Sonographer in the Making
Abdomen & Small Parts Flashcards
Informational, double sided. The most important facts on the card, an anatomy illustration and an ultrasound image on each, and a QR to the digital practice questions. No questions printed on the card. Each topic opens with its normal card or cards, anatomy, function, labs, sonographic appearance, and scanning, then moves into the pathology.
57 double sided cards across 11 topics, in the order of your list: vascular system, liver, gallbladder and biliary, spleen, pancreas, gastrointestinal tract, peritoneal cavity and abdominal wall, urinary system, retroperitoneum, thyroid and parathyroid, scrotum. Each topic now carries the same depth, weighted to how much the reference text gives it, so liver and urinary run longest and the peritoneal cavity runs shortest. Still to come: breast and musculoskeletal if there is room, and the four topics you said could stay digital only, contrast agents, ultrasound guided intervention, emergent procedures, and the transplant patient. Content is grounded in the reference texts. Anatomy and ultrasound images are shown as labeled slots until the real figures are placed. Card size and QR targets still to be set.
Card 1 · Vascular System: Aorta & IVC
Front
Course
- Retroperitoneal structure lying anterior and slightly left of the spine
- Continuation of the thoracic aorta, extending from the diaphragm to the common iliac artery bifurcation
- Bifurcates at roughly the level of the umbilicus (near the fourth lumbar vertebra) into the right and left common iliac arteries
- Tapers in diameter as it travels distally
Branches in order
- Celiac trunk (first main visceral branch; gives rise to the splenic, common hepatic, and left gastric arteries)
- Superior mesenteric artery (SMA), just inferior to the celiac trunk
- Right and left renal arteries (right renal artery origin usually slightly superior to the left)
- Inferior mesenteric artery (IMA)
Wall layers
- Tunica intima (innermost, closest to flowing blood)
- Tunica media (middle, muscular layer)
- Tunica adventitia (outermost)
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Inferior vena cava
- Situated anterior to the spine and to the right of the aorta
- Formed by the union of the common iliac veins posterior to the right common iliac artery
- Major tributaries include the common iliac, renal, and hepatic veins (hepatic veins enter just below the diaphragm)
- Left renal vein courses anterior to the aorta, posterior to the SMA, and enters the lateral wall of the IVC
- Drains blood from the lower extremities and splanchnic territories into the right atrium
- Travels a horizontal course with its proximal portion curving slightly anterior as it approaches the diaphragm
Aorta vs IVC
- Aorta is pulsatile; IVC shows respirophasic variation and greater than 50 percent collapse with a sniff
- Aorta lies to the left of midline; IVC lies to the right
- IVC is thin walled and compressible; aorta is thick walled and non compressible
Scanning technique
- Image the aorta in transverse and sagittal planes from the diaphragm to the bifurcation
- Measure the anteroposterior diameter outer wall to outer wall, perpendicular to the vessel
- Obtain measurements at the proximal, mid, and distal aorta and the proximal common iliac vessels
- Normal adult male abdominal aorta is usually less than 3 cm in diameter
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Card 2 · Vascular System: Aortic Branches
Front
Celiac trunk
- The first main visceral branch, short, giving rise to three vessels: the splenic, the common hepatic, and the left gastric arteries
- In transverse the splenic and hepatic arteries sweeping away from the trunk make the seagull sign
- The common hepatic artery branches into the proper hepatic artery and the gastroduodenal artery
- The median arcuate ligament of the diaphragm can compress the celiac trunk and produce a stenotic waveform
Hepatic artery variants
- The hepatic artery is the most variable of the abdominal arteries
- About 12 percent of people have a replaced hepatic artery arising from the superior mesenteric artery
- Two thirds have a right hepatic artery crossing posterior to the common bile duct or right hepatic duct, while the left hepatic artery crosses anterior to the left hepatic duct
- The right hepatic artery supplies the gallbladder through the cystic artery
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VASCULAR
Mesenteric & Renal
Mesenteric arteries
- The superior mesenteric artery arises from the anterior aortic wall roughly 1 cm inferior to the celiac trunk
- The inferior mesenteric artery is the last major visceral branch before the bifurcation
- An SMA to aorta angle over 15 degrees on sagittal suggests retroperitoneal adenopathy pushing the vessel forward
Renal arteries
- Lateral branches arising just inferior to the superior mesenteric artery
- The right renal artery is the longer vessel, coursing posterior to the IVC and anterior to the vertebral column to reach the right hilum
- The left renal artery runs directly from the aorta into the left hilum
- At least 30 percent of people have more than one renal artery, which is why occlusion cannot be called unless the vessel is imaged in full
Iliacs
- The common iliac arteries arise at the aortic bifurcation near the fourth lumbar vertebra and divide into internal and external iliac arteries
Trick: Celiac then SMA then renals then IMA. The renals hide just under the SMA, which is the landmark to find them from.
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Card 3 · Vascular System: IVC Tributaries & Anomalies
Front
Lateral tributaries
- The renal veins are the major lateral tributaries. Five to six veins join to form each main renal vein, emerging from the hilum anterior to the renal artery
- The left renal vein takes the longer course, passing anterior to the aorta and posterior to the superior mesenteric artery before entering the IVC
- The right suprarenal and gonadal veins drain straight into the IVC. The left ones drain into the left renal vein first. Lumbar veins enter posteriorly
Anterior tributaries
- The hepatic veins enter just below the diaphragm and are the last vessels to join before the right atrium
- Hepatic veins enlarge as they approach the diaphragm and lack the bright walls that portal veins carry
Formation and course
- Formed by the union of the common iliac veins posterior to the right common iliac artery
- Ascends vertically through the retroperitoneum to the right of the aorta, curving slightly anterior as it pierces the diaphragm
- That union sits at the fifth lumbar vertebra, and the vessel pierces the diaphragm at the eighth thoracic level
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IVC abnormalities
- Thrombus and tumour both appear as solid material in the lumen. Tumour usually expands the vessel and may show internal colour flow; bland thrombus does not
- Renal cell carcinoma is the classic source, invading the renal vein and extending into the IVC, occasionally as far as the right atrium
- Assess for luminal filling defects and loss of compressibility, then confirm with colour and spectral Doppler
Predisposing conditions
- Predisposing to renal vein thrombosis: preexisting renal disease, renal cell carcinoma, a hypercoagulable state, and IVC or ovarian vein thrombus extending into the renal vein
Congenital variants
- Duplication, left sided IVC, and azygos continuation are the variants that confuse a scan of the great vessels
- A dilated IVC that does not vary with respiration suggests raised right heart pressure rather than a vessel abnormality
Trick: Always look at the cava and the renal veins when a renal cell carcinoma is found. The tumour reaches them far more often than the report expects.
