Abdominal

ultrasonography

Autors:
Dr. Laura Liepiņa,
Dr. Nauris Zdanovskis,
Dīna Reitere,
Artūrs Šilovs,
Reinis Pitura






Sadarbībā ar:

un


Table of contents

POSITIONING OF THE PROBE ..........................................................................................................................................................3
MOVING THE PROBE .......................................................................................................................................................................3
HANDLING THE ULTRASOUND MACHINE AND IMPROVING THE VIEW ON THE SCREEN .....................................................................................4
ARTEFACTS....................................................................................................................................................................................4
MODES ........................................................................................................................................................................................5
ORIENTATION ................................................................................................................................................................................5
1. RIGHT UPPER QUADRANT- RIGHT KIDNEY AND LIVER. .....................................................................................................................6
1.1. Longitudinal section................................................................................................................................................6
1.2. Transversal section .................................................................................................................................................6
2. GALLBLADDER.....................................................................................................................................................................7
2.1. Longitudinal section .................................................................................................................................................7
2.2. Transversal section .................................................................................................................................................7
3. BIFURCATION OF THE PORTAL VEIN .......................................................................................................................................8
4. HEPATIC VEINS ....................................................................................................................................................................8
6. BIG VESSELS ........................................................................................................................................................................9
6.1. Aorta and A. mesenterica superior ..........................................................................................................................9
6.2. Vena cava inferior ..................................................................................................................................................10
6.3. Truncus coeliacus ...................................................................................................................................................11
6.4. Renal artery branching...........................................................................................................................................11
7. PANCREAS ........................................................................................................................................................................11
7.1. Transversal section ...............................................................................................................................................11
7.2. Longitudinal section..............................................................................................................................................12
8. SPLEEN .............................................................................................................................................................................13
9. LEFT KIDNEY .....................................................................................................................................................................14
10. BIFURCATION OF AORTA ................................................................................................................................................14
11. BLADDER......................................................................................................................................................................15
11.1. Cross section (transverse plane) ...........................................................................................................................15
11.2. Longitudinal section..............................................................................................................................................15

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 The Basics

Positioning of the probe

• The probe should be held tightly enough in order to achieve a stable position.
• The probe should be held in a comfortable grip so it would be easier to hold it in a position for a
longer while.
• A significant amount of pressure should always be applied to the probe – in many cases more
pressure is required than one usually expects.
• The ‘nose’ of the probe (the side with the orientation mark) (Fig.1) should always be directed either
towards the nose of the patient or to the nose of the examiner (typically to the right side of the
patient) to match the mark on the screen. E.g. in the transverse plane the mark should be directed
towards the examiner (you) (Fig.2) , in the sagittal plane it should be directed towards the patient’s
head. (Fig.3)

Fig. 1 Fig.2 Fig.3

Moving the probe
• Cranio-caudal (and medio-lateral) movement (sliding) – the probe should be maintained in a
sagittal or transverse plane and moved parallel to the skin either to cranial or caudal direction (just
like cleaning the table). Similar principle applies to medio-lateral movement. This way you are able
to scan an organ in a cranio-caudal or medio-lateral movement.
• Tilting movement – when an organ is located in a sagittal or transverse plane the probe should
be held still in one position and tilted to any side. This helps in situations where the
examination of an organ is limited by something (e.g. intercostal spaces limited by ribs) and
where it’s not enough to use cranio-caudal/medio-lateral movement. (Fig.4.)
• Rotation movement – most of the structures aren’t perfectly aligned parallel to sagittal or
transverse plane (e.g. vessels, tendons, nerves). This requires the rotation of the probe to find the
correct view of a structure. (Fig.4)

Fig. 4 Moving the probe

Ramsingh, D., & Gatling, J. (2018). Teaching Point-of-Care Ultrasound (POCUS) to the Perioperative Physician. In E. Bowe, R. Schell, & A. DiLorenzo (Eds.), Education in Anesthesia:
How to Deliver the Best Learning Experience (pp. 131-150). Cambridge: Cambridge University Press. doi:10.1017/9781316822548.013

