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pulsed wave-spectral and color

aliasing-all waves not returned, raise the pulse rep freq

as depth increases PRF decreases



spectral- horizontal axis is time, vertical is the direction and velocity



keep gate tight in artery, open it out in vein

angle

velocity scale

doppler gain

filtration



Color

set focus to at or just below the box



0 is best angle, anything <60 will do





Liver

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Anatomy
Couinaud’s sections are divisions of the liver based on vascular anatomy. Falciform lig divides right and left lobes in classic.

But in Couinaud, the division between the right and middle/left is the middle hepatic vein.

Left hepatic divides the left into left medial and left lateral.

Right hepatic divides right into right anterior and right posterior.

Quadrate-Left medial segment.

Caudate-posterior to lig venosum (used to be umbilical vein). Spared by most liver disease b/c it has a separate blood flow.

Riedel’s Lobe-extension of right liver in a tongue-like shape

Glisson’s capsule covers the liver

Falciform used to be ligamentum teres normally drains into l portal vein

Ligamentum venosum forms the anterior border of the caudate lobe

Normal Ligamentum Teres (aka falciform) is brightly echogenic, triangular or rounded, it may cast shadows

15.5 cm is upper limit of liver length



Portal vein-splenic, smv, imv.



Middle hepatic Vein separates the left medial segment from the right anterior segment. This vessel courses in the main lobar fissure



Anterior border of the caudate is the fissure for the ligamentum venosum



This structure acts as a landmark for the paraumbilical: ligamentum teres. It extends from this ligament to the left portal vein



Long thin extension on the inferior aspect of the right lobe: Reidel’s lobe



Caudal border of the left portal vein: Ligamentum teres



What differentiates hepatic veins from portal veins: portal veins have the triad coursing with them



Anterior and to the left of the ligamentum venosum=Left lobe



Thin capsule around the liver=Glisson’s capsule



Hepatic veins course interlobar and intersegmental



Sagittal of the left lobe, ligamentum venosum and caudate lobe

anterior to the ligamentum venosum is the left lobe, posterior to it is the caudate



Picture of ligamentum teres

runs from portal vein



Picture of portal vein branch (right post), posterior segment, left portal vein, caudate lobe

Right post of portal vein is located in RIGHT POSTERIOR SEGMENT

Caudate is behind the left portal vein

The Left portal is anterior to the Right and is C-shaped when imaged longitudinally



To demonstrate the three hepatic veins going into IVC-Subcostal oblique with probe angled superiorly and to the patient’s right



To see dome, use subcostal with pt in deep inspiration



AFP elevation=hepatocellular carcinoma



Adenoma
Solid hypoechoic mass with hypervascularity in liver with a patient on OCPs=hepatic adenoma



Cavernous Hemangioma
homogenous hyperechoic lesion measuring 2.4 cm in the posterior aspect of the right lobe=cavernous hemangioma

most common benign tumor-cavernous hemangioma

Cavernous hemangiomas-very slow flow, may not be detected by doppler. they are small well defined, hyperechoic masses, consist of vascular network, more common in women than men, usually asymptomatic

Focal Nodular Hyperplasia
Young female with well defined solitary mass with central scar measuring 4 cm. On doppler, prominent blood vessels coursing within the scar.-Focal nodular hyperplasia. second most common benign liver mass. more common in women (especially of childbearing age) well demarcated single mass <5 cm usually with central scar

Fatty Liver
Diffuse increased echogenicity with focal hypoechoic area anterior to the portal vein in 49 obese male=fatty liver with focal sparing

Focal fatty liver is usually found in anterior to the portal vein at the porta hepatic

Reversible, caused by obesity, may be diffuse or focal, may show rapid change in appearance with time, increased attenuation of sound beam through the liver

increased echo compared to the kidney, hyperechoic patches are usually seen periportal, around the gb, and at the liver margins

Cirrhosis
Surface nodularity, altered echo texture, ascites, regenerative nodules, not shrunken caudate lobe. Caudate lobe is actually relatively enlarged as it is spared.

search for portal hypertension.

luminal narrowing of hepatic veins/color and spectral doppler reveal high velocities through strictures-cirrhosis because the thin walled veins are compressed.



