Pocket protocols for ultrasound scanning 2rd

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Second Edition

Adapted from: Ultrasound Scanning: Principles and Protocols, Third edition

Betty Bates Tempkin, BA, RT(R), RDMSUltrasound Consultant

Formerly Clinical Director of the Diagnostic Medical Sonography ProgramHillsborough Community College, Tampa, Florida


11830 Westline Industrial DriveSt. Louis, Missouri 63146

POCKET PROTOCOLS FOR ULTRASOUND SCANNING ISBN-13: 978-1-4160-3101-7ISBN-10: 1-4160-3101-4

Copyright © 2007, 1999 by Saunders, an imprint of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic ormechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writingfrom the publisher.Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1)215 239 3804, fax: (+1) 215 239 3805, e-mail: [email protected]. You may also complete your request on-line viathe Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’.


Previous edition copyrighted in 1999.

ISBN-13: 978-1-4160-3101-7ISBN-10: 1-4160-3101-4

Acquisitions Editor: Jeanne WilkeDevelopmental Editor: Rebecca SwisherPublishing Services Manager: Pat JoinerProject Manager: Jennifer ClarkDesigner: Amy Buxton

Printed in the United States of America.

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Notice

Neither the Publisher nor the Author assumes any responsibility for any loss or injuryand/or damage to persons or property arising out of or related to any use of the materialcontained in this book. It is the responsibility of the treating practitioner, relying onindependent expertise and knowledge of the patient, to determine the best treatment andmethod of application for the patient.

The Publisher


Contributors

v

Wayne C. Leonhardt, BA, RT(R), RVT, RDMSFacultyFoothill College School of UltrasoundLos Altos, California;Staff Sonographer, Technical Director, and

Continuing Education Director Summit Medical CenterOakland, California

Scrotum Scanning Protocol; Thyroid andParathyroid Glands Scanning Protocols

Maureen E. McDonald, BS, RDMS, RDCSStaff Echocardiographer Adult Echocardiography Instructor and LecturerThomas Jefferson University HospitalPhiladelphia, Pennsylvania

Adult Echocardiography Scanning Protocol;Pediatric Echocardiography Scanning Protocol


vi

Marsha M. Neumyer, BS, RVTAssistant Professor of General and Vascular

Surgery and Director of the Vascular StudiesSection

The Milton S. Hershey Medical CenterPennsylvania State University College of

MedicineHershey, Pennsylvania

Abdominal Doppler and Color Flow;Cerebrovascular Duplex Scanning Protocol;Peripheral Arterial and Venous Duplex ScanningProtocols

Betty Bates Tempkin, BA, RT(R), RDMSUltrasound ConsultantFormerly Clinical Director of the Diagnostic

Medical Sonography ProgramHillsborough Community CollegeTampa, Florida

Scanning Planes and Scanning Methods;Pathology; Scanning Protocol; Abdominal AortaScanning Protocol; Inferior Vena Cava ScanningProtocol; Liver Scanning Protocol; Gallbladderand Biliary Tract Scanning Protocol; PancreasScanning Protocol; Renal Scanning Protocol;Spleen Scanning Protocol; Scanning Protocols forFull and Limited Studies of the Abdomen; FemalePelvis Scanning Protocol; Obstetrical ScanningProtocol; Male Pelvis Scanning Protocol; ScrotumScanning Protocol; Thyroid and ParathyroidGlands Scanning Protocols; Breast ScanningProtocol; Female Pelvis Scanning Protocol


vii

Contents

PA R T IIntroduction: Purpose and Use . . . . . . . . . . . 1PA R T IIImage Protocol For Abnormal SonographicFindings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

PA R T IIIThe Abdomen. . . . . . . . . . . . . . . . . . . . . . . . . 7

SECTION ONE

IMAGE PROTOCOLS FOR FULL SONOGRAPHICSTUDIES OF THE ABDOMEN 9

I. Liver Study with Full Abdomen 11II. Aorta Study with Full Abdomen 42III. Inferior Vena Cava Study with Full Abdomen

83IV. Gallbladder and Biliary Tract Study with Full

Abdomen 119V. Pancreas Study with Full Abdomen 157VI. Renal Study with Full Abdomen 192VII. Spleen Study with Full Abdomen 242


viii

SECTION TWO

IMAGE PROTOCOLS FOR LIMITEDSONOGRAPHIC STUDIES OF THE ABDOMEN276

I. Aorta Study 278II. Inferior Vena Cava Study 291III. Right Upper Quadrant Study 299IV. Gallbladder and Biliary Tract Study 330V. Pancreas Study 358VI. Renal Study 383VII. Spleen Study 407

PA R T IVThe Pelvis. . . . . . . . . . . . . . . . . . . . . . . . . . 415

SECTION ONE

IMAGE PROTOCOL FOR THETRANSABDOMINAL SONOGRAPHIC STUDY OFTHE FEMALE PELVIS 417

I. Transabdominal Female Pelvis Study 418

SECTION TWO

IMAGE PROTOCOL FOR THE TRANSVAGINALSONOGRAPHIC STUDY OF THE FEMALE PELVIS440

I. Transvaginal Female Pelvis Study 441

SECTION THREE

IMAGE PROTOCOLS FOR SONOGRAPHICSTUDIES OF THE MALE PELVIS 458

I. Transrectal Prostate Gland Study 459II. Scrotum Study 469III. Penis Study 516

PA R T VObstetrics . . . . . . . . . . . . . . . . . . . . . . . . . 521

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE EARLY FIRST TRIMESTER 523

I. Early First Trimester Study 524


ix

SECTION TWO

IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE LATE FIRST TRIMESTER 535

I. Late First Trimester Study 536

SECTION THREE

IMAGE PROTOCOL FOR SONOGRAPHICSTUDIES OF THE SECOND AND THIRDTRIMESTERS 545

I. Second and Third Trimesters Study 546

SECTION FOUR

IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF MULTIPLE GESTATIONS 591

I. Multiple Gestations Study 592II. The Biophysical Profile 595

PA R T VISmall Parts . . . . . . . . . . . . . . . . . . . . . . . . . 604

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE THYROID GLAND 606

SECTION TWO

IMAGE PROTOCOLS FOR THE SONOGRAPHICSTUDY OF THE BREAST 618

I. Breast Lesion Characterization 620II. Whole Breast Study 623

SECTION THREE

IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE NEONATAL BRAIN 625

PA R T VIIVascular System . . . . . . . . . . . . . . . . . . . . . 638

SECTION ONE

IMAGE PROTOCOLS FOR ABDOMINALDOPPLER AND COLOR FLOW STUDIES 639

I. Mesenteric Arterial Study 640II. Renal Arterial Study 644III. Image Examples of Various Studies 649

SECTION TWO

IMAGE PROTOCOL FOR CEREBROVASCULARDUPLEX SCANNING 655


x

SECTION THREE

IMAGE PROTOCOLS FOR PERIPHERALARTERIAL AND VENOUS DUPLEX SCANNING665

I. Lower Extremity Venous Duplex Study 665II. Lower Extremity Peripheral Arterial Duplex

Study 675

PA R T VIIIEchocardiography . . . . . . . . . . . . . . . . . . . 687

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE ADULT HEART 688

I. Adult Heart Study 688

SECTION TWO

IMAGE PROTOCOL FOR THE SONOGRAPHICSTUDY OF THE PEDIATRIC HEART 721

I. Pediatric Heart Study 721

PA R T IXAbbreviation Glossary . . . . . . . . . . . . . . . . 746


Introduction: Purpose andUse

Pocket Protocols is a response to the need for a practical imaging reference to use duringultrasound examinations. This flip-card presentation sits upright on the machine, making it easy to see and access.

The majority of the image protocols follow the American Institute of Ultrasound inMedicine’s (AIUM) imaging guidelines. Any other image protocols are patterned after theAIUM’s suggestions and the authors’ collective experiences.

Pocket Protocols is a reference devoted to documenting technically accurate andthorough ultrasound image studies for diagnostic interpretation by the physician. Thesecomprehensive imaging protocols include image and labeling examples for abdominal,pelvic, obstetrical, small parts, vascular, and echocardiography studies.

1

I

Images are presented in a logical manner and specify the scanning plane and area ofinterest. Every image is accompanied by a gray-scale, color-coded schematic to helpidentify anatomy.

These reference materials are just that. They do not include or endorse the exclusion of the necessary prerequisites for accomplished scanning skills.

I hope Pocket Protocols serve as a practical reference and imaging standard that helpssonographers obtain comprehensive, consistent, and technically accurate image represen-tations of ultrasound studies.

Betty Bates Tempkin

2

Image Protocol forAbnormal SonographicFindings

This section describes a universal imaging protocol for documenting pathology, regardless of the type. All pathology visualized by ultrasound in some way disrupts the normalsonographic pattern of the organ or structure involved and may alter its shape, size,contour, position, or textural appearance. Although familiarity with specific diseases andabnormalities is not necessary to document them accurately for physician interpretation,an understanding of pathological processes and the ways in which they affect interde-pendent body systems can be beneficial.

3

II

CRITERIA FOR DOCUMENTING ABNORMAL SONOGRAPHIC FINDINGS

a) Survey of the abnormality in at least two scanning planes following the survey of theprimary area(s) of interest. (This is not to say that the abnormality is not evaluatedas the area of interest is evaluated, but it ensures that a total evaluation is made of astructure, not just its abnormal part.)

b) Volume measurement of the abnormality.

c) High- and low-gain technical setting images of the abnormality in at least twoscanning planes.

4

REQUIRED IMAGES

1. Longitudinal image of the abnormality with measurement from the most superior tomost inferior margin.

L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”

2. Same image as Number 1, without measurement calipers.


3. Axial image of the abnormality with measurement from the most anterior to mostposterior margin and from the most lateral to lateral or lateral to medial margin.


5

SCANNING TIP: Required images of abnormal findings follow the study’s requiredimages of the area(s) of interest.

SCANNING TIP: In cases where the origin of an abnormality cannot be determined,adjacent structures must be noted for a site location. Look for bright, echogenicinterfaces where fat separates adjacent structures.

4. Same image as Number 3., without measurement calipers.


5. Longitudinal image of the abnormality with high-gain technique.

L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, HIGHGAIN

6. Axial image of the abnormality with high-gain technique.

L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, HIGHGAIN

7. Longitudinal image of the abnormality with low-gain technique.

L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, LOWGAIN

8. Axial image of the abnormality with low-gain technique.

L A B E L E D : “ORGAN or STRUCTURE” or “SITE LOCATION” and “SCANNING PLANE”, LOWGAIN

6

The Abdomen

SECTION ONE

IMAGE PROTOCOLS FOR FULL SONOGRAPHIC STUDIES OF THEABDOMEN

This section includes extensive images of the area(s) of interest accompanied by limitedviews of other major abdominal structures.

I. Liver Study with Full Abdomen

II. Aorta Study with Full Abdomen

7

III

III. Inferior Vena Cava Study with Full Abdomen

IV. Gallbladder and Biliary Tract Study with Full Abdomen

V. Pancreas Study with Full Abdomen

VI. Renal Study with Full Abdomen

VII. Spleen Study with Full Abdomen

SECTION TWO

IMAGE PROTOCOLS FOR L IMITED SONOGRAPHIC STUDIES OF THEABDOMEN

This section includes extensive images of the area(s) of interest.

I. Aorta Study

II. Inferior Vena Cava Study

8

III. Right Upper Quadrant Study

IV. Gallbladder and Biliary Tract Study

V. Pancreas Study

VI. Renal Study

VII. Spleen Study

SECTION ONE


This section includes extensive images of the area(s) of interest accompanied by limitedviews of other major abdominal structures.


9







• Criteria:— Begin studies with a survey of abdominal structures in at least two scanning

planes.— Do not share the results of the study with the patient. Legally, only physicians can

give diagnoses.

10

SECTION ONE



Liver

LONGITUDINAL IMAGES

11

1. Longitudinal image of the left lobe of the liver to include the inferior margin and theaorta.

12

Posterior

Anterior

Splenic artery

InferiorSuperiorBowel

Pancreas bodyLeft lobe

Aorta

Spine

Splenicvein

Diaphragm

L A B E L E D : LIVER SAG LT LOBE

ja3g

Sticky-Note

2. Longitudinal image of the left lobe of the liver to include the diaphragm andcaudate lobe.

13

Caudate lobe

Hepaticvein

Posterior

Anterior

InferiorSuperior Left lobe

Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum


3. Longitudinal image of the right lobe of the liver to include the inferior vena cavawhere it passes through the liver.

14

Caudate lobe

Hepaticvein

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm

L A B E L E D : LIVER SAG RT LOBE

4. Longitudinal image of the right lobe of the liver to include the main lobar fissure,gallbladder, and portal vein.

15

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission


5. Longitudinal image of the right lobe of the liver to include part of the right kidneyfor parenchyma comparison.

16

Posterior

Anterior

InferiorSuperior

Right lobe

DiaphragmRightkidney


6. Longitudinal image of the right lobe of the liver to include the dome and adjacentpleural space.

17

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES

7. Axial image of the left lobe of the liver to include its lateral margin.

18

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC

L A B E L E D : LIVER TRV LT LOBE

8. Axial image of the left lobe of the liver to include the ligamentum teres.

19

SCANNING TIP: Depending on liver size and shape, it may be possible to documentan axial image of the left lobe that includes both the lateral margin and ligamentumteres. If so, label the image as follows: LIVER TRV LT LOBE

Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel

Portal splenicconfluence

Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery


9. Axial image of the right lobe of the liver to include the hepatic veins.

20

Posterior

Anterior

LeftRight

IVC

Left hepaticvein

Right lobeMiddlehepatic vein

Righthepatic vein

Diaphragm

L A B E L E D : LIVER TRV RT LOBE

10. Axial image of the right lobe of the liver to include the right and left branches of theportal vein.

21

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine


11. Axial image of the right lobe of the liver to include the right lateral inferior lobe.

22

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel


12. Axial image of the right lobe of the liver to include the dome and adjacent pleuralspace.

23

SCANNING TIP: Routine measurements of the liver are not required.

Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm


Aorta

LONGITUDINAL IMAGE

13. Longitudinal image of the proximal and middle aorta.

24

Posterior

Anterior

Liver

Splenicartery

Superiormesenteric

artery

Pancreas InferiorSuperior

Stomach

Splenicvein

Proximal and Middle aorta

SCANNING TIP: The images of the aorta may be included with the liver images ifthe aorta is well visualized.

L A B E L E D : AORTA SAG MID

AXIAL IMAGE

14. Axial image of the middle aorta at the level of the renal arteries.

25

Posterior

Anterior

LeftRight

Spine

IVC Leftrenalvein

Liver

Superiormesentericartery

Leftrenal

artery

Pancreas

Middle aorta

Stomach

Splenic vein

L A B E L E D : AORTA TRV MID

Inferior Vena Cava (IVC)

LONGITUDINAL IMAGE

15. Longitudinal image of the distal and middle inferior vena cava.

26

SCANNING TIP: The images of the inferior vena cava (IVC) may be included withthe liver images if the IVC is well visualized.

Posterior

Anterior Hepaticartery

InferiorSuperior

Distal and Middle IVC

Vertebrae

Smallbowel

shadow

Portalvein

Liver

L A B E L E D : IVC SAG DISTAL

AXIAL IMAGE

16. Axial image of the distal inferior vena cava to include the hepatic veins.

27

Posterior

Anterior

Distal IVC

Left hepaticvein

Middlehepaticvein

Right hepatic vein

LeftRight

Liver

L A B E L E D : IVC TRV DISTAL

Gallbladder and Biliary Tract

LONGITUDINAL GALLBLADDER IMAGE

17. Long axis image of the gallbladder.

28

Posterior

AnteriorGallbladder

InferiorSuperior

Small bowel

Throughtransmission

Portal vein

Diaphragm

IVC

Liver

L A B E L E D : GB SAG LONG AXIS

AXIAL GALLBLADDER IMAGE

18. Axial image of the gallbladder fundus.

29

Posterior

AnteriorGallbladderfundus

LeftRight

Sidewallshadow

IVC

Liver

L A B E L E D : GB TRV FUNDUS

LONGITUDINAL BILIARY TRACT IMAGES

19. Longitudinal image of the common hepatic duct.

30

Posterior

Anterior Gallbladder

InferiorSuperior

Hepatic artery

IVC

Liver

Commonhepatic duct

Portal vein

L A B E L E D : SAG CHD

SCANNING TIP: Biliary tract images may be magnified to aid interpretation.

SCANNING TIP: The common hepatic duct (CHD) image may be omitted if theCHD was visualized on the gallbladder long axis image.

20. Longitudinal image of the common bile duct with anterior to posterior measurementat the widest margins of the lumen.

31

Posterior

Anterior Duodenum

InferiorSuperior

Hepatic artery

Liver

Commonbile duct

Portal vein

L A B E L E D : SAG CBD

21. Same image as Number 20 without measurement calipers.

32


Pancreas

LONGITUDINAL IMAGES

22. Long axis image of the pancreas to include as much head, uncinate, neck, body, tail,and pancreatic duct as possible.

33

Pancreaticduct

Liver Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

TailSplenicvein

Aorta

Right renalartery

IVC

Head

Spine

Duodenum

Commonbile duct

Gastro-duodenalartery

Confluenceof superiormesenteric veinand splenic vein

Neck

L A B E L E D : PANC TRV LONG AXIS

23. Longitudinal image of the pancreas head to include the uncinate process andcommon bile duct (if bile-filled).

34


Liver

Splenic vein

Left renalartery

Anterior

LeftRight

Posterior

Neck

Rightkidney

Leftkidney

Aorta

IVC

Head

Spine

Uncinate process

Left renalvein

Liver

Superiormesenteric vein

Commonbile duct

Gallbladder

Duodenum

L A B E L E D : PANC TRV HEAD

AXIAL IMAGE

24. Axial image of the pancreas head to include the common bile duct (if bile-filled).

35

SCANNING TIP: In some cases, a portion of or all of the pancreas cannot bevisualized because of overlying bowel gas and the patient cannot be given fluids todisplace the gas. When this occurs, and every effort has been made to image thepancreas, take the required images in the designated areas and add “AREA” to thelabeling.

Anterior

Posterior

Liver

Superior Inferior

Head

Commonbile ductIVC

Bowel

Liver

Portal vein

Bowel

L A B E L E D : PANC SAG HEAD

Right Kidney

LONGITUDINAL IMAGE

25. Long axis image of the right kidney.

36

SCANNING TIP: Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.

InferiorSuperior

Anterior

Posterior

Cortex

Sinus

Inferiorpole

Superior pole

Midportion

Liver

Diaphragm

L A B E L E D : RT KID SAG LONG AXIS

AXIAL IMAGE

26. Axial image of the right kidney midportion to include the hilum.

37

LeftRight

Anterior

Posterior

Cortex

Sinus

IVC

Rightrenal vein

Midportion

Liver

L A B E L E D : RT KID TRV MID

Left Kidney

LONGITUDINAL IMAGE

27. Long axis image of the left kidney.

38


InferiorSuperior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Superiorpole Midportion

Spleen Inferiorpole

L A B E L E D : LT KID COR LONG AXIS

AXIAL IMAGE

28. Axial image of the left kidney midportion to include the hilum.

39

PosteriorAnterior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Midportion

Renalvasculature

L A B E L E D : LT KID LT TRV MID

Spleen

LONGITUDINAL IMAGE

29. Long axis or longitudinal image of the spleen to include the adjacent pleural spacesuperiorly and portion of the left kidney inferiorly.

40

InferiorSuperior

Lateral

Medial

Left kidney

Long axisof spleen

Diaphragm

L A B E L E D : SPLEEN COR LONG AXIS or SPLEEN COR

AXIAL IMAGE

30. Axial image of the spleen to include the anterior and posterior margins.

41

PosteriorAnterior

Lateral

Medial

DiaphragmSplenichilum

L A B E L E D : SPLEEN LT TRV


Liver

LONGITUDINAL IMAGES


42

Posterior

Anterior

Splenic artery

InferiorSuperior Bowel


Aorta

Spine

Splenicvein

Diaphragm



43

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



44

Caudate lobe

Hepaticvein

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm



45

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



46

Posterior

Anterior

InferiorSuperior

Right lobe




47

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


48

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



49


Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery



50

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



51

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



52

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



53

Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm


Aorta

LONGITUDINAL IMAGES

13. Longitudinal image of the proximal aorta (inferior to the diaphragm, superior to theceliac trunk).

54

Superior Inferior

Anterior

Posterior

Liver

Celiac artery

SuperiormesentericarteryProximal

aorta

L A B E L E D : AORTA SAG PROX

14. Longitudinal image of the middle aorta (inferior to the celiac trunk along the lengthof the superior mesenteric artery).

55

Anterior Pancreas body

Inferior

Posterior

Superior

Stomach


Middle aortaSplenic artery

Proximalaorta

Liver

Splenic vein


15. Longitudinal image of the distal aorta (inferior to the superior mesenteric artery,superior to the bifurcation).

56

Anterior

Inferior

Posterior

Superior

Stomach

Bowel

Distal aorta

Bowel

L A B E L E D : AORTA SAG DISTAL

16. Longitudinal image of the aorta bifurcation (common iliac arteries).

57

Medial

InferiorSuperiorDistal aorta

Left commoniliac artery

Aortabifurcation

Right commoniliac artery

Lateral

L A B E L E D : AORTA SAG BIF RT or LT OBL or AORTA LT COR BIF

AXIAL IMAGES

17. Axial image of the proximal aorta (inferior to the diaphragm, superior to the celiactrunk) with anterior to posterior measurement (calipers outside wall to outside wall).