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 Handling the ultrasound machine and improving the view on the screen
Controls are usually selected with the left hand while the right hand is used to grip the ultrasound probe.
• Gain (brightness) – usually a round, rotary button. Increasing the brightness (bright scan) allows to
see most of the structures but there’s a contrast loss. If the brightness is reduced (dark scan), the
contrast is increased but some of the structures may be harder to see. Achieving the perfect view is
intuitive and usually somewhere in the middle.
• Depth – allows to change the depth of the scan according to the structure one wants to visualize.
Superficial structures (e.g. gallbladder) typically require 4-5 cm depth, however, a deeper structure
(e.g. hepato-caval confluence) requires 10-15 cm depth.
• Freeze – allows to freeze the view on the screen. Typically necessary to measure the dimensions of a
specific structure. During this action the picture stays on the screen even when the probe isn’t placed
on the patient.

Artefacts
• Distal (acoustic) enhancement (Fig.5) – hyperechoic region behind an anechoic structure (e.g.
posterior to a fluid-filled structure).
• Mirror image artifact (Fig.6) – a mirror image of a preceding structure can be observed behind a highly
reflective surface (e.g. liver structure can be seen on both sides of the diaphragm– the highly reflective
structure).
• Reverberation artifact (Fig.7) – horizontal reflection lines (reflections) produced by a highly reflective
structure.
• Acoustic shadowing (Fig.8) – hypoechoic region behind a highly reflective surface (e.g. bone)
• Lateral (edge) shadow artifact (Fig.9) – hypoechoic region lateral to liquid-filled structures

Fig. 5. Distal (acoustic) enhancement Fig. 6. Mirror image artifact Fig. 7. Reverberation artifact

Fig. 8. Acoustic shadowing Fig. 9. Lateral (edge) shadow artifact

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Modes
• B mode (brightness mode) – standard mode in abdominal US;
• M mode (motion mode) – a single US beam is emitted and recorded for a specific time.
• Color Flow Doppler (CFD) – uses color to portray the blood flow in the vessels.
• Pulsed Wave Doppler (PWD) – allows the measurement of flow velocity at a specific point.

Orientation
• Structures and organs should typically be observed in both planes – sagittal and transverse
plane for complete examination.
• A good method for switching from one plane to another involves the rotation of the probe by 90o
counter-clockwise. This happens by locating the organ in one of the planes (e.g. sagittal plane),
holding the probe still, then rotating it 90o counter-clockwise to achieve visualization in the
transverse plane. This is best managed when the probe is positioned above the centre of an
organ. (Fig.10)

Fig. 10
Right kidney in longitudinal section
In this example probes orientation is marked by a circle with letter “P”. It points cranially, therefore the left
screen side corresponds cranial, and the right- caudal.

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 Standart positions

1. Right upper quadrant- right kidney and liver.

1.1. Longitudinal section
Patient in the supine position. Evaluate right kidney during a deep inspiration for best visualization. Place
the probe longitudinally subcostal on the right flank. Remember- kidney located relatively far dorsally in
the retroperitoneum. The homogeneity, renal pyramids and renal pelvis should be evaluated. The kidney
should always be scanned and measured in its full extent.
(Fig.11)

Fig. 11
1. Right kidney
2. Liver
3. M.psoas major
4. Spine
5. Diaphragm
6. Bowel (with
shadow sign)

1.2. Transversal section
For evaluating right kidney in transversal section rotate the probe 90° anticlockwise keeping section in
the center of the screen. (Fig.12)

Fig. 12
1. Right kidney
2. Liver
2 3. Gallbladder
3
1

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2. Gallbladder

2.1. Longitudinal section
For evaluating a gallbladder it is recommend not to eat for several hours before examination
to ensure adequate gallbladder distention and to reduce upper abdominal bowel gas.[2] The
patient should be examined in different positions (supine and left decubitus) for evaluating
intraluminar structures and their mobility (e.g. stones are mobile, polyps immobile).
Starting from the first position, follow the lower line of the liver and move the probe
medially. The gallbladder appears as an elongated anechogenic structure with thin wall (<3
mm). It is important to measure the wall for the presence of inflammation and to assess the
content of the gallbladder. (Fig. 13)

