atlas of emergency ultrasound - j. fox (cambridge, 2011) ww

www.cambridge.org/9780521191685

Atlas of Emergency Ultrasound

Atlas of Emergency Ultrasound

Edited by

John Christian FoxUniversity of California, Irvine School of Medicine, CA, USA

C AM B R I D G E UN I V E R S I T Y P R E S S

Cambridge, New York, Melbourne, Madrid, Cape Town,Singapore, São Paulo, Delhi, Tokyo, Mexico City

Cambridge University PressThe Edinburgh Building, Cambridge CB2 8RU, UK

Published in the United States of America byCambridge University Press, New York

www.cambridge.orgInformation on this title: www.cambridge.org/9780521191685

© J.C. Fox 2011

This publication is in copyright. Subject to statutory exceptionand to the provisions of relevant collective licensing agreements,no reproduction of any part may take place withoutthe written permission of Cambridge University Press.

First published 2011

Printed in the United Kingdom at the University Press, Cambridge

A catalog record for this publication is available from the British Library

Library of Congress Cataloging-in-Publication Data

Atlas of emergency ultrasound / edited by John Christian Fox.p. ; cm.

Includes index.ISBN 978-0-521-19168-5 (hbk.)1. Diagnostic ultrasonic imaging–Atlases. 2. Emergency medicine–

Diagnosis–Atlases. I. Fox, J. Christian.[DNLM: 1. Ultrasonography–Atlases. 2. Emergency Treatment–

Atlases. WN 17]RC78.7.U4A85 2011616.070543–dc22

2011008590

ISBN 978-0-521-19168-5 Hardback

Cambridge University Press has no responsibility for the persistence oraccuracy of URLs for external or third-party internet websites referred toin this publication, and does not guarantee that any content on suchwebsites is, or will remain, accurate or appropriate.

Every effort has been made in preparing this book to provide accurate andup-to-date information which is in accord with accepted standards andpractice at the time of publication. Although case histories are drawn fromactual cases, every effort has been made to disguise the identities of theindividuals involved. Nevertheless, the authors, editors, and publishers canmake no warranties that the information contained herein is totally freefrom error, not least because clinical standards are constantly changingthrough research and regulation. The authors, editors, and publisherstherefore disclaim all liability for direct or consequential damages resultingfrom the use of material contained in this book. Readers are stronglyadvised to pay careful attention to information provided by the manufacturerof any drugs or equipment that they plan to use.

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Contents

List of contributors viPreface vii

1. Focused assessment of sonography intrauma 1Patricia Fermin and John Christian Fox

2. Ocular ultrasound 19George Mittendorf and John Christian Fox

3. Cardiac ultrasound 26Shane Summers

4. Ultrasound of the lung 35Justin Davis and Seric Cusick

5. Right upper quadrant ultrasonography 58Daniel Gromis and John Christian Fox

6. Intestinal ultrasound 77Warren Wiechmann and Chase Warren

7. Pelvic ultrasound 88Cindy Chau and John Christian Fox

8. Genitourinary ultrasound 103Christina Umber and John Christian Fox

9. Musculoskeletal ultrasound 133Deborah Shipley Kane and Jennifer McBride

10. Pediatric ultrasound 141Stephanie Doniger and George Mittendorf

11. Ultrasound-guided procedures 158Eric J. Chin

12. Arterial ultrasound 175Sharis Simonian and John Christian Fox

13. Venous ultrasound 185Kevin Burns and John Christian Fox

Index 191

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Typewritten Text

Contributors

Kevin BurnsNew York University School of Medicine, New York,New York, USA

Cindy Chau, MDResident, OB/GYN, University of California, IrvineMedical Center, Orange, California, USA

Eric J. Chin, MD, RDMS, MAJ, USA, MCAssociate Program Director, Emergency UltrasoundFellowship, Staff Emergency Physician, Brooke ArmyMedical Center, San Antonio Uniformed ServicesHealth Education Consortium,San Antonio, Texas, USA

Seric Cusick, MD, RDMSDepartment of Emergency Medicine,Hoag Hospital, Newport Beach, California, USA

Justin DavisKaiser Oakland Medical Center,Oakland, California, USA

Stephanie Doniger, MD, RDMSDirector of Emergency Ultrasound, Children’sHospital and Research Center Oakland, Oakland,California, USA

Patricia Fermin, MDResident, Emergency Medicine,Harbor-UCLA Medical Center, Los Angeles,California, USA

John Christian Fox, MD, Clinical RDMSProfessor of Emergency Medicine, Director ofInstructional Ultrasound, University of California,Irvine Medical Center, Orange, California, USA

Daniel Gromis, MDResident, Emergency Medicine, Advocate ChristHospital and Medical Center, Chicago, Illinois, USA

Jennifer McBride, MDResident, Emergency Medicine,Georgetown University, Washington, DC,USA

George Mittendorf, MDResident, Emergency Medicine,UCSF – Fresno, Fresno, California,USA

Deborah Shipley Kane, MD, RDMSClinical Instructor, Ultrasound Director,Washington University of St. Louis,St. Louis, Missouri, USA

Sharis Simonian, MDResident, Emergency Medicine,University of California, Irvine, Orange,California, USA

Shane Summers, MD, RDMSProgram Director, Emergency UltrasoundFellowship, Assistant Professor of Military andEmergency Medicine,San Antonio Uniformed Services Health EducationConsortium, San Antonio, Texas,USA

Christina Umber, MDResident, Emergency Medicine,UCSF – Fresno, Fresno,California, USA

Chase WarrenUniversity of California, Irvine, Orange,California, USA

Warren Wiechmann, MD, RDMSAssistant Professor of Emergency Medicine,UCSF – Fresno, Fresno, California,USAvi

Preface

When a physician examines a patient at the bedsideusing the physical exam alone they are forced to rely ontheir “mind’s eye” to imagine what organs or tissuebelow the skin that could be the culprit of their patient’sailment. With the advent of portable bedside ultra-sound, physicians are now able to image the organsand tissue directly at the point-of-care, creating animmediate impact on patient care. Harnessing thistechnology transforms the doctor–patient relationshipfrom the time of Hippocrates to the modern day.Physician-performed imaging results in greater clinicalself-reliance, reducing unnecessary CT scans, therebycausing less radiation exposure.

The Atlas of Emergency Ultrasound is designed togive the busy practicing clinician a reference tool ofpositives. Each organ is represented with common andnot so common pathological entities one encounterswhen practicing emergency ultrasound. This path-ology is clearly outlined by line-art, with detailedcaptions drawing the reader to salient points. This isnot meant to be an exhaustive didactic reference, oreven an introduction toobtaining ultrasoundwindows.This book picks up where introductory courseworkends. There already exist plenty of references designed

to teach the basics of image acquisition and ultrasoundphysics. This book assumes the reader has alreadybegun to incorporate ultrasound into practice, and isnow ready to take those skills further by focusing onpathology.

While the focus is on emergency ultrasound, thereare other specialties that would likely benefit from thepathology found in this text. Physicians who practiceprimary care will likely find many relevant images tolearn from especially with regards to the gallbladder,pelvis, and vasculature, while physicians in the ICUsetting will find the cardiac, DVT, and lung chapters ofparticular interest. Furthermore, surgeons looking forpathology related to the hepato-biliary system, softtissue, and vasculature will find information relevant totheir practice. Finally, as medical students are expectedto performmore and more ultrasound at the bedside oftheir patients on rotations in the emergency department,the ICU, surgery, andObst/Gyn, they toowill findhelpfulimages to help them perform well on these clerkships.

Ultimately, Hippocrates would be proud of thephysician who can utilize any simple bedside tool toelaborate on the physical exam, but only if that toolwould result in “first do no harm.”

vii

Chapter

1Focused assessment of sonography in trauma

Patricia Fermin and John Christian Fox

Epicardial fat padWhen imaging the heart, careful attention must bemade in identifying any surrounding fluid. The pres-ence of epicardial fat should be ruled out to have aclear determination of the presence of fluid.

HemopericardiumAn examination of the heart is crucial during traumato the chest, such as a stabbing, gunshot wound, ormotor vehicle collision. The identification of bloodsurrounding the heart is critical in order to prevent or

Atlas of Emergency Ultrasound, ed. John Christian Fox. Published by Cambridge University Press. © J.C. Fox 2011.

Epicardial fat pad: In this subxiphoid view, the four chambers ofthe heart (H) are difficult to visualize. However, a layer of fat (arrows)surrounding the heart may be seen. It is important to distinguishepicardial fat from hemopericardium, which is more echolucent.

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treat cardiac tamponade. The contractility of the heartwill also assist in determining the severity of thehemopericardium.

Left chest viewThe view of the left chest is additionally essential withtrauma to the chest, such as in a stabbing, gunshot

wound, or motor vehicle collision. The diaphragm is asignificant marker, which will have the fluid superiorto it. Fluid found in this area reveals a traumatichemothorax.

Hemopericardium: In this subxiphoid view, blood (arrows)surrounding the heart is found in a patient stabbed through thechest. There is a clear view of the echolucent space between thevisceral and parietal pericardium and the right ventricle (RV) andleft ventricle (LV).

Hemopericardium: In this subxiphoid view, blood (arrows)surrounding the heart is found in a patient stabbed through thechest. There is a clear view of the echolucent space between thevisceral and parietal pericardium and the right ventricle (RV), leftventricle (LV), right atrium (RA), and left atrium (LA).

Hemopericardium: In this subxiphoid view, blood (asterisks)surrounding the heart is found in a patient stabbed through thechest. There is a clear view of the echolucent space between thevisceral and parietal pericardium and the right ventricle (RV) and leftventricle (LV). The arrow refers to the anterior pericardium.

Hemopericardium: In this subxiphoid view, blood (asterisks)surrounding the heart is found in a patient stabbed through thechest. There is a clear view of the echolucent space between thevisceral and parietal pericardium and the right ventricle (RV), leftventricle (LV), right atrium (RA), and left atrium (LA). The arrow refersto the anterior pericardium.

Chapter 1: Focused assessment of sonography in trauma

2

Fluid in the left chest: Placing the transducer on the left axillary line superior to the rib margin with the indicator facing up, revealsfluid (F) in the patient’s left chest. The spleen (S) and diaphragm (arrows) are clearly visualized. This view is useful when there is trauma tothe chest, such as in a motor vehicle collision, stabbing, or gunshot wound.


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Morrison’s pouchThe examination of the Morrison’s pouch, the recessbetween the liver and kidney is crucial during traumato the abdomen or pelvis. Damage to internal organs

and blood vessels will result in fluid settling in thisarea primarily. A clear view of the liver and kidneyshould be obtained, which normally would not presentwith fluid in between.

Fluid in the left chest: Placing the transducer on the left axillaryline superior to the rib margin with the indicator facing up, revealsfluid (F) in the patient’s left chest. The spleen (S), kidney (K), anddiaphragm (arrows) are clearly visualized. This view is useful whenthere is a trauma to the chest, such as in a motor vehicle collision,stabbing, or gunshot wound.

Normal view of Morrison’s pouch: In this normal view of the Morrison’s pouch, the recess between the liver and kidney, the transducer isplaced in the right axillary line at the rib margin with the indicator facing up. There is a clear view of the liver (L) and kidney (K) with nopresence of fluid.


4

Fluid in Morrison’s pouch: In this view, there is remarkable freefluid (double arrow) in Morrison’s pouch, between the liver (L) andkidney (K). This is valuable during blunt trauma to the abdomenor pelvis causing damage to internal organs and blood vessels, withfluid settling in this area.

Fluid in Morrison’s pouch: In this view, there is remarkable free fluid (double arrow) in Morrison’s pouch, between the liver (L) andkidney (K). This is valuable during blunt trauma to the abdomen or pelvis causing damage to internal organs and blood vessels, with fluidsettling in this area. Keep in mind that rib shadow (asterisk) may obstruct the view.


5

PelvisExamining the lower abdomen of a patient after atrauma may reveal free fluid around bowel. This is asign that major injury has occurred in the abdomenor pelvis.

Pericardial clotWhile examining the heart, a pericardial clot may bevisualized instead of newly escaped blood. Thisreveals that the trauma has occurred for a significantperiod and careful examination of heart activityshould be performed.

Fluid in Morrison’s pouch: In this view, there is remarkable free fluid (arrows) in Morrison’s pouch, between the liver (L) and kidney (K).This is valuable during blunt trauma to the abdomen or pelvis causing damage to internal organs and blood vessels, with fluid settlingin this area.

Fluid around loops of bowel: In this view, the transducer is placed on the lower abdomen of the patient. There is a clear view offree fluid (F) around the loops of bowel (arrows).


6

Pericardial clot: This subxiphoid view was obtained on a patient with a gunshot wound to the chest. The chambers of the heart (H)are not clearly visualized; however, an echodense clot (C) between the visceral and parietal pericardium (arrows) may be seen.

Pericardial clot: This subxiphoid view was obtained on a patient with a gunshot wound to the chest. All four chambers of the heartare clearly visualized – the right ventricle (RV), left ventricle (LV), right atrium (RA) and the left atrium (LA). Additionally, an echodense clot(asterisk) between the visceral and parietal pericardium (arrow) may be seen.

Pericardial clot: This subxiphoid view was obtained on a patient with a gunshot wound to the chest. The right ventricle (RV) and leftventricle (LV) of the heart are clearly visualized. Additionally, an echodense clot (asterisks) between the visceral and parietal pericardium (arrow)may be seen.


7

Perinephric fatWhile visualizing Morrison’s pouch and the spleno-renal recess, careful consideration of perinephric fatshould be obtained. This should not be mistaken forfree fluid, which has contrasting echogenicities.

Right chestThe view of the right chest is essential as well whenperforming an exam on the left side with trauma tothe chest. The diaphragm is a significant marker,which will have the fluid superior and the liver infer-ior to it. Fluid found in this area reveals a traumatichemothorax.

Fluid in the right chest: Placing the transducer on the right axillary line, superior to the rib with the indicator facing up reveals fluid (F)in the patient’s right chest. This fluid is bordered by the diaphragm (arrows) below and with a clear view of the liver (L). This view is alsouseful when there is trauma to the chest, such as in a motor vehicle collision, stabbing, or gunshot wound.

Perinephric fat: This view reveals fat (asterisks) surrounding the kidney (K) and a clear view of the adjacent liver (L). This should not bemistaken for free fluid, with its increased echogenicity.

Perinephric fat: This view reveals fat (asterisks) surrounding thekidney (K), which should not be mistaken for free fluid, with itsincreased echogenicity.


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Splenorenal viewThe examination of the splenorenal recess is addition-ally crucial during trauma to the abdomen or pelvis.Damage to internal organs and blood vessels willresult in fluid settling in this area primarily. A clearview of the spleen and kidney should be obtained,which normally would not present with fluid inbetween. Fluid found in the stomach which is super-ior to the spleen and kidney should not be mistakenfor fluid in the chest, which is adjacent to thediaphragm.

Fluid in the right chest: (cont.)

Fluid in the right chest: Placing the transducer on the rightaxillary line, superior to the rib with the indicator facing up revealsfluid (F) in the patient’s right chest. This fluid is bordered by thediaphragm (arrows) below and with a clear view of the kidney (K).This view is also useful when there is trauma to the chest, such as ina motor vehicle collision, stabbing, or gunshot wound.


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Normal splenorenal view: In this normal view, there is no fluidpresent in the recess between the spleen (S) and kidney (K). Thetransducer is placed in the left axillary line at the rib margin with theindicator facing up. Keep in mind that rib shadow (asterisks) mayobstruct the view.

Normal splenorenal view: In this normal view, there is no fluidpresent in the recess between the spleen (S) and kidney (K). Thetransducer is placed in the left axillary line at the rib margin with theindicator facing up.

Fluid in the stomach with the splenorenal view: In this viewof the splenorenal recess, the stomach which is superior to thespleen (S) and kidney (K) is found to have fluid (FS). This should notbe mistaken for fluid in the chest, which is adjacent to thediaphragm. Keep in mind that rib shadow (asterisks) may obstructthe view.


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Fluid in the stomach with the splenorenal view: In this viewof the splenorenal recess, the stomach which is superior to thespleen (S) and kidney (K) is found to have fluid (FS). This should notbe mistaken for fluid in the chest, which is adjacent to thediaphragm.

Fluid in the splenorenal recess: In this view, there is remarkable free fluid (F) between the spleen (S) and kidney (K). This view is alsovaluable during blunt trauma to the abdomen or pelvis causing damage to internal organs and blood vessels, with fluid settling in this area.


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Fluid in the splenorenal recess: (cont.)


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Suprapubic viewAn examination of the suprapubic area is essentialfor suspected damage to the pelvic region especiallywith blunt trauma such as in a motor vehicle

collision. The bladder should be clearly visualizedwith the presence of the uterus more posteriordepending on the patient.

Fluid in the splenorenal recess: In this view, there is remarkablefree fluid (F) between the spleen (S) and kidney (K). This view is alsovaluable during blunt trauma to the abdomen or pelvis causingdamage to internal organs and blood vessels, with fluid settling inthis area. Keep in mind that rib shadow (asterisks) may obstruct theview.

Normal suprapubic view: In this suprapubic view, theecholucent bladder (B) is clearly visualized without any surroundingfluid. The transducer is placed midline just superior to the pubicsymphysis with indicator to patient’s right.

Fluid in suprapubic region: In this suprapubic view of a femalepatient, fluid (double arrow) is visualized surrounding the uteruspossessing a fibroid (F) with the bladder (B) anterior to it. This view isimportant during trauma with suspected damage to the pelvic region.


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Fluid in suprapubic region: In this suprapubic view of a female patient, fluid (arrows) is visualized surrounding the uterus possessing afibroid (F) with the bladder (B) anterior to it. This view is important during trauma with suspected damage to the pelvic region.

Fluid in male suprapubic region: In this suprapubic view of a male patient, fluid (arrows) is visualized surrounding the bladder (B).This view is important during trauma with suspected damage to the pelvic region.

Fluid in a female suprapubic region: In this suprapubic view ofa female patient, fluid (F) is visualized surrounding the uterus (U)with the bladder (B) anterior to it. This view is important duringtrauma with suspected damage to the pelvic region.


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Fluid in male suprapubic region: (cont.)


15



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Fluid in male suprapubic region with cross-sectionalview: In this suprapubic view of a male patient, fluid (arrows) isvisualized surrounding the bladder (B) seen in the cross-sectionalview.


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Fluid in male suprapubic region: In this suprapubic view of a male patient, fluid (arrow) is visualized surrounding the collapsedbladder (B) due to an apparent Foley catheter (F). This view is important during trauma with suspected damage to the pelvic region.


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Chapter

2Ocular ultrasound

GeorgeMittendorf and John Christian Fox

Damaged globeUltrasound can expedite the identification of a globerupture and subsequently surgical management.Important characteristics to look for include overall

shape and size of the globe, asymmetry, and acollapsed anterior chamber.


Gunshot wound to right eye: Traumatic path of projectile(long arrow), posterior aspect of lens (short arrow), anterior chamber(fat arrow).

Gunshot wound: Gunshot wound to right eye.

Gunshot wound: Gunshot wound through eye and patient’sunaffected eye.

Ruptured globe: Ruptured globe demonstrating decreased size,asymmetric shape, and collapsed anterior chamber (arrow).

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Optic nerveThe optic nerve has recently become an increasinglyimportant aspect to examine because of its relation-ship with elevated intracranial pressure. The optic

nerve can be easily found by looking posterior to theglobe for a hypoechoic region that runs perpendicularto the probe’s footprint.

Ruptured globe: Ruptured globe, buckling sclera (long arrow),collapsed anterior chamber (short arrow), lens (*).

Measurement of the optic nerve sheath diameter:Measurement of the optic nerve sheath diameter (horizontalmeasurement) 3 mm proximal to the optic disc (verticalmeasurement). Optic nerve sheath diameter is greater than 5 mm,indicating elevated intracranial pressure.

Elevated intracranial pressure: Elevated intracranial pressure asevidenced by an optic nerve sheath diameter greater than 5 mm(þ’s). Note the diameter is measured 3 mm posterior to the globe,(x’s) which allows measurement within an area of better contrast.

Optic neuritis: Optic neuritis (arrow). Where to measure optic disc nerve sheath: Measure 3 mmposterior to globe.

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Retinal detachmentsUltrasound is an effective way of quickly diagnosing aretinal detachment. The detached retina can be seenas a mobile and fluid hyperechoic line that undulates

especially with movement of the eye. Furthermoreone can visualize it tethered to the posterior aspectof the eye at the optic disc.

Retinal detachment: 3D reconstruction of retinal detachment(skinny arrow). Anterior chamber (small arrow), posterior surface oflens (fat arrow).

Retinal detachment: 3D reconstruction of retinal detachment.

Retinal detachment: Retinal detachment (arrow).

Retinal detachment: Retinal detachment (small arrow), anteriorchamber (a), lens (L), lateral rectus muscle (long arrow).

Chapter 2: Ocular ultrasound

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Retinal detachment: Retinal detachment (small arrow), opticnerve (fat arrow), optic disc (long arrow).

