31
Echoscopy Atlas CFD 16.01.2015 08:14:46 1 Point of Care Ultrasound (POCUS) using echoscopy Table of contents Table of contents ........................................................................................................................... 1 Introduction.................................................................................................................................... 2 Anatomical structures that can be assessed using echoscopy....................................................... 2 Abdomen ................................................................................................................................... 2 Thorax ....................................................................................................................................... 2 Emergency examinations and FAST ............................................................................................... 2 Anatomical structures that cannot be assessed using echoscopy ................................................. 2 Abdomen ......................................................................................................................................... 3 Liver ............................................................................................................................................ 3 Confluence of the hepatic veins ..................................................................................................... 3 Confluence of the portal veins ....................................................................................................... 4 Intrahepatic portal vein................................................................................................................. 5 Hepatic veins ............................................................................................................................. 5 Gall bladder and bile ducts ......................................................................................................... 6 Gall bladder ............................................................................................................................... 6 Extrahepatic bile ducts ................................................................................................................. 7 Hepatic portal, lymph nodes dorsal in the ligamentum hepatoduodenale ................................................ 8 Hepatic portal, lymph nodes ventral in the ligamentum hepatoduodenale ............................................... 9 Pancreas. .................................................................................................................................. 10 The pancreas in longitudinal section of the organ .............................................................................10 Pancreatic head ..........................................................................................................................11 Cauda pancreatis ........................................................................................................................12 Pancreas, Ductus Wirsungianus ....................................................................................................13 Retroperitoneum, large vessels ................................................................................................. 14 Aorta longitudinal, cranial ...........................................................................................................14 Aorta longitudinal, cranial over the truncus coeliacus and arteria mesenterica superior ............................15 Aorta lateral over the truncus coeliacus ..........................................................................................16 Arteria renalis dextra, longitudinal.................................................................................................17 Arteria renalis sinistra, longitudinal ...............................................................................................18 Gastrointestinal tract ................................................................................................................ 19 Oesophagus ...............................................................................................................................19 Spleen ........................................................................................................................................ 20 Urogenital tract ........................................................................................................................ 21 Kidneys ....................................................................................................................................22 Adrenal gland, right side..............................................................................................................23 Adrenal gland, left side ...............................................................................................................24 Pelvis, female ............................................................................................................................25 Urinary bladder, uterus, Douglas's cul de sac ...............................................................................25 Ovary ...................................................................................................................................26 Urinary bladder, ureteral jet .....................................................................................................27 Thorax .......................................................................................................................................... 28 Mediastinum.............................................................................................................................. 28

Point of Care Ultrasound (POCUS) using echoscopyefsumb.org/guidelines/echoscopy-vscan14012014.pdf · VCI: Vena cava inferior. AMS: Arteria mesenterica superior. J: Arteria jejunalis

Embed Size (px)

Citation preview

Echoscopy Atlas CFD 16.01.2015 08:14:46 1

Point of Care Ultrasound (POCUS) using echoscopy

Table of contents Table of contents ........................................................................................................................... 1 Introduction .................................................................................................................................... 2

Anatomical structures that can be assessed using echoscopy ....................................................... 2 Abdomen ................................................................................................................................... 2 Thorax ....................................................................................................................................... 2 Emergency examinations and FAST ............................................................................................... 2

Anatomical structures that cannot be assessed using echoscopy ................................................. 2

Abdomen ......................................................................................................................................... 3

Liver ............................................................................................................................................ 3 Confluence of the hepatic veins ..................................................................................................... 3 Confluence of the portal veins ....................................................................................................... 4 Intrahepatic portal vein ................................................................................................................. 5 Hepatic veins ............................................................................................................................. 5

Gall bladder and bile ducts ......................................................................................................... 6

Gall bladder ............................................................................................................................... 6 Extrahepatic bile ducts ................................................................................................................. 7 Hepatic portal, lymph nodes dorsal in the ligamentum hepatoduodenale ................................................ 8 Hepatic portal, lymph nodes ventral in the ligamentum hepatoduodenale ............................................... 9

Pancreas. .................................................................................................................................. 10

The pancreas in longitudinal section of the organ .............................................................................10 Pancreatic head ..........................................................................................................................11 Cauda pancreatis ........................................................................................................................12 Pancreas, Ductus Wirsungianus ....................................................................................................13