Fig. 13
1. Gallbladder
2. Liver
3. Portal veins
4. Hepatic veins
5. Diaphragm
6. Bowel (with
shadow sign)

2.2. Transversal section

In the transversal section the gallbladder appears circular and hypoechoic. The whole organ
should be assessed by tilting the probe. (Fig.14)

Fig. 14
1. Gallbladder
2. Liver
3. Right kidney
4. Diaphragm
5. Bowel (with
shadow sign)

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 3. Bifurcation of the portal vein
Angulate the probe closer to the abdominal wall until you can see the anechogenic portal vein
with highly echogenic wall. Follow it to its bifurcation into ramus dexter et sinister. This looks like
a jumping stag. (Fig.15)

Fig. 15 Bifurcation of the portal vein

4. Hepatic veins

Angulate the probe closer to the abdominal wall until you can see hepatic veins. Hepatic veins
don’t have hyperechogenic wall comparing with portal veins and their brunches. Usually you can
see V. hepatica dextra, media un sinistra, which are very easy to follow to their confluence into
the V. cava inferior. These calls “Hepatic venous star”. (Fig. 16)

Fig. 16
1. V. hep. dext.
2. V. hep. media
3. V. hep. sin.
4. V. cava inf.

5. CPC-cut– V. cava inferior, V. portae, Ductus choledochus

From the subcostal section you have to find the portal vein and you have to rotate the probe until
you can see it lengthwise (usually you can find it on a line between the right shoulder and the
navel). Ventral of the vein you will find the ductus choledochus, which is a small tubular structure. In
this region the cut of the V. cava inferior is more oval than round.

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 With a little bit of luck you can also find a cross section of the A. hepatica propria between the D.
choledochus and V.portae. (Fig. 17)

Fig. 17
1. V. portae
2. V. cava inf.
3. D. choledochus
4. A. hep. propria

6. Big vessels
The probe has to be placed under the sternum in a longitudinal cut. The mark shows towards the
head. When you angulate the probe a little, you can see the Aorta and the V.cava inferior.
You can distinguish them by their anatomic position and by seeking the arteries that leave the aorta.

6.1. Aorta and A. mesenterica superior
The Aorta appears anechoic. You can distinguish leavings of the Truncus coeliacus and A. mesenterica
superior.
You have to evaluate the diameter of aorta, focus on finding aneurysms and plaques. (Fig. 18)

Fig. 18
1. Aorta
2. Tr. coeliacus
3. A. mes. sup.
4. V. lienalis
5. Pancreas
6. Liver

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 Fig. 19
Color Doppler of the Aorta

6.2. Vena cava inferior

V. cava inferior is located on the right side of the Aorta and is anechoic structure. It shows no
brunches. (Fig.20)

Fig. 20
1. V. cava inferior
2. Heart
3. Liver
4. Kidney

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 6.3. Truncus coeliacus
Put probe below the sternum and follow the aorta untill you find swallow or fin shaped stucture –
that is Truncus coeliacus. Now you can evaluate the continuity of the artery and its anatomical
features.

Fig. 21
1. Aorta
2. Tr. coeliacus
3. A. hep. com.
4. A. lienalis

6.4. Renal artery branching

From the large blood vessels cross-section move down. Probes marker must be facing you. Here you
can visualize the aorta, A. renalis dextra et sinistra, A. mesenterica superior, V. cava inferior, and spine.
All of these structures can be difficult to see due to the contents of the intestines (gases).

