DMS Abdominal Ultrasound video notes (copy)
1. Introduction to Abdominal Sonography (0:17)
Instructor: Mikaela George Parton
Teaches general side: OBGYN, abdomen lecture and lab.
Clinical coordinator for the general side.
Specialties: abdomen, OBGYN, breast.
Credentials: RDMS sonographer.
Work Experience: Mostly radiology department (abdomen, small parts), currently PRN for an OBGYN group (babies, pelvis).
Topic: All things abdomen, including organs in the abdomen and part of the pelvic region.
Key Skill: Abdominal sonographers must be well-versed in relational anatomy (how organs fit, work together, and influence examination of other organs).
2. Lecture Objectives (1:37)
Define indications for abdominal exams.
Recognize normal abdominal anatomy and surrounding structures (relational anatomy).
Compare capabilities and limitations of ultrasounds.
Understand required instrumentation (probes, settings).
Identify indications for specific exam types.
Demonstrate basic scanability during lab (liver, right kidney, midline structures - left lobe/liver in relation to IVC/abdominal aorta).
Capture images.
3. Purpose of Abdominal Exams (2:57)
Mechanism: Use sound waves to produce images of organs and vasculature within the abdominal cavity.
Crossover Specialty: Significant overlap with vascular sonographers (abdominal aorta, liver Dopplers, renal Dopplers).
Examined Areas: Upper abdomen and part of the pelvis.
Diagnostic Uses: Help diagnose structural abnormalities or pathology of:
Liver
Gallbladder
Bile ducts (associated with liver)
Pancreas
Both kidneys and bladder
Spleen
All abdominal vasculature (from diaphragm to bifurcation into iliac arteries).
Examples of Images (4:00 onwards):
Transverse liver view showing hepatic veins from IVC.
Liver and gallbladder illustrating relational anatomy.
Pancreas (transverse view, midline, epigastric region):
Hyperechoic structure is ???, also aorta, renal vessels, SMA, splenic vein becoming portal splenic confluence/portal vein.
Emphasizes knowledge of landmarks for accurate imaging.
Right kidney and right lobe of liver (longitudinal plane) (5:30).
Spleen (left upper quadrant), noting similar echogenicity to liver parenchyma (5:59).
Color Doppler of abdominal aorta and superior mesenteric artery (SMA) (6:18) (similar to carotid lab).)
4. Credentialing and Interpreting Doctors (6:24)
Credentialing Agencies:
ARDMS (American Registry for Diagnostic Medical Sonography): Gold standard.
Credential: RDMS (Registered Diagnostic Medical Sonographer), with (AB) for abdomen specialty.
ARRT (American Registry of Radiologic Technologists): Secondary.
Credential: RT (Radiologic Technologist), with (S) for sonography.
Broader general test, less specialization in individual ultrasound specialties than ARDMS.
Interpreting Doctors:
Radiologists (vast majority):
Specialize in most medical imaging (X-ray, mammography, CT, MRI, nuclear medicine, PET scan).
Ultrasound and MRI are the main modalities without radiation.
Perform diagnostic procedures: biopsies, fluid drainage, catheter placement, OR assistance.
Utilize multiple screens to compare MRI, ultrasound, X-ray for best diagnosis (ultrasound is often a small part of the overall diagnostic evaluation).
Example: Ultrasound-guided breast biopsy (9:08).
5. Relational Anatomy of Abdominal Organs (9:30)
Importance: Critical for adequate and accurate imaging in the upper abdomen.
Organ Locations and Relationships:
Liver, Gallbladder, Bile Ducts: All associated with the liver.
Pancreas: Posterior and slightly inferior to the left lobe of the liver.
Kidneys and Bladder: Lateral, either side of the vertebrae.
Right Kidney: Posterior and slightly inferior to the right lobe of the liver.
Left Kidney: Slightly left lateral and slightly inferior to the lateral tip of the left lobe.
Spleen: Just lateral and slightly superior to the left kidney.
GI Tract: Not the best modality for bowel imaging, but improving with technology (higher frequencies, better penetration).
Bowel contains air/gases, which scatters sound waves, making images blurry.
Small intestines, ascending, transverse, and descending colon overlap organs.
Challenge: Imaging the inferior (lower) pole of the right kidney due to overlay by transverse and ascending colon (air artifact).
Imaging Planes for Comparison (12:28):
Axial/Transverse Images: Used by CT and MRI; sonographers need to recognize these for comparison.
