Ultrasound

Echogenicity:

spleen = pancreas >
liver = left kidney >
right kidney


*** *** ***

thyroid >
muscle



Liver

Normal Liver

Size	Length MCL < 15 cm
Parenchyma	Homogeneous
Surface	Smooth

Lesions

Cyst	Anechoic lumen, ↑ through transmission, well-defined back wall; Freq septn, puckering
Complex cyst	Internal echoes, thick wall, numerous or thick septns, solid elms, or calcifs E.g. hematoma, abscess, biloma, mets, echinococcus, tumor
Hemangioma	Hyperechoic, homogen
FNH	Isoechoic, spoke-wheel vascularity
Adenoma	Highly variable
HCC	V. variable. Includes target lesions
Mets	Usu target lesions, but v. variable
Lymphoma	Hypoechoic
Acute hepatitis	Starry sky (not specific)
Portal htn	Smg, ascites, portasystemic collaterals, reversal of portal venous flow

Dilated Intrahepatic Ducts


> 2 mm diameter
> 40% diameter adjacent portal vein
↑ through transmission
Irreg, tort walls
Stellate config centrally
Enlarged GB


TIPS


Normal: 90 < shunt velocity < 190 cm/s

Shunt obstruction
Hep venous stenosis
Hep art pseudoaneurysm / art-portal fistula
Hematoma
Hemoperitoneum
Biloma

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Gallbladder

Normal Gallbladder

Size	Transverse < 4 cm Longit < 10 cm
Wall thickness	< 3 mm
Lumen	Anechoic

Gallbladder Intraluminal Abnormalities

Stones	Shadowing, mobile
Polyps	Non-shadowing, non-mobile
Sludge	Non-shadowing, mobile

Acute Cholecystitis


Wall thickness > 3 mm
Pericholecystic fld
Enlarged GB
Stones
Impacted stone
Sonographic Murphy's sign

GB Fossa Shadowing

	Shadow	Wall-echo-shadow complex	Back wall
GB full of stones	Usu clean	Often	Not seen
Porcelain GB	Variable	Rare	May be seen
Intramural gas	Usu dirty	Rare	May be seen

Hyperplastic Cholecystoses


Cholesterolosis


Adenomyomatosis

Focal or diffuse mucosal hyperplasia & muscular layer thickening
Rokitansky-Aschoff sinuses - freq contain cholesterol crystals → comet-tail artefact

Common Duct


Diameter < 6 mm up to 60 y/o
then add 1 mm for every decade over 60 y/o


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Pancreas

Normal

Head < 3 cm
Body & tail < 2.5 cm
Duct < 3 mm; smooth
Homogeneous echotexture
Smooth or sl lobular surface


Acute Pancreatitis


↓ or heterogen echotexture
Enlarged
Fluid collections:
peripanc
perivascualar
periduodenal
retroperitoneal

Acute Pancreatitis Complications


Pseudocyst
Abscess
Necrosis
Biliary strictures
Venous thrombosis
Pseudoaneurysm

Chronic Pancreatitis


Calcifications
Dilated, irreg duct
Parenchymal atrophy

Solid, Hypoechoic Masses


Ca
Islet cell tumor
Lymphoma
Mets
Focal pancreatitis
Thrombosed aneurysm


Cystic Lesions


Pseudocyst
Macrocystic (mucinous) tumor [pre-malig or malig]
Microcystic (serous) tumor [benign]
Intraductal papillary mucinous tumor (IPMN)
Solid papillary epith neoplasm
Aneurysm or pseudoaneurysm
Cystic fibrosis
Autosomal domin polycystic dz
VHL


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Spleen

Normal

Longit < 13 cm
Width < 6 cm
Homogen echotexture
Smooth surface


Solid Lesions


Granuloma
Hemangioma
Hamartoma
Infarction
Abscess
Extramedullary hematopoiesis
Sarcoidosis
Lymphoma
Mets