Retroperitoneum, large vessels ................................................................................................. 14

Aorta longitudinal, cranial ...........................................................................................................14 Aorta longitudinal, cranial over the truncus coeliacus and arteria mesenterica superior ............................15 Aorta lateral over the truncus coeliacus ..........................................................................................16 Arteria renalis dextra, longitudinal .................................................................................................17 Arteria renalis sinistra, longitudinal ...............................................................................................18

Gastrointestinal tract ................................................................................................................ 19

Oesophagus ...............................................................................................................................19

Spleen ........................................................................................................................................ 20

Urogenital tract ........................................................................................................................ 21 Kidneys ....................................................................................................................................22 Adrenal gland, right side ..............................................................................................................23 Adrenal gland, left side ...............................................................................................................24 Pelvis, female ............................................................................................................................25

Urinary bladder, uterus, Douglas's cul de sac ...............................................................................25 Ovary ...................................................................................................................................26 Urinary bladder, ureteral jet .....................................................................................................27

Thorax .......................................................................................................................................... 28

Mediastinum .............................................................................................................................. 28

References .................................................................................................................................... 30

Echoscopy Atlas CFD 16.01.2015 08:14:46 2

Introduction

The introduction of a new type of small handheld ultrasound device brings greater portability and affordability. The basic ultrasound approach with these handheld devices has been defined by European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) as “EchoScopy” [(1)]. Currently the smallest device used in daily routine is the Vscan™ (GE Healthcare). The EchoScope provides conventional B-mode and colour Doppler imaging (CDI). The compact size of the EchoScope makes it possible to carry the ultrasound device almost like a stethoscope under most clinical circumstances including visiting patients. Owing to this convenience, the EchoScope could be used as adjunctive tool for the physical examination [(2)]. An atlas in German has been recently published [(3)]. The presented paper is an updated atlas version demonstrating the use and limitation of the Vscan device.

Anatomical structures that can be assessed using echoscopy

Abdomen Echoscopy is particularly suitable for imaging the heart, vessels, and structures between the blood vessels (organ limits). For example, the size of the gall bladder, extensions of the extra-and intra-hepatic bile ducts and changes in the hepatic portal can be reliably visualised using echoscopy. It is possible to make statements on the blood flow in the portal vein and the hepatic veins. Perihepatic lymph nodes are imaged in the triangle between the portal vein and the lower caval vein at the height of the ductus cysticus. Practical experience on the pancreas is extraordinarily good, in particular in imaging the ductus wirsungianus and peripancreatic liquid behaviour. The sharpness of detail at deep levels is extraordinary. It is therefore often possible to detect the right adrenal gland with its 5 layers. Extensions of the abdominal aorta can be reliably detected. Backing up of urine can be diagnosed unambiguously. A bladder scan is one of the main indications. The examination of the prostate, uterus and vagina as well as the rectum is only for orientation.

Thorax Another domain in echoscopy is formed by the assessment of the heart, the pericardium and the evaluation of contractility in the framework of required cardiolocial examinations. Pleural effusion and ascites can be reliably imaged. Excellent imaging is possible on the mediastinum (aortic arch, paratracheal region, aorto-pulmonary window but also the subcarinal region).

Emergency examinations and FAST Imaging the Douglas's cul de sac in order to assess free liquid is sufficiently possible in almost all cases. Echoscopy has particular practical significance for assessing the urinary bladder and here in particular for the exclusion of overflow incontinence (bladder scan).

Anatomical structures that cannot be assessed using echoscopy All near-surface anatomical structures cannot be sufficiently assessed using VScan echoscopy, for example the (not pathologically changed) iliocaecal region, colon sigmoideum, near-surface intestinal structures, the pleural cavity and the lateral and posterior recessus

Echoscopy Atlas CFD 16.01.2015 08:14:46 3

costodiaphragmaticus. The liver parenchyma also cannot be sufficiently assessed; in particular, it is neither possible to exclude nor sufficiently characterise liver tumours. The thyroid and cervical vessels cannot be sufficiently imaged and assessed because of their shallow position. Echoscopy is also not helpful in the assessment of surface lymph node stations. Echoscopy is not suitable for excluding hepatic, renal and pancreatic tumours. It is not possible to precisely define the size of the spleen and kidneys because of the relatively small field of view.