If you can’t see the hepatic veins in a cirrhotic pt in B-Mode, switch to color Doppler to confirm patency-otherwise the patient may have budd chiarri. Always eval for budd chiarri in pts with new ascites, hepatomegaly and pain



Indicators of hepatomegaly-rounding of the inferior border, liver longitudinal > 15.5 cm, extension of right lobe below lower pole of kidney, increased AP measurement of the right lobe, not enlargement of the portal vein



Pt with liver cirrhosis and suspected portal hypertension, evaluate size-spleen and portal vein diameter

Regenerating nodules are a feature of-cirrhosis



alcoholic liver cirrhosis look for splenomegaly, dilated veins at splenic helium, also search for portosystemic collaterals to eval for portal hypertension. Look for them at the paraumbilical vein, cornary vein, gastrorenal, intestinal, and hemorrhoidal. Also portal vein>13 cm, ascites, hepatofugal flow in portal

Portal Hypertension
Hepatofugal flow in the portal vein-portal hypertension. hepatopetal flow-towards the head and towards the liver. fugal is away from the liver

Pt c TIPS-connects portal vein and the hepatic vein



normal liver with enlarged hepatic veins and ivc=right side heart failure



majority of blood to the liver-portal vein, majority of oxygenated from hepatic artery



recanulized paraumbilical vein can be seen in-portal hypertension



best sonographic window for the prior is-sagittal subcostal through the left lobe at the level of the ligamentum teres

enlargement of the coronary vein is diagnostic of portal hypertension-aka the left gastric, it empties flow from the esophageal veins into the splenic vein. if flow direction is reversed in this vein, varices result

Cutoff for portal vein enlargement=13 cm



Best view for coronary vein-sagittal view of the splenic vein near the midline



Cavernous transformation-look for it in the porta hepatic, occurs following portal vein thrombosis. It is characterized by multiple serpginous venous channels in the porta where the portal vein was located. Flow direction is hepatopetal (into the liver)



Mets
Liver metastasis-can be single or multiple, hypo or hyperechoic, can have mixed echo, or can look like cystic masses

Cysts
Hepatic cysts-thin wall, posterior enhancement, anechoic, decreased attenuation, increased through transmission



Single large mass, well defined, smooth walls, homogenous low-level echoes in anterior right lobe of 48 y/o female, no Doppler signals-Hemorrhagic cyst

Hepatitis
Fever, elevated LFTs, RUQ tender, liver is enlarged with decreased echogenicity, GB wall is thick, thick echogenic bands around the portal veins(periportal cuffing)

Acute hepatitis is starry sky appearance from liver parenchyma contrasted with bright bile ducts





Sonographic appearance of air bubbles-brightly echogenic foci with ring-down artifact



Infestation by a parasite in sheep/cattle raising countries-Hydatid disease



Invasion of the portal vein-hepatocellular carcinoma



Pts with AIDS get-kaposis in the liver



53 female with weight loss and vague abd pain, liver is heterogenous and has numerous calcified lesions. Most likely metastatic disease from-adenocarcinoma of the colon



Bull’s eye or target lesion in the anterior right lobe-liver met from lung ca

Transplant
Post liver transplant with extrahepatic fluid collection-can be biloma, hematoma, loculated ascites or abscess

Liver transplant involves anastamoses of IVC, portal vein, hepatic artery, bile duct

no ultrasound findings to eval transplant rejection



Scan for these post transplant-biliary sludge, portal vein stenosis, hepatic artery thrombosis, liver malignancy, but not cholecystitis as the donor gallbladder is taken out before transplant



Ultrasound during liver surgery-7 mhz linear probe-placed directly on the liver



Increased through-transmission, right lobe, adjacent to the capsule, large, rounded homogenous mass poorly defined wall in pt with fever and pain-amebic abscess



most common liver malignancy-metastatic disease

Biliary Tree

Main (Interlobar) fissure is the landmark for the GB. hyperechoic linear structure that runs between the right portal vein and the GB.

Portal vein and the neck of the GB.

Normal transverse diameter is 4 cm.

Hydropic GB-transverse diameter of 5.3 cm. seen with choledocholithiasis

GB wall thickness is normally <3mm.



WES sign-wall, echo, shadow.



