Ultrasound SEM 2 (recent)

Flow going into the liver

Heptopedial

A ) triphasic

B ) biphasic

Monophasic

A ) right hepatic artery

B ) middle hepatic artery

C ) left hepatic artery

How does the flow of blood come into the liver

The hepatic artery brings ooxygen rich blood into the liver and the hepatic portal vein brings nutrient rich blood from digestive t

Liver’s 5 main functions of the liver

• Filtration

• Digestion

• Metabolism

• Protein synthesis

• Storage of vitamins and minerals

Clinical indications for PV ultrasound

Portal vein ultrasound technique

The patient is in LPO position (or take image intercostally)

The assessment of PV

Checking for thrombosis, or enlargement of vessel paired with Doppler trace.

Uniformity of colour in the vessel.

Angle of insonation

60 degrees or less

• if angle isn’t good the vessel has no colour fill

To fix angle can heel toe the transducer or can go intercostally

What’s the problem with these images

Colour gain too low

Colour gain too high

Scale set too high (Bring it down to 18)

Which is hepatopetal and which is heptofugal

The image on the left is hepatopetal → towards the liver

The image on the right is hepatofugal → away from the liver

Red is towards the transducer

Explain how pulsatility should be shown in portal vein

Should be absent in healthy patient, with flows showing normal gentle undulation

What are some PV pathology

Vascular abnormalities

• Portal vein thrombosis

• Portal vein hypertension

• Portal vein aneurysm

Metabolism disorder

• cirrhosis

PV thrombosis

What pathology is this

Thrombosis

Portal hypertension

Elavated pressure in the PV system

Increased resistance to flow (sinusoids)

Flow diverted to system veins through collaterals

Later phase: thrombosed portal vein replaced by collateral or cavernous venous malformation at ports hepatis

Portal hypertension types

Cirrhosis

• enlargement of the liver

• Mottled / hetorgonis appears of liver

Portal hypertension

Partial thrombosis

The purpose of the pelvic girdle

Support

Stability

Movement

Attachment

Thyroid anatomy

Typical size of thyroid

Normally length 5 cm, width 3 cm, depth 2cm

Isthmus 2 - 3 mm thick

Thyroid glads weigh about 20 to 30

Thyroid physiology

Is an endocrine gland, maintain body metabolism and growth by secreting thyroid hormones.

SCM → sternoclidomastoid

SC → subcutaneous layer

SH → sternohyoid muscle

ST → sternothyoid muscle

LCM → longest Colli muscle

Clinical indications for thyroid US

Palpable mass (thyroid)

? Nodule

? Goitre

Diffuse thyroid enlargement

Pain, voice changes, tightness in the throat

Extra-thyroid mass

As an aid to fine needle aspiration biopsy / core biopsy

What probe should you use for thyroid ultrasound

High frequency transducer 15 hz

Patient Preparation for thyroid US

Explain the procedure

Obtain good patient history

Mindfulness of patient comfort

Pillow under head

Use warm gel

Scanning techniques

Patient is supine, head extended

Palpation of palpable mass / ROI

Both thyroid lobes and the isthmus are scanned in both trans and long planes

Gentle transducer pressure

Imaging documentation of normal thyroid + / - pathology. Use colour Doppler

Cone loops as required

Volume measurements of both thyroid. AP measurement of the isthmus

Diffuse thyroid disease

• hyperthyroidism

• Hypothyroidism

• Thyrotoxicsis

• Graves’ disease

• Goitre

• Thyroiditis

Thyroiditis

• increase in thyroid size

• Hetrogenous

• Increased vascularity

Graves’ disease

• enlarged thyroid

• Hetrogenous (patchy)

• Increased vascularity

(Similar to thyroiditis)

Goitre

• Enlarged

• Usually multi nodular

How would you describe nodules in US

• Echogenicty

• Sharpness of border

• Calcifications

• Taller than wide

• Invasion

• Chaotic vascularity

• Halo

• Nodes

Honeycomb apperence

Typical begin spongiform nodule

Cyst within the nodule

Breast anatomy

Paired superficial structure between skin and superficial muscle

Part of the integumentary system

Accessory reproductive function - breast feeding

Consists of adipose tissue, glandular tissue and fibrous connective tissue.