58

Bowel

Liver

Proximalaorta

Posterior

Anterior

LeftRight

L A B E L E D : AORTA TRV PROX


59


19. Axial image of the middle aorta (inferior to the celiac trunk along the length of thesuperior mesenteric artery) with anterior to posterior measurement (calipers outsidewall to outside wall).

60

Left renalvein

Liver

Posterior

Anterior

LeftRight

Pancreas Superiormesenteric

artery

Middle aorta

Splenicvein

Spine

IVC



61

SCANNING TIP: If the renal arteries were represented on Number 19, Numbers 21and/or 22 may be omitted.


21. Longitudinal image of the right renal artery.

62

Posterior

Anterior

LeftRight

Pancreas

Superiormesenteric

vein

Spine

IVC

Rightrenal

artery

Aorta

Gallbladder

L A B E L E D : RT RENAL ART TRV

22. Longitudinal image of the left renal artery.

63

Posterior

Anterior

LeftRight

Spine

IVC

Rightrenalartery Aorta

Left renal vein

Liver

Splenicvein

Superiormesenteric

artery

Left renal artery

Ligamentumteres

L A B E L E D : LT RENAL ART TRV

23. Axial image of the distal aorta (inferior to the superior mesenteric artery, superiorto the bifurcation) with anterior to posterior measurement (calipers outside wall tooutside wall).

64

Posterior

Anterior

LeftRight

Distal aorta

L A B E L E D : AORTA TRV DISTAL


65


25. Axial image of aorta bifurcation (common iliac arteries).

66

Posterior

Anterior

LeftRight



L A B E L E D : AORTA TRV BIF


LONGITUDINAL IMAGE


67


Posterior


InferiorSuperior


Vertebrae

Smallbowel

shadow

Portalvein

Liver


AXIAL IMAGE


68

Posterior

Anterior

Distal IVC

Left hepaticvein

Middlehepaticvein

Right hepatic vein

LeftRight

Liver





69

Posterior

Anterior

Body

IVC

Liver

Hepaticartery

InferiorSuperior

Neck Fundus

Gallbladder

Portal vein




70

Posterior

Anterior

Liver

LeftRight

Gallbladderfundus

Sidewallshadow

IVC

Right kidney

Sidewallshadow




71



Posterior

Anterior

Liver

InferiorSuperior

Gallbladder

IVC

Portal veinDiaphragm

Commonhepatic duct

Hepaticartery



72

Posterior

Anterior

Bowel

Commonbile duct

Portal vein

Liver

Hepaticartery

InferiorSuperior



73


Pancreas

LONGITUDINAL IMAGES


74

Posterior

Anterior

Pancreaticduct

Commonbile duct

IVC

Liver

Head

LeftRight

NeckBody

Stomach

TailSplenicvein

Aorta

Left kidney

Spine

Right renalartery

Duodenum





75


Liver

Splenic vein

Left renalartery

Anterior

LeftRight

Posterior

Neck

Rightkidney

Leftkidney

Aorta

IVC

Head

Spine

Uncinate process

Left renalvein

Liver


Commonbile duct

Gallbladder

Duodenum


AXIAL IMAGE


76


Anterior

Posterior

LiverRight

Left

Head

Portal veinIVC

Bowel

Commonbile duct


Right Kidney

LONGITUDINAL IMAGE


77

SCANNING TIP Take an additional image of the superior and/or inferior poles ifthey are not clearly represented on the long axis image. Label accordingly.

InferiorSuperior

Anterior

Posterior

Cortex

Sinus

Inferiorpole

Superior pole

Midportion

Liver

Diaphragm


AXIAL IMAGE


78

Anterior

Posterior

Right Left

Rightrenal vein

Cortex

SinusMidportion

Medullarypyramids

Renalcapsule

LiverIVC

Morrison’spouch


Left Kidney

LONGITUDINAL IMAGE


79


Lateral

Medial

Superior Inferior

Inferiorpole

Cortex

Sinus

MidportionSuperior

pole

Spleen

Medullarypyramids

Renalcapsule


AXIAL IMAGE


80

PosteriorAnterior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Midportion

Renalvasculature


Spleen

LONGITUDINAL IMAGE


81

InferiorSuperior

Lateral

Medial

Left kidney

Long axisof spleen

Diaphragm


AXIAL IMAGE


82

PosteriorAnterior

Lateral

Medial




Liver

LONGITUDINAL IMAGES


83

Posterior

Anterior

Splenic artery



Aorta

Spine

Splenicvein

Diaphragm



84

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



85

Caudate lobe

Hepaticvein

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm



86

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



87

Posterior

Anterior

InferiorSuperior

Right lobe




88

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


89

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



90


Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery



91

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



92

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



93

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



94

Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm


Aorta

LONGITUDINAL IMAGE


95


Posterior

Anterior

Liver

Splenicartery



Stomach

Splenicvein



AXIAL IMAGE


96

Posterior

Anterior

LeftRight

Spine

IVC Leftrenalvein

Liver


Leftrenal

artery

Pancreas

Middle aorta

Stomach

Splenic vein



LONGITUDINAL IMAGES

15. Longitudinal image of the distal inferior vena cava to include the diaphragm andhepatic vein(s).

97

Posterior

Anterior

InferiorSuperior

Hepatic vein

Diaphragm Distal IVC

Portal vein

Liver


16. Longitudinal image of the middle inferior vena cava at the level of the head of thepancreas.

98

Posterior

Anterior

InferiorSuperior

Right renal artery

LiverPortalvein

Hepaticartery

Gallbladder neck fold shadow

Common bile duct Middle IVC

Pancreashead

Gastro-duodenal

arteryGallbladder

L A B E L E D : IVC SAG MID

17. Longitudinal image of the proximal inferior vena cava.

99

Posterior

Anterior

InferiorSuperior

BowelProximal IVC

L A B E L E D : IVC SAG PROX

18. Longitudinal image of the inferior vena cava bifurcation (common iliac veins).

100

Posterior

Anterior


Proximal IVC

Left commoniliac vein

IVC bifurcation

Right commoniliac vein

L A B E L E D : IVC SAG BIF RT or LT OBL or IVC SAG RT COR BIF

AXIAL IMAGES


101

Posterior

Anterior

Distal IVC

LeftRight

Left hepaticvein

Middlehepaticvein

Right hepatic vein


20. Axial image of the inferior vena cava at the level of the renal veins.

102

Anterior

LeftRight

Posterior

Gallbladder

LiverMiddle IVC

Left renalvein

AortaSpine

Rightrenal vein

Rightrenal artery

L A B E L E D : IVC TRV MID

21. Axial image of the proximal inferior vena cava.

103

Posterior

Anterior

Proximal IVC

LeftRight

L A B E L E D : IVC TRV PROX

22. Axial image of the inferior vena cava bifurcation (common iliac veins).

104

Posterior

Anterior

Spine

LeftRight

Commoniliac vein Common

iliac vein

Commoniliac arteries

L A B E L E D : IVC TRV BIF




105

Posterior

Anterior

Body

IVC

Liver

Hepaticartery

InferiorSuperior

Neck Fundus

Gallbladder

Portal vein




106

Posterior

Anterior

Liver

LeftRight

Gallbladderfundus

Sidewallshadow

IVC

Right kidney

Sidewallshadow




107



Posterior


InferiorSuperior

Hepatic artery

IVC

Liver

Commonhepatic duct

Portal vein



108

Posterior

Anterior

Liver

InferiorSuperior

Portal vein

Bowel

Commonbile duct

Hepaticartery



109


Pancreas

LONGITUDINAL IMAGES


110

Pancreaticduct

Liver Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

TailSplenicvein

Aorta

Right renalartery

IVC

Head

Spine

Duodenum

Commonbile duct



Neck



111


Liver

Splenic vein

Left renalartery

Anterior

LeftRight

Posterior

Neck

Rightkidney

Leftkidney

Aorta

IVC

Head

Spine

Uncinate process

Left renalvein

Liver


Commonbile duct

Gallbladder

Duodenum


AXIAL IMAGE


112


Anterior

Posterior

Bowel

IVC

Head

Portal vein

Liver

Commonbile duct

Liver

SuperiorInferior


Right Kidney

LONGITUDINAL IMAGE


113


Inferior

Superior

Anterior

Posterior

Cortex

Sinus

Inferiorpole

Superior pole

Midportion

Liver

Diaphragm


AXIAL IMAGE


114

LeftRight

Anterior

Posterior

Cortex

Sinus

IVC

Rightrenal vein

Midportion

Liver


Left Kidney

LONGITUDINAL IMAGE


115


InferiorSuperior

Lateral

Medial

Cortex

Sinus

Medullarypyramids


SpleenInferiorpole


AXIAL IMAGE


116

PosteriorAnterior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Midportion

Renalvasculature


Spleen

LONGITUDINAL IMAGE


117

InferiorSuperior

Lateral

Medial

Left kidney

Long axisof spleen

Diaphragm


AXIAL IMAGE


118

PosteriorAnterior

Lateral

Medial




Liver

LONGITUDINAL IMAGES


119

Posterior

Anterior

Splenic artery



Aorta

Spine

Splenicvein

Diaphragm



120

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



121

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm

Caudate lobe



122

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



123

Posterior

Anterior

InferiorSuperior

Right lobe




124

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


125

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



126


Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery



127

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



128

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



129

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



130


Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm


Aorta

LONGITUDINAL IMAGE


131

Posterior

Anterior

Liver

Splenicartery

Superiormesenteric

artery


Stomach

Splenicvein




AXIAL IMAGE


132

Posterior

Anterior

LeftRight

Spine

IVC Leftrenalvein

Liver


Leftrenal

artery

Pancreas

Middle aorta

Stomach

Splenic vein



LONGITUDINAL IMAGE


133

Posterior


InferiorSuperior


Vertebrae

Smallbowel

shadow

Portalvein

Liver



AXIAL IMAGE


134

Posterior

Anterior

Distal IVC

Left hepaticvein

Middlehepaticvein

Right hepatic vein

LeftRight

Liver



135

SCANNING TIP: When the gallbladder and biliary tract are the areas of interest,they are routinely surveyed in two different patient positions and the gallbladder isdocumented in both positions.

First Position

LONGITUDINAL GALLBLADDER IMAGES


136

Posterior

AnteriorGallbladder

InferiorSuperior

Small bowel

Throughtransmission

Portal vein

Diaphragm

IVC

Liver


18. Longitudinal image of the gallbladder fundus and body.

137

Posterior

Anterior

Body

Liver

InferiorSuperior

Fundus

Gallbladder Bowel

L A B E L E D : GB SAG FUNDUS/BODY

19. Longitudinal image of the gallbladder neck.

138

Posterior

Anterior

Liver

InferiorSuperior

GallbladderCommon

hepatic duct

Body

Neck

Portal vein

IVCDiaphragm

L A B E L E D : GB SAG NECK

AXIAL GALLBLADDER IMAGES


139

Posterior


LeftRight

Sidewallshadow

IVC

Liver


21. Axial image of the gallbladder body.

140

Posterior

Anterior

Liver

LeftRight

GallbladderbodySidewall

shadow

IVC

Right kidney

Spine

L A B E L E D : GB TRV BODY

22. Axial image of the gallbladder neck.

141

Posterior

Anterior

LiverLeftRight

Gallbladderneck

Sidewallshadow

IVCRight kidney

Sidewallshadow

Aorta

L A B E L E D : GB TRV NECK


142



SCANNING TIP: Biliary tract images may be taken in the second patient position ifthey were better visualized there during the survey.


143

Posterior

Anterior

Liver

InferiorSuperior

Gallbladder

IVC


Commonhepatic duct

Hepaticartery



144

Posterior

Anterior

Bowel

Commonbile duct

Portal vein

Liver

Hepaticartery

InferiorSuperior



145


Second Position



146

Posterior

Anterior

Liver

InferiorSuperior

Portal vein Gallbladder

Diaphragm

IVC

Through transmission

Right renalartery




147

Posterior


LeftRight

Sidewallshadow

IVC

Liver


Pancreas

LONGITUDINAL IMAGES


148

Anterior

Posterior

Tail

Splenicvein

LiverRight Left

Left kidney

Superiormesenteric

artery

Stomach

Body

Aorta

Spine

Right renalartery

IVC

Uncinateprocess

Head

Neck

Duodenum

Ligamentumteres

Left renal vein


29. Longitudinal image of the pancreas head, to include the uncinate process andcommon bile duct (if bile-filled).

149

Anterior

Posterior

Tail

Splenicvein

Liver

Right Left

Leftkidney

Confluence ofsplenic vein

and superiormesenteric vein

Body

Aorta

Spine

Commonbile duct

IVC

Gallbladder

Head

Ligamentum teres

Superiormesenteric

artery

Liver

Gastroduodenalartery


AXIAL IMAGE


150


Anterior

Posterior

LiverRight

Left

Head

Portal veinIVC

Bowel

Commonbile duct


Right Kidney

LONGITUDINAL IMAGE


151


InferiorSuperior

Anterior

Posterior

Cortex

Sinus

Inferiorpole

Superior pole

Midportion

Liver

Diaphragm


AXIAL IMAGE


152

LeftRight

Anterior

Posterior

Cortex

Sinus

IVC

Rightrenal vein

Midportion

Liver


Left Kidney

LONGITUDINAL IMAGE


153

InferiorSuperior

Lateral

Medial

Cortex

Sinus

Medullarypyramids


SpleenInferiorpole



AXIAL IMAGE


154

PosteriorAnterior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Midportion

Renalvasculature


Spleen

LONGITUDINAL IMAGE


155

InferiorSuperior

Lateral

Medial

Left kidney

Long axisof spleen

Diaphragm


AXIAL IMAGE


156

PosteriorAnterior

Lateral

Medial




Liver

LONGITUDINAL IMAGES


157

Posterior

Anterior

Splenic artery

InferiorSuperior

Bowel


Aorta

Spine

Splenicvein

Diaphragm



158

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



159

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm

Caudate lobe



160

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



161

Posterior

Anterior

InferiorSuperior

Right lobe




162

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


163

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



164

Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery




165

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



166

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



167

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



168


Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm


Aorta

LONGITUDINAL IMAGE


169


Posterior

Anterior

Liver

Splenicartery

Superiormesenteric

artery

PancreasInferior

Superior

Stomach

Splenicvein



AXIAL IMAGE


170

Posterior

Anterior

LeftRight

Spine

IVC Leftrenalvein

Liver


Leftrenal

artery

Pancreas

Middle aorta

Stomach

Splenic vein



LONGITUDINAL IMAGE


171

Posterior

AnteriorHepaticartery

InferiorSuperior


Vertebrae

Smallbowel

shadow

Portalvein

Liver



AXIAL IMAGE


172

Posterior

Anterior

Distal IVC

Left hepaticvein

Middlehepaticvein

Right hepatic vein

LeftRight

Liver





173

Posterior

AnteriorGallbladder

InferiorSuperior

Small bowel

Throughtransmission

Portal vein

Diaphragm

IVC

Liver




174

Posterior


LeftRight

Sidewallshadow

IVC

Liver




175

Posterior


InferiorSuperior

Hepatic artery

IVC

Liver

Commonhepatic duct

Portal vein





176

Posterior

Anterior Duodenum

InferiorSuperior

Hepatic artery

Liver

Commonbile duct

Portal vein



177


Pancreas

LONGITUDINAL IMAGES


178

Posterior

Anterior

Pancreaticduct

Commonbile duct

IVC

Liver

Head

LeftRight

NeckBody

Stomach

TailSplenicvein

Aorta

Left kidney

Spine

Right renalartery

Duodenum




23. Longitudinal image of the pancreas body and neck to include the splenic vein.

179

LigamentumteresLiver

Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

Tail

Splenicvein

AortaIVC

Head

Spine

Commonbile duct


Confluenceof superiormesentericvein andsplenic vein

Neck

L A B E L E D : PANC TRV BODY/NECK

24. Longitudinal image of the pancreas tail.

180


Liver Stomach

Leftkidney

Anterior

LeftRight

Posterior

Body

TailSplenicveinAorta

Left renalvein

Spine

IVC

Head

Uncinateprocess

L A B E L E D : PANC TRV TAIL


181


Liver

Splenic vein

Left renalartery

Anterior

LeftRight

Posterior

Neck

Rightkidney

Leftkidney

Aorta

IVC

Head

Spine

Uncinate process

Left renalvein

Liver


Commonbile duct

Gallbladder

Duodenum


AXIAL IMAGES


182

Anterior

Posterior

Bowel

IVC

Head

Portal vein

Liver

Commonbile duct

Liver

Superior Inferior


27. Axial image of the pancreas neck and uncinate process to include the superiormesenteric vein.

183

Anterior

Posterior

Bowel

IVC

Neck

Right renalartery

Uncinateprocess

Liver

Superior Inferior

Spine


L A B E L E D : PANC SAG NECK/UNCINATE

28. Axial image of the pancreas body to include the splenic vein.

184

Anterior

Posterior

DiaphragmAorta

Body

Splenicartery

Splenic vein

LiverSuperior Inferior

Spine

Superiormesenteric

arteryEsophagealgastricjunction

L A B E L E D : PANC SAG BODY

29. Axial image of the pancreas tail.

185

Anterior

Posterior

Tail

Splenicvein


Left kidney


L A B E L E D : PANC SAG TAIL

Right Kidney

LONGITUDINAL IMAGE


186

Inferior

Superior

Anterior

Posterior

Cortex

Sinus

Inferiorpole

Superior pole

Midportion

Liver

Diaphragm



AXIAL IMAGE


187

LeftRight

Anterior

Posterior

Cortex

Sinus

IVC

Rightrenal vein

Midportion

Liver


Left Kidney

LONGITUDINAL IMAGE


188

InferiorSuperior

Lateral

Medial

Cortex

Sinus

Medullarypyramids


Spleen Inferiorpole



AXIAL IMAGE


189

PosteriorAnterior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Midportion

Renalvasculature


Spleen

LONGITUDINAL IMAGE


190

InferiorSuperior

Lateral

Medial

Left kidney

Long axisof spleen

Diaphragm


AXIAL IMAGE


191

PosteriorAnterior

Lateral

Medial




Liver

LONGITUDINAL IMAGES


192

Posterior

Anterior

Splenic artery



Aorta

SpineSplenicvein

Diaphragm



193

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



194

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm



195

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



196

Posterior

Anterior

InferiorSuperior

Right lobe




197

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


198

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



199

Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery




200

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



201

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



202

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



203

Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm



Aorta

LONGITUDINAL IMAGE


204

Posterior

Anterior

Liver

Splenicartery

Superiormesenteric

artery


Stomach

Splenicvein




AXIAL IMAGE


205

Posterior

Anterior

LeftRight

Spine

IVC Leftrenalvein

Liver


Leftrenal

artery

Pancreas

Middle aorta

Stomach

Splenic vein



LONGITUDINAL IMAGE


206

Posterior


InferiorSuperior


Vertebrae

Smallbowel

shadow

Portalvein

Liver



AXIAL IMAGE


207

Posterior

Anterior

Distal IVC

Left hepaticvein

Middlehepaticvein

Right hepatic vein

LeftRight

Liver





208

Posterior

AnteriorGallbladder

InferiorSuperior

Small bowel

Throughtransmission

Portal vein

Diaphragm

IVC

Liver




209

Posterior


LeftRight

Sidewallshadow

IVC

Liver




210

Posterior


Inferior

Superior

Hepatic artery

IVC

Liver

Commonhepatic duct

Portal vein





211

Posterior

Anterior Duodenum

InferiorSuperior

Hepatic artery

Liver

Commonbile duct

Portal vein



212


Pancreas

LONGITUDINAL IMAGES


213

Pancreaticduct

Liver Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

TailSplenicvein

Aorta

Right renalartery

IVC

Head

Spine

Duodenum

Commonbile duct



Neck



214


Liver

Splenic vein

Left renalartery

Anterior

LeftRight

Posterior

Neck

Rightkidney

Leftkidney

Aorta

IVC

Head

Spine

Uncinate process

Left renalvein

Liver


Commonbile duct

Gallbladder

Duodenum


AXIAL IMAGE


215


Anterior

Posterior

Liver

Superior Inferior

Head

Commonbile ductIVC

Bowel

Liver

Portal vein

Bowel


Right Kidney

LONGITUDINAL IMAGES

25. Long axis image of the right kidney with superior to inferior measurement.

216

Anterior

Posterior

Superior Inferior

Superiorpole

Cortex

Midportion

Sinus

InferiorpoleLiver

Diaphragm



217



218

Anterior

Posterior

Superior Inferior

Superiorpole

Cortex

Midportion

Inferior pole

Liver

Diaphragm

Psoasmuscle

Sinus



219

SCANNING TIP: If the superior and inferior poles were adequately demonstrated onthe long axis images, Numbers 29 and/or 30 may be omitted.


