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SUPINE FLANK AND LATERAL DECUBITUS POSITIONS HAND - KNEE POSITION (PRONE)
A
LATERAL DECUBITUS AND SUPINE --
pas IT, ONS
SUPINE POSITION
JLJl B
Fig. 1. Patient and transducer positi~nsJ with the
corresponding ultrasonic patterns. !he mtra-abdo.m-
inal blackened area represents ascites. A. Supine
right or left flank and lateral dec~bitus positio.ns.
B. Right or left lateral decubitus and supme pOS1-
.
c
tions.
C. Hand-knee and supine positions. the gain settings are too high. The strong
back wall echoes are the result of the
strength of an echo while the distance along
high specific acoustic impedance at the
the trace represents the tissue depth from
fluid-solid interface; the fluid itself is
which the echo arises. The machine was
transonic and echo-free. Such a pattern
set to provide uniformly increasing ampli-
is seen in ascites. When no fluid is
fication of the echo signals from the trans-
present, multiple echoes arising from inter-
ducer artifact to a tissue depth of 15 em.
faces between various abdominal organs
The gain controls were positioned midway
will be recorded. A commercially avail-
between the high and low settings used to
able water-soluble gel was applied between
distinguish cystic and solid masses (11,
the transducer and abdomen to secure good
12). Empirically, the transducer can be
acoustic coupling.
placed over a full urinary bladder and the
In our standard examination, five pairs
controls adjusted until an echo-free zone
of readings were obtained; in each, the
followed by multiple strong echoes is
patient's position was changed but the
obtained; these represent the urine and the
transducer remained fixed (Fig. 1). The
back wall of the bladder, respectively.
readings were as follows:
If multiple back wall echoes are not ob-
tained, the gain settings are too low; if the 1. Supine left flank and right lateral
clear zone representing the fluid begins to decubitus positions with the trans-
decrease significantly due to reverbera- ducer placed on the left flank
tions originating from the bladder walls, 2. Right lateral decubitus and supine
Vol. 96 EVALUATION OF ASCITES BY ULTRASOUND 17
positions with the transducer placed decreased significantly when the trans-
on the portion of the right side of ducer position was fixed and the patient's
the abdomen nearest the table dependent position changed. If the trans-
3. Supine right flank and left decubitus ducer was placed too high, confusing pat-
positions with the transducer placed terns from the gallbladder, liver, and spleen
on the right flank were sometimes encountered. The gall-
4. Left lateral decubitus and supine bladder was seen as a relatively fixed
positions with the transducer placed fluid pattern, whereas the liver and spleen
on the portion of the left side of the produced a solid rather than cystic echo
abdomen nearest the table complex. If the transducer was placed
5. Hand-knee and supine positions with too near the pubis in the hand-knee posi-
the transducer placed on the mid-ab- tion, the echoes from a full urinary bladder
domen. The patient assumes the could be recorded, and the fixed echo pat-
hand-knee position and bends his tern established the fluid as loculated
elbow slightly so that the anterior rather than free. A similar pattern was seen
abdominal wall is parallel to the in abscesses or cysts. Above the umbilicus,
table. confusing echoes from the aorta could be
differentiated from ascites by the demon-
In all readings, the transducer is moved stration of expansile motion of the aortic
until the maximum fluid pattern is ob- wall echoes (13).
tained. The first position was uniformly A few scattered echoes were sometimes
more sensitive than the second; the latter seen arising from within the echo-free
was used only to demonstrate a change in zone. These were most likely due to
the echo-clear space and thus establish abdominal organs, mainly the bowel. In
the presence of free fluid. For this reason, several cases, particularly in massive as-
when referring back to our standard tech- cites when the patient was repositioned
nique for the purpose of describing relative without moving the transducer, the ultra-
sensitivities, only the first position will be sonic fluid space did not disappear com-
used and will be designated as (a) supine- pletely. However, there was always a
left flank, (b) right lateral decubitus, (c) significant decrease in the echo-free zone,
supine-right flank, (d) left lateral de- indicating that the major portion of the
cubitus, or (e) hand-knee. fluid was basically free within the peri-
In all positions, about one minute should toneal cavity. The remaining echo-free
elapse before recording the echo pattern zone may represent fluid trapped within
in order to allow sufficient time for move- one of the spaces making up the peritoneal
ment of the ascites. Free fluid will settle cavity (14).
to the most dependent part of the abdo-
men. The examination was performed in RESULTS
the sequence given in order to minimize
patient movement. Some patients were A. Experimental: Ultrasonic studies
too sick to assume the hand-knee position, for possible ascites were made on 14 cadav-
and in such cases this position was e1im- ers, using the previously described posi-
inated; however, the remaining positions tions. Ten were found to have no ultra-
could be assumed easily by all patients. sonic evidence of free intraperitoneal fluid;
The measurements were obtained with of these, immediate autopsies confirmed
the patient in bed if necessary, although a the absence of ascites in 5. In 5 other
hard surface was preferred, particularly for cadavers, varying amounts of fluid were
the lateral decubitus positions. The best introduced into the peritoneal cavity and
ultrasonic readings were obtained around serial ultrasonic tracings were obtained.