Retinal detachment: Retinal detachment (arrow).

Retinal detachment: Retinal detachment (arrow). Retinal detachment: Retinal detachment (arrows).

Retinal detachment: Retinal detachment (arrow). Retinal detachment: Retinal detachment (small arrow). Lens(large arrow).


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Retinal detachment: Retinal detachment (large arrow), iris (smallarrow), optic disc (fat arrow).

Retinal detachment: Retinal detachment.

Retinal detachment: 3D reconstruction of normal eye. Anteriorchamber (small arrow), retina (fat arrow).

Retinal detachment: Retinal detachment.

Retinal detachment: Retinal detachment. Retinal detachment: Retinal detachment (arrow).


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Retinal detachment: Mac-off retinal detachment. Retina (shortarrow), optic nerve (fat arrow), macula (long arrow), tether point ofretina to optic disc (double arrow).

Retinal detachment: Mac-off retinal detachment. Retina (shortarrow), macula (long arrow), optic nerve (fat arrow).

Retinal detachment: Retinal detachment as evidenced withendovaginal probe.

Retinal detachment: Large retinal detachment. View is capturingthe rim around a protruding portion of retina.

Retinal detachment: Large retinal detachment. Retinal detachment: Mac-off retinal detachment. Optic nerve (fatarrow), macula (skinny arrow).


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VitreousAlthough sometimes confusedwith retinal detachments,a vitreous hemorrhage can be identified as a swirling,slightly hyperechoic focus in the posterior globe.

Retinal detachment: Mac-on retinal detachment. Optic nerve (fatarrow), macula (long arrow), detached retina (short arrow).

Vitreous detachment: Detached vitreous (short arrow), opticnerve (fat arrow).

Detached vitreous body: Detached vitreous body that looks likea retinal detachment.

Detached vitreous body: Another detached vitreous body(arrow) that looks like a retinal detachment.

Vitreous hemorrhage: Vitreous hemorrhage (arrow), vitreousbody (*).

Vitreous hemorrhage: Vitreous hemorrhage (arrow).


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Chapter

3Cardiac ultrasound

Shane Summers

IntroductionCardiac ultrasound can be used at the bedside in avariety of clinical settings. From the patient withstable vital signs who complains of mild shortness ofbreath, to the patient with no palpable pulses under-going CPR. Understanding the mechanics in probeplacement is critical to obtaining the necessary viewand therefore making an accurate interpretation.Findings on bedside cardiac ultrasound can point

the clinician toward a valvular problem, obstructivepathology, or even an infectious etiology.

Normal viewsThese windows describe the primary locations oftransducer placement to visualize the heart througha transthoracic approach.

Normal subxiphoid view: In this normal subxiphoid view, all fourchambers of the heart are visualized in 1 plane by utilizing the leftlobe of the liver as an acoustic window. The subxiphoid approachmay be extremely helpful for a global cardiac assessment in a codesituation, as it does not interfere with cardiopulmonary resuscitation(CPR). This window may be used to assess for pericardial tamponade,left ventricular (LV) function in shock states, and massive pulmonaryembolism with right ventricular (RV) strain. The inferior vena cavamay also be interrogated to assess volume status (not depicted).

Normal parasternal long-axis (PLAX) view: This normalparasternal long-axis (PLAX) view was obtained by placing thefootprint of the transducer at the fourth intercostal space with theindicator pointed to the patient’s right shoulder (on cardiac presets).From anterior to posterior, the right ventricle (RV), inter-ventricularseptum (IVS), left ventricle (LV), left ventricular outflow tract (LVOT),posterior wall of the LV, anterior and posterior mitral valve leaflets(AML, PML), left atrium (LA), and descending thoracic aorta (Ao) arevisualized. The PLAX view can assess for pericardial effusions, LVejection fraction (LVEF), sequential movement of the mitral andaortic valves, wall motion abnormalities, and dilatation of the aorticroot. When the subxiphoid window is unobtainable, the PLAX offersan alternative view for the focused abdominal sonography fortrauma (FAST) examination.

Atlas of Emergency Ultrasound, ed. John Christian Fox. Published by Cambridge University Press. © J.C. Fox 2011.26

Normal parasternal short-axis view (PSAX) at papillarymuscles: The parasternal short-axis view is obtained by placing thetransducer just left of the sternum in the third or fourth intercostalspace with the indicator pointed to the patient’s right shoulder (oncardiac presets). Tilting the transducer toward the apex shouldreveal a cross-section of the mid left ventricle (LV) and the papillarymuscles. This view is useful to observe for assessment of leftventricular ejection fraction (LVEF) as well as wall motionabnormalities in acute myocardial infarctions.

Normal PSAX view at level of the mitral valve: A normalparasternal short-axis window at the mitral valve (MV) leveldemonstrates a cross-sectional view of the left ventricle (LV) that canbe useful for wall motion and ejection fraction assessment. In thisplane, the MV has a fish-mouth appearance.

Normal PSAX view at the level of the great vessels: If thetransducer is tilted toward the base in a parasternal short-axis view, across section of the aortic valve (AV) can be seen. In this patient, anormal tri-leaflet aortic valve is visualized. Note the presence of thenon-coronary (NCC), right coronary (RCC), and left coronary cusps(LCC).

Normal apical four-chamber view (A4C): The apical four-chamber view is obtained by placing the transducer at the point ofmaximal impulse (PMI) with the indicator pointed to the patient’sleft lateral chest (on cardiac presets) and the beam directed to thepatient’s right shoulder. This view is useful for assessment of relativechamber sizes, right (RV) and left ventricular (LV) function, and theatrioventricular valves. This view is optimal for Doppler imaging ofthe mitral (MV) and tricuspid valves (TV) because blood flow isparallel to the transducer in this plane. This view may also be utilizedfor an ultrasound guided pericardiocentesis.

Chapter 3: Cardiac ultrasound

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Normal apical five-chamber view (A5C): To obtain the apicalfive-chamber view, simply tilt the transducer anteriorly from theapical four-chamber view. This view may be helpful to visualizethe left ventricular outflow tract and assess function of theaortic valve.

Normal apical two-chamber view (A2C): The apical two-chamber view is obtained by rotating the transducer 75–90 degreescounterclockwise (on cardiac presets) from the apical four-chamberview. This window permits visualization of global left ventricularfunction and may detect wall motion abnormalities of the anteriorand inferior walls.

Normal apical long-axis view (A3C): For the apical long (apicalthree-chamber) view, the indicator is aimed in the same orientationas the parasternal long axis window, but the transducer is insteadplaced at the apex of the heart (PMI). This view is used to assessglobal left ventricular (LV) function, the aortic valve, and the leftventricular outflow tract (LVOT).

Normal suprasternal view: Although not sensitive, thesuprasternal view may be useful to detect proximal aorticdissections. This view is obtained by placing the transducer in thesuprasternal notch with the indicator pointing to the patient’s leftshoulder (on cardiac presets) and the probe angled as anterior aspossible. In this plane, the aortic valve (AV), ascending aorta (Asc),aortic arch (Arch), descending thoracic aorta (Dsc), brachiocephalic(BCA) artery, left common carotid artery (LCA), and left subclavianartery (LSA) are seen.


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Pericardial effusion versus pericardialtamponadeThis set of images describe the findings seen to differ-entiate simple fluid collections around the heart toobstructive tamponade.

Large circumferential pericardial effusion: Parasternal longaxis view is remarkable for a circumferential pericardial effusion(asterisks) in a patient with malignancy. Note that there is greaterthan 1 cm of echolucent space between the visceral and parietalpericardium both anterior and posterior (asterisks) consistent with alarge effusion.

Cardiac tamponade with diastolic right ventriclecollapse: Subxiphoid view in a patient with systemic lupuserythematosus (SLE) reveals a circumferential pericardial effusion(asterisks) with collapse of the right ventricular free wall duringdiastole (arrow) and near obliteration of the RV lumen, consistentwith pericardial tamponade.

Pericardiocentesis: In the same patient with an SLE andpericardial tamponade, a pericardiocentesis is attempted using asubxiphoid approach. The hyperechoic reverberating needle (arrow)can be seen entering the pericardial space (asterisk) underultrasound guidance.

Cardiac tamponade with plethoric inferior vena cava: In apatient with a large pericardial effusion (asterisk), a subxiphoid viewof the inferior vena cava (IVC) is remarkable for a plethoric IVC(arrows) greater than 2.5 cm in diameter with no collapse at endinspiration, consistent with a central venous pressure greater than20mm Hg and pericardial tamponade.


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EnlargementThese images demonstrate the pathology encounteredwhen hypertrophy and dilation are encountered.

Cardiac tamponade with anterior pericardial effusion: In along-axis view obtained for a patient with undifferentiatedhypotension, and anterior pericardial effusion (asterisk) is collapsingthe free wall of the right ventricle during diastole (arrow), nearlyobliterating the RV lumen and leading to pericardial tamponade.

Hemopericardium: This subxiphoid image was obtained in apatient with a transmediastinal gunshot wound and cardiac arrest.Echogenic material was noted in the pericardial space with severelydepressed cardiac contractility. An immediate bedside thoracotomywas performed with evacuation of pericardial clot.

Dilated cardiomyopathy: Apical four-chamber view in analcoholic patient with decompensated heart failure is remarkable fora dilated cardiomyopathy. Note the globular shape to the leftventricle (LV), thin walls, and biatrial enlargement. Real-timeechocardiography revealed little change in LV diameter fromdiastole to systole consistent with severely depressed ejectionfraction (EF).

Hypertrophic obstructive cardiomyopathy (HOCM): Anapical four-chamber view of the heart is obtained in the emergencydepartment for a patient with exertional syncope and a heartmurmur. The bedside exam was remarkable for a significantlythickened interventricular septum consistent with hypertrophiccardiomyopathy.


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Right heart strainThis may be the only clue to diagnosing a pulmonaryembolism in the setting of cardiovascular collapse.Thrombolitics are indicated for pulmonary embolismin the setting of shock.

Apical left ventricular aneurysm: An apical four-chamberview of the heart is remarkable for a large apical aneurysm (*). Thepatient was status post acute myocardial infarction with pathologicQ waves and ST segment elevation on EKG.

Left ventricular hypertrophy: Parasternal long-axis view of theheart in a patient with poorly controlled hypertension reveals leftventricular (LV) hypertrophy. In end diastole, the wall thickness of theposterior wall of the LV (arrows) measured greater than 3 cm.

Mitral stenosis with left atrial enlargement: In a patient withrheumatic heart disease and severe mitral stenosis (arrow), a grosslyenlarged left atrium is visualized on an apical four-chamber view(asterisk).

Massive pulmonary embolism with acute right heartstrain: In this parasternal long-axis view of a patient with massivepulmonary embolism (PE), a dilated right ventricle (RV) is apparentconsistent with right heart strain. Generally, a normal ratio ofchamber sizes measured across the tips of atrioventricular (AV)valves is RV:LV 0.6:1. Although no finding is sufficiently sensitive toexclude PE, other echocardiographic findings include directvisualization of the clot, paradoxical motion of the interventricularseptum (IVS) from elevated right heart pressures, and tricuspidregurgitation.


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Valvular dysfunctionUsing colorflow, one can appreciate the presence andseverity of valvular pathology.

Massive pulmonary embolism in pulseless electrical activity(PEA) arrest: An apical four-chamber view of the heart obtained ina patient with pulseless electrical activity (PEA) arrest and massivepulmonary embolism. Note the right ventricular (RV) diameterapproaches that of the left ventricle, and the RV free wall is roundedin shape. On real-time echocardiography, a severely dyskinetic RVwas apparent, and RV function improved after intravenousadministration of tissue plasminogen activator (tPA).

Mitral valve prolapse: In this apical four-chamber view withzoom on the left heart, abnormal motion of the posterior leaflet ofthe mitral valve (arrow) with prolapse into the left atrium (LA) isapparent.

Bicuspid aortic valve: In a zoomed parasternal short-axis view atthe base obtained in a patient with chest pain and syncope, abicuspid aortic valve is visualized (arrows).


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Acute mitral regurgitation: An apical four-chamber view isobtained in a patient with decompensated heart failure fromruptured papillary muscle. Color Doppler placed across the mitralvalve reveals severe mitral regurgitation with retrograde turbulentflow during systole. In variance mode, turbulent (non-laminar) flowdemonstrates a mosaic pattern of turquoise and yellow pixels(arrow).

Acute aortic regurgitation: A parasternal long-axis view isremarkable for turbulent flow (mosaic appearance) across the aorticvalve (arrow) during diastole in a patient with severe aorticregurgitation.

Proximal aortic dissection: Parasternal long-axis view of theheart demonstrates an intimal flap (arrows) and dilated aortic rootconsistent with proximal aortic dissection. Although transthoracicechocardiography (TEE) is not sufficiently sensitive to exclude aorticdissection, early diagnosis on bedside ultrasound can facilitatemobilization of resources and expedite treatment.

Ventricular septal defect: A parasternal short-axis view at themitral valve (MV) level reveals turbulent flow with mosaic colorDoppler signal (arrow) across the interventricular septum (IVS)consistent with a ventricular septal defect.


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Atrial septal defect: On B mode imaging, apical four-chamberview of the heart reveals an atrial septal defect (ASD, asterisk). Noteright atrial enlargement from left-to-right shunting. Other clues forthe presence of an ASD may include right ventricular hypertrophyand paradoxical motion of the ventricular septum. Color flowDoppler can confirm the diagnosis, determine flow direction, andestimate the size of the defect.

Atrial myxoma: On an apical four-chamber view, a largeechogenic mass is visualized in the left atrium consistent with atrialmyxoma (arrow).

Acute infective endocarditis: In an intravenous drug abuserwith fever of unknown origin, an apical four-chamber view reveals adiscrete pedunculated vegetation on the anterior leaflet of themitral valve consistent with infective endocarditis.


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Chapter

4Ultrasound of the lung

Justin Davis and Seric Cusick

Normal lungSonographic interrogation of the thoracic cavityinvolves interpretation of anatomic structures as wellas the recognition of the presence/absence of severalartifacts. This may be facilitated by the use ofM-mode and color Doppler. A variety of transducersmay be employed, including phased, convex, and

linear. The resolution of linear transducers is pre-ferred by some for characterization of pleural move-ment and artifacts arising at this level. However,phased and convex array transducers with a lowerfrequency offer greater penetration, allowing identifi-cation of deeper pathology and appreciation of fur-ther artifacts.


Normal lung, curvilinear: Normallung imaged with curvilinear probe. Againnote the ribs with acoustic shadows, thepleural line (arrowhead) and multiplehorizontal A-lines.

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Normal lung, linear: Normal lung ultrasound anatomy. Two ribsin cross-section are used as landmarks to find the pleura; as thepleura must run in a line connecting their interior surface. Thehyperechoic ribs and pleural line together form a shape suggestiveof a bat flying toward the viewer; with the body as the pleura andwings as the ribs (the “bat sign”).

Normal lung, curvilinear,M-mode: Normal lung, curvilinearprobe in M-mode (time-motion mode)showing the “seashore sign” of normallung sliding. Above the pleural line(arrowheads) the image is constant whilebelow it is constantly changing, reflectingthe shifting artifacts seen as pleura slidepast one another.

Normal lung, linear, A-line and Z-line: Normal lung withmultiple horizontal A-line artifacts (arrowheads). Running vertically isa Z-line, which arises from the pleura, enhances the A-lines and doesnot extend to the edge of the screen.

Chapter 4: Ultrasound of the lung

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Normal lung, linear, A-line: Normallung with a linear probe. A-lines are againseen (arrowheads).

Normal lung, linear,M-mode: Normal lung, linear probe inM-mode. The seashore sign representingnormal lung sliding, with the changingartifacts below the pleural line(arrowheads).


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Normal lung, linear, color power Doppler: Normallung, color power Doppler. Another way to view lungsliding is to place power Doppler over the pleural line.The movement causes localized Doppler artifacts alongthe pleural line, known as the “power slide” sign.

Normal lung, phased array, A-lines: Normal lung.Note the ribs (arrowheads) with the acoustic shadowsdeep to them. Reflected sound reverberates betweenthe pleural line (clear arrowhead) and the transducer,creating multiple horizontal artifacts called A-lines(arrows).

Normal lung, phased array, M-mode: Normal lungimaged with phased array probe in M-mode. Again, theseashore sign is seen with the motion artifacts deep tothe pleural line (arrowheads).


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Normal lung, phased array,O-lines: Normal lung imaged withphased array probe. Below the pleuralline (arrow) there are no significantA-lines seen; but rather a gray haze;sometimes referred to as a collection ofO-lines. Slight movement of the probewill often demonstrate A-lines.

Normal lung, M-mode, lungpulse: Non-ventilated lung, M-mode.When the lung is not expanding withrespiration, the M-mode shows the signknown as the “lung pulse,” with rhythmicartifacts below the pleural line thatcorrespond to translated motion from theheart. This is seen in the non-ventilatedlung after main-stem intubation, severeatelectasis, or apnea as demonstrated herewith both a linear and phased arraytransducer.


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PneumothoraxIdentification of a pneumothorax with ultrasoundrelies upon the absence of normal lung sliding andcomet-tail artifacts. Findings on M-mode and color

power Doppler may assist in identifying this. Whilethe absence of these features is sensitive for pneumo-thorax, only the identification of a lung pointprovides good specificity.

Normal lung, M-mode, lung pulse:(cont.)

Pneumothorax, curvilinear,M-mode: Pneumothorax, M-mode. Theribs (black arrowheads) frame the pleura(white arrowhead). Rather than thenormal “seashore sign” here we see the“stratosphere sign.”


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Normal lung, linear, false lungpoint: Normal lung edge. A commonreason for a false-positive pneumothoraxfinding is the misinterpretation of a lungedge adjacent to the diaphragm,pericardium, or effusion as a “lung point.”Here, the pleural line of the normal lungedge (arrows) is seen to dynamicallyobscure the pericardium (arrowhead). In apneumothorax, the area adjacent to the“lung point” must be a continuation of abright pleural line, usually with A-linesbelow it. In this example, the brightpleural line of the aerated lung edge doesnot continue, showing that the mobilelung is not displacing air as it slides alongthe chest wall, but rather tissue or fluid.

Pneumothorax, linear, lungpoint: The right side of the image showsthe pleural line (arrowheads) that islacking normal lung sliding on real-timeimaging. The left side shows intermittentlung sliding (arrows) that appears anddisappears. Known as a “lung point,” thisrepresents an area of lung thatintermittently touches the parietal pleuraand is considered 100% specific forpneumothorax.


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Normal lung, linear, M-mode, falselung point: Note the intermittent“seashore sign” of sliding aerated lung(arrowheads). In contrast to the “lungpoint” of pneumothorax, here in theintervening period the bright whitepleural line disappears entirely (arrows)and the deeper pericardium is visible.Increasing the depth would make thelung pericardial motion more apparent.

Pneumothorax, linear, M-mode,lung point: The “stratosphere sign” isagain seen below the pleural line (whitearrowheads), but this time is momentarilyinterrupted by a return of the “seashoresign” (black arrowheads) as the collapsedlung touches the chest wall withinspiration. This transition is known as a“lung point” and is considered 100%specific for pneumothorax.


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Pneumothorax, linear, color powerDoppler: Power Doppler imagingshows a lack of expected motion artifactalong the pleural line (arrow), but rather adiffuse flash artifact as the Doppler gain isincreased.

Pneumothorax, linear, M-mode: Thenormal “seashore sign” is replaced by the“stratosphere sign” or “barcode sign” inthis image. The ribs (arrowheads) arelandmarks for locating the parietal pleura(arrow). Below the pleural line, note theabsence of the normal motion artifacts,resembling either many planes leavingcontrails in the sky or a retail barcode.


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Subcutaneous air, linear, E-line: Thebright line of subcutaneous air(arrowhead) is distinguished from thepleural line by noting that it is even withthe superficial surface of the rib shown atright. An E-line (arrow) is seen echoingdownward and has similar appearance toa B-line, except that it arises fromemphysema rather than from a pleuralline.

Subcutaneous air, linear: A commonpitfall of beginning sonographers is tomistake subcutaneous air for apneumothorax. Like a pneumothorax, airin the chest wall has no lung slidingand will show a “stratosphere sign” onM-mode. The key to recognition is toalways start with identification of the ribs.The pleural line (arrowheads) resides atthe level of the deep rib surface, whilesubcutaneous air (arrows) will besuperficial to this.


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Interstitial syndromeFluid in the interlobular septae extends to the visceralpleura, creating a pathway for sound waves to enterand become reflected repeatedly between adjacent

alveoli like a hall of mirrors. The escaping echoescreate hyperechoic artifacts known as B-lines. B-linesarise from the pleura, extend to the edge of the image,erase normal A-lines, and move with lung sliding.

Interstitial syndrome, linear: B-Lines(arrowheads) arise from the pleura;obliterate A-lines (arrow); extend to theedge of the image; and move with lungsliding. Rare isolated B-lines can be seen innormal lungs.

