UltrasoundTraumaCh02 Fast Exam

8/9/2019 UltrasoundTraumaCh02 Fast Exam

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The FAST ExamRobert A. Jones, DO, RDMS, FACEP, and Robert D. Welch, MD, FACEP

C H A P T E R 2

Evaluation of patients with thoracoabdominal trauma is often a

diagnostic challenge for emergency physicians and trauma surgeons, and

is made more difficult by the insensitivity of the physical examination

for detecting major internal injuries. Studies have shown that 20% to

43% of patients with significant abdominal injuries may initially have a

normal physical examination of the abdomen. Even patients with

intraperitoneal hemorrhage can be alert and asymptomatic on arrival. A

patient with a hemopericardium, hemothorax, or hemoperitoneum can

deteriorate quickly despite a benign initial presentation. Because of the

lack of reliability of the physical examination, physicians have come to

depend on ancillary tests to detect potentially life-threatening injuries.


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The FAST Exam

Figure 2-1C

A, Fluid in Morisons pouch. Blood or fluid in this pouch appears as an anechoic (black) stripe between the liver and the right kidney. Clotspresent within the blood may be echogenic (white).This is the most dependent region of the upper abdomen. This region is also referredto as the hepatorenal pouch or hepatorenal space. B,C, Preferential locations for blood to accumulate. B, Locations on a longitudinal view.C, Locations on an anteroposterior view of the abdomen. D, Intraperitoneal free fluid. The pattern of free fluid movement within theabdominal cavity is shown. E, Views of the FAST exam. The FAST exam consists of pericardial (cardiac), perihepatic (RUQ), perisplenic(LUQ), and pelvic views. Most physicians perform the RUQ view first in patients with blunt abdominal trauma and the cardiac view first inpatients with penetrating trauma to the chest. (B,C, Reprinted with permission from Sanders RC. Clinical Sonography: A Practical Guide.2nd ed. Boston, Mass: Little, Brown; 1991:257. E, Courtesy of William Mallon, MD.)

Figure 2-1B

Figure 2-1A

Figure 2-1D

Figure 2-1E


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Sonographic Findings

Clinical findings associated with hemopericardium are nonspecific and insensitive.

Even with pericardial tamponade, Becks triad and pulsus paradoxus are not

consistently present. Hemopericardium is usually recognized clinically only after

deterioration has occurred. Cardiac ultrasonography is sensitive for detecting even

small amounts of fluid in the pericardial sac and allows for early recognition at the

bedside. Early recognition of cardiac injuries leads to immediate interventions that

decrease morbidity and mortality.20 Several studies have shown that hemopericardium

can be detected accurately by emergency physicians and trauma surgeons with limited

ultrasonography training.21,22

The subcostal window provides a four-chamber view of the heart (Figure 2-3). A

small portion of the liver is seen closest to the probe, with the heart behind it. The

hyperechoic pericardium is seen surrounding the heart. Normally, there is a small

amount of fluid between the parietal and visceral pericardium. This fluid is usually

not visualized; however, in some healthy patients, a small amount of fluid can be seen

in the dependent aspect of the heart, so clinical correlation is essential. If fluid is

present in a nondependent aspect of the heart, it should be considered abnormal.The presence of pericardial fluid is demonstrated by separation of the visceral and

parietal pericardial layers (Figure 2-4A). Acutely, blood will appear anechoic (black);

however, echoes may be present if clotting has occurred (Figure 2-4B). When looking

at a pericardial window, the pericardium should be identified; there should be only

one hyperechoic line surrounding the heart. If two lines are seen surrounding the heart

and there is no evidence of anechoic fluid, then an isoechoic fluid collection is

possible. The presence of clotting can result in fluid collections that are isoechoic to

the surrounding cardiac muscle (Figure 2-4C). False-negative results have been

attributed to this in the literature.21

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The FAST Exam

Figure 2-2

Probe placement for subcostal pericardial view. The probeindicator is directed toward the patients right side (9 oclock); thebeam is directed toward the left shoulder. The arrow indicates thedirection of the probe indicator. Imaging may be enhanced byhaving the patient take a deep breath and hold it.