Breast anatomy

Skin, subcutaneous tissue

Nipple ad aerolar

Fibroglandular tissue

Intramammary fat

Coopers ligaments

Intramammary ducts

Pectoralis muscles costal bones

What are the four quadrants of the breast

What are the three layers of breast that can be distinguished on ultrasound

• Pre mammary zone

• Mammary zone

• Retro mammary zone

Premammary zone

Between the skin and parenchyma

• contains fat - hyperechoic compared to parenchyma

• Coppers ligaments - echogenic linerar bands

Mammary zone

Parenchyma

• fibroglandular tissue - hyperechoic

• Ducts - hyperechoic / anechoic tubes running through

Retro mammary zone

Between parenchyma and muscle

• contains fat - hyperechoic compared to parenchyma

• Coppers ligaments ligments - echogenic linear bands

1) skin

2) intermammary fat

3) fibroglandular tissue

4) retro mammary fat

5) ducts

6) copper ligaments

Clinical indications for breast US

Palpable lump

Correlation with mammography

Breast pain

Nipple discharge

PHX breast ca

Fox breast ca

Breast implant

US equipment for breast

Hugh frequency transducer 15mHz

Patient prepration for breast US

Scanning techniques for US

Breast pathology

Cyst

Fibroadenomas

Malignancy

Mastitis

How to describe Breast lesions

Breast cyst

Fibroadenoma

• most common soild benign lesion

Malignancy

• Taller than wide

• Non identified lesions

• Posterior shadowing

• If put colour on you see vascularity

• Invading the tissue

Mastitis

• Dilated ducts

• hyper vascular → indicates inflammation in breast

Gynaecamastia

• Lump under the nipple area

• In men

• Ill defined

• Hyperechoic

Scrotal anatomy

A - Tunica vaginalis (parietal layer)

B - Tunica vaginalis (visceral layer)

C - Tunica albuginea

Image 1 (head of the epididymis)

Image 2 (body of the epididymis)

Image 3 (tail of the epididymis)

Clinical Indications for Scrotal US

Testicular pain

Palpable lump

Scrotal swelling

Trauma

Follow up with previous lump

Follow up of microlithiasis

Location of undescended testis

What transducer for scrotal exam

High frequency transducer 15 MHz

Patinet preparation scrotal US

Scanning technique for scrotal US

Common scrotal pathology

Cyst

Calcification

Microlithiasis

Hydroceles

Varicoceles

Epididymitis

Torsion

Trauma

Intra and extra testicular lesions

Scrotal cyst

• anechoic posterior shadowing

Microlithiasis

• intratubular calcifications

Hydrocele

• Large collection of fluid in scrotum

• Posterior enhancement

Varicocele

• Collection of abnormally dilated and tortious veins in the scrotum

• More than 3 cm

Epidymitis

• inflammation of the epididymis

• Hetrogenous

Epididymo-orchitis

• Infection / inflammatory process of epeidimus and the testice

• Increased vascularity

Testicular torsion

• When the cord that provides blood flow to the testice twists and cuts of the blood supply

• No blood flow

Trauma

• acute swelling / hematoma

• Rupture of the testicle

Testicular malignancy

What are the different types of skeletal muscle and there anatomy

Appearence of muscle on US

Tendon appearance on US

Ligaments → bone to bone

Tendons → bone to muscle

Tendon

Nerve ultrasound appearance

Which one is the nerve

MSK US what transducer would you use

High frequency transducer - 15Mhz

Clinical indications for MSK

Trauma - direct or indirect

Overuse injuries

Lumps and bumps

Numbness and pain

Joint pathology

Tendonopathy

• Heterogenous tendon thickened

• Hyper echoic bursa above the tendon

Articulatar surface tendon tear

• supraspinatus tendon

• Partial thickness tear

• Boney irregularity

Full thickness tear of the bicep

Partial thickness tear

Completely ruptured long head of bicep tendon

• Completely retracted tendon

Tennis elbow / common extensor tendonopathy

• increased vascularity to the elbow

• Patchy heterogenous tendon with hyper echoing areas (should be homogenous)

Inflammation of common extensor

???

• thickened sheath (hypoechoic)

• Increased vascularity

Chronic patellar tendonosis

Reason for a US of First Trimester

• Determine gestational age

• Localisation and viability of pregnancy

• Fetal number

• Fetal anatomy

• Nuchal translucency

What are these terms

• Gestational Age

• Menstrual Age

• True Gestational Age

Determining gestational age in very early pregnancy

• the gestational sac is the first structure visualised 5 weeks (MSD)

• The crown-rump length (CRL) is used to predict gestational age

• Towards the end of 1st trimester we can use BPD

In the second and third trimester we determine gestational age with:

Head circumference

Biparietal diameter

Abdominal circumference

Femur length

Humeral length

First trimester clinical indications

Unsure of dates - positive BHCG

Pelvic pain

Vaginal bleeding

Suspected Misscarriage

Suspected FDIU

Suspected Ectopic Pregnacy

Suspected Multiple Pregnacy

Abnormal Pregnancy developments

1st trimester scan technique

• Patient prep

• Patient history

• Scanning technique

TV → transvaginal scan

TA → trans abdominal scan

When was this taken

1st trimester scan

How can we tell if

Embryo with heart beat to tell its a viable

What do we use to measure fetal heart rate

100 beats per min under 6 weeks

Use M-mode (motion mode)

Or you can use colour box to show heart rate

How do you date the fetus

From the crown of the baby head to the rump

• CRL (crown rump length)