Splenomegaly DDx


CHF
Portal htn
Leukemia
Lymphoma
Hemolytic anemia
Hepatitis
Mononucleosis
Generalized infection

Uncommon:
Myelofibrosis
Glycogen storage dz
Malaria

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Adrenal

Masses

Hemorrhage
Myelolipoma
Adenoma
Adenocarcinoma
Pheochromocytoma
Lymphoma
Mets


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Kidney

Normal Length

Adult: 9 - 13 cm


Neonate: 43 mm (95% confidence limits 27 to 59 mm)
7 m/o: 61 mm (95% confidence limits 40 to 81 cm)

Urinary Obstruction


Hydronephrosis
Loss of ureteral jets
RI > 0.7
RI diff b/n Rt & Lt > 0.10


Hydronephrosis DDx


Grade 1	Grade 2	Grade 3
Mild	Moderate	Severe
Sl distentn (pelvicaliectasis)	Obvious diln; no cortical thinning	Cortical thinning

Obstruction
Previous obstruction
Extrarenal pelvis
Distended bladder
Pregnancy

Uncommon:
Active diuresis
DI
Reflux nephropathy

Simple Cyst


Anechoic lumen
↑ through transmission
Well-defined back wall
No measurable wall thickness


Cystic disease

	Size	Tumors	Extrarenal cysts	Extrarenal lesions
ADPKD	Large	0	Liver	Cerebral aneurysms
VHL	Nl or lge	RCC	Pancreas	Panc cystic neoplasms Islet cell tumors Pheochromocytomas CNS hemangioblastomas Retinal angiomas
Acq'd Cystic Dz of Dialysis (ACD)	Small	RCC	0	0
Tuberous sclerosis	Nl or lge	AML	0	Cerebral hamartomas Perivent nods LAM Cardiac rhabdomyomas

Solid Masses


RCC
TCC
AML
Oncocytoma
Juxtaglomerular cell tumor (reninoma)
Lymphoma
Mets
Focal pyelonephritis
Focal parenchymal hypertrophy
Column of Bertin


Complex Cystic Masses


Hemorrhagic cyst
Hematoma
Multiseptated cyst
Infected cyst
Abscess
Multilocular cystic nephroma
Cystic RCC


Urothelial Thickening


Pyelonephritis
Ureteral stone/stent
Tpt rejection or ischemia
TCC


Pyelonephritis


Focal cortical ↑ or ↓ echogenicity
Renal enlargement
Urothelial thickening
Focal ↓ blood flow

Calculus


Echogenic reflectors
Acoutic shadow
Often twinkle artefact

Medullary Nephrocalcinosis


Medullary sponge kidney (tubular ectasia)
RTA
Hyperparathyroidism

Xanthogranulomatous Pyelonephritis (XGP)


Chronic obstruction → chronic UTI → lipid-laden macrophages → yellow inflammatory masses
US: Stone, caliectasis, perinephric inflam tissue & fluid


Transplantation


Urinary obstruction
Post-op fld collections (mass effect?)
Abscess
Hematoma
Lymphocele
Seroma
Urinoma

Vascular complications
Stenosis
Thrombosis
A-V fistula
Pseudoaneurysm
Segmental infarction
Rejection
Renal swelling
Enlarged hypoechoic pyramids
Focal cortical ↓ echogen
↓ visibility sinuses
RI < 0.7
ATN - similar to rejn
Cyclosporin toxicity - similar to rejn
Infection - similar to rejn
PTLD

Bladder


Wall thickness

Well-distended < 3 mm
Poorly-distended < 5 mm

DDx:
Bladder outlet obstruction
Neurogenic bladder
Cystitis
Clots
Radiation
Neoplasia

TCC (90%)
SCC (5%)
Adeno Ca (2%)


Renal Parenchymal Disease (medical renal disease)

Cortex echogen (>= spleen) or (> liver)