Normal caliber
- The normal adult IVC measures under 2.2 cm, dilating to about 2.5 cm with a Valsalva manoeuvre
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Card 4 · Vascular System: Portal Venous System
Front
Portal vein
- Formed posterior to the pancreas by the union of the splenic vein and the superior mesenteric vein at about the level of L2
- Trunk is roughly 5 to 7 cm long; it runs to the porta hepatis and divides into right and left portal veins
- Carries blood from the intestinal tract to the liver, draining the gut from the lower esophagus to the upper anal canal, plus the pancreas, gallbladder, bile ducts, and spleen
- Upper limit of normal for the main portal vein is about 13 mm anteroposterior; it varies with respiration
Dual blood supply
- The liver is fed by both the portal vein and the hepatic artery
- Portal blood is incompletely oxygenated, under 80 percent, yet supplies up to half the oxygen the hepatocytes need because its volume of flow is so large
- The portal triad sits in a connective tissue sheath, which is what gives portal veins their bright echogenic walls
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VASCULAR
Tributaries & Findings
Splenic vein
- Crosses the upper abdomen from the splenic hilum and is best seen in the transverse plane
- Joins the superior mesenteric vein to form the main portal vein slightly to the right of midline
Superior mesenteric vein
- Begins at the ileocolic junction and ascends to the right of the superior mesenteric artery
- Passes anterior to the third part of the duodenum and posterior to the neck of the pancreas
- Larger in caliber than the superior mesenteric artery, which arises directly off the anterior aortic wall
- Forms the posterior border of the pancreatic neck and the anterior border of the uncinate process
Inferior mesenteric vein
- Drains the left colon and ascends retroperitoneally along the left psoas to join the splenic vein behind the pancreas
- Rarely identified sonographically: it is small, covered by small bowel, and has no posterior landmark to key on
Trick: Portal veins have bright walls, hepatic veins do not. Any large radicle near the porta hepatis is portal, not hepatic.
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Card 5 · Vascular System: Abdominal Doppler
Front
What Doppler answers
- Whether flow is present, which direction it travels, and whether it is disturbed
- Also used for tissue characterization and waveform analysis
- Absence of flow separates the common bile duct from the hepatic artery beside it
Resistive vs nonresistive
- Nonresistive vessels hold a high diastolic component and feed organs needing constant perfusion: internal carotid, hepatic artery, renal artery
- Resistive vessels have little or even reversed diastolic flow and feed organs that do not need constant supply: external carotid, iliac, brachial
- The resistive index compares peak systole against minimum diastole to quantify impedance
Reading the display
- Horizontal axis is time; vertical axis is Doppler shift, so velocity. Flow toward the transducer sits above baseline, flow away sits below
- Gray scale brightness shows how many cells are moving at a given velocity
- Plug flow: most cells moving at the same velocity across the lumen, typical of large arteries, giving a clear window under systole
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VASCULAR
Technique & Patterns
Technique
- Patient fasting, respiration suspended, done as part of the routine real time exam
- Size the sample volume to the vessel and no wider. A gate wider than the lumen picks up neighbouring structures and produces noise and ghost echoes
- Keep the beam parallel to flow. Accuracy holds to about 60 degrees; signal falls to zero at perpendicular, so roll the patient into obliquities rather than accept that angle
Arterial patterns
- Aorta: proximal shows a high systolic peak with low diastole; the distal aorta turns triphasic as it nears the iliacs
- Celiac axis: spectral broadening in diastole, unchanged after meals. The splenic artery is its most turbulent branch, from tortuosity
- SMA: highly resistive fasting, with little or no diastolic flow, turning low resistance after a meal
- Renal artery: nonresistive, with diastolic flow usually 30 to 50 percent of peak systole
Venous patterns
- IVC and hepatic veins cross above and below baseline, reflecting right atrial reflux and respiration. Hepatic vein flow is triphasic
- Portal flow is continuous, low velocity, and hepatopetal
- Lost portal landmarks, a dilated splenic vein and SMV, and porta hepatis collaterals are indirect signs of portal vein thrombosis
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Card 6 · Vascular System: Aortic Pathology
Front
Definition
- An aneurysm is a permanent localized dilation of an artery, generally 1.5 times the normal vessel diameter or more
- Focal dilatation of the abdominal aorta
- Sonographically diagnosed when the abdominal aorta measures greater than 3 cm in diameter
- Approximately 85 percent are infrarenal in location
- Most occur at the level of the umbilicus, at or near the iliac bifurcation
- Risk factors include atherosclerosis, hypertension, smoking, connective tissue disorders such as Marfan syndrome, and family history
Morphology
- Fusiform: symmetric, circumferential (concentric) dilatation involving the full wall; most common shape and often contains mural thrombus
- Saccular: focal outpouching involving only part of the wall; much less common and tends not to have thrombus deposition
- Mural thrombus usually lies along the anterior or anterolateral wall of the lumen
Measurement
- Measure the anteroposterior diameter on a longitudinal view, outer wall to outer wall
- Measure the aorta at three levels (proximal, mid, distal) and at any suspected wall bulges
- Include mural thrombus in the outer to outer measurement
Trick: If the lumen looks smaller than the outer wall, you are likely seeing mural thrombus; always place calipers outer wall to outer wall, not lumen to lumen.
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VASCULAR
Dissection & IVC
Aortic dissection
- Acute aortic syndrome characterized by an enlarged aorta with an intimal flap and demonstration of flow in a true and a false lumen
- An intimal flap or membrane may be seen within the aortic lumen, with two patent channels or a thrombosed false lumen
- May coexist with an underlying AAA
- Clinical presentation includes sudden onset of severe chest pain with radiation to the arms, neck, or back; syncope may be present
IVC thrombus and tumor extension
- Renal cell carcinoma commonly invades the renal vein; gross renal vein involvement occurs in about 21 to 35 percent of large tumors
- A subset extend into the IVC and may reach the right atrium
- Predisposing conditions include preexisting renal disease, hypercoagulable state, and IVC or ovarian vein thrombus with extension to the renal vein
- Sonographic appearance: solid hypoechoic material within the IVC or renal vein lumen; assess for luminal filling defects and lack of compressibility
- Evaluate with color and spectral Doppler to confirm absent or altered flow around the filling defect
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Card 7 · Vascular System: Portal Hypertension & Vascular Pathology
Front
VASCULAR
Portal Hypertension
Portal hypertension
- Raised portal venous pressure, most often from cirrhosis, reverses the normal direction of flow
- Portal flow becomes hepatofugal, away from the liver, instead of hepatopetal
- The portal vein dilates, and loses its normal respiratory variation
- Splenomegaly and ascites accompany it
- Defined by a portal venous pressure above 10 mmHg or a hepatic venous pressure gradient above 5 mmHg
Collaterals
- Portosystemic collaterals open at the sites of anastomosis: the recanalized paraumbilical vein, the coronary or left gastric vein, splenorenal collaterals, and oesophageal varices
- A recanalized paraumbilical vein in the falciform ligament, alongside the ligamentum teres, is one of the most commonly identified collaterals
- The coronary and oesophageal veins are the dominant pathway, opening in 80 to 90 percent of patients
Portal vein thrombosis
- Direct sign is visible thrombus in the lumen
- Indirect signs are loss of the normal portal landmarks, dilation of the splenic vein and superior mesenteric vein, and collaterals at the porta hepatis
- Cavernous transformation is the tangle of collaterals that replaces a chronically thrombosed portal vein
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Pseudoaneurysm
- A false aneurysm is not lined by all three arterial layers, unlike a true aneurysm
- Appears as a rounded fluid collection beside a vessel, with a neck connecting it to the artery
- Colour shows a swirling yin yang pattern inside, and the neck shows a to and fro spectral waveform
- Patients with chronic pancreatitis are particularly prone to splenic artery pseudoaneurysm
The pseudocyst trap
- A pancreatic pseudocyst and a vascular aneurysm look very similar on grey scale
- Apply Doppler to every pancreatic pseudocyst before calling it one
Renal vein thrombosis
- The renal vein shows a variable waveform similar to the IVC, so absence of flow is the finding rather than an abnormal waveform
- Evaluate the renal veins in any patient with a suspected renal tumour or obstructive lesion
Trick: Doppler is not optional on a cystic structure near a vessel. Grey scale cannot tell a pseudocyst from a pseudoaneurysm.