29. Longitudinal image of the right kidney superior pole.

220

Anterior

Posterior

Superior Inferior

Superiorpole

Cortex

Liver

Diaphragm

Sinus

L A B E L E D : RT KID SAG SUP POLE

30. Longitudinal image of the right kidney inferior pole.

221

Anterior

Posterior

Superior InferiorInferiorpole

Cortex

Liver

Sinus

L A B E L E D : RT KID SAG INF POLE

31. Longitudinal image of the right kidney just medial to the long axis.

222

Anterior

Posterior

Superior Inferior

Medialportion

Cortex

Liver

Spine

Psoasmuscle

Medullary pyramids

Diaphragm

L A B E L E D : RT KID SAG MED

32. Longitudinal image of the right kidney just lateral to the long axis to include part ofthe liver for parenchyma comparison.

223

Anterior

Posterior

Superior Inferior

Lateralportion

Cortex

Liver

Sinus

Quadratuslumborummuscle

Medullarypyramids

Diaphragm

L A B E L E D : RT KID SAG LAT

AXIAL IMAGES

33. Axial image of the right kidney superior pole.

224

Anterior

Posterior

Right Left

Cortex

Liver

SinusIVC

Medullary pyramids

Superiorpole

L A B E L E D : RT KID TRV SUP POLE

34. Axial image of the right kidney midportion to include the hilum and anterior toposterior measurement.

225

Anterior

Posterior

Right Left

Cortex

Liver

Sinus

IVC

Renal vein

Midportion



226


36. Axial image of the right kidney inferior pole.

227

Anterior

Posterior

Right Left

CortexLiver

Sinus

IVC

Psoasmuscle

Inferiorpole

Quadratuslumborum

muscle

Bowel

L A B E L E D : RT KID TRV INF POLE

Left Kidney

LONGITUDINAL IMAGES

37. Long axis image of the left kidney with superior to inferior measurement.

228

Lateral

Medial

Superior Inferior

Cortex

Spleen

Sinus

MidportionSuperiorpole

Inferiorpole

Medullarypyramids

Diaphragm



229



230

Lateral

Medial

Superior Inferior

Cortex

Spleen

Sinus


Inferiorpole

Medullarypyramids

DiaphragmDiaphragm

Pleuralspace



231



41. Longitudinal image of the left kidney superior pole with part of the spleen forparenchyma comparison.

232

Lateral

Medial

Superior Inferior

Cortex

Spleen

Sinus

Superiorpole

AortaDiaphragm

Psoasmuscle

L A B E L E D : LT KID COR SUP POLE

42. Longitudinal image of the left kidney inferior pole.

233

Lateral

Medial

Superior Inferior

Cortex

Bowel

Sinus

Inferiorpole

Aorta

L A B E L E D : LT KID COR INF POLE

43. Longitudinal image of the left kidney just anterior to the long axis.

234

Lateral

Medial

Superior Inferior

Cortex

Sinus

Anteriorportion

L A B E L E D : LT KID COR ANT

44. Longitudinal image of the left kidney just posterior to the long axis.

235

Lateral

Medial

Superior Inferior

Cortex

Sinus

Posteriorportion

L A B E L E D : LT KID COR POST

AXIAL IMAGES

45. Axial image of the left kidney superior pole.

236

Lateral

Medial

Anterior Posterior

Cortex

Sinus

Superiorpole

L A B E L E D : LT KID LT TRV SUP POLE

46. Axial image of the left kidney midportion to include the hilum and anterior toposterior measurement.

237

Lateral

Medial

Anterior Posterior

Cortex

Sinus

Midportion

Renalvasculature



238


48. Axial image of the left kidney inferior pole.

239

Lateral

Medial

Anterior Posterior

Cortex

Sinus

Inferiorpole

Medullarypyramids

L A B E L E D : LT KID LT TRV INF POLE

Spleen

LONGITUDINAL IMAGE


240

InferiorSuperior

Lateral

Medial

Left kidney

Long axisof spleen

Diaphragm


AXIAL IMAGE


241

PosteriorAnterior

Lateral

Medial




Liver

LONGITUDINAL IMAGES


242

Posterior

Anterior

Splenic artery

InferiorSuperior

Bowel


Aorta

Spine

Splenicvein

Diaphragm



243

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



244

Caudate lobe

Hepaticvein

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm



245

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



246

Posterior

Anterior

InferiorSuperior

Right lobe




247

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


248

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



249

Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery




250

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



251

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



252

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



253

Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm



Aorta

LONGITUDINAL IMAGE


254


Posterior

Anterior

Liver

Splenicartery

Superiormesenteric

artery


Stomach

Splenicvein



AXIAL IMAGE


255

Posterior

Anterior

LeftRight

Spine

IVC Leftrenalvein

Liver


Leftrenal

artery

Pancreas

Middle aorta

Stomach

Splenic vein



LONGITUDINAL IMAGE


256

Posterior


InferiorSuperior


Vertebrae

Smallbowel

shadow

Portalvein

Liver



AXIAL IMAGE


257

Posterior

Anterior

Distal IVC

Left hepaticvein

Middlehepaticvein

Right hepatic vein

LeftRight

Liver





258

Posterior

AnteriorGallbladder

InferiorSuperior

Small bowel

Throughtransmission

Portal vein

Diaphragm

IVC

Liver




259

Posterior


LeftRight

Sidewallshadow

IVC

Liver




260

Posterior


InferiorSuperior

Hepatic artery

IVC

Liver

Commonhepatic duct

Portal vein





261

Posterior

Anterior Duodenum

InferiorSuperior

Hepatic artery

Liver

Commonbile duct

Portal vein



262


Pancreas

LONGITUDINAL IMAGES


263

Pancreaticduct

Liver Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

TailSplenicvein

Aorta

Right renalartery

IVC

Head

Spine

Duodenum

Commonbile duct



Neck



264


Liver

Splenic vein

Left renalartery

Anterior

LeftRight

Posterior

Neck

Rightkidney

Leftkidney

Aorta

IVC

Head

Spine

Uncinate process

Left renalvein

Liver


Commonbile duct

Gallbladder

Duodenum


AXIAL IMAGE


265

Anterior

Posterior

Liver

SuperiorInferior

Head

Commonbile ductIVC

Liver

Portal vein

Bowel



Right Kidney

LONGITUDINAL IMAGE


266

Inferior

Superior

Anterior

Posterior

Cortex

Sinus

Inferiorpole

Superior pole

Midportion

Liver

Diaphragm



AXIAL IMAGE


267

LeftRight

Anterior

Posterior

Cortex

Sinus

IVC

Rightrenal vein

Midportion

Liver


Left Kidney

LONGITUDINAL IMAGE


268

InferiorSuperior

Lateral

Medial

Cortex

Sinus

Medullarypyramids


SpleenInferiorpole



AXIAL IMAGE


269

PosteriorAnterior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Midportion

Renalvasculature


Spleen

LONGITUDINAL IMAGES

29. Long axis image of the spleen.

270

Lateral

Medial

InferiorSuperior

Long axisof spleen

Diaphragm Left kidney

SCANNING TIP: If the adjacent pleural space and a portion of the left kidney wereadequately demonstrated on Number 29, Numbers 30 and/or 31 may be omitted.

L A B E L E D : SPLEEN COR LONG AXIS

30. Superior longitudinal image of the spleen to include the adjacent pleural space.

271

Lateral

Medial

InferiorSuperior

Spleen

Diaphragm

Rib shadows

Pleuralspace

L A B E L E D : SPLEEN COR SUP

31. Inferior longitudinal image of the spleen to include part of the left kidney forparenchyma comparison.

272

Lateral

Medial

InferiorSuperior

Spleen

Leftkidney

Pleuralspace

L A B E L E D : SPLEEN COR INF

AXIAL IMAGES

32. Axial image of the spleen to include both anterior and posterior margins.

273

Lateral

Medial

PosteriorAnterior

Splenichilum

Diaphragm

SCANNING TIP: If the anterior and posterior margins were adequatelydemonstrated on Number 32, Numbers 33 and/or 34 may be omitted.


33. Axial image of the spleen to include both anterior margin and splenic hilum.

274

Lateral

Medial

PosteriorAnterior

Splenichilum

Diaphragm

Spleen Rib shadow

L A B E L E D : SPLEEN LT TRV ANT

34. Axial image of the spleen to include the posterior margin.

275

Lateral

Medial

PosteriorAnterior

Splenichilum Diaphragm

Spleen

L A B E L E D : SPLEEN LT TRV POST

SECTION TWO

IMAGE PROTOCOLS FOR L IMITED SONOGRAPHIC STUDIES OF THEABDOMEN

• Extensive images of the area(s) of interest.

I. Aorta Study

II. Inferior Vena Cava Study

III. Right Upper Quadrant Study

IV. Gallbladder and Biliary Tract Study

V. Pancreas Study

VI. Renal Study

VII. Spleen Study

276276

277

• Criteria:— Begin studies with a survey of the area(s) of interest in at least two scanning

planes.— Do not share the results of the study with the patient. Legally, only physicians can

give a diagnosis.

I. Aorta Study/Limited Abdomen

Aorta

LONGITUDINAL IMAGES

1. Longitudinal image of the proximal aorta (inferior to the diaphragm, superior to theceliac trunk).

278

Superior Inferior

Anterior

Posterior

Liver

Celiac artery

SuperiormesentericarteryProximal

aorta

L A B E L E D : AORTA SAG PROX

2. Longitudinal image of the middle aorta (inferior to the celiac trunk along the lengthof the superior mesenteric artery).

279

Anterior Pancreas body

Inferior

Posterior

Superior

Stomach


Middle aortaSplenic artery

Proximalaorta

Liver

Splenic vein


3. Longitudinal image of the distal aorta (inferior to the superior mesenteric artery,superior to the bifurcation).

280

Anterior

Inferior

Posterior

Superior

Stomach

Bowel

Distal aorta

Bowel

L A B E L E D : AORTA SAG DISTAL

4. Longitudinal image of the aorta bifurcation (common iliac arteries).

281

Medial

InferiorSuperiorDistal aorta


Aortabifurcation


Lateral

L A B E L E D : AORTA SAG BIF RT or LT OBL or AORTA LT COR BIF

AXIAL IMAGES

5. Axial image of the proximal aorta (inferior to the diaphragm, superior to the celiactrunk) with anterior to posterior measurement (calipers outside wall to outside wall).

282

Bowel

Liver

Proximalaorta

Posterior

Anterior

LeftRight



283


7. Axial image of the middle aorta (inferior to the celiac trunk along the length of thesuperior mesenteric artery) with anterior to posterior measurement (calipers outsidewall to outside wall).

284

Left renalvein

Liver

Posterior

Anterior

LeftRight

Pancreas Superiormesenteric

artery

Middle aorta

Splenicvein

Spine

IVC



285

SCANNING TIP: If the renal arteries were represented on Number 7, Numbers 9and/or 10 may be omitted.


9. Longitudinal image of the right renal artery.

286

Posterior

Anterior

LeftRight

Pancreas

Superiormesenteric

vein

Spine

IVC

Rightrenal

artery

Aorta

Gallbladder

L A B E L E D : RT RENAL ART TRV

10. Longitudinal image of the left renal artery.

287

Posterior

Anterior

LeftRight

Spine

IVC

Rightrenalartery Aorta

Left renal vein

Liver

Splenicvein

Superiormesenteric

artery

Left renal artery

Ligamentumteres

L A B E L E D : LT RENAL ART TRV

11. Axial image of the distal aorta (inferior to the superior mesenteric artery, superiorto the bifurcation) with anterior to posterior measurement (calipers outside wall tooutside wall).

288

Posterior

Anterior

LeftRight

Distal aorta



289


13. Axial image of aorta bifurcation (common iliac arteries).

290

Posterior

Anterior

LeftRight



L A B E L E D : AORTA TRV BIF

II. Inferior Vena Cava Study/Limited Abdomen


LONGITUDINAL IMAGES

1. Longitudinal image of the distal inferior vena cava to include the diaphragm andhepatic vein(s).

291

Posterior

Anterior

InferiorSuperior

Hepatic vein

Diaphragm Distal IVC

Portal vein

Liver


2. Longitudinal image of the middle inferior vena cava at the level of the head of thepancreas.

292

Posterior

Anterior

InferiorSuperior

Right renal artery

LiverPortalvein

Hepaticartery

Gallbladder neck fold shadow

Common bile duct Middle IVC

Pancreashead

Gastro-duodenal

arteryGallbladder

L A B E L E D : IVC SAG MID

3. Longitudinal image of the proximal inferior vena cava.

293

Posterior

Anterior

InferiorSuperior

BowelProximal IVC

L A B E L E D : IVC SAG PROX

4. Longitudinal image of the inferior vena cava bifurcation (common iliac veins).

294

Posterior

Anterior


Proximal IVC

Left commoniliac vein

IVC bifurcation

Right commoniliac vein

L A B E L E D : IVC SAG BIF RT or LT OBL or IVC RT COR BIF

AXIAL IMAGES


295

Posterior

Anterior

Distal IVC

LeftRight

Left hepaticvein

Middlehepaticvein

Right hepatic vein


6. Axial image of the inferior vena cava at the level of the renal veins.

296

Anterior

LeftRight

Posterior

Gallbladder

LiverMiddle IVC

Left renalvein

AortaSpine

Rightrenal vein

Rightrenal artery

L A B E L E D : IVC TRV MID

7. Axial image of the proximal inferior vena cava.

297

Posterior

Anterior

Proximal IVC

LeftRight

L A B E L E D : IVC TRV PROX

8. Axial image of the inferior vena cava bifurcation (common iliac veins).

298

Posterior

Anterior

Spine

LeftRight

Commoniliac vein Common

iliac vein

Commoniliac arteries

L A B E L E D : IVC TRV BIF

III. Right Upper Quadrant Study/Limited Abdomen

Liver

LONGITUDINAL IMAGES


299

Posterior

Anterior

Splenic artery



Aorta

Spine

Splenicvein

Diaphragm



300

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



301

Hepaticvein

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm



302

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



303

Posterior

Anterior

InferiorSuperior

Right lobe




304

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


305

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



306


Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery



307

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



308

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



309

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



310


Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm



LONGITUDINAL IMAGE


311

Posterior


InferiorSuperior


Vertebrae

Smallbowel

shadow

Portalvein

Liver



AXIAL IMAGE


312

Posterior

Anterior

Distal IVC

Left hepaticvein

Middlehepaticvein

Right hepatic vein

LeftRight

Liver


Gallbladder and Biliary TractFirst Position



313

Posterior

Anterior

Body

IVC

Liver

Hepaticartery

InferiorSuperior

Neck Fundus

Gallbladder

Portal vein



314

Posterior

Anterior

Body

Liver

InferiorSuperior

Fundus

Gallbladder Bowel



315

Posterior

Anterior

Liver

InferiorSuperior

GallbladderCommon

hepatic duct

Body

Neck

Portal vein

IVCDiaphragm




316

Posterior

Anterior

Liver

LeftRight

Gallbladderfundus

Sidewallshadow

IVC

Right kidney

Sidewallshadow



317

Posterior

Anterior

Liver

LeftRight


shadow

IVC

Right kidney

Spine



318

Posterior

Anterior

LiverLeftRight

Gallbladderneck

Sidewallshadow

IVCRight kidney

Sidewallshadow

Aorta



319





320

Posterior

Anterior

Liver

InferiorSuperior

Gallbladder

IVC


Commonhepatic duct

Hepaticartery



321

Posterior

Anterior

Liver

InferiorSuperior

Portal vein

Bowel

Commonbile duct

Hepaticartery



322


Second Position



323

Posterior

Anterior

Liver

InferiorSuperior


Diaphragm

IVC


Right renalartery




324

Posterior

Anterior

Liver

LeftRight

Gallbladderfundus

Right kidney

IVC


Spine


Pancreas

LONGITUDINAL IMAGES


325

Anterior

Posterior

Tail

Splenicvein

LiverRight Left

Left kidney

Superiormesenteric

artery

Stomach

Body

Aorta

Spine

Right renalartery

IVC

Uncinateprocess

Head

Neck

Duodenum

Ligamentumteres

Left renal vein



326

Anterior

Posterior

Tail

Splenicvein

Liver

Right Left

Leftkidney



Body

Aorta

Spine

Commonbile duct

IVC

Gallbladder

Head

Ligamentum teres

Superiormesenteric

artery

Liver



AXIAL IMAGE


327

Anterior

Posterior

LiverRight

Left

Head

Portal veinIVC

Bowel

Commonbile duct



Right Kidney

LONGITUDINAL IMAGE


328


InferiorSuperior

Anterior

Posterior

Cortex

Sinus

Inferiorpole

Superior pole

Midportion

Liver

Diaphragm


AXIAL IMAGE


329

LeftRight

Anterior

Posterior

Cortex

Sinus

IVC

Rightrenal vein

Midportion

Liver


IV. Gallbladder and Biliary Tract Study/Limited Abdomen

Liver

LONGITUDINAL IMAGES


330

Posterior

Anterior

Splenic artery



Aorta

SpineSplenicvein

Diaphragm



331

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



332

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm



333

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



334

Posterior

Anterior

InferiorSuperior

Right lobe




335

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


336

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



337


Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery



338

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



339

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



340

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



341

Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm




342

SCANNING TIP: When the gallbladder and biliary tract are the areas of interest,they are routinely surveyed in two different patient positions and the gallbladder isdocumented in both positions.

First Position



343

Posterior

Anterior

Body

IVC

Liver

Hepaticartery

InferiorSuperior

Neck Fundus

Gallbladder

Portal vein



344

Posterior

Anterior

Body

Liver

InferiorSuperior

Fundus

Gallbladder Bowel



345

Posterior

Anterior

Liver

InferiorSuperior

GallbladderCommon

hepatic duct

Body

Neck

Portal vein

IVCDiaphragm




346

Posterior

Anterior

Liver

LeftRight

Gallbladderfundus

Sidewallshadow

IVC

Right kidney

Sidewallshadow



347

Posterior

Anterior

Liver

LeftRight


shadow

IVC

Right kidney

Spine



348

Posterior

Anterior

LiverLeftRight

Gallbladderneck

Sidewallshadow

IVCRight kidney

Sidewallshadow

Aorta



349





350

Posterior

Anterior

Liver

InferiorSuperior

Gallbladder

IVC


Commonhepatic duct

Hepaticartery



351

Posterior

Anterior

Liver

InferiorSuperior

Portal vein

Bowel

Commonbile duct

Hepaticartery



352


Second Position



353

Posterior

Anterior

Liver

InferiorSuperior


Diaphragm

IVC


Right renalartery




354

Posterior

Anterior

Liver

LeftRight

Gallbladderfundus

Right kidney

IVC


Spine


Pancreas

LONGITUDINAL IMAGES


355

Anterior

Posterior

Tail

Splenicvein

LiverRight Left

Left kidney

Superiormesenteric

artery

Stomach

Body

Aorta

Spine

Right renalartery

IVC

Uncinateprocess

Head

Neck

Duodenum

Ligamentumteres

Left renal vein



356

Anterior

Posterior

Tail

Splenicvein

Liver

Right Left

Leftkidney



Body

Aorta

Spine

Commonbile duct

IVC

Gallbladder

Head

Ligamentum teres

Superiormesenteric

artery

Liver



AXIAL IMAGE


357

Anterior

Posterior

Liver

Right

Left

Head

Portal veinIVC

Bowel

Commonbile duct



V. Pancreas Study/Limited Abdomen

Liver

LONGITUDINAL IMAGES


358

Posterior

Anterior

Splenic artery



Aorta

SpineSplenicvein

Diaphragm



359

Caudate lobe

Hepaticvein

Posterior

Anterior


Splenicvein

Diaphragm

Inferiorvenacava

Ligamentumvenosum



360

Caudate lobe

Hepaticvein

Posterior

Anterior

InferiorSuperior

IVC

Bowel

Right lobe

Right lobe

Right renal artery

Hepaticvein

Portal vein

Stomach

Diaphragm



361

Posterior

Anterior

InferiorSuperior

Right lobe

Portalvein

Bowel

Gallbladder

Diaphragm

Main lobarfissure

Throughtransmission



362

Posterior

Anterior

InferiorSuperior

Right lobe




363

Posterior

Anterior

InferiorSuperior

Right lobe

Diaphragm

Diaphragmaticmotion

DomePleuralspace


AXIAL IMAGES


364

Posterior

Anterior

LeftRight

Ligamentumvenosum

Left lobe

Caudate lobe

AortaIVC



365

Posterior

Anterior

LeftRight

Ligamentum teres

Aorta

IVC

Bowel


Portalvein

Sidewall shadow

Spine

Splenicvein

Pancreas

Left lobe

Left renalvein

Superiormesenteric

artery




366

Posterior

Anterior

LeftRight

IVC

Left hepaticvein


Righthepatic vein

Diaphragm



367

Posterior

Anterior

LeftRight

Left portalvein

IVCAorta

Right lobe

Rightportal vein

Right kidney

Spine



368

Posterior

Anterior

LeftRight

Right lobe

Right kidney

Gallbladder

Bowel



369

Posterior

Anterior

LeftRight

Right lobe

Pleuralspace

Diaphragm






370

Posterior

AnteriorGallbladder

InferiorSuperior

Small bowel

Throughtransmission

Portal vein

Diaphragm

IVC

Liver




371

Posterior


LeftRight

Sidewallshadow

IVC

Liver




372



Posterior


InferiorSuperior

Hepatic artery

IVC

Liver

Commonhepatic duct

Portal vein



373

Posterior

Anterior Duodenum

InferiorSuperior

Hepatic artery

Liver

Commonbile duct

Portal vein



374


Pancreas

LONGITUDINAL IMAGES


375

Pancreaticduct

Liver Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

TailSplenicvein

Aorta

Right renalartery

IVC

Head

Spine

Duodenum

Commonbile duct



Neck


19. Longitudinal image of the pancreas body and neck to include the splenic vein.

376

LigamentumteresLiver

Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

Tail

Splenicvein

AortaIVC

Head

Spine

Commonbile duct


Confluenceof superiormesentericvein andsplenic vein

Neck

L A B E L E D : PANC TRV BODY/NECK

20. Longitudinal image of the pancreas tail.

377


Liver Stomach

Left kidney

Anterior

LeftRight

Posterior

Body

TailSplenicveinAorta

IVC

Head

Spine

Uncinateprocess

Left renalvein

L A B E L E D : PANC TRV TAIL


378


Liver

Splenic vein

Left renalartery

Anterior

LeftRight

Posterior

Neck

Rightkidney

Leftkidney

Aorta

IVC

Head

Spine

Uncinate process

Left renalvein

Liver


Commonbile duct

Gallbladder

Duodenum


AXIAL IMAGES


379

Anterior

Posterior

Bowel

IVC

Head

Portal vein

Liver

Commonbile duct

Liver

Superior Inferior


23. Axial image of the pancreas neck and uncinate process to include the superiormesenteric vein.

380

Anterior

Posterior

Bowel

IVC

Neck

Right renalartery

Uncinateprocess

Liver

Superior Inferior

Spine


L A B E L E D : PANC SAG NECK/UNCINATE

24. Axial image of the pancreas body to include the splenic vein.

381

Anterior

Posterior

DiaphragmAorta

Body

Splenicartery

Splenic vein


Spine

Superiormesenteric

arteryEsophagealgastricjunction

L A B E L E D : PANC SAG BODY

25. Axial image of the pancreas tail.

382

Anterior

Posterior

Tail

Splenicvein

Liver

Superior Inferior

Left kidney


L A B E L E D : PANC SAG TAIL

VI. Renal Study/Limited Abdomen

Right Kidney

LONGITUDINAL IMAGES


383

Anterior

Posterior

Superior Inferior

Superiorpole

Cortex

Midportion

Sinus

Inferiorpole

Liver

Diaphragm



384



385

Anterior

Posterior

Superior Inferior

Superiorpole

Cortex

Midportion

Inferior pole

Liver

Diaphragm

Psoasmuscle

Sinus



386



5. Longitudinal image of the right kidney superior pole.

387

Anterior

Posterior

Superior Inferior

Superiorpole

Cortex

Liver

Diaphragm

Sinus

L A B E L E D : RT KID SAG SUP POLE

6. Longitudinal image of the right kidney inferior pole.

388

Anterior

Posterior

Superior InferiorInferiorpole

Cortex

Liver

Sinus

L A B E L E D : RT KID SAG INF POLE

7. Longitudinal image of the right kidney just medial to the long axis.

389

Anterior

Posterior

Superior Inferior

Medialportion

Cortex

Liver

Spine

Psoasmuscle

Medullary pyramids

Diaphragm

L A B E L E D : RT KID SAG MED

8. Longitudinal image of the right kidney just lateral to the long axis to include part ofthe liver for parenchyma comparison.

