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Intro to Bedside Ultrasound

Abdominal Ultrasound

University of California-Irvine School of Medicine

Nathan Molina nathan.d.molina@gmail.com Trevor Plescia taplescia90@gmail.com Jack Silva jpsilva42@gmail.com

TEACHERS

Liver

Kidney

Diaphragm

Intestine

Appendix

Spleen

Gallbladder

ABDOMINAL STRUCTURES

3 MHz curvilinear for heavy patients, 5 or 7 MHz for average or thin patients, high frequency linear for superficial (bowel)

PROBES

LIVER: RIGHT UPPER QUADRANT

LIVER LOCATION

LIVER AND KIDNEY

NORMAL  MORRISON’S  POUCH

ABNORMAL  MORRISON’S  POUCH

LIVER VASCULATURE

Hepatic Vein

• We can use Color Doppler to confirm the presence of vessels

• Probe indicator oriented toward the head

• Two methods for f inding the gallbladder: • X – 7 • Subcostal Sweep

• Have patient take a deep breath to push liver out from under the ribs

• Fan through the gallbladder in both axes

GALLBLADDER SONOGRAPHY

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X = Xiphoid Process

From the X, place the probe 7 centimeters laterally  to  the  patient ’s  right

Phased array (P21) probe can be used

Helpful for bigger patients

FINDING THE GALLBLADDER: X - 7

X

Place probe in sagittal position at midline beneath the xiphoid process

Sweep the probe laterally along the costal margin to visualize the liver and gallbladder

FINDING THE GALLBLADDER: SUBCOSTAL SWEEP

MILF or Main InterLobar F i ssure is visual ized between the gal lbladder and the portal vein

GALLBLADDER SONOGRAPHY

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MILF or Main InterLobar Fissure is visual ized between the gal lbladder and the portal vein

MAIN INTERLOBAR FISSURE

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MILF

PV

GB

GALLSTONE WITH POSTERIOR SHADOWING

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CHOLECYSTITIS GALLBLADDER INFLAMMATION

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The  “Mickey  Mouse  Sign”  consists of the portal vein, hepatic artery, and common bile duct in the short axis

From the long axis view of the gallbladder, follow the MILF to the portal vein.

Use minor adjustments to try and find the Mickey Mouse sign

Use Color Doppler to confirm common bile duct vs hepatic artery

MICKEY MOUSE CBD Hepatic Artery

Portal Vein

THE KIDNEY

Ureter

Pelvis

Cortex Capsule

Pyramid

KIDNEY

Cortex

Pyramid

Pelvis Ureter

KIDNEY

Anterior or Coronal position Consider decubitus (left side) positioning for posterior view

NORMAL KIDNEY

RENAL CYSTS (POLYCYSTIC KIDNEY DISEASE)

Cysts within the renal cortex, not within renal pelvis

HYDRONEPHROSIS

Fluid buildup within the renal pelvis, not the cortex

KIDNEY PATHOLOGY

SPLEEN LOCATION

SPLEEN FUNCTION-FILTERS RED BLOOD CELLS, IMMUNE RESPONSE

INTESTINAL ULTRASOUND TECHNIQUE

Start in right upper quadrant and identify the ascending colon by its constancy of position and haustra

Follow ascending colon to right lower quadrant to identify  the  cecum’s  blind -ended loop

The cecum should lead you to the terminal i leum where the appendix is typically found

Layered appearance Easily compressible Intermittent peristalsis Large intestine has wall

thickness <4 mm Small intestine thinner

than large intestine

NORMAL BOWEL

ABNORMAL BOWEL

Non-compressible tubular structure in RLQ, sitting on top of the psoas muscle.

Normal size is 6mm or less. Only visible in pelvic orientation in ~15% of

patients (vs retrocecal orientation)

APPENDIX

NORMAL APPENDIX

Psoas Iliac artery

Appendix

Abdominal muscle

ACUTE APPENDICITIS

Diameter is greater than 6mm Color Flow Doppler to see ring of fire

ABDOMINAL AORTA AND INFERIOR VENA CAVA

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ABDOMINAL AORTA AND INFERIOR VENA CAVA

Use convex probe or curvilinear probe Place probe in sagittal position with

indicator pointing to the patients’ head or transverse with the indicator to the patient’s right

Abdominal Aorta will be slightly to the patient’s left

Inferior Vena Cava will be slightly to the patients’ right

Must push hard Great way to see aortic aneurisms

SAGITTAL VIEW –

ABDOMINAL AORTA

Aorta

SMA Liver

Splenic vein

TRANSVERSE ANATOMICAL LANDMARKS

Transverse

TRANSVERSE VIEW – ABDOMINAL AORTA & IVC

IVC

Splenic vein

Aorta

L. Renal vein

Liver SMA

ABDOMINAL AORTIC ANEURYSM

Liver

IVC

RRA

Portal vein(s)

SAGITTAL IVC

Portal veins

RRA

IVC

SAGITTAL IVC

SAGITTAL OR TRANSVERSE?

TRANSVERSE

SMALL IVC = LOW CENTRAL VENOUS PRESSURE

IVC

IVC DILATED WITHOUT RESPIRATORY CHANGE = HIGH CVP

IVC

Atlas of Anatomy, Second Edition, By Gilroy, MacPherson, Ross, Schuenke, Schulte, Schumacher. Thieme Medical Publishers, 2012.

Select images from the UCISOM Ultrasound in Education Department

REFERENCES