Abdomen

Liver In terms of echoscopy, no statement can be made on blood flow in the portal vein and in the hepatic veins. Perihepatic lymph nodes are imaged in the triangle between the portal vein and the lower caval vein at the height of the ductus cysticus. Echoscopy is not suitable for excluding hepatic, renal and pancreatic tumours. It is not possible to measure the liver size precisely because of the relatively small field of view.

Confluence of the hepatic veins

Figure 1 Confluence of the hepatic veins. SV: Segment V of the liver. SVI: Segment VI. SVII: Segment VII. Segment VI. SVIII: Segment VIII. RHV: Right hepatic vein. CHV: Central hepatic vein.

a b c

Echoscopy Atlas CFD 16.01.2015 08:14:46 4

Confluence of the portal veins

Figure 2 Confluence of the portal veins (C). PV: Portal vein. AH: Arteria hepatica. MA (M): Stomach. AO: Aorta. VCI: Vena cava inferior. CD: Crus diaphragmaticum. WS: Spine.

a b

c

Echoscopy Atlas CFD 16.01.2015 08:14:46 5

Intrahepatic portal vein

Figure 3 Intrahepatic portal vein. The ductus hepatocholedochus (DHC), portal vein (PV) and vena cava inferior (VCI) are shown. SS: Sonic shadow. RHV: Right hepatic vein. ART: Artefact.

a b

c

Hepatic veins

Figure 4 Display of the right hepatic vein, from intercostal in slightly left lateral position.

RHV: Right hepatic vein. PV: Portal vein. K: Kidney. ART: Artefact.

a

Echoscopy Atlas CFD 16.01.2015 08:14:46 6

b

c

Gall bladder and bile ducts The size of the gall bladder, extensions of the extra- and intra-hepatic bile ducts and changes in the hepatic portal can be reliably visualised using echoscopy.

Gall bladder

Figure 5 Gall bladder. VCI: Vena cava inferior. PV: Portal vein. DUO: Duodenum. L: Liver. Note the echoscopically smaller field of view.

a

Echoscopy Atlas CFD 16.01.2015 08:14:46 7 b c

Extrahepatic bile ducts

Figure 6 Extrahepatic bile ducts from subcostal with a focus on the ductus hepatocholedochus (DHC). L: Liver. P: Pancreas. AH: Arteria hepatica, intrahepatic branch. PV: Portal vein. ARD: Arteria renalis dextra. FCI: Vena cava inferior. WS: Spine. PAP: Papille. DUO: Duodenum. P: Pancreatic head. A: Intrahepatic branch of the arteria gastrica.

a

b

Echoscopy Atlas CFD 16.01.2015 08:14:46 8

c

Hepatic portal, lymph nodes dorsal in the ligamentum hepatoduodenale

Figure 7 Ligamentum hepatoduodenale. Lymph node stations (LN) in the ligamentum hepatoduodenale dorsale in the aperture area of the ductus cysticus (DC) in the ductus hepatocholedochus (DHC). L: Liver. A: Arteria hepatica. VCI: Vena cava inferior. PH: Pancreatic head. ARD: Arteria renalis dextra. PV: Portal vein. MA: Stomach.

a b c

Echoscopy Atlas CFD 16.01.2015 08:14:46 9 Hepatic portal, lymph nodes ventral in the ligamentum hepatoduodenale

Figure 8 Ligamentum hepatoduodenale. Lymph node stations (LN) in the ligamentum hepatoduodenale ventrale. PUPA: Pars umbilicalis of the portal vein. LLL: Left lobe of the liver. LVA: Ligamentum venosum Arantii. AH: Arteria hepatica. VCI: Vena cava inferior. P: Pancreatic head. ARD: Arteria renalis dextra.

a b c

Echoscopy Atlas CFD 16.01.2015 08:14:46 10

Pancreas. Practical experience on the pancreas is extraordinarily good, in particular in imaging the ductus wirsungianus and peripancreatic liquid behaviour. Echoscopy is not suitable for excluding pancreatic tumours.