390

Anterior

Posterior

Superior Inferior

Lateralportion

Cortex

Liver

Sinus

Quadratuslumborummuscle

Medullarypyramids

Diaphragm

L A B E L E D : RT KID SAG LAT

AXIAL IMAGES

9. Axial image of the right kidney superior pole.

391

Anterior

Posterior

Right Left

Cortex

Liver

SinusIVC

Medullary pyramids

Superiorpole

L A B E L E D : RT KID TRV SUP POLE

10. Axial image of the right kidney midportion to include the hilum and anterior toposterior measurement.

392

Anterior

Posterior

Right Left

Cortex

Liver

Sinus

IVC

Renal vein

Midportion



393


12. Axial image of the right kidney inferior pole.

394

Anterior

Posterior

Right Left

CortexLiver

Sinus

IVC

Psoasmuscle

Inferiorpole

Quadratuslumborum

muscle

Bowel

L A B E L E D : RT KID TRV INF POLE

Left Kidney

LONGITUDINAL IMAGES


395

Lateral

Medial

Superior Inferior

Cortex

Spleen

Sinus


Inferiorpole

Medullarypyramids

Diaphragm



396



397

Lateral

Medial

Superior Inferior

Cortex

Spleen

Sinus


Inferiorpole

Medullarypyramids

DiaphragmDiaphragm

Pleuralspace



398



17. Longitudinal image of the left kidney superior pole with part of the spleen forparenchyma comparison.

399

Lateral

Medial

Superior Inferior

Cortex

Spleen

Sinus

Superiorpole

AortaDiaphragm

Psoasmuscle

L A B E L E D : LT KID COR SUP POLE

18. Longitudinal image of the left kidney inferior pole.

400

Lateral

Medial

Superior Inferior

Cortex

Bowel

Sinus

Inferiorpole

Aorta

L A B E L E D : LT KID COR INF POLE

19. Longitudinal image of the left kidney just anterior to the long axis.

401

Lateral

Medial

Superior Inferior

Cortex

Sinus

Anteriorportion

L A B E L E D : LT KID COR ANT

20. Longitudinal image of the left kidney just posterior to the long axis.

402

Lateral

Medial

Superior Inferior

Cortex

Sinus

Posteriorportion

L A B E L E D : LT KID COR POST

AXIAL IMAGES

21. Axial image of the left kidney superior pole.

403

Lateral

Medial

Anterior Posterior

Cortex

Sinus

Superiorpole

L A B E L E D : LT KID LT TRV SUP POLE

22. Axial image of the left kidney midportion to include the hilum and anterior toposterior measurement.

404

Lateral

Medial

Anterior Posterior

Cortex

Sinus

Midportion

Renalvasculature



405


24. Axial image of the left kidney inferior pole.

406

Lateral

Medial

Anterior Posterior

Cortex

Sinus

Inferiorpole

Medullarypyramids

L A B E L E D : LT KID LT TRV INF POLE

VII. Spleen Study/Limited Abdomen

Spleen

LONGITUDINAL IMAGES

1. Long axis image of the spleen.

407

SCANNING TIP: If the adjacent pleural space and a portion of the left kidney wereadequately demonstrated on Number 1, Numbers 2 and/or 3 may be omitted.

Lateral

Medial

InferiorSuperior

Long axisof spleen

Diaphragm Left kidney

L A B E L E D : SPLEEN COR LONG AXIS

2. Superior longitudinal image of the spleen to include the adjacent pleural space.

408

Lateral

Medial

InferiorSuperior

Spleen

Diaphragm

Rib shadows

Pleuralspace

L A B E L E D : SPLEEN COR SUP

3. Inferior longitudinal image of the spleen to include part of the left kidney forparenchyma comparison.

409

Lateral

Medial

InferiorSuperior

Spleen

Leftkidney

Pleuralspace

L A B E L E D : SPLEEN COR INF

AXIAL IMAGES

4. Axial image of the spleen to include both anterior and posterior margins.

410

Lateral

Medial

PosteriorAnterior

Splenichilum

Diaphragm

SCANNING TIP: If the anterior and posterior margins were adequatelydemonstrated on Number 4, Numbers 5 and/or 6 may be omitted.


5. Axial image of the spleen to include both anterior margin and splenic hilum.

411

Lateral

Medial

PosteriorAnterior

Splenichilum

Diaphragm

Spleen Rib shadow

L A B E L E D : SPLEEN LT TRV ANT

6. Axial image of the spleen to include the posterior margin.

412


Lateral

Medial

PosteriorAnterior

Splenichilum Diaphragm

Spleen

L A B E L E D : SPLEEN LT TRV POST

Left Kidney

LONGITUDINAL IMAGE


413

Lateral

Medial

Superior Inferior

Inferiorpole

Cortex

Sinus

MidportionSuperior

pole

Spleen

Medullarypyramids

Renalcapsule

L A B E L E D : LT KID SAG LONG AXIS

AXIAL IMAGE


414

PosteriorAnterior

Lateral

Medial

Cortex

Sinus

Medullarypyramids

Midportion

Renalvasculature


IV

415

The Pelvis

SECTION ONE

IMAGE PROTOCOL FOR THE TRANSABDOMINAL SONOGRAPHICSTUDY OF THE FEMALE PELV IS

SECTION TWO

IMAGE PROTOCOL FOR THE TRANSVAGINAL SONOGRAPHIC STUDYOF THE FEMALE PELV IS

SECTION THREE

IMAGE PROTOCOLS FOR SONOGRAPHIC STUDIES OF THE FEMALEPELV IS

I. Transrectal Prostate Gland Study

II. Scrotum Study

II. Penis Study

416

SECTION ONE

IMAGE PROTOCOL FOR THE TRANSABDOMINAL SONOGRAPHICSTUDY OF THE FEMALE PELV IS

• Criteria:— Begin studies with a survey of pelvic structures in at least two scanning planes.— No single organ examinations are performed.— Do not share the results of the study with the patient. Legally, only physicians can

give a diagnosis.

417

418

I. Transabdominal Female Pelvis Study

Vagina • Uterus • Pelvic Cavity

LONGITUDINAL IMAGES

Sagittal Plane • Anterior Approach

SCANNING TIP: Longitudinal images begin with representative images of thepelvic cavity followed by a long axis image of the uterus.

1. Longitudinal image of the midline of the pelvic cavity just superior to the symphysispubis.

419

Anterior

Inferior

Posterior

Superior

Vagina

Uterine cervix

Uterine body

Endometrium

Uterinefundus

Urinarybladder

L A B E L E D : PELVIS SAG MIDLINE

2. Longitudinal image of the right adnexa that may include part of the uterusdepending on its position.

420

Anterior

Inferior

Posterior

Superior

Section ofendometrium

Urinarybladder

Lateral margin ofuterine body

L A B E L E D : PELVIS SAG R1

3. Longitudinal image to include the right lateral wall of the bladder and pelvicsidewall.

421

Anterior

Inferior

Posterior

SuperiorUrinarybladder

Lateral margin ofuterine body

L A B E L E D : PELVIS SAG R2

4. Longitudinal image of the left adnexa that may include part of the uterus dependingon its position.

422

Anterior

Inferior

Posterior


Bowel

Left ovaryMusculature

L A B E L E D : PELVIS SAG L1

5. Longitudinal image to include the left lateral wall of the bladder and pelvicsidewall.

423

Anterior

Inferior

Posterior


BowelMusculature

L A B E L E D : PELVIS SAG L2

6. Long axis image of the uterus to include as much endometrial cavity as possiblewith uterine length (superior to inferior) and height (anterior to posterior)measurements.

424

Anterior

Inferior

Posterior


L A B E L E D : UTERUS SAG LONG AXIS


425

SCANNING TIP: It may be necessary to take an additional image demonstratingthe long axis of the endometrial, endocervical, and vaginal canals. If so, label asfollows: UT SAG

L A B E L E D : UTERUS SAG LONG AXIS

Vagina • Uterus • Pelvic Cavity

AXIAL IMAGES

Transverse Plane • Anterior Approach8. Axial image of the vagina.

426

Anterior

Posterior

VaginaUrinarybladder

Rectum

Patient's right Patient's left

Coccygeusmuscle

Vaginalcanal

Gluteusmaximus muscle

Coccygeusmuscle

L A B E L E D : TRV VAG

9. Axial image of the cervix.

427

Anterior

Posterior

Urinarybladder

Cervix


Shadowingfrom vaginal

fornices

Musculatureof pelvic floor

Obturatorinternusmuscle

L A B E L E D : TRV CERX

10. Axial image of the uterus body.

428

Anterior

Posterior

Uterine body

Urinarybladder

Bowel

Leftovary

Musculature

Endometrium


Portion ofright ovary

Pelvicmusculature

L A B E L E D : TRV UT BODY

11. Axial image of the uterus fundus measuring uterine width (right to left).

429

Anterior

Posterior

Urinarybladder

Patient'sright

Patient'sleft

L A B E L E D : TRV UT FUNDUS


430

L A B E L E D : TRV UT FUNDUS

431

Right Ovary

LONGITUDINAL IMAGES

Sagittal Plane • Anterior Approach13. Long axis image of the right ovary measuring length (superior to inferior) and height

(anterior to posterior).

SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: RT OV SAG OBL LONG AXIS

Anterior

Inferior

Posterior


L A B E L E D : RT OV SAG LONG AXIS

432


L A B E L E D : RT OV SAG LONG AXIS

433

Right Ovary

AXIAL IMAGES

Transverse Plane • Anterior Approach15. Axial image of the right ovary with width (right to left) measurement.

Anterior

Posterior

Urinarybladder

Patient'sright

Patient's left

SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: RT OV TRV OBL

L A B E L E D : RT OV TRV

434

16. Same image as Number 15 without calipers.

L A B E L E D : RT OV TRV

435

Left Ovary

LONGITUDINAL IMAGES


17. Long axis image of the left ovary measuring length (superior to inferior) and height(anterior to posterior).

436

Anterior

Inferior

Posterior

Superior

Urinarybladder

L A B E L E D : LT OV SAG LONG AXIS

SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: LT OV SAG QBL LONG AXIS

437


L A B E L E D : LT OV SAG LONG AXIS

438

AXIAL IMAGES

Transverse Plane • Anterior Approach19. Axial image of the left ovary with width (right to left) measurement.

Anterior

Posterior

Urinarybladder

Patient'sright

Patient's left

SCANNING TIP: If this image of the ovary was angled from midline, then theimage is obliqued and must be labeled as follows: LT OV TRV OBL

L A B E L E D : LT OV TRV

439


L A B E L E D : LT OV TRV

440

SECTION TWO

IMAGE PROTOCOL FOR THE TRANSVAGINAL SONOGRAPHIC STUDYOF THE FEMALE PELV IS

• Criteria:— In most cases, “trans” or “endo” vaginal sonography is used in conjunction with

transabdominal sonography when pelvic contents require further evaluation.— Verbal or written consent is required from the patient. Explain the details of the

exam; inform the patient that the exam is virtually painless, that the insertedtransducer feels like a tampon, and that the exam is necessary for the interpretingphysician to make an accurate diagnosis.

— The exam should be chaperoned by a female healthcare professional. The initials ofthe witness should be included as part of the film labeling.

— Begin studies with a survey of pelvic structures in at least two scanning planes.— Do not share the results of the study with the patient. Legally, only physicians can

give a diagnosis.

441

I. Transvaginal Female Pelvis Study

Uterus • Adnexa

LONGITUDINAL IMAGES


442

1. Longitudinal midline image. If the long axis of the uterus is visualized here, theninclude measurements of uterine length and height.

Uterus

Endometrium

SCANNING TIP: If the long axis is not imaged at midline, it should be takenfollowing Number 1 and be labeled as follows: TV SAG UT LONG AXIS

L A B E L E D : TV SAG ML or TV SAG ML UT LONG AXIS(“TV” indicates transvaginal)

443


L A B E L E D : TV SAG ML or TV SAG ML UT LONG AXIS

444

3. Longitudinal image of the uterus fundus to include the endometrial cavity.

Endometrium

Uterine fundus

L A B E L E D : TV SAG FUNDUS

445

4. Longitudinal image of the uterus body and cervix to include the endometrial cavity.

Endometrium

Uterinebody

Uterinecervix

Endocervicalcanal

L A B E L E D : TV SAG BODY/CERX

446

AXIAL IMAGES

Coronal Plane • Inferior Approach5. Axial image of the uterine fundus measuring uterine width.

EndometriumUterine fundus

L A B E L E D : TV COR FUNDUS

447


L A B E L E D : TV COR FUNDUS

448

7. Axial image of the uterine body.

Endometrium

Uterine body

L A B E L E D : TV COR BODY

449

8. Axial image of the cervix.

Endocervicalcanal

Uterine cervix Sidewall shadow

L A B E L E D : TV COR CERX

450

Right Ovary

AXIAL IMAGES

Coronal Plane • Inferior Approach

9. Axial image of the right ovary measuring ovarian width (right to left).

SCANNING TIP: For the sake of instruction, this assumes that the ovary long axisis visualized in a sagittal plane.

Follicles

Follicles

Follicles

Right ovary

L A B E L E D : TV COR RT OV

451


L A B E L E D : TV COR RT OV

452

LONGITUDINAL IMAGES


11. Long axis image of the right ovary measuring ovarian length and height.


Follicles

FollicleRight ovary

L A B E L E D : TV SAG RT OV LONG AXIS

453


L A B E L E D : TV SAG RT OV LONG AXIS

454

Left Ovary

AXIAL IMAGES

Coronal Plane • Inferior Approach

13. Axial image of the left ovary measuring ovarian width (right to left).


L A B E L E D : TV COR LT OV

Follicle

Follicle

Follicles

Left ovary

455


L A B E L E D : TV COR LT OV

456

LONGITUDINAL IMAGES


15. Long axis image of the left ovary measuring ovarian length and height.


L A B E L E D : TV SAG LT OV LONG AXIS

Follicles

Left ovary

457


L A B E L E D : TV SAG LT OV LONG AXIS

458

SECTION THREE

IMAGE PROTOCOLS FOR SONOGRAPHIC STUDIES OF THE MALEPELV IS


II. Scrotum Study

III. Penis Study

• Criteria:— These exams should be witnessed by another healthcare professional, whose

initials should be part of the lm labeling. For transrectal or endorectal prostateevaluations, the patient’s verbal or written consent is also required.

— Begin studies with a survey of pelvic structures in at least two scanning planes.— Do not share the results of the study with the patient. Legally, only physicians can

give a diagnosis.

459


Prostate Gland

* Images in this section are by courtesy of the Ultrasound Department of the Methodist Hospital, Houston, Texas.

460

Prostate Gland

AXIAL IMAGES

Transverse Plane • Rectal Approach1. Axial image of the seminal vesicles.

Anterior

Right Left

Seminalvesicle

Posterior(rectum)

Urinarybladder

SCANNING TIP: Because of the limited field of view, both seminal vesicles may notbe entirely visible on a single view. If so, take the following additional images.

L A B E L E D : ER TRV SEM V

461

2. Axial image of the right seminal vesicle to include its right lateral margin.

Anterior

Right Left

Right seminalvesicle

Posterior(rectum)

Urinarybladder

L A B E L E D : ER TRV SEM V RT

462

3. Axial image of the left seminal vesicle to include its left lateral margin.

462

Right Left

vesicleLeft seminal

Anterior

Urinarybladder

Posterior(rectum)

L A B E L E D : ER TRV SEM V LT

463

4. Axial image of the base of the prostate.

Anterior

Right Left

Base of prostate

Posterior(rectum)

L A B E L E D : ER TRV BASE

464

5. Axial image of the midprostate.

Anterior

Right Left

Posterior(rectum)

Midprostate

L A B E L E D : ER TRV MID

465

6. Axial image of the apex of the prostate.

Anterior

Right Left

Apex ofprostate

Posterior(rectum)

L A B E L E D : ER TRV APEX

466

LONGITUDINAL IMAGES

Transverse Plane • Rectal Approach7. Longitudinal midline image of the prostate.

Anterior

Right Left

Apex ofprostate

Posterior(rectum)

L A B E L E D : ER SAG ML

467

8. Longitudinal image of the right lateral portion of the prostate gland and seminalvesicle.

Anterior

Urinarybladder

Urethra

Prostate

Superior InferiorPosterior (rectum)

Anterior

Urinary bladder

Urethra

Prostate

SuperiorPosterior (rectum)

Inferior

L A B E L E D : ER SAG RT

468

9. Longitudinal image of the left lateral portion of the prostate gland and seminalvesicle.

Superior

Right seminalvesicle

Anterior

ProstateInferior

Posterior (rectum)

L A B E L E D : ER SAG LT

469

II. Scrotum Study

Right Hemiscrotum

LONGITUDINAL IMAGES

Sagittal Plane • Anterior Approach1. Long axis image of the spermatic cord at normal respiration or rest with anterior to

posterior measurement.

Spermatic cord

L A B E L E D : RT CORD SAG REST

470


L A B E L E D : RT CORD SAG REST

471

3. Long axis image of the spermatic cord at valsalva with anterior to posteriormeasurement.

Spermatic cord

L A B E L E D : RT CORD SAG VAL

472


L A B E L E D : RT CORD SAG VAL

473

5. Longitudinal image of the head of the epididymis.

Head of epididymis

L A B E L E D : RT EPI HEAD SAG

474

6. Longitudinal image of the right testis at its most superior margin.

Testi superior border

L A B E L E D : RT TESTIS SAG SUP

475

7. Longitudinal image of the midportion of the right testis.

Testis mid portion

L A B E L E D : RT TESTIS SAG MID

476

8. Long axis image of the right testis with superior to inferior measurement.

Testis long axis

SCANNING TIP: If necessary, use dual imaging to obtain the entire long axis of thetestis on the image.