Figure 2-3

Normal subcostal pericardial view. RV, right ventricle; LV, leftventricle; RA, right atrium; LA, left atrium. A portion of liver will bevisualized in the near field. (Courtesy of Dr. Jones and Dr.Welch.)


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Ultrasonography in Trauma: The FAST Exam

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Pericardial fluid can be mistaken for intraperitoneal or pleural fluid. Fluid in the

subdiaphragmatic space between the diaphragm and the liver can be visualized with

this window; therefore, it is important to make certain the fluid is located between the

two pericardial layers (Figure 2-5). Even though the pleural window is limited in this

view, a large hemothorax can be mistaken for hemopericardium22 (Figure 2-6). It is

also possible for a large hemothorax to obscure a small pericardial fluid collection.22

In such cases, repeat studies should always be obtained after tube thoracostomy

drainage.

Pericardial tamponade can be diagnosed based on the presence of a circumferential

fluid collection with diastolic collapse of the right atrium or ventricle seen on

real-time scanning (Figure 2-7). Patients with severe pulmonary hypertension can

demonstrate clinical cardiac tamponade without right-sided chamber collapse.

Figure 2-4CA, Small amount of pericardial fluid. This subcostal (pericardial)view demonstrates a small amount of anechoic (black) fluid in thepericardial space. B, Large amount of pericardial blood with clots.This subcostal (pericardial) view demonstrates a large amount ofblood in the pericardial space, and the right ventricle iscompressed.The echoes (white) that are seen within the darkfluid represent blood clots. On real-time imaging, there wasdiastolic collapse of the right ventricle consistent with pericardialtamponade. C, Stab wound to the chest with a large amount ofpericardial clot. There is a large amount of clotted blood presentin the pericardial space that is isoechoic to the surroundingcardiac muscle.There also is some anechoic (black) fluid presentin the pericardial space. (A,B, Courtesy of Dr. Jones and Dr.Welch. C, Courtesy of Dr. Mandavia.)

Figure 2-4A

Figure 2-4B


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in a cephalad direction if visualization of the diaphragm and pleural space is not

adequate. To visualize the paracolic gutter, the probe should be oriented in a coronal

plane and moved caudally until the lower pole of the kidney is seen (Figure 2-9).

The right subcostal technique is obtained with the probe at the right infracostal

margin, lateral to the midclavicular line (Figure 2-10). Having the patient take a deep

breath and hold it or push out the abdomen can help bring structures below thecostal margin into view. This technique requires significant patient cooperation

because respirations affect visualization. The presence of gas in the hepatic flexure of

the colon may also limit the success of this technique.

Figure 2-9

Probe placement for perihepatic (RUQ) coronal view. This view isused to visualize Morisons pouch and the right kidney. The probeis moved caudally to image the inferior pole of the right kidneyand the right paracolic gutter.

Figure 2-10

Probe placement for right subcostal view. Occasionally, it isnecessary to obtain additional perpendicular views of the RUQ toclarify findings present on prior RUQ views. This view requires apatient to take a deep breath and hold it or push out theabdomen to visualize the liver below the costal margin.

Figure 2-8

Probe placement for perihepatic or RUQ view (intercostalapproach). This provides excellent visualization of the diaphragm,liver, and Morisons pouch. A slight posterior angulation of theprobe reduces the amount of rib shadowing that is obtained byimaging directly through an intercostal space. The probe indicator

is directed toward the patients posterior axilla. The arrowindicates the direction of the probe indicator.


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The perihepatic view provides fractional views of the liver and right kidney and

allows visualization of fluid in Morisons pouch, the subphrenic space, the right

pleural space, and the retroperitoneum (Figure 2-11A-D). Hemoperitoneum appears as

an anechoic area in Morisons pouch or in the subphrenic space (Figure 2-12A-D).