the level of the umbilicus. The echo fluid In 3, a 14 gauge blunt needle was placed
pattern obtained in ascites disappeared or into the peritoneal cavity midway be-
18 B. B. GOLDBERG, G. A. GOODMAN, AND H. R. CLEARFIELD July 1970
Mean Mean
Width Width
of of
Echo- Range Echo- Range
Free (mm) Free (mm)
Space Space
(mm) (mm)
100 ml 500 ml
Right lateral decubi-
tus 13 4-30 45 22-52
Hand-knee 11 4-16 23 16-35
Supine right flank 9 0-16 37 20-50
Left lateral decubitus 4 0-18 21 4-50
Supine left flank 1 0-4 9 0-14
negative (Fig. 5). In the remaining abdominal surface. The right lateral
case, there was no evidence of ascites decubitus position is more sensitive than
initially, and this was confirmed at surgery the left lateral decubitus position, since
for chronic peptic ulcer disease. Two the large volume occupied by the liver (as
weeks later, ascites was demonstrated by compared to the spleen) decreases the
ultrasonography and its presence proved space available for free fluid. The right
by paracentesis. lateral decubitus position was also found
In , patients, fixed' ultrasonic fluid to be most useful in evaluating increases
patterns were obtained in localized areas. in the volume of ascitic fluid. The hand-
Two patients demonstrated an enlarged knee position was not as valuable in this
gallbladder in the right lateral decubitus regard, for, as the amount of ascites in-
position alone, and the gallbladder was creases, the fluid apparently spreads out
found to be enlarged at surgery, with no over a larger area of the abdominal sur-
evidence of ascites. The remaining 5 face rather than increasing in depth, ac-
patients had abscesses. Two of these counting for the lack of a proportional in-
were subhepatic and 3 were subdiaphrag- crease in the echo-free zone with increas-
matic; of these 3, one was on the right and ing volume.
2 were on the left. Four of the 5 were The use of multiple positions enabled us
proved at surgery. These and similar to demonstrate changes in the ultrasonic
fixed ultrasonic fluid patterns seen in vari- fluid pattern and thus differentiate be-
ous fluid-filled masses were easily differ- tween free and loculated fluid. The ma-
entiated from the echo pattern seen in neuvers were of particular value when
ascites (Fig. 6). confronted with an enlarged gallbladder
or abscess seen as a fixed echo-free zone.
DISCUSSION
Fluid-filled loops of bowel produced two
The skilled clinician generally has little ultrasonic patterns, a complex ultrasonic
difficulty identifying moderate to large cyst pattern produced by multiple fluid-
amounts of free intra-abdominal fluid by filled loops of bowel, similar to that seen in
physical examination; however, lesser multicystic masses, and a fixed fluid ultra-
quantities frequently escape detection. sonic pattern demonstrating no significant
It has been demonstrated experimentally change with a change in position, pro-
and clinically that ascites can easily be duced by the fixed portions of the colon.
detected by means of A-mode ultrasound. In the severely ill or debilitated pa-
The ability of ultrasonography to demon- tient, it is often difficult to obtain a reading
strate as little as 100 ml of free fluid is of in the hand-knee position. However,
value in the early detection of ascites in readings can always be obtained in the
cirrhosis and malignancy. In addition, other positions. The ultrasonic equip-
when potent diuretic therapy is used in the ment is mobile and can easily be trans-
treatment of ascites, ultrasound will docu- ported to the bedside. The examination is
ment the point at which fluid has been completely atraumatic and can be per-
eliminated, thus helping to avoid the formed by a trained technician with
hazards of overtreatment. The technique minimal time and expense.
will also prove useful in the demonstra- Department of Radiology
tion of ascites in obese patients, in whom Episcopal Hospital
Philadelphia, Penna. 19125
physical examination is more difficult.
Of the positions used to make these mea- REFERENCES
surements, the hand-knee and right lateral 1. Frimann-Dahl J: Roentgenologic examination
decubitus positions are the most sensitive, of acute abdominal lesions. Acta Radiol 20:438-451,
1939
perhaps because fluid trapped in the supine 2. Laurell H: A contribution to rdntgenological
position in the pelvis and the various ab- differential diagnosis in the presence of free fluid in
the abdomen. Acta Radiol (Proc Swedish Soc M
dominal spaces flows toward the dependent Radiol ) 16:424-425, 1935
22 B. B. GOLDBERG, G. A. GOODMAN, AND H. R. CLEARFIELD July 1970