L A B E L E D : RT TESTIS SAG LONG AXIS

477


L A B E L E D : RT TESTIS SAG LONG AXIS

478

10. Longitudinal image of the medial portion of the right testis.

Testis medial portion

L A B E L E D : RT TESTIS SAG MED

479

11. Longitudinal image of the lateral portion of the right testis.

Testis lateral portion

L A B E L E D : RT TESTIS SAG LAT

480

12. Longitudinal image of the right testis at its most inferior margin.

Testis inferior border

L A B E L E D : RT TESTIS SAG INF

481

13. Longitudinal image of the tail of the epididymis (if visualized).

Tail of epididymis

L A B E L E D : RT EPI TAIL SAG

482

Right Hemiscrotum

AXIAL IMAGES

Transverse Plane • Anterior Approach14. Axial image of the spermatic cord at normal respiration or rest with anterior to


Spermatic cord

L A B E L E D : RT CORD TRV REST

483


L A B E L E D : RT CORD TRV REST

484

16. Axial image of the spermatic cord at valsalva with anterior to posteriormeasurement.

Spermatic cord

L A B E L E D : RT CORD TRV VAL

485


L A B E L E D : RT CORD TRV VAL

486

18. Axial image of the epididymal head.

Head of epididymis

L A B E L E D : RT EPI HEAD TRV

487

19. Axial image of the superior portion of the right testis.

Testis superiorportion

L A B E L E D : RT TESTIS TRV SUP

488

20. Axial image of the midportion of the right testis with medial to lateralmeasurement.

Testis midportion

L A B E L E D : RT TESTIS TRV MID

489


L A B E L E D : RT TESTIS TRV MID

490

22. Axial image of the inferior portion of the right testis.

Testis inferiorportion

L A B E L E D : RT TESTIS TRV INF

491

23. Axial image of the tail of the epididymis (if visualized).

Tail of epididymis

L A B E L E D : RT TESTIS TRV INF / EPI TAIL

492

Left Hemiscrotum

LONGITUDINAL IMAGES

Sagittal Plane • Anterior Approach24. Long axis image of the spermatic cord at normal respiration or rest with anterior to


Spermatic cord

L A B E L E D : LT CORD SAG REST

493


L A B E L E D : LT CORD SAG REST

494

26. Long axis image of the spermatic cord at valsalva with anterior to posteriormeasurement.

Spermatic cord

L A B E L E D : LT CORD SAG VAL

495


L A B E L E D : LT CORD SAG VAL

496

28. Longitudinal image of the head of the epididymis.

Head of epididymis

L A B E L E D : LT EPI HEAD SAG

497

29. Longitudinal image of the left testis at its most superior margin.

Testis superior border

L A B E L E D : LT TESTIS SAG SUP

498

30. Longitudinal image of the midportion of the left testis.

Testis mid portion

L A B E L E D : LT TESTIS SAG MID

499

31. Long axis image of the left testis with superior to inferior measurement.

Testis long axis

SCANNING TIP: If necessary, use dual imaging to obtain the entire long axis of thetestis on the image.

L A B E L E D : LT TESTIS SAG LONG AXIS

500


L A B E L E D : LT TESTIS SAG LONG AXIS

501

33. Longitudinal image of the medial portion of the left testis.

Testis medial portion

L A B E L E D : LT TESTIS SAG MED

502

34. Longitudinal image of the lateral portion of the left testis.

Testis lateral portion

L A B E L E D : LT TESTIS SAG LAT

503

35. Longitudinal image of the left testis at its most inferior margin.

Testis inferior border

L A B E L E D : LT TESTIS SAG INF

504

36. Longitudinal image of the tail of the epididymis (if visualized).

Tail of epididymis

L A B E L E D : LT EPI TAIL SAG

505

Left Hemiscrotum

AXIAL IMAGES:

Transverse Plane • Anterior Approach37. Axial image of the spermatic cord at normal respiration or rest with anterior to


Spermatic cord

L A B E L E D : LT CORD TRV REST

506


L A B E L E D : LT CORD TRV REST

507

39. Axial image of the spermatic cord at valsalva with anterior to posteriormeasurement.

Spermatic cord

L A B E L E D : LT CORD TRV VAL

508


L A B E L E D : LT CORD TRV VAL

509

41. Axial image of the epididymal head.

Head of epididymis

L A B E L E D : LT EPI HEAD TRV

510

42. Axial image of the superior portion of the left testis.

Testis superior portion

L A B E L E D : LT TESTIS TRV SUP

511

43. Axial image of the midportion of the left testis with medial to lateral measurement.

Testis mid portion

L A B E L E D : LT TESTIS TRV MID

512


L A B E L E D : LT TESTIS TRV MID

513

45. Axial image of the inferior portion of the left testis.

Testis inferior portion

L A B E L E D : LT TESTIS TRV INF

514

46. Axial image of the tail of the epididymis (if visualized).

Tail of epididymis

L A B E L E D : LT TESTIS TRV INF / EPI TAIL

515

47. Axial image of the midportion of both testes.

RT testis LT testis

L A B E L E D : BILAT TESTES TRV

516

III. Penis Study

Penis1. Axial section of the penis.

Corpuscavernosum

Corpusspongiosum

Urethra

Deep artery

517

2. Longitudinal section of the penis.

Corpuscavernosum

Deep artery

Corpusspongiosum

Buck’sfascia

Tunicaalbuginea

Tunicaalbuginea

518

Penis

LONGITUDINAL IMAGES

Sagittal Plane • Anterior Approach1. Longitudinal image of the left lateral, superior portion of the penis to include the

corpus spongiosum, corpus cavernosum, and cavernosal artery.

L A B E L E D : SAG PENIS LT SUP

2. Longitudinal image of the left lateral, midportion of the penis to include the corpusspongiosum, corpus cavernosum, and cavernosal artery.

L A B E L E D : SAG PENIS LT MID

3. Longitudinal image of the left lateral, inferior portion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.

L A B E L E D : SAG PENIS LT INF

519

4. Longitudinal image of the left lateral glans penis.

L A B E L E D : SAG PENIS LT GLANS

5. Longitudinal image of the right lateral, superior portion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.

L A B E L E D : SAG PENIS RT SUP

6. Longitudinal image of the right lateral, midportion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.

L A B E L E D : SAG PENIS RT MID

7. Longitudinal image of the right lateral, inferior portion of the penis to include thecorpus spongiosum, corpus cavernosum, and cavernosal artery.

L A B E L E D : SAG PENIS RT INF

8. Longitudinal image of the right lateral glans penis.

L A B E L E D : SAG PENIS RT GLANS

520

Penis

AXIAL IMAGES


9. Axial image of the superior portion of the penis to include the corpus spongiosum,corpus cavernosum, and cavernosal arteries.

L A B E L E D : TRV PENIS SUP

10. Axial image of the midportion of the penis to include the corpus spongiosum, corpuscavernosum, and cavernosal arteries.

L A B E L E D : TRV PENIS MID

11. Axial image of the inferior portion of the penis to include the corpus spongiosum,corpus cavernosum, and cavernosal arteries.

L A B E L E D : TRV PENIS INF

12. Axial image of the glans penis.

L A B E L E D : TRV PENIS GLANS

521

VObstetrics

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE EARLYF IRST TR IMESTER

SECTION TWO

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE LATEF IRST TR IMESTER

SECTION THREE

IMAGE PROTOCOL FOR SONOGRAPHIC STUDIES OF THE SECONDAND TH IRD TR IMESTERS

I. Second and Third Trimester Study

SECTION FOUR

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF MULT IPLEGESTAT IONS

I. Multiple Gestations Study

II. The Biophysical ProfileMultiple Gestations

522

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE EARLYF IRST TR IMESTER

• Criteria:— No limited studies.— Before the examination, a patient history should be taken to include the date of the

first day of the patient’s last period, gravidity, parity, and history of any pelvicsurgery.

— Begin early first trimester studies with a survey of the uterus and adnexa followedby the pregnancy if present.

— When transvaginal sonography is used in conjunction with the routinetransabdominal study, the patient’s verbal or written consent is required. Also, theexam should be chaperoned by a female healthcare professional, whose initialsshould be included as part of the film labeling.

— Do not share the results of the study with the patient. Legally, only physicians cangive a diagnosis.

523

I. Early First Trimester Study

Early First Trimester

UTERUS LONG AXIS

Gestational Sac Location

Sagittal Plane • Transabdominal Approach

524

1. Long axis image of the uterus showing the location of the gestational sac.

525

Gestationalsac

Superior Inferior

Amnioticcavity/fluid

Uterus

Vaginalcanal

Vagina

Urinary bladderAnterior

Posterior

L A B E L E D : UT LONG AX SAG

GESTATIONAL SAC

Sagittal/Transverse Plane • Transabdominal Approach

526

SCANNING TIP: Gestational sac images are taken whether an embryo is identifiedor not. Depending on the earliness of gestation, it may be helpful to magnify the fieldof view for these images.

SCANNING TIP: Scanning plane is dictated by the position of the anatomy.

2. Longitudinal image of the gestational sac with length (superior to inferior) anddepth (anterior to posterior) measurements (calipers inside wall to inside wall).

527

Gestationalsac

Superior Inferior

Urinary bladderAnterior

Posterior

Endometrialspace

Uterus

Decidual reaction

Trophoblasticring

L A B E L E D : GS SAG or TRV


528


4. Axial image of the gestational sac with greatest width (right to left) measurement(calipers inside wall to inside wall).

529

Right

Anterior

Posterior

Uterus

Decidualreaction

Embryo

Left

Width measurement



530

SCANNING TIP: If the yolk sac or embryo is present and has not been clearlydemonstrated with the gestational sac measurement images, an additional image of theyolk sac or embryo (or both) should be taken and labeled accordingly.


YOLK SAC AND/OR EMBRYO

Sagittal/Transverse Plane • Transabdominal Approach6. Image demonstrating the yolk sac and/or embryo.

531

Uterus

Amnioticcavity

Embryo

Yolk sac

Amnion

Chorioniccavity

L A B E L E D : YOLK SAC / EMBRYO SAG or TRV

7. Long axis image of embryo with length (superior to inferior) or crown rump (CR)length measurement.

532

UterusDecidual reaction

Head (“crown”)

Gestational sac

Rump

L A B E L E D : EMBRYO LONG AXIS or CR


533

L A B E L E D : CR

9. Doppler documentation of viability.

534

.40

m/s

.40Fetal heart Doppler signal

Doppler gate

Trophoblasticring

Yolk sacGestationalsac

L A B E L E D : DOP VIAB

535

SECTION TWO

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE LATEF IRST TR IMESTER



— Begin late first trimester studies with a survey of the uterus and adnexa followedby the pregnancy.

— When transvaginal sonography is used in conjunction with the routinetransabdominal study, the patient’s verbal or written consent is required. Also, theexam should be chaperoned by a female healthcare professional, whose initialsshould be included as part of the film labeling.


I. Late First Trimester Study

Late First Trimester

UTERUS LONG AXIS

Gestational Sac Location


536

1. Long axis image of the uterus showing the location of the gestational sac.

537

Uterus

Anterior

Posterior

InferiorSuperior


Gestationalsac

Vagina

Maternal urinarybladder

L A B E L E D : UT LONG AX SAG

GESTATIONAL SAC

Sagittal/Transverse Plane • Transabdominal Approach

538

SCANNING TIP: Assuming an embryo is identified, the crown rump (CR) lengthmeasurement is taken in the scanning plane where its long axis appears.

SCANNING TIP: For the following images, the scanning plane is determined by theposition of the anatomy.

2. Longitudinal image of the gestational sac to include the embryo (if visualized) withmeasurement from crown to rump (if applicable) and placenta location (ifdistinguishable).

539

UterusEmbryo

Posterior

InferiorSuperior


Gestationalsac

AnteriorPlacenta

Foleyballoon

Urinarybladder


3. Same image as Number 2 without measurement calipers (if applicable).


4. Axial image of the gestational sac to include the embryo (if visualized) withmeasurement from crown to rump (if applicable) and placenta location (ifdistinguishable).

540

Uterus

Embryo


Gestationalsac

Anterior

Posterior

LeftRight

Placenta


5. Same image as Number 4 without measurement calipers (if applicable).


541

SCANNING TIP: In this case, the longest axis of the embryo was not visualized onthe previous images; therefore an additional image demonstrating the longest axis ofthe embryo with crown rump length measurement follows on the next page.

6. Long axis image of the embryo with measurement from crown to rump.

542

Limb bud

Calipers forcrown rump

length

Calipers forcrown rumplength


Head

Body

L A B E L E D : CR

7. Same image as Number 6 without calipers.

543

SCANNING TIP: In addition to the crown rump length measurement, someinstitutions require biparietal diameter, abdominal circumference, and femur lengthmeasurements of the embryo during the later part of the first trimester. Many expertsbelieve that these additional measurements are not necessary because they do not addany new information to the study and they are not as accurate as the crown rumplength measurement for determining gestational age.

L A B E L E D : CR

8. An optional view(s) of the embryo demonstrating limbs.

544

SCANNING TIP: It may be helpful to magnify the field of view for the limbimage(s).

Uterus

Gestationalsac

Arm buds

Head“Tail”

Leg buds

L A B E L E D : LIMBS

545

SECTION THREE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE SECONDAND TH IRD TR IMESTERS



— Begin second and third trimester studies with a survey of the uterus and adnexafollowed by the pregnancy.

— When transvaginal or translabial sonography is used in conjunction with theroutine transabdominal study, the patient’s verbal or written consent is required.Also, the exam should be chaperoned by a female healthcare professional, whoseinitials should be included as part of the film labeling.


I. Second and Third Trimesters Study

Second and Third Trimesters

UTERUS LONG AXIS


546

1. When the trimester allows, long axis image of the uterus and contents or bestoverall longitudinal presentation.

547

L A B E L E D : UT SAG

SCANNING TIP: In this case, the trimester was too advanced to image the entireuterus on a single view.

Amnioticfluid

Fetalcranium

PLACENTA

Scanning Plane Determined by Position of Placenta • TransabdominalApproach

2. Longitudinal image of the placenta

548

Placenta

Portion offetal chest

and abdomen

Fetal limbsMyometrium

Amnioticfluid

Lacunae

L A B E L E D : PLACENTA SAG or TRV

PLACENTA

Scanning Plane Determined by Position of Placenta • TransabdominalApproach

3. Axial image of the placenta.

549

Lamina

PlacentaCentrum

Amnioticfluid

L A B E L E D : PLACENTA SAG or TRV

CERVIX


4. Longitudinal image of the cervix to include the internal os.

550

Placenta

Cervical canal

Internal os

Uterus

Body

Inferior

Anterior

Superior

Posterior

Cervix

Urinarybladder

Amnioticfluid/cavity

L A B E L E D : CERVIX SAG

Longitudinal translabial image of the lower uterine segment.

551

SCANNING TIP: An image of the lower uterine segment to include the internal os isrequired to rule out placenta previa and to document the cervix. When the head of thefetus or the mother’s body habitus inhibits imaging of the lower uterine segment, eithera transvaginal or translabial image must be obtained. The translabial image isobtained with an empty or nearly empty bladder. The transducer is covered with asheath, condom, or glove and placed between the labia. The transducer is angled sothat the cervix is nearly perpendicular to the ultrasound beam.

Placenta

Bowel

Inferio

r

Anterior

Su

per

ior

Posterior

Cervix

Vagina

Prominentuterine

veins

Amnioticfluid

Empty maternalbladder

L A B E L E D : CERVIX TRANSLAB

AMNIOTIC FLUID

Scanning Plane Determined by Position of Anatomy • TransabdominalApproach

5. Depending on the stage of gestation, an overall longitudinal image of amniotic fluidor the largest pocket with superior to inferior measurement.

552

Placenta

Inferior

Anterior

Superior

Posterior


L A B E L E D : FLUID SAG or TRV

AMNIOTIC FLUID


6. Depending on the stage of gestation, an overall axial image of amniotic fluid or thelargest pocket with anterior to posterior and right to left measurements.

553

Placenta

Left

Anterior

Right

Posterior


L A B E L E D : FLUID SAG or TRV

FETAL ANATOMY

Transabdominal Approach

554

SCANNING TIP: At times, a quantitative measurement of amniotic fluid isrequired. Anteroposterior (AP) measurements are obtained for the right and left upperand lower quadrants. The sum of these AP measurements is called the amniotic fluidindex (AFI). Fluid pockets that contain primarily cord or fetal parts are not includedin the measurement.

SCANNING TIP: Because of the variability of fetal position and movement, thefollowing fetal anatomy images may be taken in any sequence.

SCANNING TIP: An ultrasound examination during the second and thirdtrimesters requires the documentation of a large number of anatomic structures;therefore two or more structures can be documented on a single image if they are wellrepresented.

SCANNING TIP: Because of the variability of fetal position and movement, thescanning plane is not included as part of the film labeling for the following images:

7. Longitudinal image of the cervical spine.

555

Amnioticfluid

Anteriorspinal

processes

Posteriorspinal

processes

Occipitalbone of

skull

Cervicalspine

L A B E L E D : C SPINE

8. Longitudinal image of the thoracic spine.

556

Amnioticfluid

Anteriorspinal

processes

Posteriorspinal

processes

Thoracicspine

L A B E L E D : T SPINE

9. Longitudinal image of the lumbar spine.

557

Anteriorspinal

processes

Posterior spinal processes

Fetal bladder

Fetal skin

CoccyxSpinal cord

L A B E L E D : L SPINE

10. Longitudinal image of the sacral spine.

558

Placenta

Anteriorelement

Posteriorelement Coccyx

Acoustic shadows

Sacralspine

SCANNING TIP: In some cases the long axis of the spine can be visualized on asingle image. If so, take the image, and label it as follows: SPINE LONG AX

L A B E L E D : S SPINE

11. Axial image of the cervical spine.

559

Placenta

Anteriorspinalprocessesof cervicalvertebra

Posterior spinalprocessesof cervicalvertebra


Clavicles

Clavicles

L A B E L E D : C SPINE

12. Axial image of the thoracic spine.

560

Placenta

LimbShoulder


Throracicvertebrae

Posteriorspinal

processes

Scapulae Anteriorspinal

processes

L A B E L E D : T SPINE

13. Axial image of the lumbar spine.

561

Placenta

Limb

Kidney


Lumbarvertebrae

Stomach

Limb

Kidney

L A B E L E D : L SPINE

14. Four-chamber view of the fetal heart to include its location within the thorax.

562

Right ventricle

Rib

Rightatrium

Apex ofthe heart

Leftventricularseptum

Left atriumSpine

Left

Descendingaorta

Tricuspid valve

Atrialseptum

Mitralvalve

LeftventricleForamen

ovalae

Right

Anterior

Posterior

L A B E L E D : HEART

15. An optional image showing the normal right ventricular outflow tract.

563

Pulmonaryvalve leaflet

Placenta

Right ventricularoutflow tract

Right atrium

Hand

Mainpulmonaryartery

Rightpulmonaryartery

Thorax

Aorta

Amnioticfluid

Pulmonaryvalve leaflet

Leftpulmonaryartery

Descendingaorta

Left atrium

L A B E L E D : RVOT

16. An optional image showing the normal left ventricular outflow tract.

564

Liver

AortaSpleenDescending

aorta

Rightventricle

Heart muscle

Diaphragm

Left ventricularoutflow tract

LimbInterventricularseptum

Stomach

Leftventricle

L A B E L E D : LVOT

17. Axial image of fetal kidneys together.

565

Right kidney Vertebra

Amnioticfluid

Acoustic shadow from spine

Portal vein

Liver

Left kidney

SCANNING TIP: When the kidneys cannot be imaged together because of fetalposition or movement, take separate axial images of each kidney and label accordingly.

L A B E L E D : KIDNEYS

18. Longitudinal image of the right kidney.

566

Uterus

Placenta



Rightkidney

Spine

L A B E L E D : RT KID

19. Longitudinal image of the left kidney.

567

Uterus

Stomach


Leftkidney

Spine

L A B E L E D : LT KID

20. Image of the urinary bladder.

568

Uterus

Stomach

Amnioticfluid

Limbs

Placenta

Uterus

Urinary bladder

Amnioticfluid

Muscle

L A B E L E D : UR BLADDER

21. Image of the umbilical cord insertion site on the anterior abdominal wall.

569


Placenta

Umbilicalcord

insertion

VeinArtery

SCANNING TIP: If the insertion site image does not distinguish the three vessels ofthe cord, take an additional image of the cord to demonstrate the three vessels and labelaccordingly.

L A B E L E D : CORD

22. A magnified view of an axial section of the three-vessel umbilical cord.

570


Placenta

Umbilicalcord

Umbilicalarteries

Umbilicalvein

Limb

Wharton’sjelly

L A B E L E D : CORD

23. Image of the stomach if visualized.

571

Placenta

Stomach

Vertebrae

Umbilicalportion ofleft portalvein

SCANNING TIP: The image of the stomach is not necessary if the stomach wasdocumented on any other image.

L A B E L E D : STOMACH

24. Image of genitalia.

A. Image of male genitalia.

572

Scrotum

Testicle

Limb

Foreskin

Glans

Thigh

Penis

L A B E L E D : GENITALIA

B. Image of female genitalia.

573

Placenta

Myometrium

Amnioticfluid

Minorlabium

Thighs

Vaginalcleft

Majorlabium

L A B E L E D : GENITALIA

25. Longitudinal image of the fetus to include the diaphragm.

574

Placenta

Spine

Fetal profile

Diaphragm

Abdomen

Aorta

Thorax

Heart

L A B E L E D : DIAPHRAGM

26. Biparietal diameter (BPD) image at the level of the thalamus and the cavumseptum pellucidi. Measurement is from the outside of the near cranium to the insideof the far cranium (leading edge to leading edge).