Fluid in adjacent structures such as the gallbladder, hepatic flexure of the colon, and

duodenum can be mistaken for intraperitoneal fluid.23 To prevent this error, the user

must identify peristalsis during real-time scanning and demonstrate an echogenic

border surrounding the fluid. In addition, free fluid tends to form spicules or

triangulate as it follows the path of least resistance, whereas fluid within organs or

vessels has a rounded or cylindrical appearance (Figure 2-13A-C). Morisons pouch is

a pooling site for excess pelvic fluid and perisplenic fluid; thus, it is particularly

important to adequately visualize this region.24-27 Placing the probe in a coronal plane

Figure 2-11A Figure 2-11C

Figure 2-11B Figure 2-11D

A-D, Negative studies of RUQ. Normal perihepatic views demonstrating diaphragm, liver, and kidney (left to right). The renal capsuleappears as an echogenic line surrounding the kidney.The renal cortex is slightly less echogenic than the neighboring liver, and the renalpyramids appear as hypoechoic regions that point toward the center of the kidney.The renal sinus is a central echogenic portion of thekidney. There is no anechoic (black) stripe visualized above the outer white border of the kidney. (A, Courtesy of Dr. Jones and Dr. Welch.B, Courtesy of Dr. Reardon.)


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and sliding it caudally until the inferior pole of the kidney is seen will allow detection

of both supramesocolic and inframesocolic fluid around the tip of the liver that has

not yet reached Morisons pouch (Figure 2-14A,B). Moving the probe in a cephalad

direction permits visualization of subphrenic space, a common site of fluid

accumulation.

Pleural fluid can be accurately detected using this limited view. Studies have shownsensitivities in the range of 96.2% to 97.5% and specificities in the range of 99.7% to

100% for the detection of hemothoraces using ultrasonography.4,5 The patient should

be in the supine position, although reverse Trendelenburg positioning intuitively

should improve detection. Free pleural fluid is represented by the presence of an

anechoic area cephalad to the hyperechoic diaphragm (Figure 2-15A,B). Clearly

identifying the diaphragm prevents misdiagnosing a subphrenic fluid collection or

other intraperitoneal fluid as a pleural fluid collection (Figures 2-16 and 2-17). It has

been shown that, although supine and upright chest radiographs require a minimum of

175 mL and 50 to 100 mL of pleural fluid, respectively, for detection, ultrasonography

can detect a minimum of 20 mL of pleural fluid. 4 The significance of a hemothorax

Figure 2-12A Figure 2-12C

Figure 2-12B Figure 2-12D

Perihepatic (RUQ) views with fluid in Morisons pouch. B,C, The tip of the liver is free floating. (A,D, Courtesy of Dr. Jones and Dr. Welch.B, Courtesy of Dr. Kendall. C, Courtesy of Dr. Reardon.)


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Figure 2-13A

Figure 2-14A Figure 2-14B

A, Longitudinal view (snowboarding injury with pelvic bleeding). B, Transverse view (motor vehicle crash with splenic laceration) of thelower pole of liver and kidney. Blood is seen beside the inferior pole of the liver and kidney that has not yet reached Morisons pouch.

Figure 2-13B

Figure 2-13C

Perihepatic view with gallbladder visualized. A, Longitudinal viewof a normal gallbladder. Note the echogenic wall surrounding thegallbladder. B, Perihepatic view of 25-year-old patient involved ina high-speed motor vehicle crash.This transverse view of thegallbladder demonstrates free intraperitoneal blood above the

gallbladder. C, Free intraperitoneal blood tends to form trianglesor spicules, whereas fluid in organs or vessels is round, oval, ortubular.There is free blood present to the right of the gallbladder.(A, Courtesy of Dr. Stahmer. B, Courtesy of Dr. Jones and Dr.Welch.)


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detected with ultrasonography and not visualized by plain radiography is not known;

for this reason, the detection of hemothorax is not a primary goal of FAST. Future

studies should examine the sonographic appearances of pulmonary contusions,

because a false-positive study for hemothorax has been reported in a patient with a

pulmonary contusion without hemothorax.5 When chest radiography is unavailable or

delayed, ultrasonography should be used.