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Card 8 · Liver: Anatomy
Front
Key terms
- Hepatocyte: liver cell performing all liver functions.
- Falciform ligament: connects liver to diaphragm and abdominal wall; contains the ligamentum teres.
- Ligamentum teres: remnant of the umbilical vein; bright echogenic focus; separates the medial and lateral segments of the left lobe.
- Ligamentum venosum: separates the left lobe from the caudate lobe.
- Main lobar fissure: boundary between right and left lobes; runs portal vein to gallbladder neck; landmark to the gallbladder.
- Bare area: portion of liver with no peritoneal covering; against the diaphragm.
Position & lobes
- Largest organ in the abdominal cavity; right hypochondrium, epigastrium, and left hypochondrium to the mammillary line.
- Inferior to the diaphragm; right lobe covered by the ribs.
- Lobes: right, left, and caudate (posterior lobe, independent vascular supply).
- Variant: Riedel's lobe, a tongue like projection of the right lobe.
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Portal triad & blood supply
- Portal triad: portal vein + hepatic artery + bile duct.
- Mickey Mouse sign (transverse): portal vein is the face; hepatic artery and common bile duct are the two ears.
- Vascular supply: portal vein 70 to 80% of blood; hepatic artery 20 to 30%, oxygenated.
- Right lobe receives blood from the intestine; left and caudate lobes from the stomach and spleen.
- Three hepatic veins (right, middle, left) drain into the IVC; portal vein enters at the porta hepatis.
Flow direction
- Hepatopetal: flow toward the liver (normal portal flow).
- Hepatofugal: flow away from the liver (normal hepatic vein flow; abnormal if portal).
Tricks: "petal" pulls toward • "fugitive" flees away
Embryology
- Develops from the foregut endoderm; ligamentum teres is a remnant of the fetal umbilical vein.
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Card 9 · Liver: Segmental Anatomy
Front
Anatomic vs functional
- Four anatomic lobes: right, left, quadrate, and caudate, with the falciform ligament separating right from left
- The functional division matters more surgically. The middle hepatic vein and the ascending left portal vein divide the liver into functional right and left lobes
- Under the functional division the falciform ligament belongs to the left lobe
- The right lobe is about six times larger than the left
Fissures
- The left intersegmental fissure divides the left lobe into medial and lateral segments, with the left hepatic vein running horizontally between them
- Two fissures sit in the left lobe: the fissure for the ligamentum teres and the fissure for the ligamentum venosum
- The main lobar fissure appears as a hyperechoic line running from the portal vein to the neck of the gallbladder
- The right hepatic vein lies in the right intersegmental fissure and the middle hepatic vein in the main lobar fissure
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LIVER
Couinaud & Landmarks
The Couinaud system
- Divides the left lateral, right anterior, and right posterior segments into superior and inferior subsegments
- The caudate lobe and the medial left segment are each kept as a single segment
- Hepatic veins run between lobes and segments; portal branches run within them, which is the rule that makes segmental localization possible
- The exception is the ascending portion of the left portal vein, which runs in the left intersegmental fissure
Caudate lobe
- A small lobe on the posterior surface of the left lobe
- The IVC forms its posterior border and the fissure for the ligamentum venosum its anterior border
- Drains straight into the IVC by its own small veins, so it is spared and hypertrophies in Budd-Chiari
Capsule
- The liver is covered by a thin connective tissue layer, Glisson capsule
- The bare area rests directly on the diaphragm and is not covered by peritoneum
Trick: Veins between, portals within. If a vessel runs through the middle of the tissue you are naming, it is portal.
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Card 10 · Liver: Vasculature & Doppler
Front
Telling the two systems apart
- The best discriminator is to trace each vessel to its point of entry into the liver
- Portal veins enter at the porta hepatis, get smaller toward the periphery, and carry bright echogenic walls from the surrounding fibrous sheath
- Hepatic veins drain toward the diaphragm and the IVC, get larger as they approach it, and have no bright walls
- Any large radicle near the porta hepatis is portal
The supply split
- Portal vein carries 70 to 80 percent of the blood; the hepatic artery carries the remaining 20 to 30 percent as oxygenated blood
- Blood perfuses the parenchyma through the hepatic sinusoids before reaching the terminal hepatic venules, which unite into the hepatic veins
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Normal waveforms
- Hepatic vein: triphasic, with systolic, diastolic, and atrial components, reflecting right atrial hemodynamics
- Portal vein: continuous, low velocity, hepatopetal, with mild respiratory variation
- Hepatic artery: low resistance with continuous diastolic flow, because the liver is a low impedance bed
- Normal portal vein velocity is 15 to 18 cm per second
- The normal hepatic artery resistive index is under 0.7
What changes them
- A hepatic vein waveform that flattens to monophasic suggests cirrhosis or a mass effect on the vessel
- Loss of respiratory variation in the portal vein accompanies portal hypertension
- Right heart failure exaggerates the atrial reversal component in the hepatic veins
Measurement
- Measure the portal vein during quiet respiration with the patient supine. The upper limit of normal is about 13 mm
Trick: A monophasic hepatic vein in a liver that looks coarse is a second vote for cirrhosis, not an unrelated finding.