Parallel channel sign-CBD gets big enough to be same size as portal vein



Fundus of gb folded over body-Phrygian cap



Common cause of smudgy artifacts-reverb, side lobes, slice thickness



GB sono preparation-fasted 8-12 hrs prior to exam



Abnormal thickening can be-inflammation, hepatic dysfunction, CHF, GB wall varices,



Diagnostic accuracy of GB sono-> 90%



Increase stone shadowing-increase frequency and focusing



Porcelain gallbladder-wall contains various amounts of calcifications,



Distal CBD-posterior and slightly lateral to the pancreatic head

Look at the distal CBD for choledocolithiasis

Measure duct in longitudinal near porta. Need to see IVC in the image



CBD pierces uncinate process tissue behind head of pancreas. just anterior to renal vein



Pt just ate-contracted GB with diffuse wall thickening



Cholecystitis-calculus obstruction of the GB neck or cystic duct



Dilated non-tender gb-look for mass in the head of the pancreas. Courvousier’s



Low level echoes in the GB looks like sludge, GB wall is not thickened.



Comet tail from artifact from anterior GB wall-Adenomyomatosis=echogenic foci within the GB wall. tapered and shorter than ringdown. Form of hyperplastic cholecystoses. Associated with small mucosal herniations into muscular layer of GB wall.

Rokitansky-Aschoff sinuses-Adenomyomatosis=small mucosal hernaitions into the muscular wall of the GB. May get filled with cholesterol



Polyps do not shadow



Tumefactive sludge-avascular mass with low level echoes. polypoid masslike shape. moves slowly with positional changes. if it is vascularized suspect carcinoma instead



GB wall is vascular, this can help differentiate between wall edema and pericholecystic fluid



44 male with diabetes, severe epigast pain rad to back, vomiting, chills, fever. Large GB with nondependent hyperechoic foci assoc. with ringdown artifacts-emphysematous cholecystitis



hypervascularity of acute cholecystitis-doppler of cystic artery



Acalculous cholecystitis-wall thickening, murphy’s, perichole fluid, GB wall edema without stones



Differentiate between bowel gas and posterior shadowing-roll pt into left lateral decub.



Edge shadowing=refraction artifact



Gallbladder carcinoma-irregular mass in the lumen with hypervascularity, multiple stones in the lumen-GB carcinoma



Best way to identify intrahepatic Biliary system is to image-intrahepatic portal veins



Pneumobilia-air in the bile ducts



Differentiate duct dilation from hepatic vein dilation-dilated ducts demonstrate irregular torturous walls, bile ducts will not have flow with doppler



Common bile duct-junction of the cystic and common hepatic



Thickening of bile duct walls-may be sclerosing cholangitis, pancreatitis, choledocolithiasis, cholangiocarcinoma



Junctional folds-maze like projections into GB



Weight loss and midepigastric pain with intra and extrahepatic Biliary dilation and hydropic gb-may be choledocolithiasis, pancreatic carcinoma, or chronic pancreatitis with stricture formation



cystic dilation of the CBD is choledochal cyst



they seem to think that serum billi helps differentiate between intra and extra cause of jaundice



Differentiate the duct from the hepatic artery-doppler from artery but not duct



Help to visualize distal CBD-roll pt to right posterior oblique or right lat recumbent



most common anatomic variant-GB folds



most accurate test for acute chole=cholescintigraphy



Porcelain gb are at risk for-GB carcinoma



Roll pt into LLR if you are unsure of a neck stone



Administered cholecystokinin to a patient-causes the GB to contract in a normal study.



Attempting to locate the common hepatic duct at the porta hepatic, portal triad anatomy at this location- common duct is anterior to hepatic artery and portal vein



Jaundice pain and nausea with a history of gb out-choledocolithiasis



In suspected cholangiocarcinoma, look for-dilation of the Biliary tree



Can get reverb artifact in anterior just behind wall



Turn them in llr to eval mobility of stones



bright band of echoes with posterior shadowing in the RUQ, how do you identify it as stone filled GB-connection of the shadows to interlobar fissure, wall-echo-sign, bowel gas would have ring-down artifact



A tumor that may be intrahepatic or extrahepatic bile duct is known as-cholangiocarcinoma



Old guy with ruq pain, gallstones and bright echoes in gb wall with ringdown-emphysematous cholecystitis