Interstitial syndrome, phasedarray: At times, information on thelungs can be obtained while performingother studies, as in this parasternal longaxis cardiac window. In these two images,multiple B-lines (arrowheads) move withrespiration to obscure varying amounts ofthe left ventricle (LV).


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Interstitial syndrome, phased array:(cont.)

Interstitial syndrome, phasedarray: Note the absence of A-lines.


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Interstitial syndrome, phasedarray: Three B-lines (arrowheads) areseen extending from the pleural line tothe periphery.

Alveolar interstitial syndrome,phased array: Multiple B-lines(arrowheads) are seen to converge into anearly “white lung.”


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Alveolar interstitial syndrome: Thetwo ribs (arrowheads) cast denseshadows, while the lung shows a diffusewhite artifact, consistent with aconfluence of B-lines. This “white lung” isseen in conditions that cause a peripheral“ground glass” infiltrate on CT scan,including lung contusion (this image),pneumonia, infarction, diffuse interstitialdisease, and ARDS.

Alveolar interstitial syndrome,linear: Another example of the “whitelung” sign seen in a blunt trauma patientwith a focal lung contusion.


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Alveolar consolidationConsolidations may be identified with ultrasound assegments of lung adjacent to the parietal pleuradevelop an increasing proportion of fluid andpulmonary parenchyma relative to air.

Alveolar consolidation of the rightlung base: The right lung (arrow) shows“hepatization” in this longitudinal viewof the inferior vena cava. The spineshadows (asterisks) continue above thediaphragm and are clearly visualized intothe thorax. This “spine sign” requires theabsence of normal air-induced mirrorimage artifacts across the diaphragmand indicates either effusion,consolidation, or both.

Alveolar consolidation withdynamic air bronchogram: In thesetwo images, the lung base showsminimal aeration. When observed inreal-time, air (arrowheads) is seen tomove back and forth through thebronchial tree (arrow) with respiratoryeffort, very suggestive of pneumoniaover atelectasis.


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Alveolar consolidation with dynamicair bronchogram: (cont.)

Alveolar consolidation of the leftlung base, left coronal view: Thediaphragm (arrow) overlying the spleenprovides the landmark for viewing thelung base. The lung is consolidated andnearly void of air, with the exception oftwo air bronchograms (arrowheads).There is also a small effusion and apositive “spine sign.”


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Alveolar consolidation of the rightlung base with effusion: Severalpinpoint air bronchograms (arrowheads)are seen amid the “hepatized” lung. Thedeep portion exhibits the ragged aeratedborder of the “shred sign” (arrow).

Alveolar consolidation witheffusion: The aerated lung forms anirregular deep border (arrowheads) to theconsolidated gray lung tissue, known asthe “shred sign” due to the border’sirregular appearance.


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Pleural effusionIdentification of pleural effusions with ultrasound hasimplications for both diagnosis and proceduralguidance. Coronal views (as used in the Focused

Assessment with Sonography in Trauma) provideinterrogation of the dependent portions of thethoracic cavity in the supine patient.

Normal lung with mirror-imageartifact, longitudinal subxiphoidview: The smooth and bright pleural line(arrow) creates a mirror artifact(arrowhead) of the IVC, potentially leadingto a false-positive finding of right pleuraleffusion.

Pleural effusion, M-mode:A hypoechoic fluid collection separatesthe lung surface (arrows) and the parietalpleura (arrowheads). The lung rises andfalls with respiration; creating the“sinusoid sign.”


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Pleural effusion: The effusion appearsto be bordered on four sides (arrowheads)by the lung, chest wall, and rib shadows,referred to as the “quad sign.”

Pleural effusion with fibrinousdebris, right coronal view: Thehypoechoic collection over thediaphragm (arrow) contains cordlikedebris (white arrowheads) that appears totether the consolidated lung (blackarrowhead) to the parietal pleura. Suchdebris and adhesions are less reliablyvisualized by CT.


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Right pleural effusion, transversesubxiphoid view: A hypoechoiccollection (arrow) is seen deep to theliver (arrowhead) at the right thorax base.Due to interference from bowel gasand image depth, this view is less reliablethan lateral coronal or posterior views.

Right pleural effusion and smallpericardial effusion, subxiphoidlongitudinal view: The IVC (I) runsthrough the diaphragm separating theright basilar plural effusion (arrow) andsmall pericardial effusion (arrowhead).


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Large right loculated empyema:Above the diaphragm, a well-containedhypoechoic fluid collection has layeringdebris (arrow). Color Doppler of theencircling tissue can help differentiateempyema from intraparenchymal abscess(not shown).

Left pleural effusion, coronalview: A large effusion (arrow) is seenabove the diaphragm, with a consolidatedlower lobe edge (arrowhead) floating inthe fluid, moving with inspiration onreal-time imaging.


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Left basilar pleural effusion, coronalview: A small hypoechoic fluidcollection is seen above the diaphragm(arrow). Under real-time imaging, theaerated lung (arrowhead) is seen tofollow diaphragmatic excursion.

Left pleural effusion, posteriorsagittal view: A large effusion is seenover the diaphragm (arrow), pushingaside the consolidated lung (blackarrowhead) in preparation forthoracentesis. Thoracentesis at this ribspace would endanger neither thediaphragm nor the lung. With largeeffusions, the heart (white arrowhead) cansometimes be seen from posteriorwindows.


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Left pleural effusion and pericardialeffusion, parasternal long-axiscardiac view: A pericardial effusion(arrowhead) lies anterior to thedescending aorta (black arrowhead)while a large left pleural effusion (arrow)is found posterior to the aorta.


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Chapter

5Right upper quadrant ultrasonographyPost injury intervalsDaniel Gromis and John Christian Fox

AnatomyBiliary anatomy is important to identify and can bedifficult to orient to. The utilization of landmarks andcolor flow or power Doppler are effective tools in delin-eating structures and localizing structures accurately.


Anatomy: The gallbladder (G) is the most anterior structure, lateralto the duodenum (Du) on sagittal imaging, and overlying thecommon bile duct (CBD), and portal vein (PV). More laterally, alsoseen is the short axis of the hepatic vein (HV). In the far field at thebottom of the image is the inferior vena cava (IVC).

Anatomy, Mickey Mouse sign: The “Mickey Mouse sign” iscomposed of the hepatic artery (H), portal vein (P), and common bileduct (cbd). The neck (N) and body (B) of the gallbladder are divided bythe neck fold (arrow), with the fundus (F) lying most anteriorly. Theshadowing cast (arrowheads) is as a result of edge refraction. Pancreas(Pa), superior mesenteric artery (SMA).

Anatomy, Mickey Mouse sign: Color Doppler, short axis imagingof the Mickey Mouse sign showing a strong signal in the hepaticartery (large arrow) andportal vein (PV), but a lack of flow in the commonbile duct (small arrow). Gallbladder (G), neck fold (arrowhead).

Anatomy, main lobar fissure: Identification of the main lobarfissure (large arrow) orients to the gallbladder with its fundal stone(arrowhead), common bile duct (cbd), and portal vein (PV). Neck fold(small arrow).

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CholelithiasisGallstones are the most common pathology to thegallbladder. Their location, size, quantity, and

characteristics should be noted, as each conveys dif-ferent significance to the diagnostic workup.

Anatomy, vascular: The “Playboy Bunny sign” is made up of theinferior vena cava (IVC) and middle (M) and left (L) hepatic veinswhen the liver is viewed obliquely.

Anatomy, cystic duct: The cystic duct (arrow) with its spiralvalves seen connecting the gallbladder (G) to common bile duct(bordered by x’s) commonly casts a shadow artifact. Portal vein (P).This gallbladder is contracted.

Cholelithiasis: A large gallstone (arrow) with classic anteriorhyperechogenicity and clean distal acoustic shadowing (s).

Large stone: A large stone (g) dependently oriented superiorto biliary sludge (s). Cysti duct (c), common bile duct (cbd), portalvein (PV).

Large stone: A massive stone (arrow) casts its hypoechogenicshadow as a result of sound wave reflection, while the fluid-filledgallbladder lumen (G) causes far-field attenuation andhyperechogenicity.

Chapter 5: Right upper quadrant ultrasonography

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Multiple stones: The arrows indicate multiple stones dispersedwithin the gallbladder lumen with subsequent cumulative distalacoustic shadowing (s).

Multiple stones: The arrows identify a multitude of stoneslaying along the floor of the gallbladder with a resultant aggregatedistal acoustic shadowing (s).

Multiple stones: Arrows show layering of multiple tiny stoneswith near obliteration of the gallbladder lumen, seen as a sliver ofhypoechogenicity anteriorly overlying the hyperechoic stones. Thefarfield aggregate shadow (s) cast by the stones can be seen.

Multiple stones: Seen in a sagittal dimension, the gallbladder (G)has multiple stones (gs) posteriorly casting a far-field shadow (s).Acoustic enhancement (arrowheads) from the fluid-filled gallbladderilluminates the pericholecystic fluid (arrow).

Multiple stones with sludge: The gallbladder, completely filledwith isoechoic sludge (SL) is seen anterior to multiple aggregatedgallstones (GS) collecting along the posterior gallbladder.

Gallstone locations: The four, non-shadowing stones near thegallbladder fundus (arrowheads) demonstrate the “peas in a pod”formation. The single large stone (arrow) is more heavily calcifiedand casts a clean shadow (s). Common bile duct (c), portal vein (P),inferior vena cava (IVC).

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Gallstone locations: Two large stones (arrows), confirmed bytheir respective far-field shadowing (arrowheads) can be seen in theneck of the gallbladder. Common bile duct (cbd), portal vein (P).

Gallstone locations: A hyperechoic stone (arrow) located in thegallbladder neck (N), posterior to the fundus (F) in sagittal section.

Gallstone locations: A collection of “peas in a pod” gallstones(arrowheads) without distal shadowing seen in the body of thegallbladder.

Missed stones: A non-shadowing stone (arrow) is noted atopthe neck fold (arrowhead) of the gallbladder. Fundus (F), body (B),neck (N).

Missed stones, edge refraction shadowing: A gallstone(arrowhead) could easily be missed if not carefully scrutinized for itsanterior hyperechogenicity seen at the tip of the arrowhead.A shadow (arrow) falsely identifies a stone at the gallbladder neck,and instead represents edge refraction shadowing caused by thecystic duct (c). Common bile duct (cbd).

Missed stones, reverberation artifact: Heavily calcified stones(arrow) occasionally fail to produce an acoustic shadow, but ratherdisplay hyperechoic, acoustic reverberation (arrowheads). Thedegree of pronouncement of the reverberations is thought to beproportional to the degree of calcification of the stone.

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Missed stones, over-gaining: When over-gained, gallstones(arrows) only produce faint shadowing (s), which could easily bemissed and elucidates the importance of appropriate gaincalibration.

Missed stones, neck clustering: When multiple stones (arrows)aggregate in the gallbladder neck (N), the resultant shadow (s)can be misinterpreted as edge refraction shadowing if thegallbladder is not carefully scrutinized. Fundus (F), body (B),acoustic enhancement (arrowhead).

Missed stones, lost shadow: A small, single stone (arrow) casts avery small shadow (arrowhead), which can be easily missed,especially when cast through equally hypoechogenic structures.Ascites (A).

Missed stones, tiny stone: A very small stone (arrow) casts a fineshadow (arrowhead) from the gallbladder neck (N).

Missed stones, shadows: Occasionally, even largestones (arrows) are difficult to identify, save for their far-fieldshadows (s).

Missed stones, floating stones: When the specific gravity ofbile is increased – by ingestion of contrast media or extensive biliarysludging, stones (arrows) can float in the medium and be missed.

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Common bile ductThe common bile duct (CBD) is one of the mostimportant, although often most difficult, structuresto identify when imaging the right upper quadranton a patient in whom a provider has concern forbiliary pathology. Care should be taken to identifythe portal vein, atop which lies the common bile duct.

Once identified, the internal luminal diameter shouldbe carefully measured. A patient can be consideredto have a normally sized common bile duct if thisdiameter is approximately 1 mm for every decadeof life, but generally considered dilated once it exceeds6 mm.

Normal CBD: Power Doppler sonography demonstrates flow inthe portal vein and a lack of flow in the anteriorly overlying commonbile duct. CBD thickening: Under power Doppler sonography, the internal

diameter of the common bile duct (cbd) lumen is seen to measure5.6mm. Gallbladder (G), portal vein (P), inferior vena cava (IVC).

CBD measurement, inaccurate: Improper measurement ofthe cbd. The calipers (x’s) are seen measuring the diameter of thewalls to 0.91 cm, but should only include the internal luminaldiameter. Portal vein (PV), inferior vena cava (IVC).

CBD measurement, accurate: The calipers (x’s) indicate aninternal luminal diameter of 2.5 cm.


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AscitesCommonly encountered, ascites can disrupt accurateimage interpretation. But an understanding of itscharacteristics can lead to clearly distinguishing itspresence. Free fluid, like that of ascites, does not takean organized form, but instead “wedges” into spaceswith sharp angles. Its anechoic nature attenuatesimaging and can often improve images.

CBD dilation: Dilated CBD and “olive sandwich sign.” The CBDmeasures 1.6 cm, significant for dilation, “sandwiching” the hepaticartery (arrow) – the “olive” – between the portal vein (PV).

CBD dilation: The gallbladder (G) with three, non-shadowingstones (arrows). The cbd’s internal diameter is appropriatelymeasured (x’s) to 1.1 cm, significant for dilation.

CBD dilation: cbd dilated to 5.6 mm overlying the hepatic artery(h) and IVC.

Fool’s CBD: A dilated hepatic artery (H) posterior to the portal veincan mimic the CBD. Power Doppler demonstrates flow in both theportal vein (PV) and inferior vena cava, and therefore rules out eitheras being the CBD.

Classic ascites: In this case lying anteriorly, ascites (A) is seenbordered by the peritoneum anteriorly, thickened anteriorgallbladder (G) wall posteriorly (arrowhead), and creating sharp,wedge-like angles around the adjacent bowel. Gallbladder (G),thickened gallbladder wall (arrow), duodenum (Du).


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Gallbladder wall thickeningAn indicator of more severe pathology, the thicknessof the gallbladder wall (GBW) should be noted andmeasured. A wall less than 0.3 cm in thickness is oftenconsidered normal.

Classic ascites: Large fluid collection (A) inferior to the gallbladder(G) on longitudinal scan, outlining (arrowheads) the duodenum(Du) indicates ascites. Edge refraction shadowing (arrow).

Loculated ascites: Multiple, wispy, hyperechoic septations(arrowheads) are visualized within this large, anechoic asciticcollection.

Undifferentiated free fluid: When lying posterior to thegallbladder, ascitic fluid (a) can be misinterpreted as pericholecysticfluid, but its proximity to the duodenum (Du), and characteristicwedging around the small bowel contours, helps clarify this asascites. Gallbladder fundus (F), neck fold (arrow).

Undifferentiated free fluid: The small wedge of fluid (arrow)interspersed between gallbladder and duodenum (D) representsascites and not PCF, as it tracks both anteriorly and posteriorly alongthe duodenal wall. Gallbladder fundus (F), sludge (s)).

GBW thickening: Appropriately measured gallbladder (G) wall(x’s) from the luminal outer wall to inner. Common bile duct (cbd).


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GBW thickening: An appropriately measured wall, significantfor thickening, likely as a result of the large neck stone (s).Common bile duct (cbd), acoustic shadow (arrow).

GBW thickening with pericholecystic fluid: A thickenedGBW (x’s) is seen outlined by a wedge-like, anechoic fluidcollection which represents pericholecystic fluid (arrow).

GBW thickening with pericholecystic fluid: A fine sliver offluid (arrow) lies inferior to a thickened gallbladder wall(arrowhead). Gallbladder (G).

Contracted gallbladder: Often misinterpreted for pathologicgallbladder wall thickening, a hyperechoic wall of a contractedgallbladder (arrow).

Contracted gallbladder: When magnified, a contractedgallbladder wall is more easily measured. In this case the patient hada recent meal and therefore the significance of this thickening is notrelevant.


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PneumobiliaAn indication of pathology, pneumobilia (or aerobi-lia) can often be identified on ultrasound as it accu-mulates in the biliary tree, and occasionally within the

gallbladder wall. Pneumobilia casts distal reverber-ation artifact (comet-tailing) or shadowing whichcan often lead to its being misdiagnosed as a stone,a delineation that relies on location to elucidate.

Pneumobilia, biliary tree: Air in the intrahepatic biliary ducts(arrows) is hyperechoic and casts a distal shadow (arrowhead).

Intraluminal air: Comet-tailing (arrowheads) extending fromthe gallbladder wall near the fundus is indicative of intraluminalair and significant illness. Thickened gallbladder wall (arrow).

Air bubbles: Not all pneumobilia is confined to isolated locales,but can be seen ascending as hyperechoic circles (arrows) throughthe liquid medium of the gallbladder (G). Gallstone (arrowhead), wallinflammation (w).

Air bubbles: A single, non-shadowing, hyperechoic air bubble(arrow) ascends adjacent to a large stone (arrowhead). Biliary sludge (s).


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SludgeAs particulate matter from bile precipitates – as aresult of obstruction, medications, dietary changes,or otherwise – biliary sludge is the result. The

increased viscosity of the sludge acts similarly togallstones and can cause obstruction in the samemanner, and therefore can be considered of equalsignificance to cholelithiasis in symptomatic patients.

Shadowing sludge: The more particulate matter precipitated, themore sonographically obstructing sludge becomes (arrowheads)and can result in an acoustic shadow (s). Common bile duct (cbd),portal vein (PV).

Sludge: Isoechoic in nature, sludge (arrow) often does not shadow,but will commonly layer along the most dependent aspects of thebiliary tract, depending on its specific gravity. Neck (N), cystic duct(c), common bile duct (cbd).

Severe sludge: Layering of sludge (arrowheads) within thegallbladder with signs of wall inflammation (arrow) and far-fieldacoustic attenuation. Fundus (F), neck (N), common bile duct (cbd).

Sludge and stone: Sludge layering (arrowhead) posterior to thegallbladder fundus (F) overlying a large neck stone (arrow)demarcated by its marked hyperechoic rim and distal acousticshadowing (s).


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Biliary polypsRequiring further workup to rule out neoplasm, bil-iary polyps are a common pathology, occurring any-where along the luminal wall, often non-shadowing,isoechoic structures that are immobile.

Biloma: As sludge thickens and congeals, it does not alwaysprecipitate a stone, but instead can form tumefactive sludge, or abiloma (arrows). This non-shadowing, heteroechoic, polypoid massextending into the gallbladder (G) lumen must be distinguishedfrom a neoplasm and often is found to be mobile when the patientis placed in the left lateral decubitus position, though biopsy is theonly definitive diagnostic choice. Inferior vena cava (IVC), aorta (Ao),spine shadow (S).

Biliary polyp: A polyp (P) and fine stalk (arrow) is attached to theanterior gallbladder wall, not to be confused with a stone whichwould likely orient in the dependent aspects of the gallbladder.Fundus (F), neck (N).

Biliary polyp: A single, dependent, pedunculated mass (arrow) isidentified as a polyp because of its lack of acoustic shadowing andlarge affixing stalk.

Polyposis: A small polyp (arrow), attached by a fine, hyperechoicinsertive pedicle lies superior to a large, fixed mass (arrowhead)whose pedicle is not clearly seen (likely located on a lateral wall).Both are excluded as stones due to the lack of shadowing artifact.


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WES signThe “wall-echo-shadow” (WES) sign, or “double-arch” sign results from a contracted gallbladderaround a large stone. The anterior-most hyperechoic

line represents that of the gallbladder wall, with thesecond hyperechoic rim being that of the anteriorcrest of the stone. Interposed between the two layersis a hypoechoic brim of bile.

Polyposis: Multiple, small polyps (arrows) at the gallbladder (G)fundus, right lung (Lu), kidney (K).

Polyposis: The finding of one polyp should prompt the search forothers, although even a solitary polyp should prompt furtherdiagnostic workup for possible neoplastic disease. Polyps (arrows),edge refraction artifact shadowing (s), hepatic artery (H), commonbile duct (c), portal vein (P), the “Mickey Mouse sign.”

WES: The gallbladder wall (large arrow) overlies a hypoechoic wedgeof bile or gallbladder lumen (arrowhead), encircling the hyperechoicgallstone brim (small arrow), which casts its distal acoustic shadow (s).

Difficult WES: Two hyperechoic rims (arrows) are seensandwiching a hypoechoic region (arrowhead) and casting afar-field shadow (s).


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DuodenumCommonly misinterpreted as a gallbladder with mul-tiple stones, the duodenum actually helps orient asonographer to the location of the gallbladder. Theduodenum is sonographically distinguished by its lack

of distal field clarity as a result of duodenal air, whichobscures the imaging. To further differentiate theduodenum from the gallbladder one can look forperistalsis, which should occur in the duodenum atregular intervals.

Good WES: In obese patients with poor acoustic windows, theWES’s shadow (S) can be the only indicator as to the location of acontracted gallbladder (arrow) around a large stone (arrowhead).