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Card 11 · Liver: Variants & Congenital
Front
Shape variants
- Riedel lobe: a tongue like inferior extension of the right lobe, more common in women, a normal variant rather than hepatomegaly
- The liver may be displaced inferiorly by tumour infiltration, cirrhosis, or a subphrenic abscess
- It may be elevated by ascites, marked colonic dilation, or abdominal tumours
- Retroperitoneal tumours tend to shift it slightly anterior
- Situs inversus places the liver on the left, and a congenital diaphragmatic hernia or an omphalocele can carry liver tissue into the thorax or outside the abdomen
Measurement caution
- Longitudinal length over 20 cm indicates hepatomegaly, but a Riedel lobe will breach that figure without disease
- Assess the parenchyma for size, configuration, homogeneity, and contour together, not length alone
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Perihepatic spaces
- The subphrenic space between the liver or spleen and the diaphragm is a common site for abscess
- The right posterior subphrenic space lies between the right lobe, the right kidney, and the right colic flexure
- The right subhepatic space sits inferior to the right lobe and includes Morison pouch, between the posterior right lobe and the upper pole of the right kidney
- The lesser sac lies posterior to the liver and stomach and communicates with the greater sac near the pancreatic head. It is another site for abscess
Position
- The liver occupies almost all of the right hypochondrium, most of the epigastrium, and reaches the left hypochondrium as far as the mammillary line
Embryology
- Develops from foregut endoderm
- The ligamentum teres is the remnant of the fetal umbilical vein and can recanalize in portal hypertension
- The ligamentum venosum is the remnant of the ductus venosus
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Card 12 · Liver: Sonographic & Clinical
Front
Normal appearance
- Homogeneous texture with fine, low level echoes.
- Echogenicity: minimally hyperechoic to isoechoic vs renal cortex; hypoechoic vs spleen; pancreas equal to or slightly more echogenic than liver.
- Portal veins have brighter (more echogenic) borders than hepatic veins (thicker collagen sheath). Ligaments and fissures appear echogenic to hyperechoic.
Measurements
- TRV 21 to 22.5 cm; height 13 to 17.5 cm; AP depth 10 to 12.5 cm; SAG about 15.5 cm; portal vein 1.0 to 1.2 cm.
- Longitudinal length over 20 cm indicates hepatomegaly.
Doppler
- Hepatic veins show a normal triphasic waveform, reflecting right atrial hemodynamics.
- Portal flow hepatopetal (toward liver); hepatic vein flow hepatofugal (away).
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LIVER
Function & Technique
Function
- Metabolism: converts glucose to and from glycogen, processes fats and proteins.
- Digestion: secretes bile, excretes bilirubin. Storage: iron and vitamins. Detoxification: breaks down drugs, ammonia, and toxins.
Lab values & clinical
- AST / ALT high suggests hepatocellular damage. Alk Phos / direct bilirubin high suggests obstruction.
- Ordered for abnormal LFTs, RUQ pain, jaundice, suspected hepatomegaly.
- Before scanning, correlate liver echotexture vs kidney, spleen, and pancreas, and vascular patency.
Scanning & protocol
- NPO 6 to 8 hrs; 2.5 to 5 MHz curvilinear or sector probe; supine or RAO, deep inspiration.
- Survey 4 planes: sagittal, transverse, coronal, subcostal oblique. Measure portal vein at end inspiration.
- Adequacy: about 15 cm (up to 15 to 20); homogeneous; liver brighter than kidney, less bright than pancreas and spleen; vessels, ligaments, and fissures visible; smooth surface; balanced gain (TGC).
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Card 13 · Liver: Diffuse Disease · Pathology
Front
Fatty liver (steatosis)
- Fatty deposits within the hepatocytes; the most common diffuse liver disease. Common causes: alcohol, obesity, diabetes.
- Diffusely echogenic (bright) liver; increased sound beam attenuation, so the deep liver and diaphragm penetrate poorly and hepatic vessel walls are hard to see.
- Focal fatty sparing, often near the gallbladder or porta hepatis, is a normal island in a bright liver and can mimic a mass.
Acute hepatitis
- Inflammation of the liver. The parenchyma may look normal, or the portal vein borders become brighter than usual, the "starry sky" sign, with hepatomegaly.
Trick: bright liver that hides the diaphragm points to fat
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LIVER
Cirrhosis & Portal HTN
Cirrhosis
- End stage chronic liver disease; regenerating nodules replace normal parenchyma. Progression: steatosis to steatohepatitis to cirrhosis to portal hypertension.
- Sonographic: shrunken, echogenic right lobe; enlarged caudate and left lobes; nodular surface irregularity (best seen against ascites or with a high frequency linear probe); coarse echotexture.
- Clinical: hepatomegaly early, then jaundice, ascites, and splenomegaly.
Portal hypertension
- Portal vein enlarges; portosystemic collaterals develop and the umbilical (paraumbilical) vein can recanalize; splenomegaly and ascites follow.
- Flow: normal hepatopetal portal flow slows, becomes biphasic, then reverses to hepatofugal (away from the liver) in severe disease.
Trick: "petal" toward • "fugitive" away, so reversed portal flow (hepatofugal) is the red flag
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Card 14 · Liver: Metabolic & Storage Disease
Front
Glycogen storage disease
- An inherited defect in glycogen metabolism causing accumulation within hepatocytes
- Produces hepatomegaly with increased echogenicity, similar in appearance to fatty infiltration
- Type I, von Gierke disease, carries an increased risk of hepatic adenoma
- The adenoma is well demarcated, round, homogeneous, and echogenic, turning inhomogeneous when large
Hemochromatosis
- Excess iron deposition in the liver, pancreas, and heart
- The liver enlarges and echogenicity increases, although sonography cannot quantify iron
- Carries an increased risk of hepatocellular carcinoma
- Progresses to cirrhosis and portal hypertension, so the late picture converges on the cirrhotic liver
Wilson disease
- Abnormal copper accumulation in the liver and brain
- Progresses to cirrhosis, so the sonographic picture is usually that of the cirrhotic liver
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LIVER
Diffuse Disease Review
Hepatocellular vs obstructive
- Hepatocellular disease attacks the hepatocytes directly and interferes with liver enzymes
- Obstructive disease blocks bile excretion
- AST and ALT rise with hepatocellular damage; alkaline phosphatase and direct bilirubin rise with obstruction
- ALT is more specific to the liver than AST, so ALT above AST points to a hepatic cause
- A disproportional rise of alkaline phosphatase relative to bilirubin always suggests obstruction, and alk phos can rise before bilirubin
The diffuse family
- Fatty infiltration, acute and chronic hepatitis, early alcoholic liver disease, and acute and chronic cirrhosis
- Fatty infiltration is acquired and reversible, an intracellular accumulation of triglycerides, appearing diffuse or patchy
What sonography can and cannot say
- It measures size, configuration, homogeneity, and contour
- It cannot reliably distinguish the causes of a uniformly bright liver, so laboratory data and history carry the diagnosis
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Card 15 · Liver: Focal Lesions · Pathology
Front
Simple hepatic cyst
- Anechoic, round, smooth thin wall, with posterior acoustic enhancement (STAR criteria). Solitary or multiple.
- Polycystic liver disease is associated with polycystic kidney disease.