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General Abdomen

Bowel Wall Thickening

Edema
Inflammation
Infection
Ischemia
Hemorrhage
Neoplasm

Appendicitis


Diameter > 6 mm
Not compressible
Appendicolith
Hyperemia
Inflamed, echogenic periappendiceal fat
Adjacent fluid collections

Peritoneal Masses


Mets
Pseudomyxoma peritonei (from mucinous tumors)
Mesothelioma
TB
Omental infarction


Abdominal Wall Masses


Hematoma
Abscess
Seroma
Lymphocele
Demoid
Lipoma
Hernia
Endometriosis
Sarcoma
Mets
Lymphoma

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Scrotum

Testis

(4-5) x (2-3) x (2-3 cm)
(vol 15 - 20 mL)
homgeneous
smooth surface


Scrotal Lesion

↓ chance of neoplasm	↑ chance of neoplasm
Outside testis	Inside testis
Simple cyst	Solid or cmplx cyst
No detectable vascularity	Detectable internal vascularity
Non-palpable	Palpable

Enlarged, Hypoechoic Testis

	Blood flow	Tenderness
Orchitis	↑	yes
Torsion	↓	yes
Lymphoma	↑	no
Seminoma	↑	no

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Thyroid

Normal

Isthmus < 4 mm
Lobes < 2 cm AP & transverse
Homogen
Hyperechoic to adjac muscles


Nodules

DDx: adenoma, colloid cyst, focal thyroiditis, Ca, lymphoma

↓ chance of Ca	↑ chance of Ca
Hyper- or isoechoic	Hypoechoic
Cystic elms	Entirely solid
Eggshell calcif	Microcalcifs
Inspissated colloid (colloid cyst)	Cervical LAN
No intranodal flow	Intranodal flow
Regular margins	Irregular margins
< 1 cm	> 1 cm

Metastatic LAN


Long-axis to short-axis <1.5
Oblitern echogenic hilum
Cystic changes
Microcalcifs


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Uterus

Normal (cm)

Parity	Length	AP	Width
0	8	3	5
1	8.5	3.5	5
2-5	9.3	4	5.7
> 5	9.7	4.2	6

Post-partum Uterine Length (cm)

2 days	3 weeks
18 - 23	10 - 12.5

Endometrium (cm)

	AP	Descriptn
Following menses		Thin, hyperechoic line
Prolif stage	< 8 mm	Thicker, uniformly hyperechoic line Junctional zone visible
Immed prior to ovuln		Triple layer (3 hyper- sandwiching 2 hypo-)
Secretory stage	< 15 mm	Thick, uniformly hyperechoic line
Post-partum	< 15 mm
Post-menopausal	< 5 mm (else, esp if vag bleed → endomet Bx)	Thin, hyperechoic line

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Adnexae

Ovary Upper limit of Normal (cm)

	L x W x AP	Volume (LxWxAP/2)
Nullip, young adult	3 x 3 x 2	9
Parous	5 x 3 x 2	15
Perimenopausal		9
5 yrs post-menopausal		5
10 yrs post-menopausal		3
> 15 yrs post-menopausal		2

Most ovarian cysts in postmenopausal women are benign simple cysts.
If benign characteristics (unilocular, less than 5cm etc.), follow one additional time (e.g. 3 mos)
→ If no change, assume benign.

Follicles (cysts)


Dominant follicle < 2.5 cm

Functioning:

Affected by menstrual cycle
Usu < 25 mm

Non-functioning:


Simple:

anechoic
↑ through transmission
No internal echoes
No wall thickening
Complex:
Hemorrhagic cyst
Cystic teratoma (dermoid)
Endometrioma
Cystadenoma
Cystadenocarcinoma
Mets

Adnexal Mass Scoring System

Wall thickness
< 3 mm	1
> 3 mm	2
Mostly solid	3
Inner wall structure
Smooth	1
Irregularities	2
Papillary projections	3
Mostly solid	4
Septa
None	1
< 3 mm	2
> 3 mm	3
Echogenicity
Anechoic	1
Low	2
Low with hyperechoic core	3
Mixed	4
Hyperechoic	5