Sagittal Cross-section: Shows liver (intraperitoneal) and kidney (retroperitoneal).
Scanning from anterior goes through liver and bowel (air)..
Lateral approach: Go through less liver, directly to kidney, reducing air artifact from bowel, making it easier to image.
Vasculature (13:43):
Aorta, IVC (inferior vena cava), renal vessels (arteries/veins), splenic vessels, mesenteric vessels (feed bowel, extract nutrients).
Diagram shows close relationship of all major vessels and organs: renal veins/arteries, SMA, celiac branch, hepatic veins, ureters.
General sonography images everything from diaphragm to pelvis.
6. Types of Abdominal Exams (14:38)
Principle: Do not typically scan only one organ; most are grouped into systems.
Complete Abdomen: Requested for generalized belly pain.
Scans everything in the upper abdomen: aorta, liver, gallbladder, pancreas, kidneys, spleen, often bladder.
Right Upper Quadrant (RUQ): Most common exam (for right upper quadrant pain, e.g., gallbladder stones).
Includes liver, gallbladder, bile ducts, pancreas, and only the right kidney.
Aorta and IVC are evaluated as they relate to the liver, but not a full aortic scan.
Renal Exam: Second most common.
Kidneys and bladder.
Sometimes includes abdominal aorta and IVC (retroperitoneal structures).
7. Gross Anatomy and Imaging Depth (16:08)
Visualizing Layers:
Skin line, musculature, omentum, vascular going into digestive tract.
Liver (right and left lobes), gallbladder.
Further in: intestines (small bowel, large intestine: ascending, transverse, descending colon).
Liver tissue is spongy; main portal vein splits into left and right (right often hidden behind gallbladder).
Gallbladder is green (bile).
Diaphragm visible (posterior portion).
Spleen is very posterior.
Splenic vein joining SMV to become portal vein.
Still anterior to main aorta and IVC (intraperitoneal).
Retroperitoneal Space (19:00):
Abdominal aorta, renal arteries, iliac bifurcation.
IVC: runs through the parenchyma of the liver.
Aorta: posterior to the liver and does not touch it (splits through diaphragm.
Typical scan depth: 11 to 16 cm (6 slices) from anterior to posterior wall.
8. Anatomy and Function of Specific Organs
8.1 Kidneys (20:20)
Location & Shape: Retroperitoneal, paired, bean-shaped organs.
Size: Average 10-13 cm long, 5-7.5 cm width.
Length is most diagnostic for size.
A single functioning kidney will enlarge to compensate.
Structures Examined:
Capsule (GERRARDOUS fascia): Tough protective layer.
Cortex: Outer portion.
Medulla: Inner portion, contains renal pyramids.
Renal pyramids: Where filtration occurs.
Renal sinus: Central echogenic area (fat content).
Renal pelvis/hilum: Collecting system.
Ureters: Course from kidney to bladder.
Renal artery and vein.
Main Function:
Filter toxins and excess water to form urine.
Reabsorb nutrients and salts to maintain blood balance.
Regulate blood pressure.
Refresher (A&P):
Blood with waste enters, filters through nephrons, goes to renal pelvis.
Pyramids are where primary work happens (collecting tubules).
Waste flows to bladder via ureter.
Sonographic Appearance (22:26):
Diagram (upright) rotated 90 degrees to match ultrasound (longitudinal sagittal plane).
Renal Pyramids: Hypoechoic areas.
Renal Sinus: Hyperechoic tissue (more fat content than parenchyma), where urine collects.
Renal Pelvis: Funnel-shaped, directs urine to ureter (not always visible).
Cortex: Outer portion.
Medulla: Contains pyramids.
Renal Capsule: Can be hyperechoic (sometimes an echogenic halo).
Column of Bertin: Prominent renal medullary tissue extending centrally (less focus in this class).
Ureter: Not visible normally unless obstruction (stone, mass) causing backup.
Echogenicity: Renal parenchyma slightly hypoechoic to normal right liver lobe.
Orientation: Superior pole, inferior pole, ureter extends towards feet.
8.2 Liver (26:39)
Largest Abdominal Organ: Fills most of the upper abdomen.
Extension: Far lateral left to right, sometimes down to top of pelvic bone on right.
Shape: Wedge-shaped; right lobe is majority.
Size Variation: Lots of variation; main measurement is liver length (diaphragm to most inferior point).