Pancreas

picture of the anatomy of the pancreas (p33)

body tail uncinate process



RetroP structure (as are kidneys adrenals and great vessels). Head sits on top of IVC. Uncinate wraps around SMV. GDA and CBD mark lateral border of the head. Neck anterior to SMV/splenic confluence. prominent vessel just posterior to the pancreatic neck-portal-splenic confluence

vessel anterior to uncinate process and posterior to the pancreas neck confluence of portal and splenic vein

Uncinate wraps around SMV

SMA is posterior to pancreatic neck





long axis view of head and body of pancreas-midline transverse scan with left side of the probe just slightly caudad



name of main pancreatic duct-duct of wirsung



accessory pancreatic duct-duct of santorini****



CBD relation to pancreas-CBD is posterior to the head of the pancreas



Pancreatic divisum-the two pancreatic ducts have not fused



anterior aspect of the head of the pancreas-gastroduodenal artery

posterior aspect of the head of the pancreas-CBD



coursing transversely at level of the upper panc. head-left renal vein



thin patient-curvilinear 5 mHz



repeated pancreatitis, use doppler-to increase chances of finding pseudoaneurysms



most difficult part to visualize-tail



frequency for endoscopic uts-10 MHz



most common malignant tumor-adenocarcinoma. risk factors-smoking, high fat diet, diabetes, chronic pancreatitis. stage with ct. most commonly found in the head of panc. appears as hypoechoic mass. look for lymphadenopathy and liver mets



hyperechoic mass in the head of the pancreas, dilation of panc and cb ducts, diffuse calcification in pancreas-chronic pancreatitis

Cancer=hypoechoic



looking for complications of pancreatitis-look for pseudoaneurysm, pseudocyst, phlegmon, abscess



pt with pancreatic transplant-placed in iliac fossa, rejection is indicated by-high-resistance doppler signals and heterogeneous parenchyma



non-encapsulated collection of necrotic and edematous peripancreatic tissues-phlegmon



in USA most common cause is stone, etoh is 2nd cause



Can get pseudocyst from-acute and chronic pancreatitis as well as panc ca. appearance is cyst without or with low level echoes with a well defined wall and internal septations. No epithelial cells (hence pseudo)



obese pt with small hypoechoic tumor in tail-insulinoma. they’re fat b/c of overeating during hypoglycemic attacks. insulinoma-use 10 MHz



duodenum encircles-the head



splenic vein is posterior and caudal to pancreas



celiac trunk is located at the superior border



posterior border of the pancreatic head-IVC



Courses anterior to the uncinate-SM vein



small tubular structure coursing cephalocaudad anterior to the pancreas-gastroduodenal artery



picture on p. 42 and questions 190-193

190

191

192

193

Transverse picture of the aorta and the sma with the left renal vein running between. Body of pancreas is anterior to the SMA.



Head has the largest dimensions



Normal pancreas is iso or hyperechoic in relation to the liver



Tail of the pancreas touches-left kidney, splenic flexure of the colon, and spleen

Kidney/Urinary Tract

left and right kidneys attached at their lower poles-horseshoe kidney. isthmus is anterior to the abd aorta



renal cortex-should be iso or perhaps hypoechoic in comparison to liver



angiomyolipoma may cause speed artifact



normal kidney-9-14 cm



1.5 cm thickening of the left lateral renal cortex-dromedary hump



Kidneys are-retroperitoneal, right kidney is slightly lower, tail of pancreas not in contact with the lateral dorsal aspect of left, the superomedial aspect of the right is touching adrenal, superior pole of both are slightly medial compared to the inferior pole



Central sinus is normally- highly echogenic compared to the cortex



Sonographic criteria of simple cyst-anechoic, acoustic enhancement, sharply defined, smooth wall, round or ovoid



hydronephrosis can be caused by-stone, uterine fibroid, uteropelvic junction obstruct, ovarian mass, but not acute pyelonephritis



