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Abdominal Sonography
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Abdominal Sonography

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Abdominal Sonography Abdominal Sonography Presentation Transcript

  • Abdominal Sonography 1st Department of Medicine Albert-Szent Györgyi Medical University
  • Advantages of the ultrasound method (1)
    • there isn’t any contraindication
    • non-invasive
    • it is able to visualise the examined organ
    • together with surrounding structures
  • Advantages of the ultrasound method (2)
    • it doesn’t need
      • contrast material,
      • X - ray, or
      • isotopes
    • organs and their morphologic alterations can be visualised independently of their functional state
  • Disadvantages of the ultrasound method
    • it may be less effective due to
      • obesity (subcutaneous fat)
      • gas (gastric or intestinal)
      • in patients having ascitic fluid
      • lack of co-operation (dyspnea)
  • General considerations
    • The sonogram should be evaluated from the clinical point of view
    • Sonography should be the first examination in patients having diseases of the
      • liver
      • biliary system
      • pancreas
      • urinary tract
  • Diagnostic examination of the liver
    • normal liver
      • liver parenchyma is visualised as a uniform pattern of a medium-strength echoes, stronger than spleen and renal, but weaker than pancreas parenchyma
    • liver size - enlarged or not
    • diffuse liver diseases
  • Diagnostic examination of the liver
    • liver size -
      • enlarged, shrinking,
    • diffuse liver diseases
      • more echogenic
        • cirrhosis, fatty infiltration
      • not specific - biopsy needed!
  • Diagnostic examination of the liver
    • focal liver diseases
      • benign / malignant
      • cystic, solid, mixed focal lesions
      • primary / secondary
      • not specific - ultrasonically guided percutaneous puncture/biopsy
  • Benign focal hepatic disease hepatic cyst
    • congenitally aberrant bile ducts
    • increasing frequency with age (2.5 - 7%)
    • manifestation of polycystic disease (kidney!)
    • anechoic (acoustic enhancement)
    • no perceptible wall
    • diff.dg.: abscess, hematoma, echinococcus biliary cystadenoma (aspiration)
  • Benign focal hepatic disease pyogenic abscess
    • favour the right lobe
    • irregular, poorly defines wall
    • internal echo pattern:
      • transonic, echogenic
      • equals that of the liver
    • aspiration - aspirate for culture
  • Benign focal hepatic disease echinococcal cyst
    • a maturational sequence from simple -> multiple cyst -> calcified cyst
      • ectocysts (daughter cysts)
      • endocysts, pericyst - hypoechoic
    • cysts can be
      • secondarily infected
      • endocyst layers can rupture
    • after resection a cystic cavity can remain
  • Benign focal hepatic disease amoebic abscess
    • commonly in the right lobe (peripheral)
    • typically lack border echoes
    • around the border often inhomogeneous
    • internal echoes (pyogenic)
      • aspiration - hemorrhage, pyogenic fluid
      • microscopically - evident of amoebas
  • Benign focal hepatic disease hematoma
    • central or peripheral
    • with or without rupture of the capsule
    • initially echogenic -
    • hypoechoic or cystic with time
    • diff.dg.: trauma, adenoma, malignancy, A - V malformation, iatrogenic
  • Benign focal hepatic disease hemangioma
    • most common except for hepatic cysts
    • present in 4 - 7% of the population
      • higher incidence in woman
      • most common in the posterior right lobe
      • multiple in up to 10% of cases
      • less than 3 cm in diameter
  • Benign focal hepatic disease hemangioma
    • typical appearance
      • hyperechoic focal lesion (80%)
      • hypoechoic focal mass (20%)
      • well circumscribed, homogeneous
      • never have hypoechoic border
      • can have acoustic enhancement
    • follow up in 3 - to 6 months
    • aspiration - through normal liver
  • Benign focal hepatic disease focal nodular hyperplasia (FNH)
    • disordered regeneration along a scar due to vascular thrombosis
    • multiple in 20% of cases
    • female - male 2:1
    • often located near the surface
    • echogenic structure variable
    • Tc-99m sulfur colloid (no bile ducts)
    • has no malignant potencial (biopsy?)
  • Benign focal hepatic disease liver cell adenoma
    • always solitary in young women
    • symptoms of necrosis and hemorrhage
    • may have slight malignant potential
    • well-demarcated mass with variable echoes
    • do not contain Kupffer cells (colloid scan)
  • Benign focal hepatic disease fatty masses / focal sparing
    • reversible (alcohol, diabetes, steroid)
    • rapid appearance within few days
    • segmental or subsegmental
    • normal distribution of vessels in and around
    • fatty masses
      • mimic hemangioma
    • focal sparing
      • transonic lesion (CT, NMR confirmation)
  • Malignant hepatic disease hepatocellular carcinoma
    • signs obscured by hepatitis or cirrhosis AFP is elevated (60-70%)
    • can be solitary, multiple or diffuse
    • echogenicity varies with histologic composition
    • tumour invasion (hepatic, portal veins!)