Average length: about 15 cm (variable with height, weight, gender).
Structures Imaged (General Overview):
Right and left lobes.
Caudate lobe (imaged separately from right lobe on ultrasound).
Hepatic and portal veins.
Complete imaging from far left to far right, superior to inferior, including all vasculature.
Functions (over 500):
Digestion & Metabolism: Produces bile (digests fats), metabolizes proteins/carbs.
Energy Storage: Stores excess carbs (glycogen), releases for energy.
Vitamin Storage: Stores Vitamins A, D, E, K.
Blood Filtration: Filters blood from GI tract before it goes to heart (removes bad, passes good).
Red Blood Cell Removal: Breaks down old RBCs, processes nutrients, excretes toxins.
Histologic Example (Anterior View) (29:49):
Right lobe, left lobe (can be very prominent).
Ligaments: Falciform ligament, coronary ligaments (hold liver in place).
Gallbladder: Attached posteriorly by a stem (cystic duct), like a water balloon that expands/contracts.
Posterior View: Ligamentum venosum, ligamentum teres (landmarks).
Caudate lobe is imaged separately; quadrate lobe is part of the right lobe.
Diagrams vs. Sonographic Image (31:37):
Diagrams (upright) must be conceptually rotated 90 degrees for ultrasound.
Sagittal section shows liver domed under diaphragm, kidney below.
Sound wave path: Anterior approach goes through liver, bowel (air), then kidney.
Lateral approach: Through less liver, directly to kidney, reducing air artifact.
Sonographic Appearance (33:59):
Anterior (skin line, subcutaneous fat), inferior right lobe, then kidney posteriorly.
Diaphragm: Very thin, strong, dense muscle; shows as bright echogenic line superior to liver.
Transverse view: Right/left lobes, portal vein, vertebrae, kidneys (left kidney often hard to see).
Longitudinal right lobe: Glisten's capsule (outer capsule around liver) is a bright echogenic line.
Vascular portion of liver exam: Color Doppler of hepatic/portal veins; pulse wave imaging of portal/hepatic veins and hepatic artery (small).
8.3 Gallbladder (36:47)
Location: Attached to the posterior right liver lobe by bile ducts.
Function: Liver produces bile, pumped into gallbladder via cystic duct, stored until food eaten.
Mechanism: Contracts to squeeze bile into duodenum (first part of intestine) to digest fats.
Size: Up to 10 cm in length (normal); larger may indicate obstruction.
Process: Fills between meals (fasting); contracts when eating.
Sonographic Appearance: Can be confused with blood vessel if thin/elongated; use color Doppler to differentiate.
Sits on posterior mid-right lobe, close to IVC and portal vein.
8.4 Abdominal Vasculature (38:29)
Aorta (38:29):
Sagittal Midline View: Aorta and branches (celiac, SMA).
Relationship with Liver: Separation between anterior aorta and posterior left lobe of liver.
Function: Sends oxygenated blood from heart to abdomen/lower extremities.
Imaging: Long and transverse planes (superior, mid, inferior/distal portions).
Branches imaged: Celiac, SMA, renal vessels, bifurcation towards pelvis.
Measurement: AP (anterior-posterior) and transverse width (for aneurysms).
Color Doppler: Shows celiac and SMA branching; no vessels coming directly from liver into aorta.
IVC (Inferior Vena Cava) (41:13):
Relationship with Liver: Vessel goes through the liver, touching its posterior portion.
Function: Returns deoxygenated blood from abdomen/lower extremities to right atrium of heart.
Imaging: Connects directly to heart, visible point of connection.
Imaging Difficulty: Difficult to see IVC behind bowel; typically image only superior portion.
Compressibility: Being a vein, it collapses with pressure.
Optimization: Patient sniffing or deep breath dilates IVC, making it more prominent.
Main Reason for Scan: Evaluate for thrombus, masses extending into IVC.
Color Doppler: Shows hepatic veins entering IVC and going into right atrium.
8.5 Spleen and Pancreas (42:33)
Spleen:
Location: Left upper quadrant, posterior to stomach, inferior to diaphragm.
Relationship: Sits like a cap at the end of the pancreatic tail.
Function (Adult): More of a storage container for blood; not essential for adult life.
Friable: Prone to rupture from blunt force trauma, leading to surgical emergency (splenectomy).
Other Functions: Blood filtration, immunity (more important in children).
