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Thieme The Practice of Ultrasound A Step-by-Step Guide to Abdominal Scanning Berthold Block, M.D. Private Practice Braunschweig Germany 900 Illustrations 36 Tables Georg Thieme Verlag Stuttgart • New York Library of Congress Cataloging-in-Publication Data is available from the publisher. This book is an authorized translation of the 2nd German edition published and copyrighted 2003 by Georg Thieme Verlag, Stuttgart, Germany. Title of the German edition: Der Sono-Trainer: Schritt-fur-Schritt-Anleitungen fur die Oberbauchsonographie. Translator: Terry C. Telger, Fort Worth, TX, USA Illustrators: Viorel Constantinescu, Bucharest and Jorg Decker, Stuttgart Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers' leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain. This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage. © 2004 Georg Thieme Verlag RiidigerstralSe 14, 70469 Stuttgart, Germany http://www.thieme.de Thieme New York, 333 Seventh Avenue, New York, NY 10001 USA http: //www. thieme.com Cover design: Martina Berge, Erbach-Ernsbach Typesetting by Ziegler + Miiller, Kirchentellinsfurt Printed in Germany by Grammlich, Pliezhausen ISBN 3-13-138361-5 (GTV) ISBN 1-58890-280-3 (TNY) IV 12345 Preface Health care professionals who want to practice abdominal ultrasound are often faced with two obstacles: 1. Colleagues rarely have the time or inclination to train new operators. 2. Standard textbooks of ultrasonography give little attention to the typical problems of beginners. This book is designed as a self-study guide for those who want to learn ultrasound scanning one step at a time. Several underlying principles are followed: 1. The chapters are arranged so that the book can be used during an ultrasound examination. It should be placed next to the examination couch. In this way the examiner can learn all about ultrasound anatomy in small, manageable steps. By referring to the concise text and matching illustrations, the user can quickly reproduce the technique that is being described. The scan may be performed on a patient, on a colleague, or even on the user himself. 2. Every sectional ultrasound image is two-dimensional. The image is "brought to life" by moving the transducer over the body surface to create a three-dimensional impression of what is being scanned. For this reason, the ultrasound visualization of anatomic structures is illustrated by a sequence of images, rather than by a single image as in most other books. 3. Three-dimensional artwork. Instead of showing a flat coronal view, for example, the anatomical drawings provide a "sliced" view of structures that shows just how the structures are cut by the sector-shaped beam. As source materials for these perspective views, the author used ultrasound image sequences, computed tomographic scans, and anatomical sections, depending on the requirements of the situation. The author hopes that this introduction will provide a complete and easy-touse guide to the practice of upper abdominal ultrasound. I wish the reader enjoyable reading and successful scanning. Braunschweig, Spring 2004 Berthold Block V Acknowledgments 1 express my thanks to the following colleagues, who either contributed images that I did not have in my own files or supplied me with images of better quality. Dr. med. Stefan Hanel Herzogin Elisabeth Heim Hospital Hochstrasse 11 38102 Braunschweig Dr. med. Ralf Kuhlmann Braunschweig Medical Center Celler Strasse 38 38114 Braunschweig PD Dr. med. Meinolf Karthaus Evangelisches Johannes Hospital Medical Clinic Schildescher Strasse 99 33611 Bielefeld Prof. Dr. med. Bernd Limberg Medical Clinic Municipal Hospital Alter Weg 80 38302 Wolfenbuttel Dr. med. Bernd Krakamp Medical Clinic 1 Cologne Municipal Clinics Merheim Hospital Ostmerheiner Strasse 200 51109 Cologne Dr. med. Johannes Under Medical Clinic I Braunschweig Medical Center Salzdahlumer Strasse 90 38126 Braunschweig Dr. med. Ingo Krenz Schlankreye Dialysis Center Schlankreye 38 20144 Hamburg Dr. med. Hilmar Milbradt Neustadt am Riibenberge District Hospital Lindenstrasse 75 31535 Neustadt am Rubenberge I extend special thanks to PD Dr. med. Hartmut Schmidt of the University Medical Center Charite in Berlin. I also thank Mr. Viorel Constantinescu for turning my rough sketches into precise sectional diagrams. The great majority of ultrasound images were obtained with a Siemens scanner. The author is grateful to the Siemens Corporation for generously providing the scanner on loan. I thank the staff at Thieme Medical Publishers for their constant and courteous help and support, especially Dr. Antje Schonpflug and Mrs. Claudia Giiner for their valuable advice during the production phase. I express very special thanks to Dr. Markus Becker of Thieme Medical Publishers, who encouraged me throughout the creation of this book and supported me in every way. Berthold Block VI Table of Contents 1 General How to Use This Book Examination Technique and Equipment Who do you examine first when learning to scan? How do you adjust the ultrasound machine? What can you do with the transducer? 