575

Placenta

Amnioticfluid

Thalamus

Lateralventricle

Myometrium

Thirdventricle

Lateral fissure

Frontalhorns

Cavum septumpellucidum

SCANNING TIP: Because of the obvious nature of the fetal measurements, specificsare not included as part of the film labeling.

27. Cerebellum with measurement.

576

Placenta

Parietal bone

Hemispheres ofthe cerebellum

Vermis ofthe cerebellum

Calipers forcerebellar

measurement

Occipitalbone

28. Cisterna magnum with measurement.

577

Placenta Cerebellum

Calipers formeasurement ofcisternamagnum

Cisternamagnum

Cerebralpeduncles

Occipitalbone

Amniotic fluid

29. Nuchal fold (done between 16 and 24 weeks) with measurement.

578

Placenta

Cerebellum

Calipers formeasurement ofnuchal fold

Cisterna magnumOccipitalbone

Amniotic fluid

Nuchalfold

Thalamus

SCANNING TIP: The measurement of the nuchal fold is not always routinelyperformed but should be considered for the fetus of patients over 35 or when a lower-than-normal serum alpha fetal protein (AFP) level has been detected in the mother.

30. Head circumference image at the same level as the BPD, or use the BPD image.Measurement is around the outline of the cranium. Up-to-date ultrasound equipmentprovides tracking balls to trace the cranium or calipers that open to outline thecranium.

579

Placenta

Amnioticfluid

Thalamus

Lateralventricle

Myometrium

Thirdventricle

Lateral fissure

Frontalhorns


Tentorium

31. Image of the choroid plexus.

580

Placenta

Choroid plexus

Amniotic fluid

Falxcerebrei

Occipital-parietal sutureof the calvarium

Medial wallof the lateralventricle

32. Lateral ventricle with measurement.

581

Thalamus

Choroidplexus

Lateral wall of thelateral ventricle

Falxcerebrei

Calipers formeasurementof lateralventricle

Medial wall ofthe lateral

ventricle(near the atrium)

Occipitalbone

Amnioticfluid

33. Abdominal circumference image at the level of the junction of the umbilical vein andportal vein sinus. Measurement is around the outline of the abdomen. The abdomenshould appear round.

582

Portion ofuncoiledumbilical

cord

Cross-sectionfetal abdomen

Aorta

Right portalvein

Femur

Inferiorvena cava

Vertebra

Stomach

Umbilical portionof portal vein

(left portal vein)

34. Long axis image of the femur with measurement from one ossified end of the femurto the other ossified end.

583

Femur

Placenta

Bladder

SCANNING TIP: For long bone measurements, cursors are placed at the bone-cartilage interface. The cartilaginous ends of the bones are not included in themeasurement.

35. Long axis image of the humerus with measurement from one ossified end of thefemur to the other ossified end.

584

Placenta

Humerus

Rib portions/shadow

Amnioticfluid

Soft tissue and musclesurrounding humerus

Extremitycross section

Portion of spineand spinal canal

Myometrium

Blood vessel

36. Image of the lower portion of the leg.

585

PlacentaPortionof foot

Lowerleg

Tibia

Fibula

Patella

Amniotic fluid

37. Image of the radius and ulna.

586

Placenta

Radius

Lowerarm

Hand

Amnioticfluid

Ulna

Elbow

Other arm

38. Image of a hand.

587

Placenta

HandLimb

39. Another image of the hand.

588

Open fetalhand

Wrist

Thumb

Radius

Ulna

Small(5th finger)

Bent finger(out of plane)

SCANNING TIP: Most physicians require images only of one hand, foot, arm, andleg based on the assumption that both were evaluated during the survey.

40. Image of facial profile.

589

590

41. Coronal image of the nostrils and lips.

Nostrils

Placenta

Lips

Filtrum (between& below nostrils)

Acousticshadow

Amnioticfluid

Amnioticfluid

Chin

Limb

591

SECTION FOUR

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF MULT IPLEGESTAT IONS

• Criteria:— In addition to the required images for multiple gestations, each fetus of a multiple

gestation should be imaged as previously described for singleton pregnancies.— No limited studies.— Before the examination, a patient history should be taken to include the date of the


— Begin multiple gestation studies with a survey of the uterus and adnexa followedby the pregnancies.

— When transvaginal or translabial sonography is used in conjunction with theroutine transabdominal study, the patient’s verbal or written consent is required.Also, the exam should be chaperoned by a female healthcare professional, whoseinitials should be included as part of the film labeling.


592

I. Multiple Gestations StudyMultiple Gestations

Multiple Gestations

GESTATIONAL SACS


1. Image of a twin pregnancy demonstrating separate sacs.

Uterus

Placenta A

Placenta B

Sac A with embryo

Sac B with embryo

B

A

L A B E L E D : TWINS / SEP SACS

593

2. Image of second trimester twins demonstrating the presence of a separatingmembrane.

Thin membrane

Placenta

Cord B

Sac A

Sac B

Head B

Cord A

L A B E L E D : TWINS / MEMBRANE

594

3. Image of triplets.

SCANNING TIP: It is important to demonstrate the position of the presenting fetus.This is the fetus that is lower in the uterus, closer to the cervix, and will be deliveredfirst. This fetus should be labeled “a” and the other fetus(es) labeled “b,” “c,” “d,” etc.This labeling allows individual growth rates to be determined. If possible, determine thegender of each fetus. This information may help determine whether they are fraternal oridentical.

L A B E L E D : TRIPLETS

Thickmembranes

Uterus

Sac A

Sac B(embryo not inthe scanning plane)

Cord A

Sac C

Embryo C Embryo A

II. The Biophysical Profile

An examination that is often performed during the late third trimester is the biophysicalprofile (BPP). This test measures fetal well-being and consists of five parameters. The first part of the test involves a nonstress test. This test is performed in the delivery room or in an obstetrician’s office and measures spontaneous heart rate accelerations. The remaining four parameters of the BPP are measured by sonography: (1) amniotic fluid, (2) fetalrespiration, (3) fetal tone, and (4) gross body motion. These parameters and scoring of this test are described in Table 5-1, which follows the described required images.

595

Biophysical Profile

AMNIOTIC FLUID


1. Demonstration of a pocket of amniotic fluid.

596L A B E L E D : FLUID

Fluid pocket

Venons lake

Cord A

Placenta

597

2. Demonstration of fetal respiration.

Fetalheart

Fetal bladder

Respiratorymotion

Amniotic fluid

Fetal diaphragm

L A B E L E D : DIAPHRAGM / RESP

3. Demonstration of fetal tone.

598

Fetal head

Open hand

L A B E L E D : HAND

4. Demonstration of fetal gross body motion.

599

Head

Twistingof torso

Spine

Arching ofneck or back

L A B E L E D : MOTION

5. Umbilical artery Doppler measurements and determination of the SD ratio.

600

Doppler gate

Doppler calipers.60

m/s

.60

L A B E L E D : DOP / UMB ART

SCANNING TIP: Occasionally, it is necessary to measure the resistance to bloodflow within the umbilical arteries. This measurement is obtained by interrogating theumbilical cord artery with low power Doppler. The ratio of the peak systolic flow to theend diastolic flow is calculated (SD ratio). This number varies with the age of thefetus, and charts are available to determine whether blood flow through the cord isadequate.

601

Doppler gate

Doppler calipers.30

m/s

.30

Umbilicalcord

Fetalabdomen

Spectral doppler tracing ofumbilical artery blood flow

Fetal limb

L A B E L E D : DOP / UMB ART

6. Uterine artery Doppler measurement and determination of the SD ratio.

602

Doppler gate

.30

m/s

.30

Uterus

Placenta

Spectral doppler tracing ofmaternal uterine (arcuate) artery

Fetal abdomen

Amniotic fluid

L A B E L E D : DOP / UT ART

SCANNING TIP: In some cases, the physician may also want to determine whetherthe blood flow to the placenta from the mother’s circulation is adequate, so anotherDoppler measurement is made at the interface between the placenta and uterus or inthe uterine artery if possible. The SD ratio for the Doppler waveform is calculated andchecked against a chart value for the appropriate gestational age.

603

TABLE 5-1 Biophysical Profile Scoring

CRITERION SCORE (PTS)

Part INonstress test Two accelerations of 15 beats per minute 2

in 30-min test

Part IIUltrasound examinationGross movement Three separate flexions and extensions in 2

30-min examinationTone One episode of fetal opening and closing 2

of hand or clenching of foot in 30-minexamination

Respiration At least 60 seconds of fetal breathing in 230-min examination

Fluid At least 1 pocket of amniotic fluid of at 2least 1 cm in 2 dimensions

Unqualified pass 8 or moreMaximum total 10

Data from Manning EA, Platt LD, Sipos L (1980). Antenatal fetal evaluation: development of a fetal biophysicalprofile. Am J Obstet Gynecol 136: 787-795.

Small Parts

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THETHYROID GLAND

SECTION TWO

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE BREAST

I. Breast Lesion Characterization

604

VI

605

II. Whole Breast Study

SECTION THREE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THENEONATAL BRA IN

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THETHYROID GLAND

• Criteria:— Begin studies with a survey of the thyroid gland and associated structures in at

least two scanning planes.— As a general rule, the parathyroid glands are not appreciated sonographically

unless they are abnormal.— Do not share the results of the study with the patient. Legally, only physicians can

give a diagnoses.

Thyroid Gland Study

Thyroid Gland

RIGHT LOBE

606

Transverse Plane • Anterior Approach

LONGITUDINAL IMAGES

1. Longitudinal image of the inferior portion of the right lobe.

607

Anterior

Posterior

Right Left

Sternohyoid muscleIsthmus

Trachea

Inferiorlobe

Sternocleidomastoidmuscle

Internaljugular vein

Sternothyroidmuscle

Inferiorthyroid vessel

Commoncarotid artery

Longuscolli muscle

L A B E L E D : RT LOBE TRV INF

2. Longitudinal image of the midportion of the right lobe.

608

Anterior

Posterior

Right Left

Sternohyoid muscleIsthmus

Trachea

Midlobe


Internaljugular vein

Sternothyroidmuscle


Longuscolli muscle

L A B E L E D : RT LOBE TRV MID

3. Longitudinal image of the superior portion of the right lobe.

609

Anterior

Posterior

Right Left

Sternohyoid muscle

Trachea

Superiorlobe


Internaljugularvein

Sternothyroidmuscle

Commoncarotidartery

Longuscolli muscle

Venousstructures

L A B E L E D : RT LOBE TRV SUP

4. Long axis image of the thyroid to include the isthmus and both right and left lobeattachments.

610

Anterior

Posterior

Right Left

Sternohyoid muscle

TracheaRightlobe


Sterno-thyroidmuscle

Left commoncarotid artery

Longuscolli muscle

Isthmus

Longuscolli muscle

Right commoncarotid artery

Sterno-thyroidmuscleLeft

lobe

Sternocleido-mastoidmuscle

L A B E L E D : ISTHMUS TRV

RIGHT LOBE


AXIAL IMAGES

5. Axial image of the medial portion of the right lobe.

611

Anterior

Posterior

SuperiorInferior

Platysmamuscle

Trachea

Sternothyroidmuscle

Venousstructures

Mediallobe

Sterno-hyoidmuscle

Skin

Thyroidcartilage

L A B E L E D : RT LOBE SAG MED

6. Axial image of the lateral portion of the right lobe.

612

Anterior

Posterior

Superior Inferior

SternothyroidmuscleLateral

lobe

Sterno-hyoidmuscle

Skin

L A B E L E D : RT LOBE SAG LAT

LEFT LOBE

Transverse Plane • Anterior Approach

LONGITUDINAL IMAGES

7. Longitudinal image of the inferior portion of the left lobe.

613

Anterior

Posterior

Right Left

Commoncarotidartery

Inferiorlobe

Omohyoidmuscle

Sternohyoidmuscle


Internaljugular

vein

Inferiorthyroidvessels

Longuscolli

muscle

Esophagus


Trachea

Isthmus

L A B E L E D : LT LOBE TRV INF

8. Longitudinal image of the midportion of the left lobe.

614

Anterior

Posterior

Right Left

Commoncarotidartery

Midlobe

Omohyoidmuscle

Sternohyoidmuscle


Internaljugular

vein

Longus collimuscle

Esophagus

Isthmus

Trachea


L A B E L E D : LT LOBE TRV MID

9. Longitudinal image of the superior portion of the left lobe.

615

Anterior

Posterior

Right Left


Superiorlobe


Sternohyoidmuscle


Internaljugular veinLongus

collimuscle

Esophagus

Trachea

L A B E L E D : LT LOBE TRV SUP

LEFT LOBE


AXIAL IMAGES

10. Axial image of the medial portion of the left lobe.

616

Anterior

Posterior

Superior Inferior

Longus collimuscle

Mediallobe

Sterno-hyoidmuscle

SternocleidomastoidmuscleSkin

Sternothyroidmuscle

L A B E L E D : LT LOBE SAG MED

11. Axial image of the lateral portion of the left lobe.

617

Anterior

Posterior

Superior Inferior

Lateral lobe

Sternohyoid muscle

Sternothyroidmuscle

L A B E L E D : LT LOBE SAG LAT

618

SECTION TWO

IMAGE PROTOCOLS FOR THE SONOGRAPHIC STUDY OF THEBREAST

• Criteria:— In most cases, for women under 30 and lactating and pregnant women, breast

sonography has become the first phase of imaging for evaluating palpable masses.Breast sonography, however, is not recognized as a screening study formicrocalcifications.

— Breast sonography is generally performed to determine the composition orcharacterization of a localized lesion or lesions (that may or may not be palpable)and to further evaluate mammographic and clinical findings.

— Additional indications for breast sonography include guidance of biopsies,treatment plan for radiation therapy, and evaluating complications associated withbreast implants.

— In some cases, whole breast scanning may be recommended for diffuse diseasessuch as fibrocystic disease.

— Begin studies with a survey of the structure(s) in at least two scanning planes.

— Do not share the results of the study with the patient. Legally, only physicians cangive diagnoses.

— Use the following image of normal breast tissue as a technical guideline. Rememberthat the thickness of the sonographically distinct layers of the breast varies withage.

619

Skin line

Subcutaneouslayer

Mammarylayer

Pectoralis majormuscle

Retromammarylayer

620

I. Breast Lesion Characterization

Breast Lesion

SCANNING TIP: The location of the lesion must be recorded to accompany therequired images.

The location of the lesion can be indicated by one of the following methods:- Shown on a diagram of the breast- Specifying the quadrant- Using clock notation and distance from the nipple

SCANNING TIP: Image labeling should include right or left breast, location of thelesion, and transducer orientation with regard to the breast (axial or longitudinal,radial or anti-radial).

621

RIGHT OR LEFT BREAST

Scanning Plane Determined by Lesion Shape and Location • ApproachDetermined By Lesion Location

LONGITUDINAL AND AXIAL IMAGES

1. Longitudinal image of the lesion with measurement from the most superior to themost inferior margin.

L A B E L E D : SITE LOCATION and SCANNING PLANE


3. Axial image of the lesion with measurements from the most anterior to the mostposterior margin and from the most lateral to lateral or lateral to medial margin.




622

5. Longitudinal image of the lesion with high gain technique.

L A B E L E D : SITE LOCATION, SCANNING PLANE, HIGH GAIN

6. Axial image of the lesion with high gain technique.

L A B E L E D : SITE LOCATION, SCANNING PLANE, HIGH GAIN

7. Longitudinal image of the lesion with low gain technique.

L A B E L E D : SITE LOCATION, SCANNING PLANE, LOW GAIN

8. Axial image of the lesion with low gain technique.

L A B E L E D : SITE LOCATION, SCANNING PLANE, LOW GAIN

SCANNING TIP: Depending on the size and complexity of the lesion, additionalimages (in at least two scanning planes) may be necessary to document the extent ofthe lesion.

623

II. Whole Breast Study

Whole Breast

RIGHT OR LEFT BREAST

1. 12 o’clock image of breast tissue with the base of the transducer toward the nippleand the end of the transducer facing outward so that the nipple area is closest to thetop of the imaging screen.

L A B E L E D : 12 O’CLOCK RT or LT

2. 3 o’clock image (same orientation as Number 1).


3. 6 o’clock image.


4. 9 o’clock image.


624

5. Axial image through the nipple.

L A B E L E D : NIP TRV RT or LT

6. Longitudinal image through the nipple.

L A B E L E D : NIP SAG RT or LT

7. Longitudinal image of the axillary region.

L A B E L E D : AXILLARY SAG RT or LT

8. Axial image of the axillary region.

L A B E L E D : AXILLARY TRV RT or LT

9. to 16. The same corresponding images of the other breast.

SCANNING TIP: Sometimes, whole breast scanning includes images from 12o’clock, 1 o’clock, 2 o’clock, 3 o’clock, and so on. If this is the case, label accordinglyand include nipple and axillary images.

625

SECTION THREE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THENEONATAL BRA IN

• Criteria:— Begin studies with a survey of the brain in at least two scanning planes.— Infants should be kept warm and disturbed as little as possible.— Do not share the results of the study with the patient. Legally, only physicians can

give diagnoses.

Neonatal Brain Study

Neonatal BrainAnterior Fontanelle Approach

CORONAL IMAGES

1. Coronal image of the frontal lobes of the brain with the interhemispheric fissure.Include the orbital cones and ethmoid sinus.

626

Interhemisphericfissure

Left frontallobe of

brain

Right frontallobe ofbrain

Orbital cones Ethmoid sinus

Right Left

L A B E L E D : CORONAL

2. Coronal image of the frontal horns of the ventricles encompassing the caudatenucleus. Include the germinal matrix adjacent to the ventricles and corpus callosum.

627

Corpus callosum

Caudatenucleus


Frontalhorn

lateralventricleGerminal matrix

ThalamusTemporal

lobe

Right Left


3. Coronal image of the frontal horns and thalami. Include the sylvian fissures, septumpellucidum, third ventricle, and foramen of Monro.

628

InterhemisphericfissureLateralventricle


Caudatenucleus

Sylvianfissure

with middlecerebral artery

Thirdventricle

Temporallobe

Foramenof Monro Thalamus

Right Left


4. Coronal image of the bodies of the lateral ventricles, thalami, sylvian fissures,choroidal fissures, and temporal horns.

629

Cavum vergae

Caudatenucleus bodySylvianfissure

Body lateralventricle

Thirdventricle

Temporalhorn

lateralventricle

Thalamus

ChoroidalfissureCerebellarhemisphere

Cerebralpeduncle Pons

Right Left

Tentorium


5. Coronal image of the tentorium cerebelli. Include the sylvian fissures and thecisterna magna.

630

QuadrigeminalplateTemporalhornlateralventricle


Thalamus

Sylvianfissure

Choroidalfissure

Cisterna magna Cerebellum

Right Left

Tentorium


6. Coronal image of the choroid plexus in the atrium or trigone region.

631

Choroidplexus

Right Left

Lateralventricle


7. Coronal image of the occipital lobes of the brain.

632

Right occipitalbrain lobe

Interhemisphericfissure

Right Left


SAGITTAL IMAGES

8. Sagittal midline image of the cavum septum pellucidum, corpus callosum, thirdventricle, fourth ventricle, and cerebellum, including the massa intermedia (seen intwo thirds of infants).

633SCANNING TIP: This image should be perpendicular at the midline.

Cavum septumpellucidumThirdventricle

Massaintermedia

Sulci

Occipitallobe

Cerebellarvermis

Frontallobe

Corpuscallosum

Aqueduct of SylviusFourth ventricle

Medulla

Midline

L A B E L E D : SAG ML

9. Sagittal image of the right ventricle, germinal matrix, caudate nucleus, thalamus,and choroids plexus.

634

Germinal matrix

Anterior hornlateralventricle


Trigone

Occipitallobe

Occipitalhorn

lateral ventricle

Caudatenucleus

Temporal hornlateral ventricle

Choroid plexus

Cerebellar vermis

Right lateral

Thalamus

L A B E L E D : SAG RT LAT

SCANNING TIP: In some cases the frontal horn, body, temporal horn, and occipitalhorn cannot be imaged in the same plane. Therefore an additional image (oradditional images) may be necessary. LABELED: SAG RT LAT

10. Sagittal image of the right temporal lobe of the brain at the level of the sylvianfissure.

635

Temporallobe

Sylvianfissure

Right lateral

L A B E L E D : SAG RT LAT

11. Sagittal image of the left ventricle, germinal matrix, caudate nucleus, thalamus, andchoroid plexus.

636

SCANNING TIP: In some cases the frontal horn, body, temporal horn, and occipitalhorn cannot be imaged in the same plane. Therefore an additional image (or images)may be necessary. LABELED: SAG RT LAT

Germinal matrix

Anterior hornlateralventricle


Trigone

Occipitalhorn

lateral ventricle

Occipitallobe

Caudatenucleus

Temporal hornlateral ventricle

Choroid plexus

Cerebellar vermis

Left lateral

Thalamus

L A B E L E D : SAG LT LAT

12. Sagittal image of the left temporal lobe of the brain at the level of the sylvianfissure.

637

SCANNING TIP: Alternative axial views through the temporal recess or posteriorfontanelle are options to further evaluate the lateral ventricular walls and the occipitalhorns, respectively.