Duodenum: Resembling the classic “peas in a pod” appearance ofa collection of gallstones, the duodenum (Du) is marked as beinghyperechoic and having a mixture of comet-tailing (arrow) and distalacoustic shadowing (arrowhead) as a result of its mixed gaseous andparticulate contents, respectively.

Duodenum: Another key feature distinguishing the duodenumfrom the gallbladder is the visualization of plicae circularae(arrowheads). Comet tail as a result of intestinal air (arrow).


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Liver pathologyEmergency bedside ultrasonography is not limited tothe imaging of the gallbladder and biliary pathology,but can expand itself to the identification of numer-ous other forms of hepatic pathology.

Duodenum: Outlined by a large collection of anechoic ascitic fluid(As), the plicae circularae (arrows) of the duodenum identify thestructure as bowel.

Fecalith: Commonly mistaken for a gallstone because of itsechogenicity and distal shadowing (s), the duodenum (Du) cancontain fecaliths (arrowhead), which can abut the gallbladder (G),but are clearly outside the gallbladder wall (arrow).

Fecalith: It is important to identify the posterior gallbladder (G)wall (arrows and note their continuity in overlying hyperechoicstructures such as the duodenum (Du).

Dilated hepatic ducts: Indicative of possible biliary obstruction orchronic hepatic disease, dilated intrahepatic biliary ducts (arrows) areseen converging into the proximal bile duct confluence(arrowhead). Portal vein (P). Main lobar fissure (M).


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Dilated hepatic ducts: Sustained choledocholithiasis can causeresultant upstream generalized hepatic ductal dilation (arrows).Cystic duct (arrowhead).

Cirrhotic liver: The irregular, nodular edge of the liver(arrowheads) outlined by ascitic fluid (As) identifies a cirrhotic liver.

Metastatic liver disease: Two, well-circumscribed,heterogeneous and hypoechoic liver masses (arrows).

Metastatic liver disease: A solitary, coin-shaped lesion (arrow)likely represents neoplastic changes, but would require furtherstudies to differentiate from benign processes such ashemangiomas. Middle hepatic vein (M), left hepatic vein (L), inferiorvena cava (IVC).

Metastatic liver disease: Multiple circular lesions (M) clearlyrepresent metastatic disease, differentiated from the more anechoicgallbladder (G) with its anechoic lumen and well-defined wall(arrow).


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Metastatic liver disease: A heterogenous density (arrow) withevidence of central flow under power Doppler distinguishes thisneoplasticmass from thegallbladder (G), seencasting twoedge refractionshadows (s). Portal vein (PV),main lobar fissure (M), inferior vena cava (IVC).

Metastatic liver disease: Two heteroechoic, coin-shaped masses(M) identify liver metastases, one of which contains air, as indicatedby its distal acoustic enhancement or “comet-tailing” (a).Gallbladder (G).

Hemangioma: The liver (L) imaged under Doppler sonographyshows multiple vascular structures (arrowheads) and aheterogenous, hyperechoic mass (arrow) indicative of ahemangioma. Diaphragm (D), right lung base (P).

Hemangioma: A hyperechoic, heterogenic, nodular mass (arrow)abutting the diaphragm (arrowheads) within the liver (L) likelyidentifies a hemangioma.

Cholangiocarcinoma: An echogenic, heterogenous mass(arrowheads) is seen invading the lumen of the gallbladder and containshypoechoic irregularities (arrow). The diagnosis of cholangiocarcinomawas later confirmed after biopsy to distinguish it from a biloma.

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PancreasAn often unimaged, but usually easily identifiablestructure adjacent to the readily imaged liver andgallbladder is the pancreas. Slightly more hyperechoicbut equally as heterogenous as the liver, the pancreascan provide clues to biliary pathology. When morehyperechoic, it conveys underlying inflammationand possible outlet obstruction, imploring the

sonographer to more carefully assess the biliary treefor dilation, thickening, stones, sludge, or other path-ology. Moreover, the pancreas can occasionally pre-sent with pseudocysts, which sonographically aredifficult to distinguish from the gallbladder when seenby novice sonographers.

Hemangioma: A hyperechoic, heterogenic mass (heavy arrow)near the diaphragm (D) likely representing a hemangioma casts amirror artifact into the chest (fine arrow). Liver (L).

Pleural effusion: Often the result of serious liver pathology, apleural effusion (PE) can be identified in the lung by the absence ofthe normal mirror artifact across the diaphragm. The diaphragm(arrow) divides the heteroechoic liver (L) inferiorly from thehypoechoic fluid collection superiorly. Should an effusion or otherabnormal substance collection not accumulate in the lung, the liverwill reflect across the hyperechoic diaphragm, creating a mirrorartifact. Liver mass (M).

Anatomy: The superior mesenteric artery (sm) orients thesonographer to the location of the pancreas, seen “nutcracking” theleft renal vein (R) overlying the aorta (A). Sitting atop the sm lies thesplenic vein which posteriorly borders the body of the pancreas andidentifies the pancreatic head (H), distinguished from the left lobe ofthe liver (L) by a fine, hypoechoic sliver (arrow). Spine shadow (Sp).

Anatomy: The head (H), neck (N) and body (B) of the pancreas arefound immediately anterior to the hypoechoic, arching splenic vein.Occasionally, the pancreatic duct of Wirsung (arrowhead) can beseen adjoining to the common bile duct (arrow), an important pointof interest for patients with elevated lipases and concern forgallstone pancreatitis.


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Anatomy: A sonographer interested in identifying the pancreasshould first identify the aorta (Ao) and search for the superiormesenteric artery (S) lying in the same axis as the aorta,“nutcracking” the left renal vein (arrow) which lies posteriorly, andresting like a “mantle clock” beneath the splenic vein (SV). Anterior tothe splenic vein sits the head (H), neck (N), body (B), and tail (T) ofthe pancreas, seen lying inferior to the left lobe of the liver (L), whichtends to be of more hypoechoic, heterogenous composition thanthe pancreas. Falciform ligament (arrowhead). Duodenum (Du).


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Chapter

6Intestinal ultrasound

WarrenWiechmann and ChaseWarren

The appendixAlthough it can be difficult to detect in its myriadpositions around the cecum, locating the appendixand determining whether it is normal or inflamed is

a rapid and cost-effective way of ruling out or makinga diagnosis of appendicitis. This is determined bymeasuring the diameter, compressibility, and powerDoppler data obtained from the ultrasound scan.


Normal appendix, long axis: Long-axis view of a normalappendix, which is often quite elusive and difficult to even detect.When observed, it presents as a compressible tube that is 5 mm orless in diameter.

Normal appendix, short axis: Short-axis view of a normalappendix (A), which is often quite elusive and difficult to detect.When observed, it presents as a compressible tube that is 5 mm orless in diameter.

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Appendicitis, long axis: Long-axis view of appendicitis, which isan inflamed appendix (A) > 6 mm in diameter, non-compressible,and filled with hypoechoic fluid infiltrate.

Appendicitis, short axis: Short-axis view of appendicitis, which isan inflamed appendix (A) > 6 mm in diameter, non-compressible,and filled with hypoechoic fluid infiltrate.

Appendicitis short axis: Short-axis view of appendicitis, which isan inflamed appendix (A) > 6 mm in diameter, non-compressible,and filled with hypoechoic fluid infiltrate.

Appendicitis, long axis: Long-axis view of appendicitis, which isan inflamed appendix (A) > 6 mm in diameter, non-compressible,and filled with hypoechoic fluid infiltrate.

Chapter 6: Intestinal ultrasound

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Periappendiceal free fluid: In acute appendicitis, hypoechoicfree fluid (FF) can accumulate in the space directly surrounding theinflamed appendix (AP). Artery (A).

Perforated appendix: In a long-axis view of acute appendicitis, aperforation (P) can form in the appendiceal tissue, allowing thehypoechoic fluid contents of the inflamed appendix (A) to escapeand create an abscess (PA) in nearby tissue.

Periappendiceal free fluid: In acute appendicitis, hypoechoicfree fluid (FF) can accumulate in the space directly surrounding theinflamed appendix (AP). Artery (A), vein (V).


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Psoas rectus compression: When thetransducer head is firmly pressed againstthe abdomen, the rectus (R) muscleshould be able to come into directcontact with the psoas (P) muscle. In thecase of appendicitis, the inflamed andnon-compressible appendix prohibits thisfrom occurring, and a gap between thetwo muscles is felt and observed.Intestine (I), iliac artery (IA).

Psoas rectus compression: When thetransducer head is firmly pressed againstthe abdomen, the rectus (R) muscleshould be able to come into directcontact with the psoas (P) muscle. In thecase of appendicitis, the inflamed andnon-compressible appendix prohibits thisfrom occurring, and a gap between thetwo muscles is felt and observed.Intestine (I), iliac artery (IA).


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Psoas rectus compression, long-axisview: When the transducer head isfirmly pressed against the abdomen, therectus (R) muscle should be able to comeinto direct contact with the psoas (P)muscle. In the case of appendicitis, theinflamed and non-compressible appendixprohibits this from occurring, and a gapbetween the two muscles is felt andobserved. Intestine (I), iliac artery (IA),sacrum (S).

Psoas rectus compression, short-axisview: When the transducer head isfirmly pressed against the abdomen, therectus (R) muscle should be able to comeinto direct contact with the psoas (P)muscle. In the case of appendicitis, theinflamed and non-compressible appendixprohibits this from occurring, and a gapbetween the two muscles is felt andobserved. Intestine (I), iliac artery (IA), iliaccrest (IC).


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AscitesFree fluid in the abdominal cavity is an importantetiology to prove when assessing abdominal distension

and pain, and an absolutely crucial finding when inci-dentally noted during an unrelated scan.

Ring of fire: Short-axis view of appendicitis utilizing powerDoppler, which creates a distinct “ring of fire” (F) appearance aroundthe appendix (A) in response to the increased blood flow to theinflamed area.

Ring of fire: Short-axis view of appendicitis utilizing powerDoppler, which creates a distinct “ring of fire” (F) appearance aroundthe appendix (A) in response to the increased blood flow to theinflamed area. The second “flame” is artifact.

Abdominal ascites and small bowel peristalsis: A portion ofthe small intestine (I) undergoing a peristaltic contraction (note thecompressed plicae circulares) adjacent to the hypoechoicabdominal ascites fluid (A). Intestinal gas (G) shows as a hyperechoicmass along the edge of the intestine.

Loculations: Loculations (L) (wispy, cobweb-like filaments)within the hypoechoic abdominal ascites fluid (A), that undulateand ripple with movement.


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DiverticulitisDiverticuli, havens for fecaliths and food matter, arevital to identify when evaluating patients with local-ized left lower quadrant pain, fever, and leukocytosis.

Ascites surrounding small bowel short axis: Cross-sectionalview of small intestine loops (HI) peristalsing, adjacent to thehypoechoic abdominal ascites fluid (A). Rectus abdominis (RA).

Duodenum surrounded by ascites: Short-axis view of aduodenum (D) segment surrounded by hypoechoic ascites fluid (A).

Diverticulitis: Diverticulum (D), which is an outward finger-likeprojection of intestinal lumen (IL). Often, it is surrounded by fat (F)and a thickened, edematous intestinal wall.

Diverticulitis: Diverticulum (D), which is an outward finger-likeprojection of intestinal lumen (IL). Often, it is surrounded by fat (F)and a thickened, edematous intestinal wall.


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HerniaUltrasound offers a modality unique from the otherimaging sources such as CT and films, allowing her-nias to be viewed not only statically but in motion and

in real time. The extent of protrusion and nature ofthe defective body wall can be accurately describedand measured.

Fecalith within diverticulitis, long axis: Long-axis view of afecalith (F), entrapped and hardened fecal matter within adiverticulum (D) of the intestine. Note the shadow the fecalith casts.

Fecalith within diverticulitis short axis: Short-axis view of afecalith (F), entrapped and hardened fecal matter within adiverticulum (D) of the intestine. Note the shadow the fecaliths casts.

Ventral hernia with ascites and loculations: Loculations (L)(wispy, cobweb-like filaments) within the hypoechoic abdominalascites fluid (A). A ventral wall defect (H) is present, with a significantamount of ascites outside and within the hernia itself.

Inguinal hernia: Herniated intestine (I) protruding into anddescending along the inguinal canal (IC) toward the testicle (T).


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IntussusceptionEspecially prevalent in children, intussusception is theinversion of bowel back within itself. Ultrasound isboth specific and highly sensitive in detecting theclose concentric layers of bowel wall that are pathog-nomonic of the disease.

Hernia, ascites, and loculations: Loculations (L) (wispy,cobweb-like filaments) within the hypoechoic abdominal ascitesfluid (A). A ventral wall defect (H) is present, with a significantamount of ascites outside and within the hernia itself.

Umbilical hernia: Herniated loop of intestine (I) breaching therectus abdominis (R) in the umbilical region of the abdomen,surrounded by hypoechoic ascites fluid.

Ventral hernia: Herniated loop of intestine (H) breaching therectus abdominis (R), surrounded by hypoechoic abdominal ascitesfluid (A).

Intussusception, long axis: Long-axis view of anintussusception (I), wherein a segment of bowel is pushedretrograde into the segment of bowel preceding it. This formsconcentric layers of bowel, similar to a collapsible telescope.


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Small bowel obstructionEasily confused with ileus, obstruction of the smallintestine can present ultrasonically with free fluidbetween intestinal loops and an increased thicknessof the bowel wall.

Intussusception, long axis pseudo-kidney sign: Thetelescoping bowel segments of an Intussusception bend to forma kidney-like shape in the long-axis view. Bowel lumen (L). Intussusception, short axis: Short-axis view of an

intussusception (I), wherein a segment of bowel is pushedretrograde into the segment of bowel preceding it. This formsconcentric layers of bowel, similar to a collapsible telescope.

Small bowel obstruction: Short-axis view of obstructed smallintestine. The increased pressure within the obstructed bowel forcesfluid outward through the strained intestinal wall into theabdominal cavity, creating free fluid wedges (W). Trapped fecalmatter (F) can be seen languishing in the bowel loops (L).

Small bowel obstruction: Short-axis view of obstructed smallintestine. The increased pressure within the obstructed bowel forcesfluid outward through the strained intestinal wall into theabdominal cavity, creating free fluid wedges (W). Trapped fecalmatter (F) can be seen languishing in the bowel loops (L).


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Odds and endsAlthough unanimously claimed as accidental butalmost always intentional, events of a “delicatenature” can benefit greatly from a discreet ultrasoundsurvey to assess extent and possible damage.

Rectal foreign body: Cross-sectional view of a 16 oz. bottle (O)completely filling the rectum and pushing against the urinarybladder (B).


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Chapter

7Pelvic ultrasound

Cindy Chau and John Christian Fox

AnatomyThe female internal organs are situated in the pelviccavity. The size of the uterus varies at different agesand parities. A nulliparous adult uterus measures6–8 cm in length versus 9–10 cm in multiparouswomen. The endometrial thickness also varies greatly

in thickness, 0.5–5 mm. The ovaries can be difficult toidentify. A normal size ovary measures about 3.5 � 2� 1.5 cm and 1.5 � 0.7 � 0.5 cm in pre-menopausaland postmenopausal women, respectively. The uterusand pelvic vessels are used as landmarks for identify-ing the ovaries.


Transabdominal sonogram: Sagittal view of uterus. Transvaginal sonogram: Sagittal view. Endometrial stripe (ES,arrows), uterus (U), urinary bladder (UB).

Transabdominal sonogram: Sagittal view. Endometrial stripe(ES, arrows), urinary bladder (UB).

Transabdominal sonogram: Coronal view. Uterus (U), rightovary (RO) with multiple follicles, urinary bladder (UB).

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Transabdominal sonogram: Coronal view. Uterus (U),endometrial strip (ES, arrows), urinary bladder (UB).

Ovaries: Transvaginal sonogram. Coronal oblique view. Left ovary(arrow) with multiple cysts (C), internal iliac artery (A) and vein (V),and external iliac vein (Ve). The ovaries lie anterior to the iliac vessels.

Ovaries: Coronal view sonogram. Endometrial stripe (arrow), rightand left ovaries with multiple follicles (*). In this view, ovaries arelocated behind the uterus, posterior cul-de-sac, or pouch of Douglas.

Pregnancy, abnormal: Coronal view sonogram: Abnormalpregnancy with pseudosac in utero (*). The “cornual flare,” portion ofthe uterus at the junction of the fallopian tubes, aids in locating theovaries and fallopian tubes via laterally moving the probe.

Bicornuate uterus 1: Bicornuate uterus has an indented fundusand two endometrial cavities (arrows) versus a septate uterus whichhas a normal external surface and two endometrial cavities.

Bicornuate uterus 2: Pregnancy in a septate uterus: Note thenormal external surface with two endometrial cavities (*). Septum(arrow). Intrauterine pregnancy in one horn – fetal pole (large arrow).

Chapter 7: Pelvic ultrasound

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Intrauterine device: Transabdominal sonogram. Longitudinalplane. Intrauterine device (arrow).

Intrauterine device: Transvaginal sonogram. Intrauterine device(arrow).

Intrauterine device: Transvaginal sonogram. Sagittal view.Intrauterine device.

Intrauterine device: Transabdominal sonogram. Copperintrauterine device.

Free fluid: Transabdominal sonogram. Longitudinal plane. Patientwith a ruptured ectopic pregnancy (not seen in this view). Note theempty uterus and free fluid in the pelvic cul-de-sac.

Free fluid: Coronal view sonogram. Ectopic pregnancy with freefluid in the pelvic cul-de-sac (pouch of Douglas). Free fluid may also bevisualized in the hepatorenal recess. Free fluid is anechoic (black).


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Intrauterine pregnancyThe ability to visualize an intrauterine pregnancy(IUP) via sonography correlates with the level ofbeta-human chorionic gonadotropin (hCG). Ontransvaginal ultrasound examination, a gestationalsac is visible at 4.5–5 weeks of gestation, which cor-responds to an hCG level of > 1500 IU/L. The yolksac appears between 5–6 weeks. A fetal pole is detect-able at 5.5–6 weeks. Cardiac motion is detectable athCG > 6000 IU/L. An IUP is visible via transabdom-inal ultrasound at >6500 IU/L.

Free fluid: Transvaginal sonogram. Sagittal view. Free fluid (ff) incul-de-sac. Note the heterogenicity of the fluid, likely clotted blood.

Free fluid: Transabdominal sonogram. Sagittal view. Free fluid (ff)in pelvic cul-de-sac (pouch of Douglas).

Free fluid: Transabdominal sonogram. Coronal view. Free fluid (ff)in pelvic cul-de-sac (pouch of Douglas).

Intrauterine pregnancy: Transvaginal sonogram. Coronal view.Intrauterine pregnancy, fetal pole (*).


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Intrauterine pregnancy: Transvaginal sonogram. Earlyintrauterine pregnancy. Presence of both yolk sac (*) and fetal pole(arrow) gives an estimated gestational age of 5–6 weeks.

Intrauterine pregnancy: Transvaginal sonogram. Earlyintrauterine pregnancy. Presence of yolk sac (*), fetal pole (bigarrow), and amniotic sac (small arrows, AS) gives an estimatedgestational age of 5–6 weeks.

Intrauterine pregnancy: Coronal view sonogram. Earlyintrauterine pregnancy (IUP). Presence of fetal pole (arrow) and yolksac (*) indicates a 5–6 week IUP.

Intrauterine pregnancy: Transvaginal sonogram. Yolk sac (arrow)presence indicates a pregnancy at ~5 weeks gestational age.

Intrauterine pregnancy: Transvaginal sonogram. Earlyintrauterine pregnancy, 6 weeks gestational age. Fetal pole (whitearrow), yolk sac (not shown here), and amniotic sac (part of theamniotic sac membrane in yellow arrow).

Intrauterine pregnancy: Transvaginal sonogram. Earlyintrauterine pregnancy, 6 weeks gestational age. A 2- to 3-mmgestational sac, yolk sac, and embryonic pole with cardiac activityare visualized via transvaginal ultrasound at gestational ages 4, 5, 6weeks. Yolk sac (*), amniotic sac (AS), fetal pole (arrow), urinarybladder (UB).


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Intrauterine pregnancy: Transvaginal sonogram. Intrauterinepregnancy. Amniotic sac (AS), embryo (E), free fluid (ff), urinarybladder (UB).

Intrauterine versus ectopic pregnancy: Transvaginalsonogram. Coronal view. Note empty intrauterine cavity. Earlyintrauterine pregnancy (IUP) versus ectopic pregnancy. Need tocorrelate with serum beta-hCG levels. Normal IUP is visible at beta-hCG 1500–2000 IU/L via transvaginal ultrasound and >6500 IU/L viatransabdominal ultrasound. Bilateral ovaries with follicles (arrows).