Cavernous hemangioma
- The most common benign tumor of the liver; a spongelike mass of blood filled spaces.
- Typically well defined, homogeneous, and hyperechoic.
Other benign
- Focal nodular hyperplasia and hepatic adenoma; adenoma is closely linked to oral contraceptive use.
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LIVER
Malignant & Infection
Hepatocellular carcinoma (HCC)
- The most common primary liver malignancy; strongly linked to cirrhosis and chronic hepatitis.
- Variable echogenicity; may invade the portal vein. Clinical: elevated AFP, weight loss.
Metastases
- The liver is a common site for metastatic spread, and metastases are the most common malignant liver masses overall.
- Multiple, variable echogenicity; may show a "target" or "bull's eye" pattern, an echogenic center with a hypoechoic halo.
Pyogenic abscess
- A pus forming collection, often spread from appendicitis, diverticulitis, or cholecystitis.
- Complex mass with internal echoes and debris; gas can cause dirty shadowing or ring down. Clinical: fever, hepatomegaly.
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Card 16 · Liver: Infectious & Inflammatory Lesions
Front
Pyogenic abscess
- Usually a complex collection with irregular walls, internal debris, and posterior acoustic enhancement
- May contain gas, which produces bright reflectors with dirty shadowing
- Appearance ranges from nearly anechoic to almost solid depending on the internal consistency of the collection
- Presents with fever, right upper quadrant pain, and leukocytosis
- The right central lobe is the most common site, and 50 to 67 percent are multiple
- Bacteria arrive by the biliary tree, the portal vein, the hepatic artery, direct extension, or trauma
Amebic abscess
- Tends to be round or oval, hypoechoic, with low level internal echoes and a lack of significant wall echoes
- Often abuts the liver capsule and may rupture through the diaphragm
- Entamoeba histolytica invades the colonic mucosa and reaches the liver through the portal circulation
Where to look
- Hepatic abscesses form in three sites, intrahepatic, subhepatic, and subphrenic, so search Morison pouch and the subdiaphragmatic space as well as the parenchyma
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Echinococcal cyst
- Hepatic echinococcosis is an infectious cystic disease seen in sheep herding regions
- A cyst within a cyst, or daughter cysts inside a mother cyst, is the characteristic pattern
- Detached, undulating membranes give the water lily sign
- Wall calcification may occur
Hepatic candidiasis
- Seen in immunocompromised patients
- Multiple small lesions producing a wheel within a wheel or bulls eye pattern
- Bull eye pattern in the early phase, becoming echogenic foci as lesions heal
Differential thinking
- A complex cystic hepatic lesion with debris covers pyogenic abscess, echinococcal cyst, candidiasis, haemorrhagic cyst, and necrotic tumour. Clinical history separates them more reliably than the image
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Card 17 · Liver: Vascular Disorders
Front
Budd-Chiari syndrome
- Obstruction of hepatic venous outflow, from thrombosis, tumour invasion, or a membranous web
- In the acute phase the hepatic veins enlarge and thrombus may be visible
- In chronic cases the veins become narrowed or are not identified at all, and intrahepatic collaterals develop
- The caudate lobe hypertrophies because it drains directly into the IVC by its own small veins and is spared
- Doppler shows absent, reversed, or continuous rather than triphasic hepatic vein flow
- Primary Budd-Chiari is a congenital membranous web across the upper IVC at the hepatic vein entries. Secondary is thrombosis from oral contraceptives, pregnancy, tumour, infection, or a hypercoagulable state
- The right lobe atrophies as the caudate hypertrophies, and that pairing is the classic morphology
Clinical
- Presents with hepatomegaly, ascites, and abdominal pain
- Associated with hypercoagulable states
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Passive hepatic congestion
- Develops secondary to congestive heart failure, with hepatomegaly
- Laboratory data show normal to slightly elevated liver enzymes
- The hepatic veins and IVC distend and lose their normal respiratory collapse
- The hepatic vein waveform shows exaggerated atrial reversal
- Long standing congestion can progress to cardiac cirrhosis
- Congestion also dilates the superior mesenteric, portal, and splenic veins, not only the IVC and hepatic veins
Separating the two
- Congestion distends the hepatic veins and they still connect to the IVC
- Budd-Chiari obstructs them, so they narrow, thrombose, or disappear, and collaterals appear
Trick: Both give a big liver and ascites. The hepatic veins tell them apart: distended and patent is congestion, absent or reversed is Budd-Chiari.
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Card 18 · Gallbladder & Biliary: Normal
Front
GALLBLADDER
Anatomy & Function
Regions of the Gallbladder
- Fundus: rounded distal tip, projects beyond the inferior liver edge.
- Body: mid portion, contacts the duodenum, transverse colon, and anterior abdominal wall.
- Neck: narrow proximal end, continuous with the cystic duct.
Biliary Tree
- Cystic duct: lined by the spiral valves of Heister, arising in the neck.
- Common hepatic duct + cystic duct: unite to form the common bile duct (CBD).
- CBD: joins the pancreatic duct at the ampulla of Vater to enter the duodenum.
Size & Blood Supply
- Roughly 7 to 10 cm long, up to about 4 cm wide; holds approximately 30 to 50 mL of bile.
- Blood supply: cystic artery (branch of the right hepatic artery); venous return via the cystic vein.
Anatomic Variants
- Phrygian cap: fundus folds back on itself.
- Junctional fold: kink at the neck.
- Hartmann pouch: small outpouching near the neck where stones commonly lodge.
Function
- Stores and concentrates bile produced by the liver.
- Contracts in response to a fatty meal, releasing bile to the duodenum for fat emulsification.
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Sonographic Appearance & Protocol
Normal Sonographic Appearance
- Lumen: anechoic, pear-shaped, with posterior enhancement.
- Wall thickness: less than 3 mm, measured on the anterior wall.
- CBD diameter: up to about 6 mm in adults under 60; add roughly 1 mm per decade after 60, and up to about 10 mm may be normal post-cholecystectomy.
- Landmark: the main lobar fissure connects the neck of the gallbladder to the right portal vein.
Scanning Protocol
- Patient prep: NPO for at least 6 hours so the gallbladder is fully distended.
- Transducer: broadband curvilinear, 2.5 to 5 MHz.
- Position: begin supine; roll to left lateral decubitus or upright to shift stones and separate small stones from the wall.
- Image and measure the gallbladder in long and transverse; measure wall on the transverse view, anterior wall, outer margin to outer margin, with the beam perpendicular.
Trick: Follow the main lobar fissure like an arrow; it points straight from the right portal vein to the gallbladder neck.
