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Abdominal Sonography  1st Department of Medicine Albert-Szent Györgyi Medical University
Advantages of the ultrasound method (1) <ul><li>there isn’t any contraindication </li></ul><ul><li>non-invasive </li></ul>...
Advantages of the ultrasound method (2) <ul><li>it doesn’t need  </li></ul><ul><ul><li>contrast material, </li></ul></ul><...
Disadvantages of the ultrasound method <ul><li>it may be less effective due to </li></ul><ul><ul><li>obesity (subcutaneous...
General considerations <ul><li>The sonogram should be evaluated from the clinical point of view </li></ul><ul><li>Sonograp...
Diagnostic examination of the liver <ul><li>normal liver </li></ul><ul><ul><li>liver parenchyma is visualised as a uniform...
Diagnostic examination of the liver <ul><li>liver size - </li></ul><ul><ul><li>enlarged, shrinking, </li></ul></ul><ul><li...
Diagnostic examination of the liver <ul><li>focal liver diseases </li></ul><ul><ul><li>benign / malignant </li></ul></ul><...
Benign focal hepatic disease hepatic cyst <ul><li>congenitally aberrant bile ducts </li></ul><ul><li>increasing frequency ...
Benign focal hepatic disease pyogenic abscess <ul><li>favour the right lobe </li></ul><ul><li>irregular, poorly defines wa...
Benign focal hepatic disease echinococcal cyst <ul><li>a maturational sequence from simple -> multiple cyst -> calcified c...
Benign focal hepatic disease amoebic abscess <ul><li>commonly in the right lobe (peripheral) </li></ul><ul><li>typically l...
Benign focal hepatic disease hematoma <ul><li>central or peripheral </li></ul><ul><li>with or without rupture of the capsu...
Benign focal hepatic disease hemangioma <ul><li>most common except  for hepatic cysts </li></ul><ul><li>present in 4 - 7% ...
Benign focal hepatic disease hemangioma <ul><li>typical appearance </li></ul><ul><ul><li>hyperechoic focal lesion (80%) </...
Benign focal hepatic disease focal nodular hyperplasia (FNH) <ul><li>disordered regeneration along a scar due to vascular ...
Benign focal hepatic disease liver cell adenoma <ul><li>always solitary in young women </li></ul><ul><li>symptoms of necro...
Benign focal hepatic disease fatty masses / focal sparing <ul><li>reversible (alcohol, diabetes, steroid) </li></ul><ul><l...
Malignant hepatic disease hepatocellular carcinoma <ul><li>signs obscured by hepatitis or cirrhosis AFP is elevated (60-70...
Malignant hepatic disease metastatic focal lesions <ul><li>controversial and constantly evolving </li></ul><ul><li>metasta...
Sonography of the Gallbladder and the Bile Ducts <ul><li>Sonography should be the first examination in patients having dis...
Indications (Gallbladder) <ul><li>stone disease </li></ul><ul><li>cholecystitis (acute/chronic) </li></ul><ul><li>hydrops/...
Indications (Bile Ducts) <ul><li>Common Bile Duct stone </li></ul><ul><li>Cholestatic jaundice </li></ul><ul><ul><li>(intr...
Stones in the Gallbladder <ul><li>echogenic (echorich) </li></ul><ul><li>“ shadow“ </li></ul><ul><li>stone - (min. 2-3 mm)...
Sludge in the Gallbladder <ul><li>echogenic layer </li></ul><ul><li>without “shadow“ </li></ul><ul><li>crystal(s) - (max. ...
Polyp, Tumour <ul><li>fixed echogenic area </li></ul><ul><li>liver infiltration </li></ul><ul><li>metastatic liver </li></ul>
Cholecystitis <ul><li>acute </li></ul><ul><li>pain (under transducer) </li></ul><ul><li>stone / sludge </li></ul><ul><li>h...
Cholecystitis <ul><li>chronic </li></ul><ul><li>stone (history) </li></ul><ul><li>wall fibrotic (echogenic) </li></ul><ul>...