Intrauterine pregnancy, abnormal: Sonogram showing anabnormal intrauterine pregnancy with fetal demise. Note thecollapsing and abnormally shaped gestational sac. Subchorionic hemorrhage: First trimester subchorionic

hemorrhage (arrow). Hematoma is collected between the uterinewall and the chorionic membrane. Vaginal bleeding may or may notbe present. Patients are at increased risk of miscarriage, stillbirth,placental abruption, and preterm labor.

Intrauterine pregnancy with intrauterine device: Embryo(white arrow) and IUD (orange arrow). Urinary bladder (UB). Overallincidence of ectopic pregnancy is lower than the general populationgiven its effectiveness in preventing pregnancies. However, patientsare at increased risk of having an ectopic pregnancy if pregnancyoccurs.


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Ectopic pregnancyEctopic pregnancy is a pregnancy outside of the uter-ine cavity. The most common extra-uterine locationis the fallopian tube (98%). Diagnostics tests includetransvaginal ultrasound (TVUS) and quantitativebeta-hCG. Absence of an IUP via TVUS at beta-hCG above the discriminatory zone, the level of

hCG (>1500 IU/L) in which an IUP should be visu-alized by TVUS, increases the suspicion of an ectopicor nonviable intrauterine pregnancy. Color Dopplercan be used to identify a “ring of fire” surrounding anectopic pregnancy. A pseudosac, present in ~20%, ofectopic pregnancies, is a small fluid collection locatedwithin the endometrial cavity.

Ectopic pregnancy, ring of fire: Transvaginal color Doppler ofadnexa showing the ring of fire (arrow), produced by the placentalblood flow within the periphery of the complex adnexal mass.Ectopic pregnancy with a fetal pole (*).

Ring of fire: The ring of fire is associated with ectopic pregnancies.Notice the adjacent ovary with follicles (*).

Ectopic pregnancy: Ring of fire.

Ectopic pregnancy: Coronal view sonogram showing a rightectopic pregnancy. Note the gestational sac (yellow arrow) and yolksac (white arrow). Uterine cavity with a pseudosac (*).

Ectopic pregnancy, cornuate versus tubalpregnancy: Transvaginal sonogram. Coronal view. Note the leftsided cornuate versus tubal pregnancy (arrow).


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Ectopic pregnancy (cornual): The arrows outline a mass rightalong the edge of the uterus instead of in the fundus of the uterus.At this location, the edge of the uterus, the mantle is very thin and atrisk for uterine rupture should the ectopic grow large enough. This isalso termed “interstitial ectopic” as the pregnancy is located in theinterstitium, the site at which the fallopian tube enters the uterus.

Ectopic pregnancy with pseudosac: Ectopic pregnancy withgestational sac (*) and fetal pole (arrow). Urinary bladder (UB).Uterine cavity with pseudosac (not shown here).

Ectopic pregnancy with pseudosac: Ectopic pregnancy (notshown here). Pseudosac (*) in the uterine cavity. Note the absence ofthe yolk sac and fetal pole. Uterus (U), urinary bladder (UB).

Ectopic pregnancy and pseudosac: Sagittal view sonogram.Ectopic pregnancy (not shown here) with intrauterine pseudosac(arrow). Note also the free fluid. Urinary bladder (UB).

Ectopic pregnancy and free fluid: Sagittal view sonogram ofpatient with an ectopic pregnancy (not shown here). Nabothiancysts (small arrows). Free fluid (big arrow). Pseudosac (*), urinarybladder (UB).


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Molar pregnancyMolar pregnancies, complete or partial mole, resultfrom aberrant fertilization. Women typically presentwith signs and symptoms of early pregnancy. Someof the clinical manifestations include vaginal bleed-ing, enlarged uterus, pelvic pressure or pain, thecalutein cysts, anemia, hyperemesis gravidarum, hyper-thyroidism, preeclampsia before 20 weeks of gesta-tion and vaginal passage of hydropic vesicles.

Diagnostic evaluation includes quantitative beta-hCGand ultrasound. Beta-hCG levels are typically ele-vated, 40% greater than 100,000 IU/L. Ultrasoundfindings in a complete mole include absence of anembryo or fetus, no amniotic fluid, heterogenousmass with discrete anechoic spaces (correspondingto hydropic chorionic villi – described as snowstormpattern).

Ectopic pregnancy and free fluid: Coronal view sonogram.Patient with an ectopic pregnancy (yellow arrow), fetal pole(*, better viewed on another slide) and a hemorrhagic cyst(white arrow). Note the reticular/weblike pattern within the cyst.

Ectopic pregnancy and hemorrhagic cyst: Ectopic pregnancy,fetal pole (yellow arrow). Hemorrhagic ovarian cyst (white arrow).

Ectopic pregnancy: Transabdominal sonogram. Ectopicpregnancy (white arrow). Embryo (*). Uterus (yellow arrow).


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Molar pregnancy: Hydatidiform (molar) pregnancy: Echogenicmass in the uterine cavity with multiple small, hypoechoic areas(arrows).

Molar pregnancy: Hydatidiform (molar) pregnancy. Echogenicmass with multiple hypoechoic areas (*) filling the uterine cavity.Note the “snow storm” effect on the sonogram.

Molar pregnancy: Hydatidiform (molar) pregnancy. Echogenicmass filling the uterine cavity with multiple hypoechoic areas (*).Note the “snow storm” effect on the sonogram.

Molar pregnancy: Theca-lutein cysts, frequently seen in disorderswith increased hCG such as multiple pregnancies, hydatidiformpregnancy (which this sonogram is derived from), choriocarcinoma,fetal hydrops, exogenous hCG treatment, or polycystic ovary.Typically, it has a multiloculated appearance.

Molar pregnancy: Coronal view sonogram. Hydatidiform (molar)pregnancy (white arrow) and theca lutein cysts (yellow arrow). Notethe echogenic mass with the hypoechoic areas filling the uterinecavity, and the typical multiloculated appearance in the right ovariancysts. Urinary bladder (UB).

Molar pregnancy: Hydatidiform (molar) pregnancy: note theechogenic mass in the uterine cavity with multiple hypoechoic areas(*) secondary to trophoblastic proliferation and edema of villousstroma.


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CystsCysts are small fluid-filled sacs. There are differenttypes of ovarian functional cysts: follicular (75% of allcysts), corpus luteum, hemorrhagic, dermoid, theca-lutein (bilateral) endometrioid, and polycystic-appearing ovaries. The internal cystic structure may

be categorized into simple, complex or completelysolid. When cysts are less than 6 cm in size in repro-ductive age women, management is to observe for 6–8weeks plus a repeat ultrasound. Cysts are measuredfrom outer wall to inner wall. When filled with bloodor blood clots, cysts have a reticular or web-like pattern.

Ovarian mass: Transabdominal sonogram. Ovarian mass(arrow).

Corpus luteal cyst: Ovary (arrows), corpus luteal cyst (*). Viableintrauterine pregnancy (not shown here).

Ovarian follicles: Intrauterine pregnancy (*), fetal pole not shownhere. Right ovary (arrows) with multiple follicles.

Ovarian follicles: Right ovary with multiple follicles (arrows).Urinary bladder (UB).


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Ovaries: Multifollicular ovary (O), follicles (*). Ovaries: Transverse view. Left ovary (LO), endometrial stripe(arrows). Uterus (U).

Corpus luteal cyst and IUP: Corpus luteal cyst (white arrow) andintrauterine pregnancy (yellow arrow; yolk sac and fetal pole notshown here). Cysts are measured from outer wall to inner wall,1.64 � 1.82 cm. Ovarian cysts: Ovarian cyst.

Ovarian cysts: Ovary with multiple simple cysts. Ovarian cyst: Ovarian masses or cysts > 4 cm are at increased riskof torsion.


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Ovarian torsionOvarian torsion is the fifth most common gyneco-logic emergency. The risk of an adnexal mass toundergo torsion markedly increases at sizes > 4 cm.Absence or impaired ovarian venous flow on Dopplermay be found in the setting of torsion.

Nabothian cysts: Sagittal view. Nabothian cysts (*), located in thecervix. Normal appearing uterus with thin endometrial stripe(arrows). Urinary bladder (UB).

Hemorrhagic cyst: Left ovarian hemorrhagic cyst, 4 � 5 cm (OC),also known as a hematocele. Urinary bladder (UB).

Hemorrhagic cyst: Hemorrhagic ovarian cyst (white arrow) withblood clot (yellow arrow). Note the reticular or weblike patternwithin cyst, resulting from lysis of red blood cells.

Hemorrhagic cyst: Transvaginal sonogram. Patient with rupturedhemorrhagic cyst with associated free fluid in the pelvic cul-de-sac(pouch of Douglas). Patients may present complaining of suddenonset of pelvic pain after intercourse.

Ovarian torsion: Transvaginal sonogram. An 18-year-old femalewith intermittent right lower quadrant pain. Post-operativediagnosis of ovarian cyst and torsion. Right ovary with a 5.4 � 6.3 �5.4 cm anechoic cyst. Note the enlarged ovary with multiple follicles(*) at the periphery and free fluid (f) surrounding the ovary.


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Fibroid uterusUterine leiomyomas are benign monoclonal tumors.They arise from the smooth cells of the myometrium.Fibroids are clinically relevant when they cause uter-ine enlargement greater than or equal to 9-weeks size,fibroid greater than or equal to 4 cm or submucosalfibroids. Transvaginal ultrasound has a high sensitiv-ity (95–100%) for detecting fibroids. Fibroids appearheterogenous. When fibroids undergo necrosis, theymay have anechoic components.

Ovarian torsion: Transvaginal sonogram. Sagittal view. An18-year-old female with intermittent right lower quadrant pain.Post-operative diagnosis of ovarian cyst and torsion. Color Dopplercan be used to evaluate ovarian arterial blood flow. Note thedecreased blood flow to the ovary. However, approximately 50% ofpatients will have a normal Doppler flow study.

Ovarian torsion: Transvaginal sonogram. Ovarian torsion. Duplexultrasound showing asymmetry of arterial waveforms withdiminished diastolic component of the ovarian arterial flow.

Ovarian torsion: A 12-year-old patient with ovarian torsion.Venous waveform measured. Note the decreased flow in theadnexal mass.

Fibroid uterus: Uterine leiomyoma.


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Fibroid uterus: Transabdominal sonogram. Longitudinal view.Uterine leiomyoma.

Fibroid uterus: Transabdominal sonogram. Longitudinal view.Uterine leiomyoma.

Fibroid uterus: Transabdominal sonogram. Transverse view.Uterine leiomyoma.

Fibroid uterus: Transverse sonogram. Multiple fibroids (arrows).

Fibroid uterus: Transverse sonogram. Multiple fibroids (arrows).


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Chapter

8Genitourinary ultrasound

Christina Umber and John Christian Fox

Normal kidneyRenal ultrasound is an efficient way to screen thekidneys for major pathology. It is non-invasive andcan be completed within minutes. Care must be takento ensure that appropriate landmarks are found. The

liver should be visualized adjacent to the right kidneyand the spleen should be seen adjacent to the leftkidney. Determination of normal renal anatomy canbe accomplished through utilization of the renalborder, pyramids, parenchyma and pelvis as markers.


Normal right kidney: Renal border (arrow), liver (*).

Normal renal pyramids: Renal pyramids (small arrows), renalborder (large arrow).

Normal renal pyramids: Renal pyramids (small arrows), renalborder (large arrow).

Perinephric fat: Perinephric fat (arrows), adipose capsule of thekidney, renal parenchyma (*).

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Perinephric fat: Perinephric fat (arrows), adipose capsule of thekidney, renal parenchyma (*).

Renal blood flow: Normal renal blood flow as seen with Dopplersonography (blue and red colors). Renal border (arrow).

Renal blood flow: Renal blood flow asseen with Doppler sonography (blueand red colors). Renal parenchyma (*),perinephric adipose tissue (arrows).

Renal blood flow: Normal blood flowof the kidney as seen with Dopplersonography (blue and red colors). Renalborder indicated by arrow.

Chapter 8: Genitourinary ultrasound

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Renal variationVariation in the anatomical location and size of thekidneys as well as how they maintain vascularizationdoes not necessarily predict pathology or symptoms.

This is especially true when the anomaly is unilateral.Conversely, when symptoms are present, sonographyis a quick way to screen for obvious anatomicalpathology.

Renal blood flow: Normal blood flowof the kidney (blue and red colors).Renal border indicated by arrow.

Atrophic and normal kidney: Normal kidney, approximately 5 cm (left frame); small atrophic kidney, approximately 3 cm (right frame).Renal borders indicated with arrows.


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Renal masses, cysts, and abscessesThe kidneys may present with several forms ofimpinging anomalies. Differentiation between thevarious pathologies is initiated through ultrasound.The echogenicity of abnormal findings is the firststep in determining the underlying pathology.A follow-up renal biopsy is frequently needed fordefinitive diagnosis.

Atrophic kidney: Small atrophic kidney, approximately 3 cm,renal border (arrows), renal pelvis (*).

Horseshoe kidney: Right (R) and left (L) kidneys connectedanterior to the spine by an isthmus (arrow) of renal tissue. This is acongenital anomaly that affects approximately 1 in 400 people.

Pelvic kidney: Pelvic kidney (arrow) seen on endovaginalultrasound. Uterus (*). It is estimated that in the United States 1 inevery 500 births are affected by fetal pelvic kidney.

Duplicate renal arteries: Arterial lumens indicated by *. Thisanomaly is present in 15–20% of the general population.

Duplicate renal arteries: Arterial borders indicated by arrows.This anomaly is present in 15–20% of the general population.


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Renal mass: Renal cell carcinoma (A and B; also known ashypernephroma) is a kidney cancer that originates in the lining ofthe proximal convoluted tubule. Renal border (arrowhead).

Renal mass: Renal cell carcinoma (between white lines; alsoknown as hypernephroma) is a kidney cancer that originates in thelining of the proximal convoluted tubule. Renal border (arrow).

Renal mass: Renal cell carcinoma (large arrow) – (also known ashypernephroma) is a kidney cancer that originates in the lining ofthe proximal convoluted tubule. Renal border (small arrow).Parenchyma (#), pelvis (*).

Renal cell carcinoma: Renal cell carcinoma (also known ashypernephroma) is a kidney cancer that originates in the lining ofthe proximal convoluted tubule. Renal mass (small arrows), renalborder (large arrow).


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Renal cell carcinoma: Renal cell carcinoma (also known ashypernephroma) is a kidney cancer that originates in the lining ofthe proximal convoluted tubule. Renal mass (small arrows), renalborder (large arrow).

Wilms’ tumor: Wilms’ tumor (small arrows) or nephroblastoma iscancer of the kidneys that typically occurs in children, rarely inadults. Renal border (large arrow).




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Renal calculus: Large renal calculus (between lines), acousticalshadowing (between small arrows), renal border (large arrow).

Wilms’ tumor: Wilms’ tumor (small arrows) or nephroblastoma iscancer of the kidneys that typically occurs in children, rarely inadults. Renal border (large arrow), renal pelvis (*).

Renal cyst: Kidney (small arrow) with renal cyst (large arrow) –fluid collection in the kidney.

Renal cyst: Renal cyst (*) – fluid collection in the kidney. Renalborder (white line), liver (X).

Renal cyst: Renal cyst (*) – fluid collection in the kidney. Renalborder (arrow), liver (X).


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Hydronephrosis and hydroureterHydronephrosis is distension and dilation of the renalpelvis and calyces, usually caused by obstruction ofthe free flow of urine from the kidney, leading toprogressive atrophy of the kidney. Hydronephrosiscan be seen as an enlarged area of decreased echo-genicity usually originating at the renal pelvis andextending into the parenchyma.

Abnormal enlargement of the ureter by any block-age that prevents urine from draining into the bladderresults in hydroureter. Normal ureter size is approxi-mately 1.8 mm, when obstructed average width is7 mm.

Renal cyst: Renal cyst (*) – fluid collection in the kidney. Renalborder (arrow).

Renal abscess: Renal abscess (small arrow), renal border (largearrow).

Moderate hydronephrosis: Dilated calyces (small arrows), renalparenchyma (*), renal border (large arrow).

Severe hydronephrosis: Dilated calyces (#), compressed renalparenchyma (*), renal border (arrow).


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Severe hydronephrosis: Dilated calyx (#), compressed renalparenchyma (*), renal border (arrow).

Massive hydronephrosis: Dilated renal calyces (small arrows),compressed renal parenchyma (*), renal border (large arrow).

Hydronephrosis in 3D: Accumulation of urine in the kidney, as seenwith 3-dimensional ultrasound. Renal border indicated by the arrow.

Hydronephrosis with debris: Accumulation of urine in thekidney with debris (fuzzy opacities) in the collecting system (smallarrows). Renal border (large arrow).

Hydronephrosis with debris: Accumulation of urine in thekidney with debris (fuzzy opacities) in the collecting system (arrows).Renal parenchyma (*).

Hydronephrosis with debris: Accumulation of urine in thekidney with debris (fuzzy opacities) in the collecting system (smallarrows). Renal border (large arrow).


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Polycystic kidney diseaseAn inherited disorder that over time causes manygrape-like clusters of fluid-filled cysts to form in bothkidneys. Frequently patients have no symptoms and

their physical condition appears normal for manyyears, so the disease can go unnoticed. Upon sono-graphy it is seen as multiple cystic structures envelop-ing fluid seen as decreased echogenicity.

Hydronephrosis with stone: Hydronephrosis with renal calculus.Dilated calyx (#), calculus (large arrow), acoustic shadow (smallarrows), renal border (white line).

Hydronephrosis with stone: Hydronephrosis with renal calculus.Dilated calyx (*), calculus (large arrow), acoustic shadow (smallarrows), renal border (white line).

Hydroureter: Hydroureter without hydronephrosis. Dilatedureter (*), renal border (arrow).

Hydroureter: Hydroureter without hydronephrosis. Dilated ureter(between white lines). Renal border (arrow).


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Polycystic kidney disease: Cysts (*), renal border (arrow).


Polycystic kidney disease: Cysts (dotted lines), renal border (arrow).




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Normal urinary bladderUrinary bladder ultrasound is an efficient way toscreen the bladder for major pathology. It is non-invasive and can be completed within minutes. The

bladder is best visualized when full, with the probeimmediately superior to the pubic symphysis angledinferiorly behind the pubic bone.

Bladder volume, sagittal plane: Urinary bladder volumemeasurement 3 is taken from the lumen of the bladder (*) in thesagittal plane. Measurements 1 and 2 are taken in the transverseplane.

Urine jet: Urine jet (orange) within the bladder lumen. Bladderborder (arrow).

Urine jet: Over-gained urinary bladder (*) image demonstratingurine jet (arrow).

Bladder volume, transverse plane: Urinary bladder volumemeasurements 1 and 2 are taken from the lumen of the bladder (*)in the transverse plane. Measurement 3 is taken in the sagittal plane.

Urine jet: Over-gained urinary bladder (*) image demonstratingurine jet (arrow).


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Urinary bladder variationVarious forms of disease pathology may affect theurinary bladder. Several major pathologies can beseen by ultrasound. Any increased echogenic areas

within the bladder lumen may indicate the presenceof a mass or calculi. Visualization of the bladder wallis also useful to screen for cystitis as well as impinge-ment from the prostate.

Bladder mass: Mass within the urinary bladder lumen (largearrow). Border of the bladder indicated by small arrow.

Urine jet: Over-gained urinary bladder (arrow) imagedemonstrating disbursement of urine jet (pale areas in the lumenof the bladder).




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Foley catheter: Foley catheter (arrow) within the lumen of theurinary bladder (*).

Pediatric cystitis: Inflammation of the urinary bladder. Thickenedbladder wall (between lines). Urinary bladder lumen (*). Bladderborder (arrow).

Bladder stone: Vesical calculus (bladder stone, #). Urinary bladderlumen (*). Acoustical shadow from stone (arrows).

Bladder stone: Vesical calculus (bladder stone, *). Urinary bladderborder (large arrow). Acoustical shadow from stone (small arrows).


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Normal testesTesticular ultrasound is an efficient way to screen formajor pathology. It is non-invasive and can be com-pleted within minutes. It is frequently useful to

visualize the asymptomatic testis as well as theaffected testis when the patient presents with unilat-eral pathology. Initial visualization of both testes isaccomplished utilizing a cleavage window.

Enlarged prostate: Enlarged prostate (dotted lines). Urinarybladder lumen (*). Normal prostate size is 4 � 2 � 3 cm.

Bilateral testes: Bilateral testes (*) in asingle frame. Scrotum (#).

Enlarged prostate: Enlarged prostate (PROST) decreasing thevolume of the urinary bladder lumen (BL). Normal prostate size is4 � 2 � 3 cm.


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Bilateral testes: Bilateral testes (*) in asingle frame. Scrotum (arrow).

Mediastinum testis: Mediastinum testis (large arrow), testisborder (small arrow), scrotum (*).

Mediastinum testis: Mediastinum testis (large arrow), testisborder (small arrow), scrotum (*).

Testis blood flow: Normal testis blood flow (orange color), testisborder (arrow).