Perisplenic Window (Left Upper Quadrant)

Technique

The perisplenic view is obtained using an intercostal approach; it is technically

more difficult for the novice sonographer than the perihepatic view. With practice,

however, the user can obtain quality images in most cases. The intercostal approach is

similar to that of the perihepatic view, with a few exceptions. The probe should be

Figure 2-15B

Perihepatic view with fluid noted in the pleural space. A, Fluid inthe pleural space makes a V shape on the longitudinal view,whereas subdiaphragmatic fluid has a crescent shape. B, Thehemothorax is compressing the adjacent lung tissue, and the tipof the atelectatic lung is clearly visible. (A, Courtesy of Dr. Jonesand Dr. Welch.)

Figure 2-16

Perihepatic view with a large amount of fluid noted in thesubdiaphragmatic space. (Courtesy of Dr. Kendall.)

Figure 2-17

Perihepatic view with echogenic liver contusion. The liverhematoma has a heterogeneous appearance, and there is freeblood to the right of it between the liver and kidney. (Courtesy ofDr. Jones and Dr. Welch.)

Figure 2-15A


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placed in the intercostal space between ribs 9 and 10 or 10 and 11. The bulk of the

spleen is located more dorsal than the liver and the organ is smaller; thus, the probe

placement must be more posterior. In a coronal plane, the probe is placed near the

posterior axillary line with the probe indicator directed cephalad (Figure 2-18A). To

place the probe in the proper plane, it is occasionally necessary to either turn the

patient slightly on the right side (this can be done only if it will cause no further

injury to the patient) or place the patient near the edge of the stretcher. The probe can

be slightly rotated clockwise to reduce rib shadowing (image beam parallel to ribs),

thus obtaining a better longitudinal view of the spleen and kidney (Figure 2-18B). The

beam is then swept anterior and posterior, as well as cephalad and caudal, to visualize

the regions of interest.

With more experience, the user can predict, with some certainty, the best probe

position based on patient body habitus. In most patients, a depth of 12 to 15 cm is

appropriate for this examination. More depth is useful if finding the spleen is difficult

(more depth translates into a larger field of view), and is required in very large

patients. Less depth helps magnify regions of interest. Asking the patient to slowly

take a deep breath helps bring the spleen into view. A significant amount of pressure

on the probe might be required to obtain a quality image in an obese patient and, as a

result, may not be tolerated if injuries are present in that region.

Ideally, portions of the left hemidiaphragm, spleen, and left kidney appear in a

single view (Figure 2-19). Occasionally, the sonographer cannot adequately visualize

the diaphragm (Figure 2-20). If this occurs, two (or more) separate views are needed.

The patient may take a deep breath, or the probe may be moved up one intercostal

space, or the beam may be directed more cephalad to visualize the spleen and left

hemidiaphragm. Moving the probe down one intercostal space and directing the beam

more caudally might be required to visualize the spleen and lower pole of the left

kidney (Figure 2-21A-C). If these structures are not visualized, the study must beconsidered incomplete. The user must keep in mind that the subphrenic space is the

most frequent site for fluid accumulation in this region; failure to visualize the

diaphragm will result in a significant number of false-negative studies.

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Probe placement for perisplenic views. Arrow indicates the direction of the probe indicator. A, Coronal LUQ view. B, LUQ intercostalapproach. The intercostal approach may provide a clearer image with less rib shadowing than the coronal view.


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Figure 2-21C

Perisplenic views showing diaphragm and splenorenal fossa.Multiple views of the LUQ often must be obtained to view thediaphragm, spleen, and the entire kidney. A,B, Subdiaphragmaticfluid/blood is seen in these views.The left kidney is poorlydepicted in A but nicely imaged in B. C, A small stripe of blood isvisualized in the splenorenal space.The diaphragm is not seen.(Courtesy of Dr. Kendall.)

