIONS: Emphysematous cholecystitis, Gangenous chlolecystitis, Perforation (subacute) Pseudolithiasis: drug ceftriaxone complexes with calcium bile salts to form precipitate PITFALLS: signs: Gallbladder Sludge Diffuse, wall

EXAMINATION TECHNIQUE Supine position in coronal plane

SONOGRAPHY OF THE SPLEEN Left kidney: inferior and lateral Splenic vein: useful landmark for identifying splenic hilum Splenic parenchyma Homogenous Mid to low-level echogenicity

PATHOLOGY:

More echogenic than the liver

Have epithelial endothelial lining

or

SPLENOMEGALY Most commonly used method is the eyeball technique Mild to moderate Infection Portal hypertension AIDS

SPLENIC SOLID MASSES Most common:

Tuberculosis Histoplasmosis SPLENIC INFARCT: More common cause of focal lesion Typical sonographic appearance:

Marked splenomegaly Leukemia Lymphoma Infectious mononucleosis

Peripheral Wedge-shape Hypoechoic lesion

Massive splenomegaly Myelofibrosis

SPLENIC CYSTS Echo-free area, sharp, borders, enhancement Small: splenic parenchyma Large: exophytic Infectious cyst: Hydatid cysts Usually caused echinococcus by smooth SPLENIC TRAUMA CONGENITAL ANOMALIES Supenumerary (splenunculi): ACCESSORY SPLEEN Asplenia Polysplenia Must be differentiated from posttraumatic splenosis Absence of spleen Impairment of the immune response spleen

Posttraumatic cyst: Have no cellular lining and also called pseudocyst

primary congenital cyst: Also called epidermoid cyst

For confirmation: nuclear studies with technitium-labelled, heatdamaged red blood cells

PITFALLS

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