Appendix testis: Appendix testis (orange arrow), testis (*),scrotum border (white line). The appendix testis (or hydatid ofMorgagni) is a vestigial remnant of the Müllerian duct, present onthe upper pole of the testis and attached to the tunica vaginalis. It ispresent about 90% of the time.

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Testes variationThere is a wide range of pathology that may affect thetestes. Internal dilatations, internal and externaltrauma, hernias, and infections are a few of thedisease processes that can be screened for withultrasound.

Testicular torsion: Orange coloring within the green linesindicates blood flow to the testis. A lack of blood flow is seen withtesticular torsion. Testis border (arrow).

Torsion infarcted testis: Echoic variation throughout the testiscaused by infarction secondary to torsion. Testis border (arrow).

Torsion infarcted testis (left): Echoicvariation throughout the testis caused byinfarction secondary to torsion. Normaltestis (right), testes borders (arrows).


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Fractured testis: Fractured testis (#),normal testis (*), testes borders (arrows).

Gunshot wound to testis: Gunshot path (large arrows)with blood clot (between the white lines) within the scrotum(small arrow).

Scrotal hematoma: Scrotal hematoma (arrows), scrotum (*). Scrotal hematoma: Scrotal hematoma (*), scrotum (#).


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Inguinal hernia: The loop of bowel (*) is adjacent to the testis (#).Inguinal hernia: The bowel wall (arrow) is adjacent to the testis(#). Bowel lumen (*).

Scrotal hernia: Loop of bowel (*) in the scrotum (#). The testis isnot in the frame.

Scrotal hernia: Loop of bowel (arrows) in the scrotum (#). Thetestis is not in the frame.


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Spermatocele:Retention cyst (*)in the head of theepididymis (arrow)distended withfluid that containsspermatozoa.Testis (#).

Spermatocele:Retention cyst (*)in the head of theepididymis (largearrow) distendedwith fluid thatcontainsspermatozoa.Testis (#), scrotum(small arrow).

Varicocele: Dilatation of the veins associated with the spermaticcord in the testes. Dilated pampiniform plexus (arrows). Testis (*).

Varicocele: Dilatation of the veins associated with the spermaticcord in the testes. Dilated pampiniform plexus (arrows). Testis (*).

Orchitis: Increased blood flow (orange color) within the testis.Testis border (arrows).

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Testicular masses, cysts, and abscessesThe testes may present with several forms of impin-ging anomalies. Differentiation between the variouspathologies is initiated through ultrasound. The

echogenicity of abnormal findings as well as theiranatomical location are the first steps in determiningthe underlying pathology.

Testicularcarcinoma:Testicular carcinoma(*), mass border(small arrow), testisborder (large arrow).

Microlithiasis: Microlithiasis is seen as small hyperechoic areasthroughout the testis. Testis border (arrow). Testicular microlithiasisarises from microscopic calcium deposits within the testicles. It is notassociated with risk of testicular cancer.

Microlithiasis: Microlithiasis is seen as small hyperechoic areasthroughout the testis. Testis border (arrow). Testicular microlithiasisarises from microscopic calcium deposits within the testicles. It is notassociated with risk of testicular cancer.

Extratesticular mass: Hyperechoic extratesticular mass (*)adjacent to normal testis (#).


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Extratesticular mass: Hyperechoic extratesticular mass (*)adjacent to normal testis (#).

Intratesticular cyst: Intratesticular cyst (*), testis (#), scrotum(arrow).

Intratesticularcyst: Intratesticular cyst (A & B), testis (#), scrotum (*).

Epididymal cyst: Epididymal cyst (arrow), epididymis (*), testis (T).

Tubular ectasia of rete testis: Benign tubular cysts (#), rete testis(arrow), testis (*).


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Testicular abscess: Testicular abscess (dotted lines), scrotum(arrow), testis (*).

Testicular abscess: Testicular abscess (large arrow), scrotum(small arrow), testis (*).

Scrotal abscess: Scrotal abscess (*), abscess border (arrows).

Scrotal abscess: Scrotal abscess (*), abscess border (arrows).

Tubular ectasia of rete testis: Benign tubular cysts (#), rete testis(arrows), testis (*).


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HydroceleA hydrocele is a fluid-filled sack along the spermaticcord within the scrotum. The main symptom is a

painless, swollen testicle, which feels like a waterballoon. It is seen on ultrasound as a region ofdecreased echogenicity surrounding the testis.

Hydrocele: Testis (X), scrotum (#), hydrocele fluid (*).

Hydrocele: Testis (X), scrotum (arrow), hydrocele fluid (*).

Hydrocele: Testis (X), scrotum (arrow), hydrocele fluid (*).Hydrocele: Hydrocele (HYDRO), epididymis (EPI), right testis(R TESTE).


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Loculated hydrocele: Epididymis (large arrow). Loculations,fibrous adhesions (small arrows), hydrocele fluid (*), scrotum (#).

Loculated hydrocele: Testis (*), scrotum (#), hydrocele fluid(arrow) with loculations (thin gray lines), fibrous adhesions.

Hydrocele with debris: Hydrocele with debris (fuzzy appearingopacities) in the lumen (*).

Hydrocele with debris: Hydrocele with debris (fuzzy appearingopacities) in the lumen (*).

Bilateral hydroceles in an infant: Bilateral hydroceles (*) shownon cleavage window in 1-week-old with normal appearing testes (#).


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EpididymitisEpididymitis is inflammation of the epididymis,which stores and carries sperm. Pain and swellingare the most common signs and symptoms. Males ofany age can get epididymitis, but it is most common

in men between the ages of 20 and 39. In some cases,the testis may also become inflamed. This condition iscalled epididymo-orchitis. Upon sonography epididy-mitis presents as a thickened epididymis withincreased blood flow.

Epididymitis: Increased blood flow (orange color) in theepididymis (arrow). Testis (*).

Epididymitis: Increased blood flow in the epididymis shown withorange color. Testis (*).

Epididymitis of head: Increased blood flow in the head of theepididymis shown with orange color. Testis (*), thickenedscrotum (#).

Epididymitis of tail: Thickened tail of the epididymis (X). Testis (*).


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Epididymitis, coronal view: Thickened epididymis (arrows)adjacent to the testis (*).

Epididymitis, coronal view: Thickened epididymis (betweenarrows) adjacent to the testis (*).

Epididymitis of tail: Increased bloodflow in the tail of the epididymis(arrow) shown with orange color.Testis (*).

Epididymitis blood flow, coronal view: Blood flow throughthickened epididymis (between white lines) adjacent to the testis (*).


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Epididymitis with hydrocele: Thickened epididymis (#).Hydrocele (X), a disorder in which serous fluid accumulates in a bodysac (especially in the scrotum). Testis (*).

Epididymitis blood flow, coronal view: Increased blood flow(orange color) of epididymitis. Thickened epididymis (betweenwhite lines). Testis (*).

Epididymitis with hydrocele: Thickened epididymis (betweenwhite lines). Hydrocele (X), a disorder in which serous fluidaccumulates in a body sac (especially in the scrotum). Testis (*).

Epididymitis with loculated hydrocele: Thickened epididymis(large arrow). Loculation borders (small arrows), testis (*).


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Epididymitis with loculated hydrocele: Thickened epididymis(large arrow). Loculation borders (small arrows), testis (*). Epididymo-orchitis: Thickened epididymis (large arrow),

enlarged testis (*), thickened scrotal skin (small arrow).

Epididymo-orchitis: Thickened epididymis (large arrow),enlarged testis (*), thickened scrotal skin (small arrow).

Epididymo-orchitis: Thickened epididymis (large arrow),enlarged testis (*), thickened scrotal skin (small arrow).

Epididymo-orchitis: Increased blood flow in both theepididymis and testis shown with orange color. Testis (*), thickenedscrotum (#), epididymis (between white lines).


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Penile fracture and penile implantA penile fracture is an injury caused by the rupture ofthe tunica albuginea, which envelops the corpuscavernosum penis. It is most often caused by a blunttrauma to an erect penis. When ultrasound is

performed rupture of the tunica albuginea and pres-ence of a hematoma can be visualized.

Penile implants are seen as symmetric areas ofincreased echogenicity within the corpus cavernosum.

Penile fracture: Hematoma (*), corpus cavernosum (#), corpusspongiosum (arrow).

Penile fracture: Hematoma (*), corpus cavernosum (small arrows),corpus spongiosum (large arrow).

Penile implant: Penile implant (arrow), corpus cavernosum (*).


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Chapter

9Musculoskeletal ultrasound

Deborah Shipley Kane and Jennifer McBride

Normal anatomyUltrasound can be used to view various bones, liga-ments, tendons, and other musculoskeletal structures.

Here are several examples of normal anatomy. Thenormal anatomy can also be used for comparisonwith the abnormal extremity.


Normal ankle: Long axis of anterior ankle without effusion.Arrows pointing toward the tibia and the talus.

Normal elbow: Long axis of posterior elbow. Here one can see thesmooth lines of the distal humerus and the olecranon (arrows).

Normal shoulder: Compare the dislocatedshoulder to this normal left anterior shoulderview. Here the proximal humerus is seen closeto, and well aligned with, the glenoid fossa.

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Normal MCP joint: Here is thecontralateral right metacarpophalangealjoint without effusion. No dark/anechoicfluid is seen in this joint.

Wrist anatomy: Transverse/shortaxis of distal left wrist. Notice the shortaxis of multiple tendons as well as theradius and ulna.

Normal knee: Long axis of anterior knee. Both the distal femurand the patella are seen in this image (arrows).

Normal scaphoid: This image of the scaphoid was taken with theprobe in the anatomical snuffbox. Notice the normal hyperechoicscaphoid.

Chapter 9: Musculoskeletal ultrasound

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Fractures and dislocationsBone is easily visualized by ultrasound, and appearsbright/hyperechoic. Fractures look like an incontinu-ity of the normally smooth line. Dislocations arenoted when the bone/joint are not in normalalignment.

Transverse hip: Transverse view ofanterior hip. Here the femur can be seenlying within the acetabulum.

Distal radius fracture: Long axis. Thebone appears as a hyperechoic line.The discontinuity of this line representsthe fracture line seen above.


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Femur fracture: Long axis. Proximaland distal fracture fragments are visiblewith large fracture line, representingdisplacement.

Dislocated finger: Notice the long, straight, hyperechoic (brightwhite) line in this picture, which is the proximal phalanx of the fifthdigit. Then notice the arrow pointing toward the dislocatedproximal interphalangeal joint. Normally these two bones would bealigned.

Shoulder dislocation: This is an image of the anteriorright shoulder of a patient with an anterior shoulder dislocation.The proximal rounded humeral head is readily seen; althoughnotice the separation from the glenoid fossa representingdislocation. Compare this to the contralateral normal leftshoulder.


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Scaphoid fracture: Left: Long axis ofthe scaphoid. Bold arrow represents thefracture line. Also a small effusion is seenaround bone. Right: Short axis of thescaphoid, again the bold arrow ispointing toward the fracture line. Effusion(Eff), radial artery (RA).

Tibial fracture: Fracture line is depicted with arrows. Notice adisplacement of the fracture fragment.

Nasal fracture: Sagittal/long axis view of the anterior nose. Thearrow, representing a non-displaced nasal fracture, shows a break inthe hyperechoic line of bone.

Rib fracture: Anterior right rib fracture. The ultrasound probe wasplaced over the tender area – fracture line represented by arrow.

Dislocated shoulder: Another image of a dislocated rightshoulder. Here the separation of the distal humerus with theshoulder joint is readily noticeable. Only the lower portion of theglenohumeral joint is seen in this image.


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Joint and ligament pathologyUltrasound can also be utilized to visualize otherpathology; including effusions, tendon/ligament rup-tures, and foreign bodies. Fluid appears anechoic/black on ultrasound. Tendons and ligaments appearas a bundle of alternating hypo- and hyperechoiclines. In addition, foreign bodies can often be seenunder ultrasound. If the structure is very small andsuperficial, a waterbath may be helpful.

Skull fracture: Image of posterior skullin trauma patient with skull fracture. Thebeginning of the fracture line is noted byarrow, but is slightly distorted by largeoverlying scalp hematoma.

Sternal fracture: Long axis of anteriorsternum. Arrow points to the fracture line.

Ankle effusion: Hyperechoic bone is surrounded by anechoicfluid representing an effusion. This is an image of the long axis of thedistal tibia.

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Ruptured Achilles tendon: Still image of aruptured Achilles tendon. Long axis of posteriorankle. Achilles tendon seen proximal to bone(arrow); and appears as linear hypoechoicstructure. Notice the abrupt end of thisstructure, representing the rupture. A smallhematoma is noted by the rupture.

Knee effusion: Sagittal/long axis view of theproximal, anterior knee. An effusion is seenanterior to the hyperechoic bone.

Gout: Left metacarpophalangeal joint in apatient diagnosed with gout. The arrow ispointing to a small joint effusion. Also noticesome dark fluid within the surrounding tissue,possibly representing inflammation. This maybe more noticeable when compared to thecontralateral side.

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Hand in water bath: This technique is used to increase theresolution of small, superficial structures. Here a finger is placedunder water, and the ultrasound probe is placed shallower in thewater bath – to allow the water to be used as a sonographicwindow. Now, one can notice the hyperechoic superficial structureunder the skin, which is a bee stinger in this patient. Hip effusion: This is a transverse view of the anterior hip. The

effusion is seen anterior to the bone as dark fluid.

Olecranon bursitis: This picture represents an image of theposterior elbow in long axis. The bursa (arrow) is filled with anechoic(dark) material, which is fluid.


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Chapter

10Pediatric ultrasound

Stephanie Doniger and GeorgeMittendorf

AppendicitisUltrasound can be used as a method to diagnose acuteappendicitis without placing the patient at the risk ofradiation. The appendix can be seen as a blind ended

tubular structure. With acute appendicitis, theinflamed appendix is noncompressible, has anincreased diameter, and often contains anappendicolith.


Acute appendicitis: Acute appendicitis with large appendicolith(arrow).

Acute appendicitis: Transverse view of an inflamed appendix inacute appendicitis.

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Acute appendicitis: Incompressible appendix withoutperforation.

Acute appendicitis: The blind-ended, noncompressible tubularstructure is consistent with acute appendicitis.

Acute appendicitis: Transverse view of acute appendicitis withcentral fecalith (arrow): Diameter is greater than 6 mm (dotted line).

Acute inflammation: Longitudinal view of acute inflammationof appendix (long line). Diameter of appendix (short line).Fecalith (arrow).

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Chapter 10: Pediatric ultrasound

Acute appendicitis: Longitudinal view of acute appendicitis.Fluid filled tubular appendix (asterisk), fecalith (arrow).

Acute appendicitis: Acute appendicitis in a 15-year-old male.Appendiceal lumen (skinny arrow), fecalith (fat arrow), diameter (“{”).

Acute appendicitis: Longitudinal view of acute appendicitis.Fluid filled lumen (asterisk). Fecalith (skinny arrow), inflamedappendiceal wall (fat arrow). The left panel shows the appendix priorto graded compression, while the right panel is after gradedcompression. Note that the appendix does not compress.

Acute appendicitis: Inflamed appendix adjacent to bladder.Lumen of appendix (A), lumen of bladder (B), inflamed appendicealwall (skinny arrow), inflamed bladder wall (fat arrow).


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Child with acute appendicitis: Diameter of appendix ¼ 1.03 cm(A). Lumen (L), appendiceal wall (arrow).

Child with acute appendicitis: Transverse view. Diameter ofappendix is 0.92 cm (A). Free fluid (arrow).

Acute appendicitis: Longitudinal view of a largely inflamedappendix with appendicolith.

Acute appendicitis: Transverse view of perforated acuteappendicitis. Appendiceal diameter, lumen of appendix (skinnyarrow), surrounding abscess (fat arrow).


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Acute appendicitis: Longitudinal view.

Acute appendicitis with perforation: Appendix (skinny arrow),surrounding abscess (fat arrow).

Acute appendicitis with perforation: Appendix (small arrow)with surrounding abscess (large arrow). Image on right is withcompression.

Acute appendicitis with perforation: Inflamed appendicealwall (skinny arrow), appendiceal lumen (asterisk), surroundingabscess (fat arrow).


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InfectionUltrasound can be used to evaluate various types ofinfections in pediatric patients. Skin infections can bestudied to distinguish cellulitis from abscesses, whichwill aid in patient management.

Cellulitis

Acute appendicitis: Transverse view of an acutely inflamedappendix. The left panel demonstrates the appendix before gradedcompression, and the right panel is after graded compression.Note that the appendix does not compress.

Child with cervical lymphadenitis: Enlarged lymph nodedemonstrating a hyperechoic center.

Cervical lymphadenitis: Cervical lymphadenitis (arrow) in closeproximity to carotid artery (C).

Cellulitis: Cellulitis in right calf with “cobblestoning” (“{}”).Hyperechoic subcutaneous tissue (asterisks) with subcutaneousedema filling the interlobar septae (arrows).Cellulitis: Cellulitis (“{}”), lymph node (arrow).


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Abscess: Abscess on buttock (dotted cross) with expectedincreased echogenicity deep to the lesion (“}”).

Abscess: A 2 cm� 3 cm abscess on buttock. Loculated abscess (fatarrows) with septations (skinny arrow).

Peritonsillar abscess: Peritonsillar abscess after drainage with18-gauge needle. Residual lumen (asterisk).

Peritonsillar abscess: A 17-year-old female with a peritonsillarabscess. Hypoechoic debris within abscess (asterisk), abscess capsule(arrow).

Pneumonia: Girl with pneumonia, loculated pleural effusions (fatarrows), and bright echoes with posterior acoustic shadowingconsistent with air bronchograms (skinny arrow).


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IntussusceptionIntussusception can be viewed by ultrasound as aswirling mass of telescoping bowel. Alternatinghyperechoic and hypoechoic layers represent the

intussuscipiens and the intussusceptum. Both trans-verse and longitudinal views are valuable in demon-strating this morphology.

Infant with intussusception: Classic “target sign” withhyperechoic ileum (skinny arrow) telescoping into the outerhyperechoic ascending colon (fat arrow). Lumen of colon with fecalmatter (small arrows).

Infant with intussusception: Transverse view of right upperquadrant. Hyperechoic small bowel in center (small arrow)surrounded by a layer of hypoechoic cecal lumen (large arrow).

Infant with intussusception: Small bowel (small arrow)telescoping into the cecum (large arrow) with surroundinghypoechoic colic fluid (asterisk).

Child with intussusception: Longitudinal view ofintussusceptum.


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IV accessObtaining intravenous access in the pediatric patientis often a difficult task. Ultrasound can be a valuabletool in this procedure.

Brachial vein: Brachial vein after compression (asterisk).

Brachial vein: Brachial vein before compression (asterisk) withposterior acoustic enhancement (“}”).

Internal jugular vein: Internal jugular vein with tenting duringneedle entry (large arrow), common carotid artery (small arrow).

Intussusception: Longitudinal view. Pseudokidney (small arrow),start of intussusceptum (large arrow).


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MiscellaneousThe following section includes various implementa-tions of ultrasound including cardiac, foreign bodies,and genitourinary applications.

Asystole during a FAST scan of a trauma patient: (A) Leftparasternal long axis view. Right ventricular outflow tract (RVOT), leftventricle (LV), septum (arrow), left ventricular outflow tract (LVOT),aortic valve (AV), mitral valve (MV), left atrium (LA). (B) Motion modedisplaying cardiac standstill. BB: BB implanted near heart (skinny arrow). Parietal pericardium

(arrowhead). Epicardium (fat arrow).

BB: BB (arrow) lodged just beneath the skin (fat arrow) withposterior acoustic shadowing (bracket).

Bee stinger: Bee stinger (arrow) seen in water bath.


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Pyloric stenosisPyloric stenosis usually presents at roughly 3 weeksafter birth with nonbilious projectile vomiting. It isrecommended that any infant with these symptomshave ultrasound evaluation immediately because thesensitivity and specificity for this diagnostic tool isclose to 100%. Transverse and longitudinal views willdemonstrate hypertrophied muscle and a narrow pyl-oric channel.

BB: BB lodged within soft tissue with posterior acoustic shadowing.

Ovarian mass: Transvaginal view of ovarian mass withindividualized locules (arrowheads). Ovary (“{”), uterus (fat arrow).

Testicular appendix: Testicular appendix (short arrow), hydrocele(double arrow), testicle (T).

Wilms’ tumor: Inferior aspect of Wilms’ tumor (“{”) in a 3-year-oldpatient.

Wilms’ tumor: A 3-year-old with Wilms’ tumor (“{”).


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Normalpylorus: Cross-sectionof normal pylorus inhealthy infant. Pylorus(short arrow), gastriclumen (long arrow).

Pylorus: Longitudinalview of pylorus inhealthy infant, pyloriccanal lumen (dottedline), liver (L).

Normal pylorus: Longitudinal view of normal pylorus. Gastriccontents are traversing the pyloric canal (arrow). Liver (L).152

Pyloric stenosis: Diameter of pylorus (A) and pyloric canal (B).Hypertrophied pyloric muscle (arrow).