The pancreas in longitudinal section of the organ

Figure 9 Upper abdominal section, pancreas. LLL: Left lobe of the liver. LTH: Ligamentum teres hepatis. MA: Stomach. DUO: Duodenum. GB: Gall bladder. PH: Pancreatic head. CO: Corpus pancreatis. Cauda: Cauda pancreatis. C: Confluence of the vena portae. DW: Ductus Wirsungianus. AO: Aorta. VCI: Vena cava inferior. AMS: Arteria mesenterica superior. J: Arteria jejunalis. WS: Spine. LK: interaortocaval lymph nodes.

a b

c

Echoscopy Atlas CFD 16.01.2015 08:14:46 11

Pancreatic head

Figure 10 Cranio-caudal diameter of the pancreatic head (between the markers). The caput pancreatis and the vena cava inferior (VCI) are marked. CO: Confluence of the vena portae. AH: Arteria hepatica.

a

b

c

Echoscopy Atlas CFD 16.01.2015 08:14:46 12 Cauda pancreatis

Figure 11 Cauda pancreatis (CP) with imaging of the spleen. VL: Vena lienalis. C: Colon. SS: Sonic shadow. WS: Spine. NN: Adrenal gland. D: Diaphragm. DD: Small intestine.

a

b

c Figure 12 Cauda pancreatis, colour Doppler sonogram imaging of the splenic vein as a

landmark of the cauda pancreatis. CP: Cauda pancreatis. VL: Vena lienalis. "Art vessels": Arterial vessels.

a

Echoscopy Atlas CFD 16.01.2015 08:14:46 13

b

c Pancreas, Ductus Wirsungianus

Figure 13 Ductus Wirsungianus. AO: Aorta. VCI: Vena cava inferior. PH: Pancreatic head. LTH: Ligamentum teres hepatis. LLL: Left lobe of the liver. VL: Vena lienalis. AMS: Arteria mesenterica superior. Between the markers Ductus Wirsungianus. ART: Artefacts.

a

Echoscopy Atlas CFD 16.01.2015 08:14:46 14

b c

Retroperitoneum, large vessels

Aorta longitudinal, cranial

Figure 14 Aorta. Longitudinal section over the Aorta (AO) with imaging of the truncus coeliacus (TC) and the arteria mesenterica superior (AMS). AHC: Arteria hepatica communis. PUPA: Pars umbilicalis of the portal vein. On this image, it is easily recognisable that the field of view diverges significantly in the two procedures.

a

Echoscopy Atlas CFD 16.01.2015 08:14:46 15

b c

Aorta longitudinal, cranial over the truncus coeliacus and arteria mesenterica superior

Figure 15 Aorta. Aorta (AO) longitudinal over the truncus coeliacus (TC) and arteria mesenterica superior (AMS). VMS: Vena mesenterica superior. D: Diaphragm.

a b

Echoscopy Atlas CFD 16.01.2015 08:14:46 16

c Aorta lateral over the truncus coeliacus

Figure 16 Section over the Truncus coeliacus (TC). AHC: Arteria hepatis communis. AL: Arteria lienalis. LTH: Ligamentum teres hepatis.

a

b

c

Echoscopy Atlas CFD 16.01.2015 08:14:46 17

Figure 17 Alternative. Section over the truncus coeliacus (TC). AHC: Arteria hepatis

communis. AL: Arteria lienalis. AGS: Arteria gastrica sinistra. a

b c Arteria renalis dextra, longitudinal

Echoscopy Atlas CFD 16.01.2015 08:14:46 18

Figure 18 Arteria renalis dextra in an upper abdominal section. AO: Aorta. ARD: Arteria renalis dextra. VCI: Vena cava inferior. DHC: Ductus hepatocholedochus. C: Confluence. AMS: Arteria mesenterica superior. VL: Vena lienalis. Cauda: Cauda pancreatis. MA: Stomach. LLL: Left lobe of the liver. AGD: Arteria gastroduodenalis superior.

a b c

Arteria renalis sinistra, longitudinal

Figure 19 Arteria renalis sinistra: AO: Aorta. ARS: Arteria renalis sinistra. VCI: Vena cava inferior. PDLE: Pancreas dorsal less echoic, variant. PH: Pancreatic head. VL: Vena lienalis. Corpus: Corpus pancreatis. LLL: Left lobe of the liver. AGD: Arteria gastroduodenalis superior. WS: Spine. VRS: Vena renalis sinistra. VL: Vena lienalis.

a

Echoscopy Atlas CFD 16.01.2015 08:14:46 19

b

c

Gastrointestinal tract

Oesophagus

Figure 20 Oesophagus. Imaging of the oesophago-cardial transition (OE). LLL: Left lobe

of the liver. H: Heart. AO: Aorta. D: Diaphragm. TC: Truncus coeliacus.