Complications <ul><li>pericholecystic fluid </li></ul><ul><li>liver abscess </li></ul><ul><li>subhepatic abscess </li></ul...
Bile Duct Stones <ul><li>sensitivity - 50% </li></ul><ul><li>bile duct dilatation </li></ul><ul><li>stone / shadow / dilat...
Diagnostic value of the ultrasound in jaundice <ul><li>dilated bile ducts = obstruction </li></ul><ul><li>place of the obs...
Diagnostic examination of the pancreas (1) <ul><li>pancreas size (head, body, tail) </li></ul><ul><ul><li>enlarged, shrink...
Diagnostic examination of the pancreas (2) <ul><li>focal diseases </li></ul><ul><ul><li>benign / malignant </li></ul></ul>...
Indications <ul><li>epigastric pain </li></ul><ul><li>pancreatitis (acute, chronic) </li></ul><ul><ul><li>follow -up </li>...
Acute (oedematous) pancreatitis <ul><li>Head oedema </li></ul><ul><ul><li>enlarged, transonic </li></ul></ul><ul><ul><li>c...
Pancreatitis follow-up <ul><li>irregular echo pattern  </li></ul><ul><li>transonic areas (necrosis?) </li></ul><ul><li>pse...
Chronic pancreatitis <ul><li>echogenic,  </li></ul><ul><li>calcified </li></ul><ul><li>cystic </li></ul><ul><li>solid (tum...
Pancreas tumour <ul><li>transsonic (echogenic) </li></ul><ul><li>endocrine tumour </li></ul><ul><li>endosonography </li></...
Diagnostic examination of the kidney <ul><li>normal kidney (anatomy) </li></ul><ul><ul><li>parenchyma - (1.5 -2.5 cm) weak...
Indications <ul><li>lumbar pain </li></ul><ul><li>hematuria </li></ul><ul><ul><li>nephritis (acute, chronic) </li></ul></u...
Diagnostic examination of the spleen <ul><li>normal spleen </li></ul><ul><ul><li>size (10 x 4 cm) </li></ul></ul><ul><li>i...
Diagnostic examination of the retroperitoneum <ul><li>abdominal aorta </li></ul><ul><ul><li>ectasia, aneurysm </li></ul></...
Palpable (bowel?) masses <ul><li>bowel tumour (colon) </li></ul><ul><ul><li>normal wall < 5 mm </li></ul></ul><ul><li>infl...
Ultrasound guided interventions <ul><li>biopsy guide transducer </li></ul><ul><li>needle direction </li></ul><ul><ul><li>n...
Ultrasound guided interventions <ul><li>therapeutic interventions </li></ul><ul><ul><li>fluid (cyst) evacuation </li></ul>...
Cytology - histology <ul><li>aspiration </li></ul><ul><ul><li>sigillocellular tumour cells </li></ul></ul><ul><ul><li>medu...
Endoscopic ultrasound (EUS) <ul><li>radial scanning (diagnostic) </li></ul><ul><ul><li>endoscopic </li></ul></ul><ul><ul><...
WEB sites <ul><li>VH Dissector – Visible Human Project </li></ul><ul><ul><li>www.toltech.net </li></ul></ul>
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Abdominal Sonography

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Transcript of "Abdominal Sonography"

  1. 1. Abdominal Sonography 1st Department of Medicine Albert-Szent Györgyi Medical University
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 11. Benign focal hepatic disease echinococcal cyst <ul><li>a maturational sequence from simple -> multiple cyst -> 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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 > 95% </li></ul>
  25. 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. 26. Polyp, Tumour <ul><li>fixed echogenic area </li></ul><ul><li>liver infiltration </li></ul><ul><li>metastatic liver </li></ul>
  27. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 43. Palpable (bowel?) masses <ul><li>bowel tumour (colon) </li></ul><ul><ul><li>normal wall < 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. 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. 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. 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. 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. 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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