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Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
Abdominal Sonography
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Abdominal Sonography

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

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