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Card 19 · Gallbladder & Biliary: Ducts & Ductal Pathology
Front
GALLBLADDER
Biliary Anatomy
The apparatus
- Right and left hepatic ducts, common hepatic duct, common bile duct, the pear shaped gallbladder, and the cystic duct
- Divided into intrahepatic and extrahepatic segments
- Intrahepatic ducts run in the portal triads alongside the portal veins and hepatic arteries
- The extrahepatic portion includes the common hepatic duct, the common bile duct, and part of the central right and left ducts
Course and junction
- The right and left hepatic ducts emerge at the porta hepatis and unite into the common hepatic duct, which passes caudally and medially
- The common bile duct is joined by the main pancreatic duct, and together they open through the ampulla of Vater into the duodenal wall
Relations
- The common duct lies anterior and lateral to the portal vein; the hepatic artery lies anterior and medial to it
Trick: At the porta hepatis, duct to the right, artery to the left, portal vein behind both.
Normal caliber
- The common bile duct measures up to 6 mm, borderline at 7 mm, dilated above 10 mm, and widens with age and after cholecystectomy
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GALLBLADDER
Ductal Pathology
Obstruction patterns
- Dilated intrahepatic ducts run beside portal branches, giving the parallel channel or shotgun sign
- Dilatation above the cystic duct with a normal gallbladder points to a proximal obstruction
- A dilated duct plus a dilated gallbladder points to a lesion at or below the cystic duct
- Intrahepatic ducts should stay under 40 percent of the adjacent portal vein, and peripheral ducts under 2 mm
Named lesions
- Cholangiocarcinoma: tumour of the bile duct. A Klatskin tumour sits at the junction of the right and left hepatic ducts and causes intrahepatic dilatation with a collapsed gallbladder
- Caroli disease: congenital saccular dilatation of the intrahepatic ducts
- Choledochal cyst: cystic dilatation of the common bile duct, presenting in children with pain, jaundice, and a mass
- Sclerosing cholangitis: irregular duct wall thickening with strictures, associated with inflammatory bowel disease
- Cholangiocarcinoma is classified by site: intrahepatic, hilar (the Klatskin position), and distal. Most are hypoechoic and hypovascular
Compression from outside
- Mirizzi syndrome: a stone impacted in the cystic duct or gallbladder neck compresses the common hepatic duct from outside, giving intrahepatic dilatation with a normal common duct
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Card 20 · Gallbladder: Stones & Obstruction
Front
GALLBLADDER
Cholelithiasis & Sludge
Cholelithiasis
- Classic triad: echogenic, mobile, posterior acoustic shadowing within the gallbladder lumen.
- Stones shift to the most dependent portion when the patient rolls into left lateral decubitus or upright.
- WES sign (Wall, Echo, Shadow): a contracted, stone-filled gallbladder shown as a bright wall, a curved echogenic arc, and dense posterior shadow.
Biliary Sludge
- Low-level, nonshadowing echoes that layer in the dependent gallbladder.
- Moves slowly with changes in patient position.
- Tumefactive sludge: fills the lumen and can appear isoechoic to liver, mimicking a mass; still nonshadowing and mobile.
Trick: Stones shadow and shift; sludge layers and lags; polyps stay put and cast no shadow.
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GALLBLADDER
Choledocholithiasis & Obstruction
Choledocholithiasis
- Stone within the common bile duct, often lodged at the distal CBD.
- Sonographic appearance mirrors gallstones: echogenic focus within the duct with posterior shadowing.
- CBD greater than about 6 mm is considered dilated in adults under 60; add roughly 1 mm per decade after 60, and up to about 10 mm may be normal post-cholecystectomy.
Biliary Obstruction
- Bile ducts expand outward from the point of obstruction; extrahepatic dilation occurs before intrahepatic dilation.
- Dilated CBD paralleling the portal vein at the porta hepatis (often called parallel channel sign).
- Dilated intrahepatic ducts coursing parallel to portal vein branches within the liver (too many tubes / shotgun sign).
- Note: terminology varies across texts; some sources apply parallel channel and shotgun sign to the extrahepatic finding, so favor the anatomic description.
- Courvoisier gallbladder: painless jaundice with a distended, non-inflamed gallbladder from distal CBD obstruction, classically a pancreatic head carcinoma.
Trick: One tube next to the portal vein is normal; two parallel tubes is the CBD talking back.
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Card 21 · Gallbladder: Wall & Inflammatory Pathology
Front
GALLBLADDER
Acute Cholecystitis
Sonographic Findings
- Wall thickening greater than 3 mm, measured on the anterior wall in transverse.
- Distended lumen greater than 4 cm.
- Gallstones, often with an impacted stone in Hartmann pouch or the cystic duct.
- Pericholecystic fluid tracking along the gallbladder bed.
Sonographic Murphy Sign
- Maximal tenderness reproduced when the transducer is pressed directly over the sonographically identified gallbladder.
- Highly suggestive of acute cholecystitis when combined with wall thickening and stones.
- May be diminished in advanced disease.
Trick: Think "3, 4, stone, sore": wall over 3 mm, lumen over 4 cm, stone impacted, positive Murphy under the probe.
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GALLBLADDER
Adenomyomatosis, Polyps & Porcelain GB
Adenomyomatosis
- Benign hyperplasia of the gallbladder wall with Rokitansky-Aschoff sinuses.
- Focal or diffuse wall thickening with small echogenic intramural foci.
- Comet-tail artifact projecting from the wall into the lumen is characteristic.
Gallbladder Polyps
- Echogenic soft tissue arising from the wall; most commonly cholesterol polyps.
- Non-mobile with position change and produce no acoustic shadow.
- May generate a comet-tail artifact, overlapping with adenomyomatosis.
Porcelain Gallbladder
- Calcification of the gallbladder wall; typically clinically silent.
- Wall appears as a bright echogenic curve with dense posterior shadowing, obscuring the lumen.
- Associated with an increased risk of gallbladder carcinoma.
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Card 22 · Gallbladder: Other Cholecystitis
Front
GALLBLADDER
Acalculous & Emphysematous
Acalculous Cholecystitis
- Cholecystitis without gallstones; seen in critically ill, trauma, burn, or post-op patients.
- Sonographic findings mirror acute cholecystitis: wall thickening, sludge, pericholecystic fluid, positive sonographic Murphy, but no stones.
- High morbidity; may progress rapidly to gangrene or perforation.
Emphysematous Cholecystitis
- Gas within the gallbladder wall or lumen from gas-forming organisms; strongly associated with diabetes.
- Bright echogenic foci with dirty shadowing and ring-down / reverberation artifact.
- Gas rises to the non-dependent side and shifts with patient position, unlike stones.
Trick: No stones, sick patient, sick gallbladder equals acalculous; bright foci that rise instead of drop equals gas.
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GALLBLADDER
Gangrenous & Chronic
Gangrenous Cholecystitis
- Advanced complication with wall necrosis; high risk of perforation.
- Sonographic findings: heterogeneous or striated wall, intraluminal membranes from sloughed mucosa, focal wall defects.
- Sonographic Murphy sign is often diminished or absent due to nerve damage.