Column of Bertin Pseudomass-if isoechogenicity with the rest of the cortex, continuity with the cortex. lack of mass effect or splaying of renal sinus fat, and normal vascularity by color doppler



multicystic, dysplastic kidney (MCDK)-will have multiple varably sized cysts, nonmedial location of the largest cyst, no sinus, bright echogenic tissue between cysts. They will not have a dilated ureter MCDK is usually dx in utero or in early childhood



crossed renal ectopia-both kidneys on same side of abd



wilm’s tumor-children 2-5



sinus has fat, calyces, vessels and infundibli of the collecting system

Ureteral Jets
periodic ureteral jets-normal. look for them to verify no ureter obstruction

look with color doppler to find the urinary jets



prep is moderate hydration, no fasting



31 y/o c htn and multiple cysts-polycystic kidney disease



solid mass in 47 y/o-look for extension into renal vein, search for liver mets, search for retroperitoneal adenopathy



Angiomyolipoma
solid hyperechoic mass in patient with tuberous sclerosis-angiomyolipoma-

renal mass that is highly echogenic due to its high-fat content- angiomyolipoma



uts appearance of the ureteropelvic junction obstruction-pelvialectiasis to level of junction?



pyelo-kidneys usually look normal, though may be slightly enlarge or loss of corticomedullary differences



doppler of normal main renal artery-low resistance with forward flow throughout the cardiac cycle



bladder outlet obstruction-thickening of bladder wall is muscular hypertrophy



chronic renal disease-small hyperechoic kidneys



nephocalcinosis-highly echogenic renal pyramids, possibly with posterior shadowing



false positives for hydronephrosis-overdistension of bladder,parapelvic cysts, prominent hilar vessels, large extrarenal pelvis



small round cystic structure projecting into the urinary bladder-ureterocele, from UTIs



transitional cell carcinoma, may have hematuria and mass in bladder



2 week old renal transplant, fluid collection with septations and internal debris adjacent to kidney-lymphocele



interlobar arteries course alongside the renal pyramids



left renal vein-between the sma and the aorta (NUTCRACKER)



right renal artery-posterior to the ivc



renal cortex-normally >10 mm



lymphoma of the kidney-multiple bilateral hypoechoic masses in enlarged kidneys



on top of renal pyramids and give rise to tiny interlobar arteries-arcuate



indication for doppler renal study to rule out renal artery stenosis-htn. compute ratio comparing velocity of the renal artery to abdominal aorta. 3.5 or greater renal aortic ratio is abnormal.



cysts in 50% of people over 50



PCKD-autosomal dominant will involve both kidneys, progressive renal failure is common, cysts may be complicated by bleeding and infection, htn is common, liver cysts in 30% of pts



Resistive index is normally .7 or less, a RI of 1 indicates a diastolic flow of 0. can occur with renal vein thrombosis, renal obstruction, chronic renal disease, may also seen with transplant rejection



look for the pelvic kidney if you only see one



evaluate all cysts post biopsy with color doppler to evaluate for pseudoaneurysm



SMA is the most useful landmark for the renal arteries. It is immediately superior to the origin of both sides



Hemorrhage into the cyst of PCKD kidney-low level echoes within the cyst



transplant-is in the right lower quadrant



chronic renal artery occlusion can shrink the kidney



doppler parameter for rejection-RI



irregular thickening of the bladder wall in 53 m with hydro and dilated ureter-transitional cell



Veins are Anterior to the Arteries



ureteral outlets are at base of trigone along posterior aspect



view with best doppler of kidney-patient in posterior oblique, coronal view through posterior axillary line



adjust to improve sensitivity to flow-decrease PRF



Atypical cyst has-internal septations, wall calcifications, internal echoes or irregular walls



dialysis for 4 years-small hyperechoic kidneys with mult cysts of varying sizes



most common solid renal mass of adults-renal cell carcinoma



emphysematous pyelo-multiple echogenic foci within parenchyma or sinus with dirty posterior acoustic shadows



normal renal art waveform=low resistance



medullary nephrocalcinosis-calcified pyramids



subcapsular hematoma-perirenal collection that flattens the underlying contour



most common cause of ARF-ATN



hypertrophy is normal a few weeks post-transplant



renal artery is usually anastamosed to external iliac artery



Scrotum

mediastinum testis-prominent echogenic linear echo in midline. rete testis is located within it



orchitis shows hyperemic flow-may have large hydrocele with it



most common germ cell tumor is seminoma



bell clapper deformity-associated with torsion



abd aorta to testicular to capsular artery to centripetal arteries



normal testes artery has low resistance waveform



spermatic cord contains-vas deferens, testicular artery, cremasteric artery, deferential artery