Temporallobe

Sylvianfissure

Left lateral

L A B E L E D : SAG LT LAT

638

Vascular System

SECTION ONE

IMAGE PROTOCOLS FOR ABDOMINAL DOPPLER AND COLOR FLOWSTUDIES

I. Mesentric Arterial Study

II. Renal Arterial Study

III. Image Example of Various Studies

VII

SECTION TWO

IMAGE PROTOCOLS FOR CEREBROVASCULAR DUPLEX SCANNING

SECTION THREE

IMAGE PROTOCOLS FOR PER IPHERAL , ARTER IAL , AND VENOUSDUPLEX SCANNING

I. Lower Extremity Venous Duplex Study

II. Lower Extremity Peripheral Arterial Study

SECTION ONE

IMAGE PROTOCOLS FOR ABDOMINAL DOPPLER AND COLOR FLOWSTUDIES

639

I. Mesenteric Arterial Study

1. Locate the celiac trunk as it arises from the anterior abdominal aortic wall justinferior to the diaphragm.

I M A G E : LONGITUDINAL AORTA-CELIAC ORIGIN

L A B E L E D : AORTA-CELIAC ORIGIN

2. Sample with Doppler throughout the celiac trunk.

I M A G E : DOPPLER SPECTRAL WAVEFORM FROM THE ORIGIN OF THE CELIAC

L A B E L E D : CELIAC ORIGIN

I M A G E : DOPPLER SPECTRAL WAVEFORM FROM THE DISTAL CELIAC TRUNK

L A B E L E D : CELIAC DIST

3. Return to a transverse image of the aorta at the level of the celiac origin. Locate theartery and its bifurcation into the common hepatic and splenic arteries.

I M A G E : LONGITUDINAL VIEW CELIAC ARTERY, COMMON HEPATIC AND SPLENIC ARTERIESAT THE BIFURCATION

640

L A B E L E D : CELIAC BIFURCATION

4. Sample with Doppler throughout the length of the celiac trunk and the proximalcommon hepatic and splenic arteries.

I M A G E : SPECTRAL WAVEFORMS FROM THE CELIAC, COMMON HEPATIC AND SPLENICARTERIES

L A B E L E D : CELIAC ART or COMMON HEP ART or SPLENIC ART

641

SCANNING TIP: The hepatic artery may be followed from the celiac bifurcation tothe level of its entry into the liver at the porta hepatis. Images and Doppler spectralwaveforms should be documented throughout the proximal, middle, and distalsegments of the vessel.

SCANNING TIP: In a similar manner, the splenic artery may be examined from itsorigin at the celiac bifurcation to the level of the splenic hilum. Images and Dopplerspectral waveforms are documented throughout the proximal, middle, and distalsegments of the vessel. The splenic artery is frequently quite tortuous, and color flowmay facilitate examination of this vessel.

642

Black and white version of a color Doppler image demonstrating flow in the region of the portahepatic.

5. Return to the longitudinal image of the aorta just inferior to the origin of the celiacartery. Locate the origin of the superior mesenteric artery, which is usually 1 to 2 cminferior to the celiac. The celiac and superior mesenteric artery (SMA) may share acommon origin.

I M A G E : LONGITUDINAL VIEW OF THE SMA FROM ITS ORIGIN TO THE MIDSECTION OF THEVESSEL

L A B E L E D : PROX-MID SMA

6. Sample with Doppler throughout the visualized segments of the SMA beginning atits origin.

I M A G E : SPECTRAL WAVEFORMS FROM THE PROXIMAL TO THE MID SMA

L A B E L E D : PROX SMA or MID SMA

643

SCANNING TIP: The inferior mesenteric artery (IMA) is not routinely examined. Ifthe celiac or SMA is critically stenosed or occluded, the IMA would be evaluated in amanner similar to the study of the SMA.

644

II. Renal Arterial Study

1. Longitudinal view of the abdominal aorta.

I M A G E : LONGITUDINAL VIEW OF THE AORTA

L A B E L E D : LONG AO

2. Transversely scan the aorta. Locate the left renal vein as it crosses anterior to theaorta just inferior to the SMA origin. Locate the right and left renal arteriesimmediately posterior to the renal veins.

I M A G E : TRANSVERSE VIEW OF THE AORTA AT THE LEVEL OF THE LEFT RENAL VEIN ANDORIGIN OF THE RIGHT OR LEFT RENAL ARTERY

L A B E L E D : ORIGIN RT or LT REN ART

3. Continuously sample with Doppler from within the lumen of the aorta through therenal artery orifice by moving the Doppler sample volume slowly along this course.

I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE ORIGIN OF THE RIGHT OR LEFT RENALARTERY

L A B E L E D : ORIGIN RT or LT REN ART

4. Using gray-scale or color flow imaging, follow the course of the renal artery from theproximal to the midsegment of the vessel.

I M A G E : LONGITUDINAL VIEW OF THE RIGHT OR LEFT RENAL ARTERY FROM ITS ORIGINFROM THE POSTEROLATERAL WALL OF THE AORTA AS FAR DISTALLY AS POSSIBLE

645

L A B E L E D : PROX or MID RT / LT REN ART

646

5. Sample continuously with Doppler throughout the visualized length of the renalartery.

I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE PROXIMAL THROUGH THEMIDSEGMENTS OF THE RENAL ARTERY

L A B E L E D : PROX or MID RT/LT REN ART

6. Transverse image of the renal artery from the hilum of the kidney as far proximalas possible.

I M A G E : TRANSVERSE VIEW OF THE KIDNEY AND THE DISTAL TO MIDRENAL ARTERY FROMTHE LEVEL OF THE HILUM

L A B E L E D : DIST RT/LT REN ART

7. Sample continuously with Doppler from the level of the renal hilum throughout thedistal to midrenal artery.

I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE DISTAL TO MIDRENAL ARTERY

L A B E L E D : DIST RT/LT REN ART

8. Obtain a long axis measurement of the kidney. You may use color flow imaging todemonstrate the arterial and venous perfusion of the organ.

I M A G E : LONGITUDINAL VIEW OF THE RIGHT KIDNEY SHOWING MEASURED LENGTH ANDPERFUSION

647

L A B E L E D : RT or LT KIDNEY

9. Sample with Doppler throughout the intersegmental arteries of the renal medullaand the arcuate arteries of the renal cortex. You will obtain both arterial and venoussignals at the cortical level because of the small size of the vessels and thearteriovenous shunting that occurs at this level.

I M A G E : DOPPLER SPECTRAL WAVEFORMS FROM THE RENAL MEDULLA AND CORTEX

L A B E L E D : RT or LT REN MED COR

648

SCANNING TIP: Approximately 20% of patients have more than one renal arteryon each side. These accessory or multiple renal arteries may be detected using severalstrategies:

• Power Doppler (Doppler power angio) may be useful because this technique relies onthe intensity of the signal and is less affected by the angle of insonation than colorDoppler imaging.

• Accessory renal arteries usually course to the surface of the lower pole of the kidney. Asa consequence, the Doppler signals from the renal pole with the additional artery mayhave higher amplitude than the signal from the other region of the organ.

• Enlarge the Doppler sample volume, and listen along the wall of the aorta foradditional low resistance renal artery signals. Multiple renal arteries may ariseanywhere along the aortic wall to the level of the common iliac arteries.

III. Image Examples Of Various Studies

649

Abdominal Venous Flow Study. Black and white version of color flow Doppler in hepatic veins.

650

Abdominal Venous Flow Study. Black and white version of color Doppler flow in the portal vein.

651

Obstetrical Study. Black and white version of color Doppler in the three vessel umbilical cord.

652

Obstetrical Study. Black and white version of color Doppler flow in the four chamber fetal heart.

653

Gynecological Study. Black and white version of a color Doppler spectral display of blood in anactive ovary.

654654

Scrotal Study. Black and white version of color Doppler flow in a testicular artery.

SECTION TWO

IMAGE PROTOCOL FOR CEREBROVASCULAR DUPLEX SCANNING

• Criteria:— No limited studies.— Use the following five images (beginning on the following page) of normal

cerebrovascular structures as a technical guideline.

655

656

Longitudinal section of the common carotid artery.

657

Axial sections of the common carotid artery (CCA) and internal jugular vein (IJV).

658

Longitudinal section of the carotid artery bulb.

659

Axial section of the carotid artery bulb.

660

Internal and external carotid artery origins.

661

CEREBROVASCULAR DUPLEX STUDY

1. Longitudinal image of the right proximal common carotid artery.

L A B E L E D : SAG RT PCCA

2. Spectral waveform from the right proximal common carotid artery with peaksystolic and end diastolic velocities measured.

L A B E L E D : RT PCCA

3. Longitudinal image of the right distal common carotid artery.

L A B E L E D : SAG RT DCCA

4. Spectral waveform from the right distal common carotid artery with peak systolicand end diastolic velocities measured.

L A B E L E D : RT DCCA

5. Longitudinal image of the proximal internal carotid artery showing its origin fromthe bulb.

L A B E L E D : SAG RT PCCA

6. Spectral waveform from the proximal internal common carotid artery with peaksystolic and end diastolic velocities measured.

L A B E L E D : DIST RT ICA

7. Longitudinal image of the right middle internal carotid artery.

L A B E L E D : SAG RT MICA

8. Spectral waveform from the middle internal carotid artery with peak systolic andend diastolic velocities measured.

L A B E L E D : RT MICA

9. Longitudinal image of the right distal internal carotid artery.

L A B E L E D : SAG RT DICA

10. Spectral waveform from the distal internal carotid artery with peak systolic and enddiastolic velocities measured.

L A B E L E D : RT DICA

662

663

11. Longitudinal image of the right external carotid artery.

L A B E L E D : SAG RT ECA

12. Spectral waveform from the external carotid artery with peak systolic and enddiastolic velocities measured.

L A B E L E D : RT ECA

13. Optional longitudinal image of the right vertebral artery.

L A B E L E D : SAG RT VERT

14. Spectral waveform from the right vertebral artery with peak systolic and enddiastolic velocities measured.

L A B E L E D : RT VERT

15. Transverse image of the carotid bulb just prior to vessel bifurcation.

L A B E L E D : TRV RT BULB

SCANNING TIP: The spectral image of this vessel is often not satisfactory becauseof the depth of the vertebral vessels.

664

SCANNING TIP: The image and spectral data from the vertebral arteries and thesubclavian are required to bill for a complete carotid examination and receive vascularlaboratory accreditation.

SCANNING TIP: Even in the absence of pathology, it is important to carefullyimage the bulb. It is thought that this area is most prone to atherosclerosis because ofthe shear forces imposed on the vessel wall by the blood flow patterns and the vesselgeometry. Stenotic lesions are often asymptomatic until they reduce the diameter of thevessel lumen by more than 60%. Lesser lesions may occasionally be detected only withcareful, thorough scanning in the transverse plane.

SCANNING TIP: Stenotic plaque may be measured in the transverse plane to ensureaccuracy.

SCANNING TIP: Additional images of plaque may be necessary. It is important tolook for irregularities along the borders of the plaque, which may indicate ulcerations.

SCANNING TIP: Repeat the required images on the left side, beginning with athorough survey.

SECTION THREE

IMAGE PROTOCOLS FOR PER IPHERAL ARTER IAL AND VENOUSDUPLEX SCANNING

I. Lower Extremity Venous Duplex Study

665

SCANNING TIP: Examination of veins is easiest in a transverse plane, butlongitudinal imaging should also be performed to help ensure adequate venousmapping (so that no small thrombosis is missed) and assessment of the venous valves,especially with color flow Doppler.

SCANNING TIP: Because a venous duplex examination requires a thoroughmapping of the veins, it is unnecessary to perform a survey and then a more detailedexam to obtain images. Images may be obtained as you go. A diagnosis is rarely madefrom hard copy alone in this exam.

SCANNING TIP: Always examine both legs for comparative purposes. It may behelpful to examine the asymptomatic leg first.

666

• Begin transversely high on the thigh at or above the level of the groin crease. Locatethe common femoral vein (CFV) and common femoral artery (CFA). To confirm thatyou are in the CFV, identify the insertion of the saphenous vein and the bifurcationinto the superficial femoral vein (SFV) and the profunda femoris vein (PFV).

• Assess the entire length of the CFV for compressibility by compressing every 1 to2 cm. The walls of the CFA should not deform with adequate compression of the vein.

1. Images of noncompressed and compressed common femoral vein (on split screen ifavailable).

L A B E L E D : LT or RT CFV

• Still at the level of the CFV, turn on the Doppler and place the cursor toward flow.Spontaneous, phasic flow should be present throughout the CFV.

2. Duplex image of Doppler spectral CFV waveform demonstrating respiratory changesand augmentation.

L A B E L E D : RT or LT CFV

SCANNING TIP: For split screen imaging, use the left side for noncompressed viewsand the right side for compressed.

667

• Return to a gray scale image. Move inferiorly and locate the insertion of thesaphenous vein medially. Assess the proximal portion of the saphenous vein forcompressibility.

3. Images of noncompressed and compressed saphenous vein (split screen).

L A B E L E D : RT or LT SAPH V

• Investigate the saphenous vein with Doppler to confirm normal flow characteristics.

4. Duplex image of a Doppler spectral waveform from the saphenous veindemonstrating augmentation and respiratory changes.

L A B E L E D : RT or LT SAPH V

• Return to gray scale imaging, and return to the level of the CFV. Move inferiorly tolocate the insertion of the profunda vein. This lies posterior and lateral to the SFV.Follow this vein as inferiorly as possible, assessing compressibility.

SCANNING TIP: A complete exam requires assessment of the entire length of thegreater saphenous vein.

5. Images of noncompressed and compressed profunda vein (split screen).

L A B E L E D : RT or LT PROF V

• Return superiorly to the deep vein insertion, and begin sampling with Doppler. Assessfor normal characteristics. Follow as inferiorly as possible.

6. Duplex image of a Doppler spectral waveform from the profunda vein demonstratingaugmentation and respiratory changes.

L A B E L E D : RT or LT PROF V

• Return to a gray scale image, and move superior to the level of the SFV insertion.Begin following that vein inferiorly compressing every 1 to 2 cm at a level near itsinsertion.

7. Images of noncompressed and compressed SFV near its insertion (split screen).

L A B E L E D : RT or LT SFV SUP668

SCANNING TIP: Compressibility may be difficult to assess in vessels lying deep ortangent to the skin.

• Sample the same segment of vein with Doppler. Assess for normal characteristics.

8. Duplex image of a Doppler spectral waveform from the SFV near its insertiondemonstrating augmentation and respiratory changes.

L A B E L E D : RT or LT SFV

• Return to a gray scale image, and continue to follow the SFV inferiorly, assessing forcompressibility.

9. Images of noncompressed and compressed superficial femoral vein at approximatelymidthigh (split screen).

L A B E L E D : RT or LT SFV MID

• Sample SFV at a midthigh level with Doppler. Assess for normal characteristics.

10. Duplex image of a Doppler spectral waveform from the SFV at midthigh leveldemonstrating augmentation and respiratory changes.

669

SCANNING TIP: Make very careful note of vein compressibility because that is themost important indicator of venous thrombosis.

670

L A B E L E D : RT or LT SFV MID

• Return to a gray scale image, and investigate the remaining segment of SFV,compressing at regular intervals.

11. Images of noncompressed and compressed SFV as inferiorly as possible (splitscreen).

L A B E L E D : RT or LT SFV INF

• Doppler in the SFV just superior to the knee: The vein will have passed medially andnow lies posterior to the artery. Augmentation is especially important here becausecompression is often less than adequate.

12. Duplex image of a Doppler spectral waveform from the SFV just superior to theknee demonstrating augmentation.

L A B E L E D : RT or LT SFV INF

SCANNING TIP: As you approach Hunter’s canal just superior to the knee,compression is often very difficult, if possible at all. This is due to the tendons presenthere.

• The popliteal veins can be examined either with the patient prone or with the kneebent and relaxed away from the patient to the side.

• Locate the popliteal vein posterior to the artery and assess for normal characteristics.— Follow the vein as far superiorly behind the thigh as possible. Continue to assess

compression.— Begin to move inferiorly, following the popliteal vein to the level of its bifurcation

into the anterior tibial trunk and the tibioperoneal trunk. Follow the tibioperonealtrunk to the level where it bifurcates into the posterior tibial and peroneal trunks.

— Once the entire length of the popliteal vein has been adequately assessed forcompressibility, return to a midpopliteal level.

13. Images of noncompressed and compressed popliteal vein at its midpoint (splitscreen).

L A B E L E D : RT or LT POP V MID

• Sample with Doppler throughout the entire length of the popliteal vessels atmidpopliteal level.

671

SCANNING TIP: Document any vessel duplication, which is fairly common at thislevel. If there is more than one popliteal vessel, they must both be carefully examined.

14. Duplex image of a Doppler spectral waveform from the midpopliteal veindemonstrating augmentation.

L A B E L E D : RT or LT POP V MID

672

Black and white version of color Doppler image of popliteal vein and artery.

• Color Doppler may be used to rescan the entire leg in a longitudinal plane. ColorDoppler provides a visual means of assessing spontaneous flow, augmentation, andvalve competence.

• To assess valve competence, rescan quickly to locate a venous valve (this may be donewithin the scanning protocol of that particular venous segment) and scan to a leveljust inferior to the valve.— While observing color flow Doppler (or a spectral waveform), squeeze the patient’s

leg superior to the valve. If the valve is too superior to the scanning site, have thepatient take in a deep breath, hold it, bear down hard, and release (Valsalvamaneuver).

— There should be no remarkable amount of retrograde (inferior) venous blood flowthrough the valve. Significant retrograde flow indicates the presence of anincompetent valve.

— Any valve can be examined in this manner.• Examine only the deep veins of the thigh.

— It has been shown that the majority of life-threatening pulmonary emboli originatein the proximal deep veins of the leg. Although pulmonary emboli may originate

673

SCANNING TIP: It may be awkward to squeeze a patient’s thigh and maintaintransducer location at the same time. Having the patient quickly flex the ipsilateralfoot will have a similar effect.

674

from the smaller veins of the calf, these emboli are usually not clinically significant.The importance of detecting and treating isolated calf vein thrombi remainscontroversial.

• Repeat on the affected leg.

675

II. Lower Extremity Peripheral Arterial Duplex Study

• Beginning with the patient in a supine position, obtain bilateral brachial bloodpressures. Record on worksheet (see section on blood pressures).

• With the patient in supine position, palpate the following pulses:— Groin (iliac/common femoral artery)— Popliteal— Posterior tibial— Dorsalis pedis

• Using a low frequency probe (2.25 to 3.0 MHz), the distal aorta and proximal iliacarteries may be examined in both longitudinal and transverse planes.

1. Longitudinal view of the distal aorta.

L A B E L E D : SAG AORTA DIS

2. Longitudinal view of the right iliac artery.

L A B E L E D : SAG RT ILIAC

3. Longitudinal view of the left iliac artery.

L A B E L E D : SAG LT ILIAC

4. Transverse view of the distal aorta.

L A B E L E D : TRV AORTA DIS

5. Transverse view of the right and left iliac arteries.

L A B E L E D : TRV RT/LT ILIAC

• Begin scanning with a 5.0- or 7.0-MHz transducer. You will need to start superior tothe groin crease in a sagittal plane. Locate the common femoral artery (CFA).

• Sample with Doppler thoroughly to assess blood flow velocity and waveformmorphology throughout the length of the CFA.— Use simultaneous imaging for duplex studies if available. Although this may

slightly decrease image resolution on some ultrasound systems, it will makescanning much quicker.

676

SCANNING TIP: The iliac arteries may be examined simultaneously from a coronalplane with the patient in a right lateral decubitus position.

SCANNING TIP: If one leg is significantly more symptomatic than the other, beginwith the less symptomatic leg.

677

Systolicpeak

“O”Diastolic

flow

Base line

Systolicrise

Seconds

Flowreversal

Vel

ocity

cm

/sec

or

KH

Z�

Normal triphasic arterial signal from a high-resistance system.

678

6. Longitudinal gray scale view of the common femoral artery.

L A B E L E D : SAG RT or LT CFA

7. Doppler spectral waveform of the CFA.

L A B E L E D : RTOR LT CFA

• The CFA will bifurcate into the superficial femoral artery (SFA) and the deep femoralor profunda femoris artery.

• Follow the profunda femoris artery as inferiorly as possible with duplex sampling.

8. Longitudinal view of the profunda femoris artery origin.

L A B E L E D : SAG RT or LT PROF ART

9. Doppler spectral waveform of the profunda femoris artery near its insertion.

L A B E L E D : SAGRT or LT PROF ART

SCANNING TIP: If simultaneous imaging is not available, you will have to B-scanfor a short segment, freeze an image, then move a Doppler cursor thoroughly over thatfrozen image, and continue on to the next segment through the entire vessel.

679

• Return superiorly to the level of the bifurcation, and locate the SFA. Follow thisartery inferiorly to just above the knee.

10. Longitudinal view of the SFA origin.

L A B E L E D : SAGRT or LT PROX SFA

11. Doppler spectral waveform of the SFA near its origin.

L A B E L E D : SAGRT or LT PROX SFA

12. Longitudinal view of the SFA at approximately midthigh.

L A B E L E D : SAGRT or LT MID SFA

13. Duplex spectral waveform at midthigh.

L A B E L E D : SAGRT or LT MID SFA

SCANNING TIP: It may be difficult to follow the profunda for more than a fewcentimeters because the vessel usually courses deep into the leg. If you are able to followthe profunda artery for a longer length, another set of images should be documentedmore inferiorly along the vessel.