Chronic Cholecystitis
- Repeated inflammation from long-standing stones; wall becomes fibrotic and contracted.
- Sonographic findings: small contracted gallbladder around stones, often producing the WES sign.
- Wall thickening without acute inflammatory features (no pericholecystic fluid, negative Murphy).
Trick: Membranes and a quiet Murphy equals gangrene; small, stone-filled, silent equals chronic.
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Card 23 · Spleen: Normal
Front
Position & relations
- Intraperitoneal organ of the left upper quadrant, just inferior to the diaphragm.
- Left kidney lies inferior to the spleen.
- Tail of the pancreas lies posterior to the stomach and lesser sac as it approaches the splenic hilum and splenic vessels.
- A mass in the LUQ may displace the spleen inferiorly.
Function & parenchyma
- Defense against disease (immune organ).
- Hematopoiesis and erythropoiesis (active in the fetus).
- Destruction and removal of flawed red blood cells and platelets.
- Culling (destruction of aged or abnormal RBCs) and pitting (removal of intracellular inclusions from RBCs) occur in the red pulp.
- Parenchyma is red pulp (venous sinuses, RBC turnover) plus white pulp (Malpighian corpuscles, the lymphoid follicles responsible for immune function).
- Blood storage.
Variants: accessory spleen, polysplenia, asplenia
- Accessory spleen (splenule): small round island of splenic tissue, typically located near the splenic hilum or near the tail of the pancreas.
- Splenule appears isoechoic to the spleen on ultrasound.
- Polysplenia: failure of fusion of splenic masses on the dorsal mesogastrium, producing multiple small spleens and often associated with cardiac or situs anomalies.
- Asplenia: congenital absence of the spleen.
Trick: a splenule at the hilum can mimic a mass. Match its echotexture to the spleen to sort it out.
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SPLEEN
Sonographic & Technique
Normal appearance
- Homogeneous parenchyma; commonly isoechoic to slightly hyperechoic relative to the liver (references vary), and more echogenic than the left renal cortex.
- Tubular structures visible at the splenic hilum.
Measurement
- Measured on a longitudinal image from the upper margin (near the diaphragm) to the inferior margin.
- Adult upper limit about 12 to 13 cm long axis; over 13 cm is splenomegaly; thickness over 6 cm also abnormal.
- Compare parenchymal echogenicity to the liver on the same study.
Scanning technique
- Coronal LUQ approach through intercostal spaces.
- Right lateral decubitus opens the intercostal windows and brings the spleen into the coronal imaging plane; avoid steep decubitus, which can cause the spleen to fall away from the abdominal wall.
- Deep inspiration brings the spleen into view.
- Long axis of the spleen with color Doppler at the hilum; measure length. Transverse at the hilum; measure width.
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Card 24 · Spleen: Pathology
Front
SPLEEN
Splenomegaly & Cyst
Splenomegaly
- Enlargement of the spleen beyond the upper limit of normal length on the longitudinal image.
- Survey the parenchyma to confirm it remains uniform and homogeneous, aside from the tubular structures at the hilum.
- When portal hypertension is suspected as the cause, closely evaluate the splenic hilum for abdominal varices.
Causes of congestive splenomegaly
- Heart failure.
- Portal hypertension, portal or splenic vein thrombosis.
- Leukemia, lymphoma, mononucleosis.
- Generalized infections, hemolytic anemias, glycogen storage disease.
Simple splenic cyst
- Cystic masses are uncommon in the spleen; classified as congenital or acquired.
- Sonographic findings: round, smooth walled, anechoic, with posterior enhancement.
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Splenic infarct
- May show a localized hypoechoic area, depending on time of onset.
- Fresh hemorrhage has a hypoechoic appearance.
- Healed infarctions appear as echogenic, peripheral, wedge shaped lesions with their base toward the subcapsular surface.
Splenic trauma & rupture
- After blunt injury a subcapsular hematoma may develop with subsequent rupture.
- Assess for free fluid surrounding the splenic capsule in blunt abdominal trauma.
- Small hypoechoic separation medial to the splenic capsule represents a subcapsular hematoma; inhomogeneity of the splenic texture may represent intraparenchymal hematoma.
- Blood exhibits various echo patterns depending on the time since trauma.
Splenule vs mass
- An accessory spleen is isoechoic to the spleen and typically sits at the hilum or near the pancreatic tail.
- Match echotexture to the spleen to distinguish a splenule from a true splenic or peripancreatic mass.
Trick: splenosis (ectopic splenic implants) can follow splenic rupture and mimic peritoneal masses.
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Card 25 · Spleen: Masses
Front
Primary benign tumours
- Primary tumours of the spleen are rare
- The benign group is hemangioma, hamartoma, and lymphangioma
- Hemangioma is the most common of them and usually appears as a well defined echogenic lesion
- Hamartoma is hyperechoic with mixed solid and cystic components, well defined but not encapsulated
Cysts
- Cystic masses are not common in the spleen
- Classified as congenital (true, endothelial lined) or acquired (usually post traumatic, without a lining)
- A simple splenic cyst shows the standard cystic criteria: thin wall, anechoic contents, and posterior enhancement
- Echinococcus is the only parasite that forms splenic cysts. Look for daughter cysts, wall calcification, or fine internal echoes
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SPLEEN
Malignant & Infiltrative
Malignant tumours
- Malignant splenic tumours are uncommon
- Primary malignancies are lymphoma and hemangiosarcoma
- Very rare primaries include malignant fibrous histiocytoma, leiomyosarcoma, and fibrosarcoma
- Lymphoma is the most common malignant process to involve the spleen and often presents as splenomegaly with or without focal lesions
- Splenic lymphoma takes four patterns: diffuse, focal small nodular, focal large nodular, and bulky. Lesions are typically hypoechoic
Storage and blood disorders
- Storage diseases affecting the spleen: amyloidosis, Gaucher disease, Niemann-Pick disease
- Erythropoietic abnormalities: sickle cell, hereditary spherocytosis, hemolytic anaemia, chronic anaemia, polycythemia vera, thalassaemia, and myeloproliferative disorders
Infection
- The spleen may be infected in subacute bacterial endocarditis, septicaemia, immunocompromise, drug abuse, and after trauma or infarct
- A pyogenic abscess is hypoechoic with septations and low level echoes. A gas containing abscess is echogenic with reverberation, and microabscesses give a bulls eye pattern
Metastases
- The spleen is the tenth most common site of metastases, from breast, lung, ovary, stomach, colon, kidney, prostate, or melanoma. Lesions are usually well defined and range from hypoechoic to hyperechoic, including target and halo patterns
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Card 26 · Spleen: Trauma & Vascular
Front
Blunt trauma
- The spleen is the organ most commonly injured in blunt abdominal trauma
- Injuries include linear or stellate lacerations, capsular tears, puncture wounds from foreign bodies or rib fractures, and subcapsular hematomas
- A subcapsular collection lies against the splenic capsule and shows a double contour sign, separating from splenic tissue
Appearance over time
- An acute haematoma may appear hypoechoic and can still be hard to separate from splenic tissue, so it is easy to miss
- It becomes progressively more lucent as it liquefies
- Free fluid in Morison pouch or the left upper quadrant may be the only sign of injury
Delayed rupture
- A contained subcapsular haematoma can rupture days after the injury, so a normal early scan does not close the question
Trick: Look for the fluid, not only the organ. A normal looking spleen with free fluid is still an abnormal study.