1 1 2 2 2 4 2 Basic Physical and Technical Principles 10 Ultrasound Definitions Propagation of sound Production and detection of ultrasound waves: the pulse-echo principle Diagnostic ultrasound: propagation of ultrasound in biological tissue Producing an Image A-Mode B-Mode M-Mode Artifacts Noise Acoustic shadowing Posterior acoustic enhancement Reverberations Beam-width artifact Side-lobe artifact Mirror-image artifact Lateral edge shadow 10 10 10 11 11 12 12 13 13 14 14 14 14 14 15 16 17 18 3 Blood Vessels: The Aorta and its Branches, the Vena cava and its Tributaries 19 Organ Boundaries 19 Locating the aorta and vena cava 19 Demonstrating the aorta and vena cava in their entirety 20 Organ Details 22 Demonstrating arterial and venous pulsations 22 Evaluating the vessel walls and lumina 22 Identifying and defining the branches of the aorta and vena cava — 24 Anatomical Relationships 28 Relationship of the aorta and vena cava to the diaphragm, liver, and cardia 28 Area surrounding the celiac trunk and the course of the hepatic artery, splenic artery, and left gastric artery 29 VII Table of Contents Superior mesenteric artery, splenic vein, and renal vessels Iliac vessels Lymph nodes near the retroperitoneal vessels 33 38 40 4 Liver 43 Organ Boundaries Locating the liver Imaging the liver in its entirety Organ Details Shape Size Parenchymal pattern Vessels of the liver Division of the liver into lobes, segments, and subsegments The portal vein and its branches Anatomical Relationships Relationship of the left portion of the liver to the heart and stomach Relationship of the central portion of the liver to the vena cava, stomach, and pancreas Relationship of the right portion of the liver to the gallbladder, duodenum, and kidney Ascites 43 43 44 53 53 53 53 60 62 82 87 5 Porta hepatis 96 Organ Boundaries: Identifying the Vessels in the Porta Hepatis Vena cava and portal vein Hepatic artery and bile duct Transverse and longitudinal survey of the porta hepatis Organ Details: Details of the Vessels in the Porta Hepatis Portal vein 97 97 98 99 102 102 6 Gallbladder 106 88 90 93 95 Organ Boundaries 106 Locating the gallbladder 106 Imaging the entire gallbladder 108 Variable position of the gallbladder. . . . . . . . . . . . . . . . . . . . . . . . .111 Nonvisualization of the gallbladder. . . . . . . . . . . . . . . . . . . . . . . . .111 Organ Details 114 Regions of the gallbladder 114 Size of the gallbladder 114 Variable shape of the gallbladder 116 Gallbladder wall 117 Gallbladder contents 119 Special acoustic phenomena in gallbladder scanning 123 Anatomical Relationships 125 Relationship of the gallbladder to the liver 126 Relationship of the gallbladder to the portal vein 129 Relationship of the gallbladder to the antrum, bulb, and duodenum 132 VIII Table of Contents 7 Pancreas 135 Organ Boundaries Locating the pancreas Imaging the entire pancreas Variable shape of the pancreas Organ Details Pancreatic parenchyma Pancreatic duct Common bile duct Measuring the pancreatic diameter Anatomical Relationships Relationships of the tail of the pancreas Relationships of the body of the pancreas Relationships of the head of the pancreas 135 135 138 140 141 141 145 146 148 149 149 152 156 8 Stomach, Duodenum, and Diaphragm 164 Organ Details Stomach wall Organ Boundaries and Relationships Esophagus and cardia Body of the stomach Antrum and duodenum Diaphragm 165 165 166 166 170 172 176 9 Spleen 178 Organ Boundaries Locating the spleen Imaging the entire spleen Organ Details Shape of the spleen Determining the size of the spleen Echo pattern Anatomical Relationships Relationship of the spleen to the pancreas, kidney, colic flexure, and stomach Relationship of the spleen to the pleura 178 178 179 181 181 182 183 186 187 189 10 Kidneys 191 Organ Boundaries Locating the right kidney Imaging the entire right kidney Locating the left kidney Imaging the entire left kidney Organ Details Size and shape of the kidneys Renal parenchyma and renal sinus Anatomical Relationships of the Right Kidney Relationship of the right kidney to the liver Relationship of the right kidney to the psoas and quadratus lumborum muscles 191 193 195 197 198 200 200 204 214 215 218 IX