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First Trimester

^{MSD: mean sac diameter}

Gestational Age	Finding
< 5 wks	Intradecidual sac sign
5 wks (serum β-HCG 1000-2000 mIU/mL)	MSD approx 5 mm (grows 1.1 mm/day)
5-6 wks	Double decidual sac sign
5 - 8 wks	HR > 100
> 8 wks	avg HR 140 (120-180)

Feature	Finding
MSD 8 mm transvaginally or 20 mm transabdominally (Serum β-HCG 7,200)	Yolk sac visible
MSD 16 mm transvaginally or 25 mm transabdominally (Serum β-HCG 10,000)	Embryo visible (If not → 100% predictive of abnl IUP)
Crown-rump length > 5 mm	Cardiac activity

Vaginal Bleeding

Implantation bleed
Subchorionic hemorrhage
Embryonic pregnancy/blighted ovum
Embryonic demise
Spontaneous abortion
Ectopic pregnancy
Molar pregnancy


Positive β-HCG and Empty Uterus

Early normal intrauterine pregnancy (<5 weeks)
Complete spontaneous abortion
Ectopic pregnancy


Sonographic Findings Associated with Ectopic Pregnancy

Embryo located outside of the uterus is 100% diagnostic of an ectopic pregnancy
Complex or solid adnexal mass
Moderate to large amount of pelvic free fluid, especially if particulate
Empty uterus in conjunction with serum β-HCG above level at which gestational sac should be seen.

Abortions

Type of Abortion	Definition	Findings
Blighted ovum	Failed or abnormal embryonic development	Empty gestational sac or sac with abnormal yolk sac and no embryo
Embryonic demise		No cardiac activity
Threatened	Vaginal bleeding + closed cervical os	Ranges from live embryo to small, empty gestational sac to normal empty uterus
Abortion in progress	Intrauterine gestation in process of being expelled	Irregular gestational sac in lower uterus/cervix +/- live embryo
Incomplete	Incomplete passage of gestational tissues	Thickened endometrium +/- fluid and debris; areas of ↑ endometrial vascularity
Complete	Expulsion of all gestational tissues	Normal empty uterus, may be mildly vascular

First Trimester US

Ultrasonography - Sample Reports

NORMAL RIGHT UPPER QUADRANT

TECHNIQUE: Real-time ultrasound evaluation of the right upper quadrant was performed using a curved array transducer. Color Doppler imaging was used to assess vascular flow.

DESCRIPTION: The visualized pancreas is normal.

The liver is homogenous in echotexture. No evidence of an intrahepatic mass or biliary ductal dilatation. Color Doppler interrogation of the main portal vein demonstrates hepatopetal flow.

The gallbladder is sonographically normal. The common duct is normal in caliber measuring ____mm in AP diameter.

Limited imaging of the right kidney demonstrates no hydronephrosis. No ascites in the visualized abdomen.

NORMAL LIVER DOPPLER

TECHNIQUE: Real-time ultrasound evaluation of the abdomen was performed utilizing a curved array transducer. Color Doppler imaging was used to assess vascular flow.

DESCRIPTION: The visualized liver and pancreas appear normal. Normal waveforms and appropriate direction of flow are identified in the following vessels: right, main and left hepatic arteries; right, main and left portal veins; right, middle and left hepatic veins.

Hepatopetal flow is demonstrated in the main portal vein, and the portosplenic confluence appears normal.

There is no ascites in the visualized abdomen.

IMPRESSION: Normal Doppler ultrasound of the abdomen.

RIGHT UPPER QUADRANT - PANCREAS NOT SEEN

DESCRIIPTION: The pancreas is not seen due to _____(overlying bowel gas OR body habitus).

IMPRESSION: Pancreas not seen. Otherwise, normal right upper quadrant ultrasound.