Figure 2-21AFigure 2-19

Normal perisplenic (LUQ) view with the structures as labeled.(Courtesy of Dr. Jones and Dr. Welch.)

Figure 2-20

Perisplenic view showing spleen and kidney. The diaphragm isnot well visualized in this view.There is fluid/blood seen at the tipof the spleen. (Courtesy of Dr. Kendall.)

Figure 2-21B


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The perisplenic view provides fractional views of the spleen, left kidney,

retroperitoneal region, and left pleural space (Figure 2-22). Hemoperitoneum appears

as an anechoic area in the subphrenic space or in the splenorenal fossa. Fluid in this

region preferentially goes to the subphrenic space, with overflow going to the

splenorenal fossa and across the midline to Morisons pouch13 (Figure 2-23A-G). Onestudy found that, of 69 patients with isolated spleen injuries, only 33.3% had a

positive perisplenic view, whereas 77.3% had a positive perihepatic view.28 The

diaphragm must be clearly identified so that a pleural fluid collection is not mistaken

for a subphrenic collection. Once blood coagulates, the sonographic appearance is that

of varying echogenicity. With time, the clots can become isoechoic and difficult to

differentiate from solid organs. Fluid in adjacent structures such as the stomach or

splenic flexure of the colon can be mistaken for intraperitoneal fluid.23 Careful

inspection for the presence of peristalsis during real-time scanning and recognition of

the appearance of fluid in the gastrointestinal tract is crucial to prevent this error.23

Pleural fluid (hemothorax) in the left pleural space can be accurately detected on

this limited view as an anechoic region cephalad to the left hemidiaphragm (Figure

2-24A-C). Clearly identifying the diaphragm prevents misdiagnosing a subphrenic

fluid collection as a pleural fluid collection; this is described in more detail in

Chapters 3 and 6.

Ultrasonography is not as sensitive as CT in the detection of spleen injuries, but the

fractional view of the spleen seen on the perisplenic window might provide

information about parenchymal injury (Figure 2-25). Because intraparenchymal

hemorrhage can appear similar to the surrounding normal tissue, it can be easily

missed.27, 28 A complete description of solid organ injuries is provided in Chapter 5.

Figure 2-22

Normal perisplenic view. There is a mirror image of spleenevident cephalad to the diaphragm (mirror artifact). (Courtesy ofDr. Reardon.)


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Figure 2-23A Figure 2-23D

Figure 2-23F

Figure 2-23B Figure 2-23E

Figure 2-23G

A-G, Perisplenic views (LUQ) with freeintraperitoneal blood. In contrast to theRUQ, blood appears most commonly inthe subdiaphragmatic area and lessfrequently in the splenorenal fossa.(A-D,F, Courtesy of Dr. Jones and Dr.Welch.)

Figure 2-23C


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Figure 2-24C

Perisplenic views of left pleural fluid/hemothorax. A,B, A largeamount of anechoic fluid in the chest. C, Patient with a stabwound to the left chest that displays free blood and echogenicclot within the hemothorax. (Courtesy of Dr. Jones and Dr.Welch.)

Figure 2-24A

Figure 2-24B

Figure 2-25

Perisplenic view of a 19-year-old man who was assaulted with abaseball bat. Note the lack of homogeneity of this injured spleenwith a small stripe of free blood in the subdiaphragmatic space.(Courtesy of Dr. Jones and Dr. Welch.)


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Pelvic Window

Technique

The pelvic view is best accomplished when the patients bladder is filled. For this

reason, the FAST exam should be completed before Foley catheter placement or

spontaneous bladder emptying. If a catheter is already in place, retrograde filling with

saline can create a sonographic window (but this is often impractical during a

resuscitation). Another option is to clamp the catheter long enough to allow normal

bladder filling. This is performed most frequently when repeat scans are done or when

a patient has been transferred from another facility. The goal of this view is to detect

pelvic fluid (hemoperitoneum) in the most dependent part of the peritoneum.

The pelvic view can be obtained in either a longitudinal or transverse plane.