7. Pancreas
7.1. Transversal section
Place the probe in a horizontal position (transversely) below the sternum. Follow the aorta down to
see A. mesenterica superior ventrally coming from the aorta. You will see the spleen vein longitudinal
view (longitudinal section). It is a structure that always points to the region of interest - the pancreas.
The pancreas is ventral to the spleen and its parenchyma is homogeneous, isoheogenic or
hyperehogenic compared to hepatic parenchyma. (Fig.22)

Fig. 22
1. Aorta
2. A. mes. sup.
3. V. lienalis
4. Pancreas

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7.2. Longitudinal section
Rotate the probe to obtain a longitudinal view of the pancreas and surrounding tissue, continuing to
focus on the structure in question in the middle of the image. Pancreas, liver, aorta, A. mesenterica
superior, V. linealis, V. cava inferior should be seen.

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 8. Spleen
Move the probe to the right. Position it in the intercostal slit along the linea axillaris media (or
linea axillaris posterior). If the probe is held firmly upright, the ribs can cast a shadow without
allowing full view of the spleen in longitudinal view. Rotate the probe clockwise and change the
spacer gaps until the spleen is fully visible. It may be more cranial and dorsal than it could be
seem. As well as causing the patient to take a deep breath and hold it. Next, the spleen should be
measured, its size and the parenchyma homogeneity assessed. (FIg. 23)

Fig. 23
1. Spleen
2. Hilum of the spleen
3. Diaphragm
4. Shadow sign of the bowel
5. Shadow sign of the rib

Fig. 24
Color Doppler of the spleen blood vessels

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 9. Left kidney
Position and probe remain in the same position as when looking at the spleen. You may need to
skew probe down or move it 1-2 slit gaps below. The aim is to evaluate kidney size, parenchyma,
sinus, calices and pyelon. Often observed pathologies include cysts and hydronephrosis.(Fig.25)

Fig. 25
1. Spleem
2. Left kidney
3. M. psoas

10. Bifurcation of Aorta
Tilt the probe transversely (similar to looking at the pancreas) under the sternum and while
holding the aorta in the field of vision move the probe down until you see its bifurcation. Aortic
bifurcation is about the height of the navel and it decomposes a. Iliaca communis dextra et sinistra.

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 11. Bladder
11.1. Cross section (transverse plane)
Place the probe above the pubic symphysis to obtain a cross-sectional view. Probe marker points
to you. If the bladder is well filled, it can be visualized as an anechogenic structure. When
investigating a woman, behind the bladder you can see the uterus. Below you can visualize the
vagina. Investigating a man can be visualized rectum and prostate. (Fig.26)

Fig. 26
1. Bladder
2. Uterus

11.2. Longitudinal section
Longitudinal view is obtained by rotating the probe counterclockwise until the probe is completely
upright. In both planes the bladder content, wall position thickness as well should be evaluated if
necessary, measure the bladder volume. Recent injuries or abnormalities in the case of a process,
fluid (including blood) may accumulate in the abdomen. And hence free liquid in the case of
abdominal cavity, blood may accumulate. It is most commonly seen in the umbilical space of women
(between rectum and uterus) or in the rectovecal space for men. Small amount of free liquid (up to
about 1-1.5cm) can be in women of childbearing age until menopause. (Fig.27)


Fig. 27
1. Bladder
2. Uterus
3. Vagina
4. Rectum

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Standart values

Pancreas Ductus pancreaticus (Virsunga vads): <2-3
mm
Head <3 cm
Body <2,5 cm
The tail <2,5 cm

Spleen Length between poles: <11 cm
Width at spleen gate level: <4 cm
Kidneys Length: 9-13 cm
Width: 4-6 cm
Bladder < 550 ml (female)
< 750 ml (male)
Residual urine < 50 ml
Liver <18 cm
Gallbladder Length <120 mm
Width <40 mm
Wall: 3-4 mm
Ductus choledochus <6-8 mm
After cholecystectomy: <10mm
Portal vein <1,3 cm
Signs of portal hypertension if >1,5 cm
Aorta Suprarenal <2,5 cm
Infrarenal <2,0 cm
Aneurysm if >3 cm
Aneurysmal extension 2,5-3 cm
V. cava inferior <2,5 cm
Hepatic veins <1 cm

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