RIGHT UPPER QUADRANT - GALLSTONES

DESCRIPTION: The gallbladder contains multiple shadowing stones in its dependent portion, but there is no evidence of gallbladder wall thickening or pericholecystic fluid. The common duct is normal in caliber measuring ____mm in AP diameter.

IMPRESSION: Cholelithiasis with no sonographic evidence of cholecystitis.

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NORMAL RENAL ULTRASOUND

TECHNIQUE: Real-time ultrasound evaluation of the kidneys and urinary bladder was performed using a curved array transducer. Color Doppler imaging was used to assess vascular flow.

DESCRIPTION: Both kidneys are normal in size and echogenicity. The right kidney measures ___cm in long length, and the left kidney measures ___cm in long length. There is no evidence of hydronephrosis, mass, cyst or shadowing calculus.

Limited imaging of the urinary bladder demonstrates no abnormality. No ascites in the visualized abdomen and pelvis.

NORMAL RENAL ULTRASOUND WITH FOLEY CATHETER

DESCRIPTION: The urinary bladder is decompressed by a Foley catheter and cannot be evaluated.

IMPRESSION:
1. Normal kidneys.
2. Foley catheter in place.

NORMAL RENAL TRANSPLANT ULTRASOUND

DESCRIPTION: The renal transplant is normal in size and echogenicity and measures ______cm in long length. There is no evidence of hydronephrosis, mass, shadowing calculus or peritransplant fluid collection.

Color Doppler imaging demonstrates normal arterial waveforms and arterial resistive indices, which range from 0._____ to 0._____.

Limited imaging of the urinary bladder demonstrates no abnormality. No ascites in the visualized abdomen and pelvis.

IMPRESSION: Normal ______renal transplant ultrasound.

ULTRASOUND OF TRANSPLANTED KIDNEY

TECHNIQUE: Real-time ultrasound evaluation of the transplanted kidney and urinary bladder was performed utilizing a curved array transducer. Color Doppler imaging was used to assess blood flow.

FINDINGS: The transplanted kidney is in the left iliac fossa and measures 10.7 cm longitudinally, which is within normal limits. Mild to moderate hydronephrosis is demonstrated. A small amount of anechoic fluid is adjacent to the inferior pole.

Arterial resistive indices are 0.67, 0.74, and 0.66. Venous flow is within normal limits. No evidence of stenosis, thrombosis or infarction. Renal cortex, pyramids and sinuses well visualized.

The urinary bladder is collapsed around a Foley catheter making assessment of the bladder suboptimal.

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NORMAL THYROID ULTRASOUND

TECHNIQUE: Real-time ultrasound evaluation of the neck was performed using a high resolution linear array transducer. Color Doppler imaging was used to assess vascular flow.

DESCRIPTION: Both lobes of the thyroid are homogenous in echotexture and normal in size. The right lobe measures ____x ____x ____cm. The left lobe measures ____x ____x ____cm. The isthmus measures ____mm in AP dimension.

There is no evidence of nodules. No extrathyroidal mass is seen.

Color Doppler imaging demonstrates normal vascularity of the gland.

IMPRESSION: Normal.

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NORMAL TRANSABDOMINAL & TRANSVAGINAL PELVIC ULTRASOUND

TECHNIQUE: Real-time ultrasound evaluation of the pelvis was performed using transabdominal and transvaginal approaches. Color Doppler imaging was used to assess vascular flow.

FINDINGS: The uterus is homogeneous in echotexture and normal in size measuring _____ x _____x _____cm. The endometrial stripe is normal in caliber measuring _____mm in the AP dimension.

Both ovaries are normal in size and appearance. The right ovary measures ____x _____x _____cm. The left ovary measures ____x ____x ____cm. Color Doppler imaging demonstrates arterial and venous waveforms in both ovaries. No adnexal masses are identified.

No free fluid in the cul-de-sac.

Limited imaging of the urinary bladder demonstrates no abnormality.

TECHNIQUE: Real-time ultrasound evaluation of the pelvis was performed using transabdominal and transvaginal approaches. Color Doppler imaging was used to assess vascular flow.