a b

Echoscopy Atlas CFD 16.01.2015 08:14:46 20

c Spleen

Figure 21 Spleen. It is only possible to measure the spleen to a limited extent using echoscopy.

a b

c

Echoscopy Atlas CFD 16.01.2015 08:14:46 21

Figure 22 Area around the spleen. RCL: Recessus costodiaphragmaticus lateralis. D: Diaphragm. 1: Interior muscle layer. 2: Exterior muscle layer. LPC: Ligamentum phrenicocolicum. Art: Artefacts.

a

b

c

Urogenital tract

Echoscopy Atlas CFD 16.01.2015 08:14:46 22

Kidneys

Figure 23 Kidney, longitudinal. It is a challenge to precisely measure the kidney using the

VScan due to the small angle of insonication which is depth dependent a b

Figure 24 Kidney, lateral. a b

Echoscopy Atlas CFD 16.01.2015 08:14:46 23 Figure 25 Renal cortical vessels. a

b

Adrenal gland, right side

Figure 26 Adrenal gland, right side (between the markers). RHV: Right hepatic vein. PV:

Portal vein. VCI: Vena cava inferior. D: Diaphragm. SA: Sonic shadow. a

Echoscopy Atlas CFD 16.01.2015 08:14:46 24

b c

Adrenal gland, left side

Figure 27 Left adrenal gland. NN: Adrenal gland. RF: Mass. D: Diaphragm. WS: Spine.

a

b

Echoscopy Atlas CFD 16.01.2015 08:14:46 25

c

Pelvis, female

Urinary bladder, uterus, Douglas's cul de sac

Figure 28 Urinary bladder (UB), uterus (U) and a small amount of free liquid in Douglas's cul de sac (FF). V: Vagina. R: Rectum.

a

b

Echoscopy Atlas CFD 16.01.2015 08:14:46 26

c

Ovary Figure 29 Ovary. Ovary, left, in the recess between the pelvic vessels. Between the markers,

small physiological ovarian cyst of a young woman. AIE: Arteria iliaca externa. VIE: Vena iliaca externa. VII: Vasa iliaca interna.

a b c

Echoscopy Atlas CFD 16.01.2015 08:14:46 27

Urinary bladder, ureteral jet

Figure 30 Ureter. Ureter outlet, shown using colour Doppler sonogram with the ureteral jet (echoscopically left-sided, high-end device right side)

a

b

Echoscopy Atlas CFD 16.01.2015 08:14:46 28

Thorax

Mediastinum

Figure 31 Mediastinal sonography. Aorticopulmonary window (APF). VA: Vena anonyma. V: Vena jugularis. AA: Aorta ascendens. AOB: Aortic arch. AD: Aorta descendens. AS: Arteria subclavia. ACC: Arteria carotis communis. RSP: Recessus superior pericardii. TP: Truncus pulmonalis.

a b

c

Figure 32 Paratracheal region, right side. With digits indicates the tracheal cartilage rings. PVR: Prevascular region. VA: Vena anonyma. AA: Aorta ascendens. AOB: Aortic arch. TPC: Truncus brachiocephalicus. BIF: Bifurcation. SCR: Subcarinal region.

a

Echoscopy Atlas CFD 16.01.2015 08:14:46 29

b

c Figure 33 Paratracheal region, venous sectional image. PVR: Prevascular region. VCS:

Vena cava superior. VA: Vena anonyma. VBC: Vena brachiocephalica. SA: Sonic artefact. SCR: Subcarinal region. PV: Pulmonary vein. AA: Aorta ascendens. AOB: Aortic arch.

a b

Echoscopy Atlas CFD 16.01.2015 08:14:46 30

c

References

Reference List

1. Piscaglia F, Dietrich C.F., Nolsoe C, Gilja OH, Gaitini D. Birth of echoscopy. The EFSUMB point of view. Ultraschall 2013; 34(1):92.

2. Barreiros AP, Cui XW, Ignee A, De Molo C, Pirri C, Dietrich CF. EchoScopy in scanning

abdominal diseases: initial clinical experience. Z Gastroenterol 2014; 52(3):269-275.

3. Dietrich C.F. Ultraschall in der Lehre, ein kleiner Atlas der Echoskopie. Gastroenterologie

Up2Date 2014; 10:279-294.