Normal Length: Up to 13 cm; larger is cause for concern.
Ideal Window: Left side, lateral or coronal approach (longitudinal and transverse); often imaged in relation to kidney.
Pancreas:
Location: Closely related to spleen at tail, but central portion related to duodenum and gallbladder.
Regions: Epigastric region and left upper quadrant (tail).
Functions: Endocrine (hormone control, blood glucose) and exocrine (food digestion, secretes enzymes into bowel).
Relationship: Both organs work closely with bile duct to digest food.
Ideal Window: Midline transverse orientation (head, body, tail visible).
Ultrasound Image: Uncinate process, head, body, tail extending posteriorly.
Left lobe of liver anterior to it, surrounded by vasculature.
9. Review of Echogenicity (45:40)
Left liver lobe is medial to the right kidney.
Liver is hypoechoic to the diaphragm (diaphragm is very echogenic).
Kidney appears complex/heterogeneous (renal pyramids hypoechoic to renal cortex, both hypoechoic to renal sinus fat).
Renal sinus fat is hyperechoic to renal pyramids.
Normal kidney parenchyma is slightly hypoechoic to a normal right liver lobe (used for echogenicity comparison).
10. Scanning Orientation & Patient Positioning (46:50)
Orientation Labels: Consistent with other anatomy.
Sagittal/Coronal: Superior/Inferior.
Lateral approach: Top of image is right/left or right/medial.
Patient Positioning (Lots of variation):
Supine, Left Lateral Decubitus (LLD), Left Posterior Oblique (LPO), Right Lateral Decubitus (RLD), Right Posterior Oblique (RPO), Upright.
Sonographers typically scan from the right side of the patient (sitting or standing, find what works ergonomically).
Sonographer Ergonomics (48:20):
Machine near patient's head.
Adjust bed height.
Maintain less than 30-40 cm reach with either arm.
Keep scanning arm close to body (less than 30 degrees abduction).
Monitor at eye level.
Lean into patient, move machine/patient, adjust chair/bed.
Use pillows/cushions/bolsters/wedges to rest arm.
Protect body to avoid long-term injuries.
Probe Placement/Scan Windows (49:11):
Varies by organ and even within the same organ (e.g., liver requires multiple windows).
Windows: Midline epigastric, right/left lateral, intercostal, pelvic.
Planes: Transverse, sagittal, oblique, coronal (all over the belly).
Example Scan Path (50:20):
Midline (pancreas, abdominal vasculature, left liver lobe).
Lateral intercostal (upper right liver, part of kidney).
Lower right liver, right kidney.
Tail of pancreas, spleen, left kidney (superior portion).
Lower portion of left kidney.
Lower abdominal vasculature, bladder.
At least 6 different windows on one body.
Probe Angulation: Angle and push into belly, angle up towards chest to see entire superior portion of organs (e.g., liver).
Imaging organs in bits and pieces is necessary for adequate imaging.
Patient Respiration (52:33):
Deep breath and hold (inspiration): Pushes diaphragm out from behind ribs, pushes liver/kidney down, moves bowel out of the way.
Diaphragm pulls lungs down, liver pushed to subcostal orientation, bowel moved inwards/downwards.
11. Instrumentation (60:04)
Probes:
Curved Linear Probe: Most common for abdominal exams.
Frequency: Typically 2-6 MHz (mid-range, good for deeper structures).
Higher megahertz for thin patients.
Phased Array Probe: Smaller footprint.
Frequency: Typically 1-5 MHz (lower for larger/denser patients).
Good for intercostal scanning (gets between ribs) even in smaller patients.
Controls/Settings:
Overall Gain & TGC Profile: Adjust brightness; TGC compensates for sound attenuation in far field.
Depth: Adjust to optimize organ visualization, avoid cutting off posterior structures or wasting space.
Focus: Position at or just posterior to region of interest for sharpest resolution.
Focal range (on Philips machines): Highlight and adjust the size of the focal zone for specific areas.
Frequency/Fusion (Philips specific):
Options: Penetration, General, Resolution optimized.
Penetration: Lower frequencies (e.g., 2-4 MHz).
Resolution: Higher frequencies (e.g., 4-6 MHz).
General: Mid-range (e.g., 3-5 MHz); default preset.
Control wheel on 2D button for adjustment.
12. Exam Preparation & Indications
12.1 General Preparation (66:45)
Fasting: Nothing by mouth for 4-12 hours (longer is better).