Pyloric stenosis: Infant with pyloric stenosis, cross-sectional view.Diameter of pylorus, lumen of pyloric canal (arrow), hypertrophiedpyloric muscle (fat arrow).

Pyloric stenosis: Hypertrophied pyloric muscle (short arrow),pyloric canal (skinny arrow), gastric lumen (fat arrow), liver (L).

Pyloric stenosis: Infant with pyloric stenosis. Duodenal width(shorter line), hypertrophic pylorus muscle (longer line), wallthickness of pylorus (between arrows).

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TraumaUltrasound has become an important part of evaluat-ing the trauma patient. In addition to detecting freefluid with the FAST scan, ultrasound can also be used

to detect fractures. Furthermore, Doppler can beapplied to quickly assess vascular function at the siteof the injury.

FAST scan of handlebar injury: Perihepatic view. Liver (L),kidney (K), perirenal fat (arrow), small amount of free fluid inhepatorenal space (arrowhead).

Fractured bone prior to reduction: Fracture site (skinny arrow),medullary cavity (M), cortical bone (fat arrow), periosteum(outlined arrow).

Patient with handlebar injury: Transabdominal sagittal view ofbladder (B) with surrounding free fluid (arrows).

Bladder: Dilated, fluid filled bladder (B) with posterior acousticenhancement as a result of the low attenuation of the urine (arrow).


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Morrison’s pouch: Free fluid within Morrison’s pouch betweenliver and kidney (arrowhead). Liver (fat arrow), kidney (skinny arrow).

Bone fracture after reduction: Reduced fracture site (arrow).

Humerus fracture: Severe left humerus fracture with injury toradial artery. Failure to acquire waveform with Doppler. Radial artery(long arrow), radial vein (short arrow).

Greenstick fracture: A 6-year-old female with left radiusgreenstick fracture (arrow). Radius (arrowhead).

Pleural effusion: M-mode showing characteristic pattern of apleural effusion. Pleural line (arrow). Note that the granular layer thatnormally represents respiration movements of the lung is absent(bracket). Normal “seashore sign” is absent.

Post-operative complication: Post-operative complication ofdiaphragm laceration and hemothorax after liver transplant.Transabdominal view of RUQ showing the hemothorax (fat arrow)and lung floating within the hemothorax (skinny arrow).

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Urinary tractUltrasound can be used to evaluate the urinary tracts ofpediatric patients, including cystitis, obstructive uro-pathies with enlarged ureters, and hydronephrosis.

Patient with obstructive uropathy: Transverse view of bladder(B) and bilaterally dilated ureters (arrows).

Patient with obstructive uropathy: Sagittal view of bladder(B) with dilated hydroureter (arrow).

Patient with cystitis: Bladder lumen (asterisk, thickened bladderwall (arrow).


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Hydrocele: A 1-week-old with bilateral hydrocele (asterisks),testicles (T’s).

Bilateral hydronephrosis: Left kidney. Dilated renal calyces(arrows), renal cortex (fat arrow), renal capsule (arrowhead).

Child with obstructive uropathy and bilateralhydronephrosis: View of right kidney. Dilated renal calyx (arrow),renal cortex (arrowhead).

Cystitis: A 6-year-old female with cystitis. Thickened bladder wall(fat arrow), psoas muscle (skinny arrow), bladder lumen (asterisk).


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Chapter

11Ultrasound-guided procedures

Eric J. Chin

Ultrasound-guided nerve blocksNerve blocks are an ideal way to provide regionalanesthesia for patients undergoing painful proceduresor with painful conditions. Traditionally, nerve blockswere performed primarily using a landmarks-basedapproach. Ultrasound is being increasingly utilizedwith traditional landmarks to provide more accurate

anatomical information not previously available andreal-time visualization of the nerve being anesthetized.

Axillary blockThe axillary block is a relatively safe way to block thedistal portion of the brachial plexus to provide anes-thesia distal to the elbow region.


Axillary block, prior to infiltrationwith anesthetic: The probe should beplaced in the axillary region in thetransverse plane. In this view, the axillaryartery (A) and vein (V) are readilyidentifiable. The median (M), radial (R),and ulnar (U) nerves will typically belocalized around the axillary artery invariable locations.

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Brachial plexus nerve blockThe brachial plexus nerve block is an effective way toprovide anesthesia to the entire arm distal to the

shoulder region. It can be technically more challen-ging since the approach is more prone to cause apneumothorax or vascular insult.

Axillary block, after infiltration withanesthetic: The anesthetic should beinjected adjacent to each of the nerves(median (M), radial (R), ulnar (U)) toprovide anesthesia for the hand andforearm. The axillary block is generallyconsidered safer than a more proximalbrachial plexus approach, however, themusculocutaneous nerve is frequentlymissed with this technique.

Brachial plexus nerve block,supraclavicular approach: Thesupraclavicular approach to the brachialplexus nerve block is an effectivetechnique to provide anesthesia to theupper extremity distal to the shoulder.The probe is placed above the middlethird of the clavicle angled toward theipsilateral scapula. In this view, you willsee the subclavian artery (SA), andadjacent to it the brachial plexus (circle),which classically has a honeycombedappearance.

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Femoral nerve blockThe femoral nerve block is a relatively simple tech-nique that can be used to provided anesthesia to thehip, knee, and anterior thigh.

Brachial plexus nerve block prior to infiltration withanesthetic: The needle (arrows) is inserted laterally and directedtoward the brachial plexus (circle) and subclavian artery (SA). Toavoid an iatrogenic pneumothorax, it is recommended the needletip be followed during its insertion.

Brachial plexus nerve block after infiltration withanesthetic: Once the needle (arrows) tip approaches the brachialplexus, approximately 25 mL of local anesthetic is injected with real-time visualization of anesthesia (circle) spreading around thebrachial plexus (N).

Femoral nerve block anatomy: Theprobe is placed transversely across thefemoral triangle, where you should seethe femoral nerve (arrow), femoral artery(FA), and femoral vein (FV).


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Median nerve blockThe median nerve block is a simple way to provideanesthesia to the first through fourth fingers andlateral portion of the hand.

Femoral nerve block during infiltration: The anesthesia (circle)needs to infiltrate deep to the fascia lata (not seen) to ensure thefemoral nerve (arrow) is surrounded by local anesthetic. Failure tosurround the nerve completely may result in inadequate anesthesia.

Femoral nerve block after infiltration with anesthetic: Theanesthesia (outline) can be seen surrounding the femoral nerve (FN),which rests lateral to the femoral artery (FA) and femoral vein (FV).

Median nerve block, forearm approach: The median nerve(arrow) should appear as a heteroechoic honey-combed shapedstructure within the carpal tunnel or interposed within the forearmflexors, depending on the placement of the ultrasound probe alongthe forearm. Radius (R).

Median nerve block with needle in view: The needle (arrows)can be seen approaching the median nerve (N).

Median nerve block after infiltration of anesthetic: The localanesthesia (outline) is infiltrated around the median nerve (N).


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Radial nerve blockThe radial nerve block can be used to provide anes-thesia to the dorsolateral portions of the hand.

Radial nerve block, forearmapproach: The radial nerve (outline) canbe located by following its courseproximally from the wrist along the radialartery. In this view, the needle can beseen approaching the radial nerve priorto infiltration of a local anesthetic.

Radial nerve block after infiltrationof anesthetic: In this view, the needle(arrows) is seen injecting local anesthesia(outline) around the radial nerve (circle).


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Ulnar nerve blockThe ulnar nerve block can be utilized to provideanesthesia to the fourth through fifth fingers andmedial portion of the hand.

Ultrasound-guided vascular accessVascular access is a necessity in nearly every aspect ofmedicine, however, it can be difficult to accomplish inmany patients due to a variety of reasons. Ultrasoundhas been shown to be effective in shortening the timeto obtain vascular access, as well as minimizing manyof the complications associated with it.

Peripheral IV placementUltrasound can be used to facilitate the placement ofperipheral IV catheters in patients in whom IV accessis difficult to accomplish through standard techniques.It is an effective alternative to more invasive methodsof venous access, such as a PICC line and central venouscatheter.

Ulnar nerve block, forearm approach: The ulnar nerve (arrow)can be located anywhere between the wrist and just proximalto the elbow. In this view, the ulnar nerve is located near theulnar artery (UA).

Ulnar nerve block with needle: In this view, the needle tip(white arrow) can be seen depositing local anesthesia (black outline)next to the ulnar nerve (outlined arrow). Ulnar artery (UA).

Ulnar nerve block after infiltration of anesthetic: Localanesthesia (outline), ulnar nerve (arrow), ulnar artery (UA).

Peripheral vein with needle tip: The ultrasound can assist withlocalizing superficial or deep peripheral veins (arrow) that are toodifficult to palpate. The peripheral vein should be easilycompressible to ensure it is not an artery. Needle tip (circle).


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Internal jugular (IJ) vein central lineplacementUltrasound-guided IJ vein central line placement canbe an effective adjunct to expedite the placement ofcentral venous catheters, as well as reducing compli-cations associated with their placement (i.e., pneumo-thorax, arterial puncture).

Subclavian vein central line placementSubclavian vein central line placement is traditionallyconsidered to be a blind procedure. With the properprobe placement, ultrasound-guided IJ vein centralline placement can be an effective adjunct to expeditethe placement of central venous catheters, as well asreducing complications associated with their place-ment (i.e., pneumothorax, arterial puncture).

IJ vein anatomy: The IJ vein (IJV) is readily found near the apex ofthe triangle created by the two heads of the sternocleidomastoidmuscle, and is typically located lateral to the carotid artery (CA).The IJ vein is usually easily compressible and its diameter can beaugmented by placing the patient in a Trendelenburg position.

IJ vein with needle tenting blood vessel: Often whenattempting to puncture the IJ vein (IJV), the needle tip (arrow) willcause tenting without entering the lumen of the vessel. To easethe entry of the needle tip into the vessel, a very small quick jabwith the needle may be enough to get the tip into the vessel.Carotid artery (CA).

IJ vein after insertion of needle lumen into vessel: IJ vein(IJV), carotid artery (CA), catheter (circle).

Placement of ultrasound probe for subclavian vein lineplacement: The probe should be placed inferior to the middlethird of the clavicle with the indicator pointing cephalad.


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Radial artery line placementThe radial artery line can be a frustrating procedureto perform in the critically ill patient. However, ultra-sound-guided radial artery line placement can make itless difficult to localize the radial artery, especially inthe hypotensive patient.

Subclavian vein anatomy: With the probe indicator orientedcephalad, the clavicle (not seen) may be visible on the left side ofthe image. The subclavian artery (SA) will usually be superiorand deep to the subclavian vein (SV). Note the close proximity ofthe pleural line to the subclavian vein.

Subclavian vein with needle and tenting of the bloodvessel: The distal shaft of the needle (arrow) can be seen tentingthe subclavian vein (SV). Subclavian artery (SA).

Subclavian vein with needle in lumen: Subclavian vein (SV)with needle (arrow) in lumen of blood vessel.

Radial artery anatomy: The ultrasound probe is positionedtransversely just proximal to the wrist. The radial artery (arrow) isusually readily seen near the distal radius.


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Cardiothoracic proceduresPericardiocentesisThe pericardiocentesis is a potentially life-saving pro-cedure performed when cardiac tamponade is sus-pected or recognized in a symptomatic patient. With

the use of bedside ultrasound, it is possible to confirma provider’s clinical suspicion for cardiac tamponadeand aid in the success of a pericardiocentesis.

Radial artery line placement: Radial artery line placement withneedle (arrow) within lumen or radial artery (circle).

Subxiphoid view of a pericardial effusion: The ultrasoundprobe is placed just inferior to the xiphoid process and directedcephalad. In this view, the pericardial sac (arrow) can be seensuperficial to a pericardial effusion (PCE) that surrounds the right (RV)and left ventricles (LV).

Pericardiocentesis with needle in pericardialspace: Traditionally, pericardiocentesis is performed by insertinga needle (arrow) next to the xiphoid process oriented toward theleft shoulder. Using ultrasound, it is also possible to aspirate apericardial effusion (PCE) from a parasternal or apical approach.Right ventricle (RV), left ventricle (LV).


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ThoracentesisA thoracentesis is typically performed by localizingthe top of the pleural effusion with percussion to thethoracic cavity. Ultrasound can be used to aid the

practitioner performing a thoracentesis in localizingthe largest pocket of pleural fluid and minimize thechances of inadvertently puncturing solid organs.

Placement of ultrasound probe forthoracentesis: The ultrasound probe is typicallyplaced posteriorly with the patient in the uprightposition.

Insertion of thoracentesis needle: Thethoracentesis needle should be inserted on the superiorside of the rib to minimize the chance of injuring theneurovascular bundle on the inferior side of the rib.

Pleural effusion: You should try toidentify the largest fluid pocket, whiletaking note of the location of the lungand diaphragm (not seen).


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Transvenous pacerTransvenous pacemaker wire placement can be achallenging skill to perform. Ultrasound can be util-

ized to monitor the real-time placement of the pacingwire lead, thereby improving the likelihood of properplacement.

Miscellaneous proceduresFoley balloon ruptureOn rare occasions, a Foley catheter can malfunction,with the balloon failing to deflate.

Pleural effusion with loculations: Inthis view, note the multiple septations(arrows) within the pleural effusion.

Transvenous pacemaker wire inright ventricle: In this subxiphoid viewof the heart, the pacemaker wire (arrow)can be seen entering the right ventricle(RV). Of note, there is also a pericardialeffusion (PCE) that can be seen superficialto the heart. Left atrium (LA), left ventricle(LV).


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Foley balloon with needle (arrow) inbladder: A malfunctioning Foleyballoon can be ruptured by inserting aneedle into the bladder suprapubically.

Foley balloon exploding: Foleyballoon exploding after puncture withneedle.

Foley exploded with remainingtube: Residual Foley catheter (arrow)after being ruptured with needle.

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Foreign body removalForeign bodies can be detected with plain radiographsto varying degrees of success. Ultrasound can be usedas a primary or secondary tool to localize foreign

bodies within soft tissue. More importantly, ultra-sound can be used in real-time to assist with localiza-tion of the foreign body and to help minimize damageto surrounding structures.

Lumbar punctureThe lumbar puncture typically requires the practi-tioner to readily identify specific landmarks (i.e., theL4-L5 interspinous space) to ensure the successfulcompletion of the procedure. On occasion, it can benearly impossible to identify the traditional

landmarks for the lumbar puncture due to excessiveadipose tissue and variations in individual anatomy.Ultrasound can be used to identify the L4-L5 inter-spinous space, when traditional methods fail to iden-tify the proper landmarks.

Metallic foreign body in soft tissue: Foreign bodies in softtissue (arrow) that are difficult to visualize with traditionalradiographs may be readily identifiable with ultrasound. Foreign body extraction: Foreign body (outlined arrow) being

extracted from soft tissue with forceps (solid arrow).

Ultrasound-guided lumbar puncture probe placement,longitudinal plane: Place the probe on the lumbar regionmidline between an imaginary line across the superior portion of theiliac crests. The indicator should be oriented toward the head.


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Longitudinal view of spinousprocesses: After applying theultrasound probe in the longitudinal axis,move the probe side-to-side and identifythe spinous processes (SP), which willappear as hyperechoic curved outlineswith shadowing. Then, center theinterspinous space (ISS) on the middle ofyour screen.

Ultrasound-guided lumbar puncture, horizontalmarking: After centering your probe on the interspinous space,you will slide a paperclip under the middle of the probe and hold itin place while you remove the probe from the skin. Using a markeror pen, make a straight line across the paperclip leaving a horizontalmark on the skin.

Ultrasound-guided lumbar puncture probe placement,transverse place: Next, you will rotate the probe 90 degrees sothat the indicator is toward the left.

Transverse view of spinous: Movethe probe up and down until you are ableto identify the spinous process (SP) andmove it to the middle of the screen.

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ParacentesisThe paracentesis is a relatively safe and easy proced-ure to perform when there is a large amount of ascitesto drain. However, every practitioner will encounter asituation where it is difficult to identify the ideal

location to perform the paracentesis. Ultrasound canassist the practitioner to localize the largest pocket offluid, and thereby minimize the chances of iatrogeniccomplications.

Ultrasound-guided lumbar puncture verticalmarking: Again, slide a paperclip under the middle of the probeand hold it in place while you remove the probe from the skin. Usinga marker or pen, make another straight line across the paperclipleaving a vertical mark on the skin.

Ultrasound-guided lumbar puncture mark: Using ultrasoundto identify your anatomical landmarks for a lumbar punctureshould result in a mark at the L4-L5 interspinous space.

Paracentesis probe placement: To assist with paracentesis, theultrasound probe can be placed in the traditional locations belowthe umbilicus or slightly medial and cephalad to the anteriorsuperior iliac spine. However, with real-time visualization it is morepractical to use the ultrasound to find the largest fluid pocket awayfrom intra-abdominal structures, such as bowel.

Paracentesis: Paracentesis with large ascites and needle tip(arrow).


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Peritonsillar abscess drainageThe diagnosis of a peritonsillar abscess is typicallymade through physical examination and/or computedtomography. Ultrasound can be utilized in combin-ation with the physical examination to identify peri-tonsillar abscesses without the use of ionizingradiation.

Paracentesis with small bowel loopand needle tip: A loop of smallbowel (SBL) can be seen floating in asciteswith the needle tip (arrow) inside theperitoneum.

Paracentesis with needle stuck: Inthis view, a paracentesis is beingperformed, but the operator is havingdifficulty getting the needle tip (arrow)to enter the peritoneum.

Placement of ultrasound probe for peritonsillar abscess(PTA): The endocavitary probe can be used to distinguish betweenperitonsillar cellulitis and a peritonsillar abscess. The key toevaluating for a PTA is to anesthetize the posterior pharynx withtopical anesthetic, cover the probe with a sheath, and ask thepatient to assist in localizing the area of maximal pain with thetransducer.

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Cellulitis

Large peritonsillar abscess, prior todrainage: Peritonsillar abscesses willusually appear hypoechoic and areusually in close proximity to tonsillartissue.

Large peritonsillar abscess, afterdrainage: This is the same largeperitonsillar abscess after aspiration with aneedle.

Cellulitis: Cellulitis in right calf with “cobblestoning” (“{}”).Hyperechoic subcutaneous tissue (asterisks) with subcutaneousedema filling the interlobar septae (arrows).

Cellulitis: Cellulitis (“{}”), lymph node (arrow).


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Chapter

12Arterial ultrasound

Sharis Simonian and John Christian Fox

Carotid artery stenosisCarotid artery stenosis is typically diagnosed andassessed with a color flow duplex ultrasound scan ofthe carotid arteries in the neck. Carotid artery stenosis

can manifest itself as asymptomatic or symptomatic.Generally, carotid artery duplex ultrasound scans area safe and relatively inexpensive method for evalu-ation of carotid artery stenosis.


Left internal carotid artery stenosis, sagittal view,> 70%: Sagittal view of a proximal left internal carotid arterydemonstrating greater than 70% stenosis. The white arrowdemonstrates abnormal artery intima secondary to plaque.

Left internal carotid artery stenosis, > 70%: A 71-year-oldmale with proximal left internal carotid artery displaying greater than70% stenosis, demonstrated in Doppler flow. The white arrowindicates abnormal carotid artery intima. The white asteriskdemonstrates the lumen of the artery.

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Left common carotid artery bulb stenosis, with colorDoppler: Left common carotid artery bulb demonstrated withcolor Doppler flow, indicating an occlusion with greater than 50%stenosis of the bulb. The white arrow demonstrates the plaqueleading to an abnormal carotid artery intima. The white asteriskindicates the lumen of the carotid artery.

Left common carotid artery bulb stenosis, > 70%: Sagittalview of the left common carotid artery bulb, demonstratingsignificant stenosis. White arrow indicates plaque leading to anabnormal carotid artery intima. White asterisk demonstrateslumen of the artery.

Left common carotid artery (CCA) bulb stenosis,> 70%: Sagittal view of the left common carotid artery bulb.The white arrow indicates plaque within the CCA bulb, withgreater than 70% stenosis. The white asterisk indicates the lumenof the artery.

Proximal left external carotid artery, no occlusion: Proximalleft external carotid artery, with no evidence of occlusion of bloodflow. White arrow demonstrates normal intima. White asterisk pointsto lumen of artery.

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Proximal left external carotid artery, no occlusion: Proximalleft external carotid artery, with color Doppler flow. White arrowindicates normal carotid intima. White asterisk indicates lumen ofcarotid artery.

Right common carotid artery, sagittal view, normalintima: Sagittal view of right common carotid artery,demonstrating normal intimal thickness (arrow). Asterisk indicateslumen of carotid artery.

Right internal carotid artery, sagittal view, normalintima: Right internal carotid artery with color Doppler imaging.The white arrow indicates normal carotid artery intima. Asteriskdemonstrates lumen of artery.

Right common carotid artery, sagittal view, normalintima: Sagittal view of proximal right common carotid artery.The white arrow demonstrates normal carotid intima. The whiteasterisk indicates the lumen of the artery.