FINDINGS: Demonstration of a live, single intrauterine pregnancy with crown-rump length consistent with 8.5 to 9 weeks gestational age. Cardiac activity is demonstrated with a heart rate of 177. The gestational sac measures 3.1 x 2.9 x 4.1 cm. The uterus is homogeneous in echotexture and measures 10 cm longit x 6.1 cm in AP dimension x 6.8 cm transversely.

Both ovaries are small in size and with normal blood flow. The right ovary measures 2.1 x 2.5 x 0.9 cm. The left ovary measures 2.3 x 1.2 x 1.6 cm. No adnexal mass is present. No free fluid in the cul-de-sac.

IMPRESSION:
Live, single intrauterine pregnancy consistent with 8.5 to 9 weeks gestational age. Cardiac activity normal. No evidence of ectopic pregnancy.

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NORMAL SCROTAL ULTRASOUND

TECHNIQUE: Real-time ultrasound evaluation of the scrotum was performed using a high resolution linear array transducer. Color Doppler was used to assess vascular flow.

FINDINGS: Both testes are homogeneous in echotexture and normal in size. The right testicle measures ___x ___x ___cm. The left testicle measures ____x ____x ___cm. No evidence of an intratesticular mass or abnormal calcification.

Color Doppler imaging demonstrates arterial and venous waveforms in both testes.

Both epididymides are normal in appearance, and there is no evidence of a hydrocele or varicocele.

IMPRESSION: Normal.

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NORMAL BABY HEAD ULTRASOUND

PORTABLE NEONATAL ECHOENCEPHALOGRAM

TECHNIQUE: Real-time ultrasound evaluation of the neonatal brain was performed using the anterior fontanelle as an acoustic window. Multiple sagittal and coronal images were obtained.

DESCRIPTION: The cortical sulcation pattern is within normal limits. OR The lack of cortical sulcation and wide cavum septum pellucidum is consistent with the patient's history of prematurity.

There is no evidence of acute intracranial hemorrhage, mass effect or midline shift. The ventricles are symmetric and normal in size and configuration.

IMPRESSION: No evidence of acute intracranial pathology.

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NORMAL COLOR DOPPLER IMAGING OF THE VEINS OF THE LOWER EXTREMITY

TECHNIQUE: Using duplex and color flow Doppler, the common femoral, superficial femoral and popliteal veins were evaluated in the (right or left) lower extremity. (or bilateral lower extremities)

DESCRIPTION: Normal flow, compressibility and augmentation are identified in the following visualized venous segments: common femoral vein; superficial femoral vein - proximal, middle and distal segments; and the popliteal vein.

There is no evidence of a Baker's cyst.

IMPRESSION: No evidence of a deep vein thrombosis in the visualized venous segments of the (right or left) lower extremity (bilateral lower extremities).

Procedure Notes

ULTRASOUND-GUIDED LIVER BIOPSY:

CLINICAL HISTORY:

PHYSICIANS:

TECHNIQUE:
18 gauge coaxial Temno biopsy instrument.

FINDINGS:
Three 18 gauge x 2 cm long core biopsy specimens taken to lab in formalin


COMPLICATIONS: None.

IMPRESSION: Ultrasound-guided liver biopsy without complications.

I personally supervised the performance of this procedure and reviewed and approved the report.

TECHNIQUE: With the patient sitting upright, real-time ultrasound examination of the left posterior chest was performed using a curved array transducer. At the point where the pleural effusion was deepest, the skin was marked with indelible ink.

FINDINGS: Moderate to large left pleural effusion. The skin was marked where effusion was deepest. Distance from skin to inner surface of chest wall was 2.5 cm. Distance from inner surface of chest wall to collapsed lung was approximately 7 cm.

IMPRESSION: Left pleural effusion assessed and skin marked for subsequent thoracentesis to be performed on floor by the clinical service. Patient tolerated procedure well.