Quiets bowel, allows gallbladder to expand.
Bladder (for renal exam): Fasting, then drink water and hold bladder for prevoid volume measurement; post-void residual measured after emptying.
Attire: Comfortable, loose-fitting clothes, easy to remove, not easily damaged by gel.
12.2 Liver Exam Indications (68:07)
Generalized abdominal pain (upper portion).
Abnormal blood work (liver functions, general check-ups).
Screening for hepatic disease.
Jaundice (physical exam or blood work).
Monitoring chronic liver disease (hepatitis, cirrhosis).
Portal hypertension (impeded blood flow to liver).
Guidance for interventional studies (biopsies, therapeutic interventions for cancer).
Conjunction with other imaging modalities (MRI, CT, X-ray); common follow-up from CT for liver masses (e.g., hepatocellular carcinoma).
Follow-up on Liver Function Tests (LFTs).
12.3 Kidney & Bladder Scan Indications (69:59)
Pain (abdominal or flank).
Abnormal blood work.
Hematuria (blood in urine, visualized or on urinalysis).
Recurrent UTIs.
Kidney stones (big indication, cause pain, urine backup).
Crystals form in collecting system, painful if stuck in ureter.
Sonographic appearance: bright echo with shadow (e.g., stone causing shadow in renal pelvis).
Follow-up from renal injury.
Follow-up on cysts or tumors/masses.
Evaluation of congenital anomalies (improper formation or location).
Following up on other imaging exams (CT is common).
13. Professional Organizations & Protocols (71:50)
AIUM (American Institute of Ultrasound in Medicine): Sets minimum required images for each exam type, collaborates with doctors and sonographers.
Protocols: Vary slightly by practice/location (different order, extra images).
Examples:
Complete Abdominal Scan: Liver, gallbladder, pancreas, spleen, kidneys, aorta, IVC (includes required images for each).
Limited Exam (e.g., RUQ): Liver, gallbladder, pancreas, right kidney, aorta/IVC (as they relate to liver, not full scan).
Renal Exam: Right/left kidneys, bladder (sometimes aorta/IVC due to retroperitoneal location).
14. Lab Focus & Imaging Examples (73:41)
Lab Scan Focus:
Coronal and anterior windows.
Liver (longitudinal orientation, midline, cutting through mid-portion of left lobe).
Slide over to image anteriorly or intercostally for right liver and kidney.
Example Images to Collect:
Longitudinal right kidney & right liver: Diaphragm, hepatic veins, portal veins, Glisten's capsule, GERRADA's capsule, renal pelvis, renal pyramids.
Orientation: Superior/Inferior, Anterior/Right Lateral, Posterior/Medial.
Note inferor pole of kidney appears fuzzy due to bowel overlap.
Rib shadowing indicates intercostal scanning.
Transverse kidney: Turn probe 90 degrees counterclockwise (notch to patient's right).
Kidney appears C-shaped, more rounded/oval.
Pyramids, pelvic fat visible; vessels (renal artery/vein) visible with color Doppler.
Main portal vein may be visible; right lobe, turning into left lobe medially.
Midline Vasculature Options (choose one):
Aorta: Separation between liver and aorta; celiac/SMA branching with color Doppler.
IVC: Touches posterior liver wall; hepatic veins entering IVC, going into right atrium with color Doppler.
Live Scan Example (Liver Ultrasound) (78:25):
Patient Position: Supine, legs bent, arm above head to expose ribs.
Probe Placement: 9th or 10th rib space, mid-axillary line.
Probe Indicator: Towards patient's head.
Standard Ultrasound Setting: Indicator on screen on left side.
Identify from Superior to Inferior:
Lung: Most superior, shows mirror artifact (normal, due to sound scattering by air at diaphragm).
Diaphragm: Hyperechoic (bright) structure below lung, above liver.
Liver: Grayish appearance.
Right Kidney: Below liver.
Morrison's Pouch: Space between liver and right kidney where free fluid (ascites or blood) accumulates.
Scan towards liver tip to check for fluid.
Hepatomegaly Measurement: From top of diaphragm to inferior edge of liver.
Echogenicity: Bright for chronic scarring/cirrhosis; dark for hepatitis (fluid/inflammation).
15. Supplemental Materials (81:25)
List of videos, diagrams, instructional information on abdominal scanning.
Resource for review before lab.