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Abdominal aortic aneurysmThe traditional abdominal aortic aneurysm (AAA)triad demonstrates with hypotension, pulsatileabdominal mass, and back pain. Ultrasound is a

reliable modality for initial screening and diagnosisof an abdominal aortic aneurysm. Generally, surgicalrepair is indicated for AAA diameters exceeding 5.5cm in males and 5.0 cm in females.

Right common carotid artery, sagittal view, normalintima: Sagittal view of right common carotid artery, with Dopplerflow. The white arrow demonstrates normal carotid artery intima.The black asterisk indicates arterial lumen.

Abdominal aortic aneurysm, transverse view: Transverseview of the abdominal aortic aneurysm (AAA). The green lineoutlines the AAA. The white asterisk demonstrates the lumen of theabdominal aorta.


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Abdominal aortic fusiform aneurysm, sagittal view: Sagittalview of distal abdominal aortic fusiform aneurysm. The white arrowdemonstrates the fusiform shape of the aneurysm. The yellowasterisk points out the lumen of the abdominal aorta proper.

Fusiform abdominal aortic aneurysm, sagittal view: Sagittalview of a color Doppler ultrasound image of a 76-year-old femalewith a fusiform abdominal aortic aneurysm. White arrow pointsout fusiform aneurysm.

Fusiform abdominal aortic aneurysm: Sagittal view ofabdominal aorta fusiform aneurysm. White arrows demonstratefusiform aneurysm. White asterisk indicates the lumen of the aorta.

Abdominal aortic fusiform aneurysm, demonstrated withcolor Doppler: Abdominal aortic fusiform aneurysm, with colorDoppler ultrasound. The green line outlines the fusiform aneurysmportion of the abdominal aorta. The white asterisk indicates thelumen of the abdominal aorta proper.

Fusiform abdominal aortic aneurysm: An 80-year-old femaledemonstrating fusiform abdominal aortic aneurysm. The whitearrow points out the fusiform appearance of the aneurysm. Theyellow asterisk indicates the lumen of the abdominal aorta.


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Abdominal aortic aneurysm and patent graft, sagittal view,demonstrated in color Doppler: Sagittal view of abdominalaortic aneurysm with patent graft in color Doppler. White arrowdemonstrates the patent graft within the aorta. The two whiteasterisks indicate the two lumens of the aorta status post graftplacement.

Abdominal aortic aneurysm and patent graft, sagittal view,demonstrated in color Doppler: Sagittal view of the abdominalaortic aneurysm (AAA), with color Doppler ultrasound. White arrowdemonstrates aneurysm. White asterisk points out lumen of the aorta.

Abdominal aortic aneurysm, with large thrombus:Abdominal aortic aneurysm with large thrombus occluding thelumen. Asterisk indicates non-occluded portion of the lumen.

Abdominal aortic aneurysm and patent graft, transverseview: Transverse view of the abdominal aortic aneurysm withpatent graft in place. White arrow demonstrates the patent graftwithin the aorta. The two white asterisks indicate the abdominalaorta status post graft placement.

Abdominal aortic aneurysmandpatent graft, transverse view,demonstratedincolorDoppler: Transverse view of the abdominalaortic aneurysm with patent graft in color Doppler. The white arrowdemonstrates the patent graft. The two black asterisks indicate thetwo abdominal aortic lumens present status post graft placement.


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Abdominal aortic aneurysm, with thrombus: Abdominalaortic aneurysm with significant thrombus. White arrowdemonstrates the mural thrombus. The dotted white line measuresthe outer edge of the abdominal aneurysm. The yellow linesindicate the spine shadow. White asterisk points out lumen of aorta.

Abdominal aortic aneurysm, with patent graft, transverseview: Transverse view of a distal abdominal aorta with evidence ofpatent graft, in color Doppler flow. White arrow indicates the patentgraft. The two white asterisks point out the lumens of the iliacs.

Abdominal aortic aneurysm, with patent graft, sagittalview: Transverse view of distal abdominal aorta, with patentgraft. White arrow indicates region of the graft. White asterisks pointout the two lumens of the aorta.

Sacular abdominal aortic aneurysm: Sacular abdominal aorticaneurysm. The white arrow demonstrates the width of the sacularaneurysm. The yellow asterisk indicates the lumen of the properabdominal aorta.

Abdominal aortic aneurysm: This is an example of anabdominal aortic aneurysm that measures 5.5 cm.


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Femoral artery pseudoaneurysmFemoral artery pseudoaneurysm is a common com-plication of cardiac catheterizations. A femoral arterypseudoaneurysm often manifests as a pulsatile mass

with a systolic bruit overlying the insertion site. Ultra-sound duplex imaging can confirm the presence of afemoral artery pseudoaneurysm.

Right common femoral artery pseudoaneurysm: Rightcommon femoral artery pseudoaneurysm, status post cardiaccatheterization, with color Doppler imaging. White arrowdemonstrates portion of artery that is considered thepseudoaneurysm. White asterisk indicates lumen of the artery.

Right common femoral artery pseudoaneurysm: ColorDoppler ultrasound image of right femoral artery pseudoaneurysm.White arrow points out pseudoaneurysm. White asterisk displayslumen of artery proper.

Right common femoral artery pseudoaneurysm: ColorDoppler ultrasound image of right femoral artery pseudoaneurysmstatus post cardiac catheterization. White arrow demonstratespseudoaneurysm portion of the artery. Black asterisk indicateslumen of the femoral artery.

Right femoral artery pseudoaneurysm, with color Dopplerflow: Color Doppler ultrasound transverse image of apseudoaneurysm of the right femoral artery. White “V” indicatesfemoral vein. White asterisk lumen of femoral artery.


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Renal artery embolismRenal artery embolism is an uncommon, but acute,diagnosis, which may lead to renal artery occlusionand ultimately, renal failure and necrosis. Ultrasound

imaging is one of several different imaging modalitiesutilized to visualize renal artery emboli to renalarteries.

Right femoral artery pseudoaneurysm, transverseview: Transverse view of right femoral artery status post cardiaccatheterization. White arrow demonstrates pseudoaneurysm of theartery. Yellow arrow points out femoral vein. White asterisk indicateslumen of femoral artery.

Renal artery embolism: This imagedepicts a renal artery embolism, whichleads to a renal artery infarction. Thewhite arrows in the image indicate theregion of infarction, with absence ofDoppler flow in the region.

Renal artery embolism: This image depicts renal arteryembolism in the intrarenal arteries of the upper pole of the kidney.The white arrows demonstrate absence of color Doppler flowthrough the upper pole of the kidney due to the embolism.


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Renal artery thrombosisRenal artery thrombosis is an acute diagnosis, whichmay lead to an acute renal infarct and ultimate renal

failure. Ultrasound imaging is a modality used tovisualize thrombi and an area of hypoperfusionsecondary to a renal artery thrombosis.

Renal artery thrombosis: This imagedepicts a partially occlusive renal arterythrombosis. The white arrows depictareas of decreased blood flow via colorDoppler imaging.

Renal artery thrombosis: This imagedepicts a transplant renal artery withpartially occlusive thrombosis. The whitearrows indicate areas of thromboses.The Doppler spectrum depicts the lowvelocity of flow in the artery.


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Chapter

13Venous ultrasound

Kevin Burns and John Christian Fox

Normal venous anatomy and negativecompression testingThe deep veins of the leg are common locations forthrombosis due to immobility or a hypercoagulablestate. In a normal patient, the deep veins run with a

paired artery and are fully compressible. Compressionultrasonography can be performed along the lengthof the femoral and popliteal vein at the bedside toquickly rule out deep venous thrombosis (DVT).


Normal right femoral vein: The transducer is placed transversely to view the right femoral vein (V), superficial femoral artery (SFA) anddeep femoral artery (DFA) in cross-section. While visualizing the femoral vein and artery, pressure is applied via the transducer to compress thevein. The femoral vein compresses completely while the arteries remain patent, ruling out venous thrombus at this location.

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Normal right femoral vein: The right femoral vein (V) is seen medial to the femoral artery (A). The transducer is used to compress thevein indicating the absence of thrombus. Cycles of compression-decompression are continued along the length of the vein to excludevenous thrombosis.

Normal left femoral vein: The leftfemoral vein (V) is visualized medial tothe superficial (SFA) and deep femoralarteries (DFA) along with a superficiallymph node (LN). When the transducer ispressed firmly, the normal vein willcollapse and the arteries will remain open.

Normal left femoral vein: Thetransducer is used to visualize the leftfemoral vein (V) with and withoutcompression. The femoral artery (A) willremain patent when applying cycles ofpressure along the vein. Completecollapse of the vein during compressionindicates the absence of thrombosis.

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Chapter 13: Venous ultrasound

Deep venous thrombosis (DVT)In the setting of suspected pulmonary embolism orlower extremity swelling, compression ultrasonogra-phy can be used in the emergency department to

detect a DVT, allowing the clinician to quickly begintreatment and prevent significant morbidity and mor-tality from embolization.

Normal popliteal vein: The transducer is placed transversely in the popliteal fossa to visualize the popliteal vein (V) and artery (A). Thepopliteal artery is deep to the vein. A patent popliteal vein will compress completely when pressure is applied and the artery may appearmore superficial due to compression of the surrounding soft tissue.

Normal popliteal vein: The popliteal vein (V) and artery (A) are seen in cross-section in the popliteal fossa. When pressure is applied viathe transducer, the vein collapses while the artery remains patent.


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Non-compressible femoral vein thrombosis: There is a thrombus in the left common femoral vein (V) preventing collapse whenincreasing amounts of pressure are applied. The great saphenous vein (GSV) also contains a thrombus and is non-compressible. Thepressure applied to the vessels is great enough to collapse the femoral artery (A). In a normal patient, the vein should compress withoutcompressing the artery. These findings are positive for deep venous thrombosis.

Femoral vein thrombosis: The left common femoral vein (V) contains a non-compressible thrombus. When the transducer is used tocompress the vein, the accompanying artery (A) collapses while the vein maintains its shape (2). Color flow Doppler imaging reveals theabsence of blood flow in the thrombosed vein (3).

Non-compressible femoral vein with thrombus compared to compressible vein: The right femoral vein is visualized after pressure isapplied to the vessels in a patient with a thrombus (left) and normal patient (right). The thrombus prevents the walls of the vein (V) fromcollapsing, even under enough pressure to deform the appearance of the artery (A).


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Upper extremity DVTThrombosis in the veins of the upper extremity andneck can occur secondary to central venous or

peripherally inserted central catheter placement,transvenous pacemakers, or hypercoagulable states.

Popliteal vein withthrombosis: A thrombus in thepopliteal vein prevents collapse when thetransducer is pressed firmly in thepopliteal fossa. The popliteal artery isdeep to the vein. This finding indicatesdeep venous thrombosis at the level ofthe knee.

Non-compressible clot in the rightpopliteal vein compared to fullycompressible left popliteal vein:This patient has a thrombus in the rightpopliteal vein and a patent left poplitealvein. Images of both veins are shownafter compression is applied via thetransducer. The thrombus preventscollapse of the right popliteal vein, whilethe normal vein disappears. The poplitealartery (A) remains open.


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Axillary vein thrombosis: The axillary vein (V) is imaged with the transducer placed in the infraclavicular region with the patient’s, armabducted to 90 degrees. The vein does not compress when enough pressure to collapse the axillary artery (A) is applied using the transducer.No blood movement is seen in the vein using color flow Doppler.

Jugular vein thrombosis: The jugular vein lumen (V) is filled with a non-compressible occlusive thrombus. The vein fails to compressand demonstrates no flow on color flow Doppler imaging.


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Index

A-lines, pulmonary 35, 36–7, 38abdominal aortic aneurysm 178–81abdominal paracentesis 172–3abdominal trauma 4–6, 9–13, 154abscessesperitonsillar 147, 173–4renal 110scrotal 125soft tissue 147testicular 125

Achilles tendon, ruptured 139aerobilia 67air bronchograms 49–51alveolar interstitial syndrome

45–8ankle 133effusion 138

aortic aneurysm, abdominal 178–81aortic dissection, proximal 33aortic regurgitation 33aortic valve, bicuspid 32apical views of heart 27–8appendicitis 78–82, 141–6psoas rectus compression 80–1ring of fire 82

appendicolith 141appendix 77–82free fluid around 79normal 77perforated 79, 144, 145

arterial ultrasound 175–84ascites 64–5, 82–3paracentesis 172–3ventral hernias 84, 85

atrial myxoma 34atrial septal defect 34axillary nerve block 158–9axillary vein thrombosis 190

B-lines, pulmonary 45–8barcode (stratosphere) sign

40, 42, 43bat sign 36BB pellets 150, 151bee stinger 150biliary anatomy 58–9biliary polyps 69–70biliary sludge 68–9biloma 69

bladder, urinary 13, 114–17masses 115–16stones 116volume measurement 114

brachial plexus nerve block 159–60brachial vein 149

cardiac tamponade 29–30, 166cardiac ultrasound see heartcardiothoracic procedures 166–8carotid artery stenosis 175–8cellulitis 174central venous line placement 149,

164–5cervical lymphadenitis 146chest trauma 1–4, 6–7, 8–9cholangiocarcinoma 74cholelithiasis 59–62cirrhotic liver 73common bile duct (CBD) 63–4compression testingappendicitis 80–1, 143, 145, 146deep venous thrombosis

187–9, 190negative 185–7veins for vascular access 149, 163,

164corpus luteal cysts 98, 99cystic duct 59cystitis, pediatric 116, 156

deep venous thrombosis (DVT) 187–9negative compression testing 185–7upper extremity 189–90

diaphragm laceration 155dilated cardiomyopathy 30dislocations 135–8diverticulitis 83–4double arch (WES) sign 70–1duodenum 71–2, 83

ectopic pregnancy 90, 93, 94–6elbow 133, 140emphysema, subcutaneous 44empyema, pleural 55endocarditis, infective 34epicardial fat pad 1epididymal cyst 124epididymitis 128–31

epididymo-orchitis 128, 131eye 19–25

FAST 1–8, 150fecalithsappendiceal 142–3duodenal 72intestinal diverticula 84

female patientspelvic ultrasound 88–102suprapubic FAST 13–14

femoral artery pseudoaneurysm 182–3femoral fracture 136femoral nerve block 160–1femoral vein 186thrombosis 188

fibroid uterus 101–2finger, dislocated 136focused assessment of sonography in

trauma (FAST) 1–8, 150Foley catheter 116balloon rupture 168–9

foreign bodiespediatric patients 150–1rectal 87removal 170

fractures 135–8, 154–5

gallbladder 58contracted 66wall-echo-shadow (WES) sign 70–1wall thickening 65–6

gallstones 59–62genitourinary ultrasound 103–32globe (of eye), ruptured 19–20gout 139great saphenous vein, thrombus 188gunshot wounds (GSW)chest 7, 30eye 19pediatric patients 150, 151testis 120

hand 140handlebar injury 154heart 26–34enlargement 30–1fluid collections around 29–30normal views 26–8

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heart (cont.)strain, right 31–2trauma 1–4, 6–7, 150valvular dysfunction 32–4

hemangioma, hepatic 74–5hemopericardium 1–2, 30hemothorax 8–9, 155hepatic ducts, dilated 72–3hernias 84–5hip 135effusion 140

beta-human chorionic gonadotropin(hCG) 91, 93, 94, 96

humerus fracture 155hydrocele 126–7, 130–1, 151, 157hydronephrosis 110–12, 157hydroureter 110–12hypernephroma 107–8hypertrophic obstructive

cardiomyopathy (HOCM) 30

infections, pediatric 146–7infective endocarditis 34inguinal hernia 84, 121internal jugular vein 149, 164intestinal ultrasound 77–87intracranial pressure, raised 20intrauterine devices 90, 93intrauterine pregnancy 91–3intravenous (IV) access 163–5pediatric patients 149

intussusception 85–6, 148–9

jointsdislocations 135–8normal 133–5pathology 138–40

jugular vein thrombosis 190

kidney 103–13atrophic 105–6horseshoe 106masses, cysts and abscesses106–10

normal 103–4pelvic 106variations 105–6

knee 134effusion 139

left chestFAST 2–4fluid in 4

left ventricular aneurysm,apical 31

left ventricular hypertrophy 31leiomyomas, uterine 101–2ligament pathology 138–40liver

main lobar fissure 58metastases 73–4pathology 72–5

lumbar puncture 170–2lung 35–57alveolar consolidation 49–51hepatization 49, 51interstitial syndrome 45–8mirror-image artifact 52white 48

lung pointfalse 41, 42pneumothorax 41, 42

lung pulse sign 39

male patientsgenital tract 117suprapubic FAST 14–18

median nerve block 161metacarpophalangeal joint 134metastatic liver disease 73–4Mickey Mouse sign 58, 70mirror-image artifact, lung 52mitral regurgitation 33mitral stenosis 31mitral valve prolapse 32molar pregnancy 96–7Morrison’s pouch 4–6, 155musculoskeletal ultrasound 133–40

Nabothian cysts 95, 100nasal fracture 137nephroblastoma (Wilms’ tumor)

108–9, 151nerve blocks 158–63

O-lines, pulmonary 39obstructive uropathy 110–12,

156, 157ocular ultrasound 19–25olecranon bursitis 140olive sandwich sign 64optic nerve 20orchitis 122ovarian cysts 98–100corpus luteal 98, 99hemorrhagic 96, 100Nabothian 95, 100theca lutein 97

ovarian mass 151ovarian torsion 100–1ovaries 88, 89

pacemakers, transvenous 168pancreas 75–6pancreatic duct of Wirsung 75paracentesis, abdominal 172–3parasternal long axis (PLAX) view of

heart 26

parasternal short axis (PSAX) views ofheart 27

pediatric ultrasound 141–57pelvis 88–102female anatomy 88–91free fluid 6, 90–1, 95–6trauma, FAST 4–6, 9–18

penile fractures 132penile implants 132pericardial clot 6–7pericardial effusion 29, 54, 166pericardial tamponade 29–30, 166pericardiocentesis 29, 166perinephric fat 8, 103–4peripheral intravenous (IV) access

149, 163peritonsillar abscess 147drainage 173–4

Playboy Bunny sign 59pleural effusion 52–7

alveolar consolidation with 51liver disease 75pediatric patients 147, 155thoracentesis 56, 167–8

pneumobilia 67pneumonia 147pneumothorax (PTX) 40–4polycystic kidney disease 112–13popliteal vein 187thrombosis 189

pouch of Douglas, free fluid 90–1power slide sign 38, 43pregnancyabnormal 89, 93ectopic 90, 93, 94–6intrauterine 91–3molar 96–7

procedures, ultrasound-assisted158–74

prostate, enlarged 116–17psoas rectus compression, appendicitis

80–1pulmonary edema 47pulmonary embolism 31–2pyloric stenosis 151–3

quad sign 53

radial arteryinjury 155line placement 165–6

radial nerve block 162radius fractures 135, 155rectal foreign body 87renal abscess 110renal arteryduplicate 106embolism 183thrombosis 184

Index

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renal blood flow 104renal calculus 109, 112renal cell carcinoma 107–8renal cysts 109–10renal ultrasound 103–13rete testis, tubular ectasia 125–4retinal detachment 21–5right chest, FAST 8–9right upper quadrant ultrasonography

58–76ring of fireappendicitis 82ectopic pregnancy 94

scaphoid 134fracture 137

scrotal abscess 125scrotal hematoma 120scrotal hernia see inguinal herniaseashore sign 36, 37, 38, 42shoulder 133

dislocation 136, 137shred sign 51sinusoid sign 52skin infections 146, 147skull fracture 138sludge, biliary 68–9small bowelobstruction 86peristalsis 82

spermatocele 122spine sign 49, 50splenic vein 75splenorenal view, FAST 9–13stab wounds, chest 2sternal fracture 138stratosphere sign 40, 42, 43subchorionic hemorrhage 93subclavian vein 164–5subcutaneous air 44subxiphoid view of heart 26superior mesenteric artery 75, 76suprapubic view, FAST 13–18suprasternal view of heart 28

testes 117–25abscess 125blood flow 118cyst 124fractured 120gun shot wound 120mass adjacent to 123–4microlithiasis 123torsion 119

testicular appendix 118, 151testicular carcinoma 123theca lutein cysts 97thoracentesis 56, 167–8tibial fracture 137transvenous pacemakers 168

trauma 1–8pediatric 150, 154–5

ulnar nerve block 163ultrasound-assisted procedures

158–74umbilical hernia 85upper extremity deep venous

thrombosis 189–90urinary tract 103–17pediatric 156–7

uterus 88–9bicornuate 89fibroid 101–2

valvular heart dysfunction 32–4varicocele 122vascular access 149, 163–6venous ultrasound 185–90ventral hernia 84, 85ventricular septal defect 33vitreous 25

wall-echo-shadow (WES) sign 70–1water bath 138, 140white lung 48Wilms’ tumor 108–9, 151wrist 134

Z-line, lung ultrasound 36

193

Index

atlas of emergency ultrasound - j. fox (cambridge, 2011) ww

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