Although Rozycki et al29 recommend only a transverse view, most recommend both

the transverse and longitudinal views as being necessary for optimal sensitivity.30 To

obtain the longitudinal view, the probe is placed on the patients abdomen in the

midline just above the pubic symphysis with the probe indicator directed toward the

patients head (Figure 2-26). The probe can be angled in a posteroinferior direction to

obtain better visualization of the pelvic structures. The transverse view is obtained byplacing the probe in the midline just above the pubic symphysis with the probe

indicator directed toward the patients right (Figure 2-27).

It has been noted that, in nontrauma patients, an overdistended bladder may

obscure free pelvic fluid. Some urine is needed in the bladder to create an acoustic

window, but a very large bladder can displace fluid from the pouch of Douglas

(cul-de-sac) in females and cause a false-negative study.31 If the bladder is noted to be

overdistended on the original scan, the bladder should be partially drained with a

Foley catheter and the pelvis rescanned. Further study is needed to determine if a

repeat partial void study increases sensitivity in injured patients.

Figure 2-26

Probe placement for longitudinal pelvic view. Arrow indicates thedirection of the probe indicator.

Figure 2-27

Probe placement for transverse pelvic view. Arrow indicates thedirection of the probe indicator.


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Figure 2-28C

Longitudinal pelvic views (female). A, Normal longitudinal view.B,C, Longitudinal views with anechoic fluid/blood noted in thepouch of Douglas. (B,C, Courtesy of Dr. Mandavia.)

Figure 2-28A

Figure 2-28B


In a female patient, fluid appears in the pouch of Douglas just posterior to the

uterus, with overflow fluid extending around the uterus (Figures 2-28A-C and

2-29A,B). A small amount of fluid may be present as a normal finding in

premenopausal females, and clinical correlation is essential. Although not a primary

indication of the FAST exam, the uterus should be observed for the presence of anintrauterine pregnancy.

In a male patient, fluid appears in the rectovesicular pouch or cephalad to the

bladder (Figures 2-30A-E and 2-31A,B). The seminal vesicles are paired structures

that appear hypoechoic and lie posterior to the bladder; they can easily be confused

with free intraperitoneal fluid23 (Figures 2-32 and 2-33). They can be distinguished

from free fluid based on their appearance between the bladder and prostate and by the

fact that, on the longitudinal view, the seminal vesicles taper off in the cephalad

direction and do not extend beyond the bladder, in contrast to free intraperitoneal

fluid.


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SummaryThis chapter summarizes the techniques and the sonographic findings of the basic

FAST exam. The chapters that follow address clinical applications of the FAST exam,

specific organ injuries, pitfalls, and additional applications and provide a review of the

literature and issues regarding training and credentialing.


Transverse pelvic views (female). A, Normal transverse view. B, Transverse view with anechoic fluid/blood noted in the pouch of Douglas.(Courtesy of Dr. Mandavia.)


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Figure 2-30A

Figure 2-30B

Figure 2-30C

Figure 2-30D

Figure 2-30E

Longitudinal pelvic views (male) with large amount of anechoicfluid/blood cephalad to bladder. Loops of bowel are nicelyvisualized in A,D,E. (A,C, Courtesy of Dr. Jones and Dr. Welch.D, Courtesy of Dr. Reardon.)


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Figure 2-31BTransverse pelvic views (male). A, Normal transverse view of thepelvis demonstrating bladder and prostate. B, Anechoic bloodposterior to the bladder in a patient with intraperitonealhemorrhage.

Figure 2-32

Longitudinal pelvic view (male) with a hypoechoic region posteriorto the bladder, which represents seminal vesicles. (Courtesy ofDr. Jones and Dr. Welch.)

Figure 2-33

Transverse pelvic view (male) with hypoechoic seminal vesiclesposterior to the bladder. Seminal vesicles vary in appearance anddo not always have the classic paired profile. (Courtesy of Dr.Jones and Dr. Welch.)

Figure 2-31A


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References

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