left testicular vein drains into-left renal



torsion doppler-low PRF, low filter, high gain, high packet size

power doppler may be better b/c there is no aliasing



mass-malignant if irregular shaped testes and intratesticular location, not if large hydrocele



epididymitis-increased flow by doppler



infertility-look for varicocele. more common on the left than the right veins larger than 2 mm in supine or 2.5 mm in standing are abnormal. valsalva may emphasize



hydroceles form in-space between two layers of the tunica vaginalis



transtesticular artery-common anatomic variant, course opposite direction as the centripetal, enters at mediastinum testis, large vein frequently accompanies it



microlithiasis not associated with orchitis, hypoechoic, hyperemic testis that is enlarged is



Prostate

posterior to prostate is the rectum



cancers most commonly in peripheral zone



BPH is transition zone



seminal vesicles are posterior and superior to prostate



left lateral decub positioning



get uts if abnormal digital exam, elevated PSA, guidance for biopsy, CA response to treatment



color doppler may allow better imaging of pathological vessels



ca can be any echogenicity



For prep-enema; antibiotics before and after if biopsy



zonal anatomy is the new standard



prostaticovesical arteries are branches from the internal iliac



rectum is shown at the bottom of the screen; 7-8 MHz probe



most lateral tissues are the peripheral zone



Seminal vesicles appear-hypoechoic, symmetrical, irregularly shaped



BPH enlarged gland which may be focal or diffuse



ejaculatory duct cysts can cause infertility



anechoic mass in pt with protatitis-abscess



Spleen

12-13 cm long, 4-6 in trans

Width x AP >48 is abnormal



Structures abutting spleen-left hemidiaphragm, stomach, pancreas, splenic flexure of colon



best long axis-intercostal coronal with pt supine



mild to moderate splenomegaly-portal htn, infection, AIDS. lymphoma causes severe splenoemegaly



Small rounded mass at hilum that is homogenous and isoechoic to spleen-accessory spleen



moderate splenomegaly most common finding in a patient with aids



hypoechoic wedge shaped lesion-splenic infarction. Increased confidence in finding by evaluating the lesion with doppler.



moderate splenomegaly and dilated, tortuous vessels-portal hypertension



structure at splenic hilum-splenic vein



pancreatic tail is inferomedial to spleen



Splenic parenchyma-homogenous with mid to low level echogenicity



Spleen is intraperitoneal



histoplasmosis-multiple focal bright echogenic granulomatous lesions in spleen. Can see the same in sarcoid and tb



Splenic vein drains into-portal vein



Calcified ring at splenic hilum in pt with portal htn-eval c doppler for aneurysm



Retroperitoneum

Striated hypoechoic structure immediately posterior to the right kidney and left kidney-quadratus lumborum muscles

striated structure posteromedial to kidney-psoas

psoas and quadratus are in retrofascial space



kidneys are in the anterior perirenal space



hypoechoic structures measuring greater than 2 cm adjacent to celiac trunk in periaortic area.-lymph nodes



fluid in pararenal space in a patient with elevated amylase most likely represents pseudocyst



retroperitoneal fibrosis-abdominal aorta



Measure any lymph nodes found



Lung can met to the adrenals



Right adrenal gland-posterior to the IVC



Search for adenopathy-splenic hilum, porta hepatic, renal hilum, para-aortic



Solid mass in upper pole of kidney-scan the patient in deep inspiration and expiration to separate these two structures



Adrenal mass masqueraders-thickened diaphragmatic crus, accessory spleen, gastric diverticulum, retroperitoneal lymphadenopathy