    • colour Doppler - basket pattern
    • CT, NMR, - biopsy
  • Malignant hepatic disease metastatic focal lesions
    • controversial and constantly evolving
    • metastases can be:
      • echogenic, hypoechoic, anechoic or mixed
    • some associations:
      • colon cancer - hyperechoic
      • leiomyosarcoma - anechoic
      • rapidly expanding - hypoechoic halo
    • ultrasound-guided biopsy - surgery
  • Sonography of the Gallbladder and the Bile Ducts
    • Sonography should be the first examination in patients having diseases of the
      • liver
      • biliary system
        • gallbladder and the bile ducts
      • pancreas
  • Indications (Gallbladder)
    • stone disease
    • cholecystitis (acute/chronic)
    • hydrops/empyema
    • tumour (cc. of the gallbladder)
    • pain (right subcostal)
    • assessment of contractility
  • Indications (Bile Ducts)
    • Common Bile Duct stone
    • Cholestatic jaundice
      • (intra/extrahepatic)
    • Obstructive jaundice
      • (cause, localisation)
    • Pneumobilia
  • Stones in the Gallbladder
    • echogenic (echorich)
    • “ shadow“
    • stone - (min. 2-3 mm)
    • accuracy > 95%
  • Sludge in the Gallbladder
    • echogenic layer
    • without “shadow“
    • crystal(s) - (max. 2-3 mm)
    • movable dots
  • Polyp, Tumour
    • fixed echogenic area
    • liver infiltration
    • metastatic liver
  • Cholecystitis
    • acute
    • pain (under transducer)
    • stone / sludge
    • hydrops /empyema
    • wall oedema (transonic)
    • pericholecystitis
  • Cholecystitis
    • chronic
    • stone (history)
    • wall fibrotic (echogenic)
    • shrinkened
  • Complications
    • pericholecystic fluid
    • liver abscess
    • subhepatic abscess
    • subphrenic fluid collection
  • Bile Duct Stones
    • sensitivity - 50%
    • bile duct dilatation
    • stone / shadow / dilatation
    • intrahepatic / extrahepatic
  • Diagnostic value of the ultrasound in jaundice
    • dilated bile ducts = obstruction
    • place of the obstruction
      • proximal - distal
    • cause of the obstruction
      • stone - tumour
  • Diagnostic examination of the pancreas (1)
    • pancreas size (head, body, tail)
      • enlarged, shrinked,
    • diffuse alterations in the echo pattern
      • echogenic, transonic, peripancreatic
      • acute / chronic pancreatitis
      • Wirsung duct alterations
  • Diagnostic examination of the pancreas (2)
    • focal diseases
      • benign / malignant
      • cystic, solid, mixed focal lesions
      • primary / secondary /retroperitoneal
      • not specific - CT, MRI,
      • ultrasonically guided percutaneous puncture/biopsy
  • Indications
    • epigastric pain
    • pancreatitis (acute, chronic)
      • follow -up
    • jaundice (head tumour)
    • newly developed diabetes
  • Acute (oedematous) pancreatitis
    • Head oedema
      • enlarged, transonic
      • compressed Wirsung duct
    • Tail oedema
      • enlarged, transonic
  • Pancreatitis follow-up
    • irregular echo pattern
    • transonic areas (necrosis?)
    • pseudocyst formation (peripancreatic)
    • uncinate process cyst
    • pancreas head - pseudocyst
    • epigastrial fluid collection
  • Chronic pancreatitis
    • echogenic,
    • calcified
    • cystic
    • solid (tumour?)
  • Pancreas tumour
    • transsonic (echogenic)
    • endocrine tumour
    • endosonography
    • US guided biopsy
  • Diagnostic examination of the kidney
    • normal kidney (anatomy)
      • parenchyma - (1.5 -2.5 cm) weaker than liver
      • size (8-10 cm x 4-5 cm)
      • pyelon - echogenic
    • renal artery and vein
    • urether - not visualised
  • Indications
    • lumbar pain
    • hematuria
      • nephritis (acute, chronic)
      • stone disease, cyst, tumour
    • pyelonephritis
    • renal insufficiency
    • renal transplant (rejection)
  • Diagnostic examination of the spleen
    • normal spleen
      • size (10 x 4 cm)
    • indications
      • splenomegaly
      • focal diseases
        • lymphoma, hemangioma, infarct
        • hematoma (rupture)
  • Diagnostic examination of the retroperitoneum
    • abdominal aorta
      • ectasia, aneurysm
    • inferior cava vein
      • thrombosis
    • lymphnodes
      • lymphoma, metastasis
  • Palpable (bowel?) masses
    • bowel tumour (colon)
      • normal wall < 5 mm
    • inflammatory masses
      • IBD (Crohn’s disease)
    • fluid collections (abscesses)
  • Ultrasound guided interventions
    • biopsy guide transducer
    • needle direction
      • needle types
    • diagnostic interventions
      • aspiration
      • core biopsy
  • Ultrasound guided interventions
    • therapeutic interventions
      • fluid (cyst) evacuation
      • cyst sclerotherapy
      • abscess drainage
      • PT bile duct drainage
      • tumour ablation
  • Cytology - histology
    • aspiration
      • sigillocellular tumour cells
      • medullar cells from the spleen
    • core biopsy
      • pancreas adenocc.
      • HCC
  • Endoscopic ultrasound (EUS)
    • radial scanning (diagnostic)
      • endoscopic
      • sonoprobe
        • upper - lower GI tract
    • longitudinal scanning
      • endoscopic
      • diagnostic and therapeutic
  • WEB sites
    • VH Dissector – Visible Human Project
      • www.toltech.net