680

14. Longitudinal view of the SFA just superior to the knee.

L A B E L E D : SAGRT or LT DIST SFA

15. Duplex spectral waveform just superior to knee SFA

L A B E L E D : SAGRT or LT DIST SFA

• Next, the popliteal artery is to be examined. This may be done in a number of ways.The patient may be placed in a prone position with the knee slightly flexed, the legmay be bent slightly and positioned out to the side away from the patient, or thepatient may be placed in a lateral decubitus position with the knee slightly flexed.— Placing the patient in a prone position will allow for a more direct, easier approach,

but it may be difficult or time-consuming to have the patient roll over.• Locate the popliteal artery posterior and slightly lateral to the vein.

— Follow the artery as superiorly as possible into the thigh while gray scale imaging.— Begin duplex scanning and follow the artery inferiorly to the superior aspect of the

calf to the level of the vessel trifurcation into the anterior tibial, posterior tibial,and peroneal arteries.

681

Black and white version of color Doppler image of popliteal artery.

682

16. Longitudinal view of the popliteal artery.

L A B E L E D : SAGRT or LT POP ART

17. Doppler spectral waveform of the popliteal artery.

L A B E L E D : SAGRT or LT POP ART

• The tibial arteries may be evaluated using color Doppler.— It may be helpful to follow the arteries up the left from the ankle if there is any

difficulty following them down the calf.• After examining the popliteal artery, move down to the patient’s ankle to examine the

posterior tibial artery (PT) and dorsalis pedis artery (DP).— All three tibial arteries should be sampled with Doppler using a high frequency

transducer

18. Doppler spectral waveform of the posterior tibial artery.

L A B E L E D : SAG RT or LT PT

SCANNING TIP: Gray scale images may be taken to demonstrate pathology.

19. Doppler spectral waveform of the dosalis pedis artery.

L A B E L E D : SAG RT or LT DP

683

Spectral analysis of the posterior artery demonstrating normal triphasic flow. Courtesy of ATL,Bothell, Washington.

684

Black and white version of color Doppler image of the posterior tibial artery and vein.

• Cuff placement depends on whether a 3-cuff or 4-cuff method is to be used. If the 4-cuff procedure is used, appropriately sized cuffs are to be placed as follows:a) As high as possible on the thighb) Just above the kneec) Just below the kneed) Just above the ankle

— If the 3-cuff technique is used, a wide thigh cuff is placed snugly over the thigh andbelow knee and above ankle cuffs are used.

— Inaccurate blood pressures will be measured if inappropriate cuff sizes are used. Itis necessary to use only cuffs that are at least 20% wider than the diameter of the

685

SCANNING TIP: Determine the strongest and most easily accessible artery to use forpressure monitoring.Duplex ultrasonography is used to complement arterial assessment using indirectnoninvasive physiologic studies. Ankle brachial indices, segmental systolic pressuremeasurements, pulse volume recording photoplethysmography, and constant-loadexercise testing are among the more common procedures employed for primaryevaluation. The scope of this chapter does not permit detailed discussion of each ofthese physiologic test modalities. A brief description of the protocol for segmental systolicpressure measurements follows. The reader is referred to the references listed at the endof this section for additional information.

limb at that segment.• Start at ankle level and measure the pressure at each cuff level, moving superiorly.

The popliteal artery signal may be used, if necessary, to measure the thigh pressures.• Repeat on the contralateral leg.

686

SCANNING TIP: If the high thigh pressure is reduced, the Doppler spectralwaveform from the common femoral artery will indicate the likelihood of more proximaldisease.Normally, the waveform will be triphasic.If the CFA Doppler signal demonstrates loss of the reverse diastolic flow component,occlusive disease of the common or external iliac artery is suggested. If the CFA signalis abnormal bilaterally, aorto-iliac disease is indicated.

SCANNING TIP: It may be difficult to obtain a high thigh pressure on obesepatients. When the arterial wall is calcified (i.e., with diabetic patients), pressures maybe falsely elevated.

687

VIIIEchocardiography

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE ADULTHEART

SECTION TWO

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THEPED IATR IC HEART

SECTION ONE

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THE ADULTHEART

I. Adult Heart Study

REQUIRED IMAGES

688

SCANNING TIP: The study is videotaped, allowing for real-time assessment ofstructures. At least 6 to 10 beats of each view should be recorded, with additionalimages of any pathology.

689

1. Parasternal long axis.

SCANNING TIP: The anterior portion of the aortic root and the interventricularseptum should be continuous and as perpendicular to the ultrasound beam as possible.The posterior portion of the aortic root runs continuous with the anterior mitral valveleaflet.

Interventricularseptum

Left ventricle

Posterior wall

Mitral valve

Descending thoracic aorta

Right ventricle

Aortic root

Aortic valve

690

2. Right ventricular inflow view.

Right ventricle

Right atrium

Tricuspid valve

3. Right ventricular outflow view.

691

Right ventricle

Main pulmonary artery

Pulmonic valve

4. Parasternal short axis at the level of the aortic valve.

692

Right ventricle

Mainpulmonary

artery

Pulmonic valve

Leftatrium

Descending thoracic aortaInteratrial septum

Right atrium

Tricuspidvalve

Noncoronarycusp

Right coronarycusp

Left coronarycusp

Aortic valve

5. Parasternal short axis at the level of the mitral valve.

693

Right ventricle Interventricularseptum

Anterior mitralvalve leaflet

Posterior mitralvalve leaflet

6. Parasternal short axis at the level of the papillary muscles.

694

Right ventricle Anterior wall

Left ventricle

Anterolateralpapillary

muscle

Lateral wall

Posterior wallPosteromedial

papillary muscle

Inferior wall


7. Apical four-chamber view.

695

Rightventricle

Left ventricle

Lateral wall

Leftatrium

Mitral valve


Rightatrium

Tricuspidvalve

Interatrial septum

8. Apical five-chamber view.

696

Rightventricle

Left ventricle


Leftatrium

Rightatrium

Aorticvalve

9. Apical two-chamber view.

697

Left ventricle

Inferior wall

Left atrium

Descending aorta

Anterior wall

698

Left ventricle

Left atrium

Descending aorta

SCANNING TIP: When questions involving the aorta arise, a portion of thedescending thoracic aorta can be visualized posterior to the two-chamber view andshould be evaluated for pathology.

10. Apical long axis.

699

Left ventricle

Left atrium


Right ventricle

Aortic valve

Aorta

Mitral valve

Posterior wall

11. Subxiphoid four chamber.

700

Left ventricle

Left atrium


Right ventricleTricuspid valve

Rightatrium

Mitral valve

Lateral wall

Liver

12. Subxiphoid short axis papillary muscle level.

701

Leftventricle

Right ventricle

Papillary muscles

Liver

13. Subxiphoid short axis at the level of the mitral valve.

702

Right ventricle

Mitral valve

Liver

14. Subxiphoid short axis at the level of the aortic valve.

703

Right ventricle

Aortic valve

Liver

Left atrium

Pulmonaryartery

Right atrium

15. Subxiphoid short axis viewing the inferior vena cava (IVC) entering the rightatrium (RA).

704

Inferior vena cava

LiverRight atrium

16. Suprasternal notch viewing the long axis of the aorta.

705

Leftsubclavian artery

Left commoncarotid artery

Innominate artery

Aortic arch

Right pulmonaryartery

Descending aorta

SCANNING TIP: This view should be used when questions involving the aortaarise, such as dissection or Marfan’s syndrome. A short axis of the aorta should also beevaluated in these cases.

706

SCANNING TIP: A minimum of six beats should be recorded at each level todemonstrate both systolic and diastolic motion.

SCANNING TIP: The M-mode may be documented on either videotape or strip chartrecorder. If the strip chart is used, begin with a frozen image of the parasternal longaxis view to demonstrate the orientation of the heart.

SCANNING TIP: The 2D image must be as perpendicular to the ultrasound beamas possible, lessening the chance for inaccurate measurements. (A tipped ventricle willyield exaggerated numbers.) If you are unsure of a dimension when measuring, omit it.

M-Mode EvaluationAortic Valve Level

• The cursor is placed so that it transects the right ventricle (RV), aorta, and leftatrium (LA) in either the parasternal long or short axis view.

707

Left atrium

Right ventricle

Aorticcusps

Aorticroot

• Measurements taken1:

(a) Aortic root: from the anterior wall of the root to the posterior wall of the root, atthe level of the Q wave on the electrocardiogram (EKG); normally 1.9 to 4 cm.

(b) Aortic valve cusp separation: normally has the shape of a box when open with theright coronary cusp more anterior and the noncoronary cusp posterior; measuredat the onset of systole (when the valve first opens); normally 1.5 to 2.6 cm.

1Normal values used in the lab at Thomas Jefferson University, Philadelphia, Pennsylvania.

708

(c) Left atrium: measured at the largest dimension (end systole); normally 1.9 to 4 cm.

709

Left atrialdimension

Aortic cuspseparation

Aortic rootdimension

SCANNING TIP: Always measure structures from leading edge to leading edge.

Mitral Valve Level

• Slowly sweep the cursor through the left ventricular outflow tract (LVOT) region tothe tip of the mitral valve leaflets. This sweep will demonstrate structural continuity.The biphasic opening of both mitral leaflets should then be documented.

710

Posterior mitral leaflet

Anterior mitral leaflet


Right ventricle

A

CF

E

D

711

SCANNING TIP: The mitral valve is labeled to describe the different phases of itsmotion.D: beginning of diastole.E: maximal excursion of the valve.F: point to which the valve had closed following the passive filling phase.A: atrial contraction (P wave on the EKG).B: extra bump between A and C (occurs only when pathology, such as diastolic

dysfunction, is present).C: closure of the valve and the beginning of systole.

• Measurements2:

(a) D to E excursion; normally greater than 1.6 cm.(b) E to F slope over the period of one second (expressed in mm/sec); normally greater

than 70 mm/sec.(c) E point to septal separation; normally no greater than 1 cm.


712

E point to septalseparation

Velocity(mm/sec)

D to Eexcursion

1 second

E

F

E

Left Ventricular Level

• Slowly sweep the cursor just beyond the mitral leaflets but stopping before thepapillary muscles. Both systolic and diastolic dimensions of the LV should bedocumented.

713

Right ventricle

Left ventricle

Posterior wallInterventricularseptum

Chordaetendineae

• Measurements3:

(a) All of the following are measured at the level of the Q wave on the EKG: RV (nogreater than 2.7 cm); interventricular septum (IVS), posterior LV wall (bothnormally between .6 and 1.2 cm); and LV end diastolic dimension (LVEDD)(normal range 3.5 to 5.7 cm).


714

Tricuspid valve

(b) LV end systolic dimension (LVESD): Measure at the smallest dimension.

715

SCANNING TIP: Often, the free wall of the RV is not visualized because of its closeproximity to the transducer, which makes it difficult to determine the true size of thechamber. The measurement is therefore taken from the point where motion is firstobserved, to the leading edge of the interventricular septum. Then subtract .5 cm fromthe total to compensate for the RV wall thickness.

SCANNING TIP: The LVEDD and the LVESD should be measured on the samebeat.

SCANNING TIP: Be careful not to include chordae tendinea in the thickness of theLV walls.

Tricuspid and Pulmonic Valves

• An M-mode of the tricuspid or pulmonic valve is used to demonstrate thickness andmotion and is not necessarily a routine part of the exam. There are no standardmeasurements obtained.

716

Tricuspid valve

717

Pulmonic valve

Doppler EvaluationValve Survey

Color Doppler Survey

• The color sector should be placed so that the valve or area being assessed is in thecenter of the sample. Normally, mitral and tricuspid flow appear red, and pulmonicand aortic flow are blue. When the valves are closed, no color (regurgitation) should beseen below them. Mitral and tricuspid regurgitation appear blue; aortic and pulmonic

718

SCANNING TIP: The following sequence should be used in the evaluation of eachvalve: color Doppler, continuous wave (CW) Doppler, then pulse-wave (PW) Doppler.Assess each value separately beginning with the mitral valve. Repeat this process on theaortic, tricuspid, and pulmonic valves and the left ventricular outflow tract (LVOT) ifnecessary.

SCANNING TIP: Flow moving toward the transducer appears as various shades ofred. Flow moving away is blue. A lower velocity would be deeper in color and graduallylighten as the velocity increases to almost yellow or white. At times, a variance map isused. This is usually a green color tagged on the end of the color spectrum. The greenmakes the higher velocities or turbulent flows stand out.

719

regurgitation are usually red.• Slowly angle the transducer back and forth across the valve plane to locate any

eccentric areas of turbulence. Demonstrate the size and location of any regurgitationor turbulent flow.

• Color can also be used to locate the peak flow velocity across the valve, allowing foreasy placement of the continuous wave (CW) Doppler cursor.

Continuous-Wave Doppler Survey

• CW is best for determining peak flow velocities. Place the cursor so that it bisects theopening of the valve that is to be sampled. If the peak velocity across a valve exceedsits normal velocity, the peak should then be measured. Three profiles are measuredand averaged. Do not measure post PVC beats. If the patient is in atrial fibrillation,average at least five or six beats.

• The peak velocity of tricuspid regurgitation is also measured to help with theevaluation of pulmonary hypertension.

SCANNING TIP: Regurgitation or any pathology should be demonstrated in morethan one view.

Pulsed-Wave Doppler Survey

• Pulsed Doppler demonstrates exactly where a flow disturbance occurs and is thenused to map out the direction and size of the disturbance. Place the cursor or Doppler“gate” slightly above the valve opening. Slowly move below the valve, then across thevalve plane in both directions. If regurgitation is detected, follow the flow into thechamber as far back as it goes, mapping the length and also the width of theturbulent area.

720

SCANNING TIP: If you are unable to find a peak velocity on any valve, tricuspid,or aortic regurgitation, a nonimaging, stand-alone CW probe should be used. Becauseof the smaller footprint of the transducer and the lower frequency, the peak velocity canbe easily found.

SCANNING TIP: If any additional flow disturbances (e.g., ASD, VSD) arevisualized, they too should be evaluated with color, CW, and PW Doppler.

SECTION TWO

IMAGE PROTOCOL FOR THE SONOGRAPHIC STUDY OF THEPED IATR IC HEART

I. Pediatric Heart Study

REQUIRED IMAGES

721

SCANNING TIP: The following views are all recorded on videotape, allowing forreal-time assessment of cardiac structures. At least 8 to 10 beats of each view isrecorded with additional images for color, PW, and CW Doppler.

1. Subcostal view demonstrating the orientation of the aorta and IVC.

722

Spine

Aorta

Hepaticvein

Inferiorvena cava

Liver

2. Subcostal four-chamber view.

723

Left atriumMitral valve

Pulmonaryvein

Tricuspidvalve

Rightatrium

Right ventricle

Liver


Pulmonary veins

Left ventricle

3. Subcostal five-chamber view showing the aorta and the LVOT.

724

Aortic valve

Aortic root

Rightventricle

Liver

Left ventricle


4. Subcostal long axis angled anteriorly to demonstrate the RV outflow tract, pulmonicvalve, and the pulmonary artery.

725

Pulmonic valve Main pulmonaryartery

Rightventricle

Liver

5. Short axis subcostal showing the IVC and superior vena cava (SVC) entering theright atrium.

726

Liver

Superiorvena cava

Right atrium

Inferiorvena cava

6. Short axis subcostal demonstrating the aortic valve, pulmonary artery, andinteratrial septum.

727

SCANNING TIP: A small angulation may be needed to fully visualize theinteratrial septum.

Aortic valve

Interatrialseptum

Left atrium

Right atrium

Tricuspidvalve

Liver

Pulmonicvalve

Main pulmonaryartery

Right ventricle

7. Short axis subcostal of the mitral valve.

728


Mitral valve

Right ventricle

8. Short axis subcostal of the left and right ventricles.

729

Left ventricle


Papillary muscles

Right ventricle

9. Apical four-chamber view.

730

Interatrialseptum

Right atrium

Tricuspidvalve

Right ventricleInterventricular

septum

Left ventricle

Mitral valve

Left atrium

Pulmonary veins

10. Apical long axis documenting the LVOT.

731

Aortic root

Left atrium


Left ventricleInterventricularseptum

Right ventricle

Aorticvalve

11. Parasternal long axis.

732



Leftventricle

Posterior leftventricular wall

Mitral valve

Right ventricle

Aortic root

Aorticvalve

Left atrium

Descendingaorta

12. Right ventricular inflow view.

733

Tricuspid valveRight ventricle

Right atrium

13. Right ventricular outflow view.

734

Pulmonicvalve

Right ventricle

Left atriumMain pulmonary

artery

14. Parasternal short axis at the level of the aortic valve to document the orientation ofthe great vessels.

735

Pulmonicvalve

Right ventricle

Left atrium

Mainpulmonary

artery

Left coronarycusp aortic valve

Noncoronarycusp aortic valve

Interatrialseptum

Rightatrium

Tricuspidvalve

Right coronarycusp aortic valve

15. Parasternal short axis documenting the left coronary artery.

736

SCANNING TIP: Angle slightly above the aortic valve leaflets and zoom in on theregion to simplify coronary evaluation.

Right ventricle

Left atrium

Left anteriordescending

(LAD)coronary

artery

Leftcircumflexcoronary

artery

Left maincoronaryartery

Aorta

16. Parasternal short axis documenting the right coronary artery.

737

Left atrium

Right coronaryartery

Aorta

17. Parasternal short axis to document the right and left pulmonary branches and thepresence or absence of a patent ductus arteriosus.

738

SCANNING TIP: If a ductus is present, demonstrate its connection to the aorta.


Descending aorta

Aorta

Left atrium

Patent ductusarteriosus

Left pulmonary artery

Right pulmonary artery

18. Parasternal short axis at the level of the mitral valve to document thickness andmotion of the leaflets.

739

Right ventricle

Interventricularseptum Anterior mitral

valve leaflet

Posterior mitralvalve leaflet

19. Parasternal short axis at the level of the papillary muscles.

740

Right ventricleInterventricularseptum

Anterolateralpapillary muscle

Posteromedialpapillary muscle

Left ventricle

20. Suprasternal notch documenting the aortic arch and its branches.

741

Descending aorta

Aortic arch

Left subclavianartery


Left commoncorotid artery

Brachiocephalic(innominate) artery

Ascendingaorta

Left atrium

21. Suprasternal notch documenting the branch pulmonary arteries and short axis ofthe aorta.

742

Aorta

Left pulmonaryartery



M-Mode EvaluationAortic Valve Level

743

Aortic leafletsRight ventricle

Aorticroot

Left atrium Aortic root

Right ventricle

Aortic valve

Left atrium

Mitral Valve Level

744

Right ventricle

Right ventricle

Mitral valve

Anterior mitral leaflet

Posterior mitral leaflet

Left Ventricular Level

745

SCANNING TIP: Sweep speed of the M-Mode is increased to 100% to accommodatethe increased heart rate of neonates.

Right ventricle

Rightventricle


Posteriorventricular wall

Left ventricle

Posteriorventricular wall

Left ventricle


Abbreviation Glossary

746

IXAIUM: American Institute of Ultrasoundin MedicineALARA: As low as reasonably acceptableANT: AnteriorART: ArteryAV: AtrioventricularAV: Atrioventricular valvesBIF: BifurcationCBD: Common bile ductcc: Cubic centimeterCD: Common ductCERX: Cervix

CFA: Common femoral arteryCFV: Common femoral veinCHD: Common hepatic ductcm: CentimeterCOR: CoronalCR: Crown rumpC-SPINE: Cervical spineCW: Continuous wave DopplerDECUB: DecubitusDP: Dorsalis pedis arteryEKG: ElectrocardiogramER: Endorectal

747

EV: EndovaginalFd: Doppler shift frequencyFo: Operating frequencyGB: GallbladderGS: Gestational sacHz: HertzIN: InchesINF: InferiorIVC: Inferior vena cavaIVS: Interventricular septumkHz: KilohertzKID: KidneyLA: Left atriumLAD: Left anterior descendingLAT: LateralLLD: Left lateral decubitusLPO: Left posterior obliqueL-SPINE: Lumbar spineLT: LeftLV: Left ventricularLVOT: Left ventricular outflow tract

MED: MedicalMHz: MegahertzML: Midlinemm: MillimeterMV: Mitral valveNIP: NippleOBL: ObliqueOV: OvaryPA: Pulmonary arteryPDA: Patent ductus arteriosusPFV: Profunda femoris veinPOP: Popliteal arteryPOST: PosteriorPRF: Time and depth limitationsPROX: ProximalPT: Posterior tibial arteryPV: Pulmonic valvePW: Pulsed wave DopplerRA: Right atriumRCA: Right coronary arteryRI: Resistive indices

748

RLD: Right lateral decubitusRPO: Right posterior obliqueRT: RightRV: Right ventricleSA: Sinoatrial nodeSAG: SagittalSEM V: Seminal vesiclesSFA: Superficial femoral arterySFV: Superficial femoral vein

SMA: Superior mesenteric arterySUP: SuperiorSVC: Superior vena cavaTGC: Time-gain compensationTRV: TransverseT-SPINE: Thoracic spineTV: Tricuspid valveUT: UterusVAG: Vagina

Documents

Pocket protocols for ultrasound scanning 2rd