Left adrenal gland-lateral to abd aorta and diaphragm crus



Right diaphragmatic crus-posterior to IVC and right renal artery



Lymph nodes >1cm are abnormal



lymphocele-anechoic mass with mult sepatations lateral to midline, 2 cm below abdominal wall



posterior pararenal and retrofascial space contain no solid organs



pseudocyst usually in anterior pararenal



Aorta in anterior pararenal space



Abdominal Vasculature

Splenic vein and superior mesenteric vein form the portal vein



celiac trunk branches into splenic, left gastric, common hepatic (Seagull Sign)

hepatic branches to GDA and Proper. Seen transverse at celiac axis



In transverse, SMA has a fat collar



Playboy Bunny-2 of 3 hepatic veins over IVC



Left renal passes between SMA and Aorta



Left renal vein is anterior to aorta and posterior to sma



Measure aneurysm sagittal plane along axis of artery



if you can’t obtain a color doppler signal from portal vein decrease the PRF



abd aorta usually tapers towards feet



median arcuate ligament syndrome-pinching of the celiac trunk

median arcuate ligament syndrome-obtain doppler in inspiration or expiration and while supine and standing



htn-renal artery stenosis



waveform in mesenteric arteries-high resistance in fasting patient



doppler of abd vessels, you detect a stenosis in the right renal art-spectral broadening distal to stenosis, increased peak systolic velocity at stenosis, increased pulsatility proximal to stenosis, dampening of the waveform distal to the stenosis



chronic pancreatitis and bruit-pseudoaneurysm of the hepatic or splenic artery



splenic vein empties into portal not IVC



common hepatic artery splits into proper hepatic and gastroduodenal



replaced hepatic artery, right hepatic originates from SMA



vessel between SMA and aorta behind the pancreas-left renal vein NUTCRACKER



gastroduodenal art-caudal course anterior to pancreatic head



small intestine, right colon, and most of the transverse-SMA



chronic mesenteric ischemia-postprandial abd pain and weight loss

look at celiac, sma, ima



cirrhosis of liver from etoh abuse is most common cause of portal htn



hepatic veins drain into IVC

portal vein-mildly undulating flow



aaa are infrarenal commonly



if bowel gas is obscuring the abd, roll into recumbent and image from coronal



image budd chiarri-hepatic veins, ivc, portal vein



hepatic vein flow-triphasic



portal vein provides 70% of blood to liver



greatest angle of incidence when eval tips stent-60 degrees



waveform in the neck of a pseudoaneurysm-high velocity, bidirectional



splenic artery most commonly involved with pseudoaneurysm



right renal artery courses posterior to IVC



splenic vein is posterior and inferior to pancreas



SMV and splenic vein join to form portal vein



hepatic veins are intersegmental



multiple renal arteries are rare



IVC is posterior to caudate lobe



Copy Question 421 pseudoaneurysm doppler

shows reversal of flow



Question 426 portal vein

hepatic veins are triphasic

portal veins are continuous



IVC lies immediately posterior to panc head



dilation > 3cm =AAA



Most aneurysms are infrarenal. Fusiform is a normal summit. aneurysm, saccular has only one side of the vessel distended. Retroperitoneal fibrosis is assoc with mycotic aneurysms; it causes hypoechoic masses to envelop the aorta.

fusiform has gradual transition from normal to abnormal Ectatic is dilated (>3.5) throughout its length



Arteries
High Resistance-high systolic uptake, low diastolic flow

FACE, FEET, SMA beFORE MEAL

Low-low systolic uptake, high diastolic flow

Spleen, Liver, Kidneys, SMA after fatty meal and Brain



Veins


GI Tract

Gut-five layers



Scan with compression to better delineate mass



Doppler differentiates between ischemic and inflammatory masses



Most common malignant tumor-adenocarcinoma



target and pseudokidney are abnormal gut scans



crohns-gut wall thickening, strictures, creeping fat, increased vascularity



Gradual and uniform pressure over area



Appendix diameter >6mm or noncompressible

use 5 MHz linear with short focus



normal gut thickness 3-5 mm



Creeping fat-hyperechoic mass effect, looks like thyroid



Mucosa is innermost lining



Neck

longus coli is behind each lobe of the thyroid



hashimotos shows diffuse enlargement



Graves disease has increased vascularity



four parathyroid glands

adenoma causes hypercalcemia. homogenous, hypoechoic, solid oval shaped usually one of the parathyroids are involved in hyperpara



all four in hyperplasia



ultrasound can detect normal ln



have pt swallow to locate esophagus



papillary carcinoma is most common thyroid



thyrocervical from subclavian



Superficial Structures

10 MHz for breast



Instrumentation

comet tail=metallic



gas=ringdown



refraction=at edges

reverb = anterior surface of gall bladder



Image Gallery

diaphragmatic crura on either side of aorta





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