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Splenic infarct
- Classically a peripheral wedge shaped lesion with its base at the capsule
- Hypoechoic when acute, becoming more echogenic as it heals, and may leave a contour defect
- Colour Doppler shows absent flow within the wedge
- Seen with sickle cell disease, endocarditis, and embolic disease
Splenic artery
- The splenic artery shows the greatest turbulence of the celiac branches, owing to its tortuosity
- It is prone to aneurysm, so apply Doppler to any suspected mass at the hilum, since a splenic artery aneurysm can mimic a cystic or solid lesion
Splenic vein
- Splenic vein thrombosis is classically a complication of pancreatitis, so look for it whenever pancreatitis is present
- The splenic hilum contains both the splenic artery and vein, so use colour before calling any hilar lesion a node or mass
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Card 27 · Pancreas: Normal
Front
PANCREAS
Anatomy & Landmarks
Four Regions
- Head: largest portion, seated in the C-loop of the duodenum to the right of the SMV
- Uncinate process: posteromedial extension of the head that hooks behind the SMV
- Neck: short segment anterior to the SMV and portal confluence
- Body and tail: extend leftward toward the splenic hilum
Vascular Landmarks
- Posterior: aorta and IVC are the posterior landmarks of the gland
- Splenic vein: hugs the posterior border of the body and tail; primary sonographic landmark
- SMA and SMV: lie posterior to the neck and body; SMA sits to the left of the SMV
- CBD: courses through the posterolateral head
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PANCREAS
Duct, Echotexture & Function
Pancreatic Duct (Duct of Wirsung)
- Normal duct measures less than 2 mm
- Seen centrally within the body as two parallel echogenic walls with an anechoic lumen
Echogenicity
- Normally isoechoic to hyperechoic relative to the liver
- The pancreas is typically more echogenic than the adjacent liver parenchyma
- Gland atrophies and becomes more echogenic with advancing age from fatty replacement
Function
- Exocrine: acini cells secrete digestive enzymes; amylase digests carbohydrates and lipase digests fats
- Endocrine: islets of Langerhans secrete insulin and glucagon into the blood
Scanning Approach
- Transverse epigastric plane is the primary window
- Head with IVC and SMV; body and tail with SMV and SMA
- Water in the stomach can be used as an acoustic window when bowel gas obscures the gland
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Card 28 · Pancreas: Ducts & Variants
Front
Two ducts
- The duct of Wirsung is the main pancreatic duct, running the length of the gland and joining the common bile duct at the ampulla of Vater
- The duct of Santorini is the accessory duct, draining the upper head separately into the duodenum
- A normal main duct measures up to about 2 mm and should taper smoothly toward the tail
Blood supply
- Supplied by the splenic artery and the pancreaticoduodenal arteries
- The splenic artery supplies body and tail through four branches: suprapancreatic, pancreatic, prepancreatic, and prehilar
- The gastroduodenal artery runs along the anterolateral border of the head, just right of the neck, before dividing into the superior pancreaticoduodenal branches
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PANCREAS
Variants & Function
Congenital variants
- Annular pancreas: a rare anomaly in which the head surrounds the second portion of the duodenum, and can obstruct it
- Pancreas divisum: failure of the dorsal and ventral ducts to fuse, so most drainage passes through the accessory duct
- Ectopic pancreatic tissue may sit in the stomach or duodenal wall
Two glands in one
- Exocrine: the acini cells produce up to 2 litres of pancreatic juice a day, which enters the duodenum with bile
- Endocrine: the islets of Langerhans secrete glucagon and insulin into the blood
- Delta cells are the third islet type and make somatostatin, which inhibits both insulin and glucagon
Enzymes
- Both amylase and lipase rise in acute pancreatitis. Lipase is excreted specifically by the pancreas, rises earlier, and stays elevated longer
- Glucose reflects the endocrine side
Trick: Lipase is the specific one. Amylase rises with salivary and bowel disease too.
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Card 29 · Pancreas: Inflammatory Pathology
Front
PANCREAS
Acute Pancreatitis
Sonographic Findings
- Gland may appear normal early in the disease
- Diffusely enlarged, hypoechoic pancreas from edema
- Focal hypoechoic area within the gland in focal disease
- Borders remain distinct but become irregular
- Peripancreatic fluid collections; may progress to hemorrhage
Clinical & Labs
- Elevated amylase within 24 hours
- Elevated lipase within 72 hours; lipase is the more specific enzyme
- Leukocytosis and elevated ALT may be present
- Common causes include alcohol use, gallstones, and hypercalcemia
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PANCREAS
Pseudocyst & Chronic Pancreatitis
Pancreatic Pseudocyst
- Complication of acute or chronic pancreatitis
- Pancreatic juice escapes and collects in the anterior pararenal space
- Typically anechoic with well-defined walls and posterior acoustic enhancement
- May contain internal debris or septations after hemorrhage or infection
- Extrapancreatic collections may resolve spontaneously within 4 weeks of onset
Pancreatic Abscess / Phlegmon
- Complication of acute pancreatitis in which pancreatic enzymes accumulate in the surrounding space and become infected
- Appears as a complex collection with internal debris, septations, and possible gas
Chronic Pancreatitis
- Recurring destruction of pancreatic tissue leading to atrophy and fibrosis with scarring
- Parenchymal calcifications within the gland cast posterior shadowing
- Dilated pancreatic duct greater than 2 mm
- Gland becomes small and heterogeneous
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Card 30 · Pancreas: Cystic & Endocrine Neoplasms
Front
Benign cystic lesions
- Autosomal dominant polycystic disease, von Hippel-Lindau syndrome, and cystic fibrosis all produce true pancreatic cysts
Four cystic neoplasms
- The cystic neoplasms carry varying malignant potential: serous cystic tumours, mucinous cystic neoplasms, intraductal papillary mucinous neoplasms, and solid pseudopapillary neoplasms
- Serous tumours tend to be microcystic with many small locules; mucinous tumours tend to be macrocystic with fewer, larger locules and higher malignant potential
- IPMN communicates with the duct system, so a dilated main duct with no obstructing mass raises it
- Solid pseudopapillary neoplasm: young women, usually the tail, heterogeneous solid and cystic, with lower malignant potential than the others
- A central stellate scar, sometimes calcified, is classic for serous cystadenoma, the least likely of these to turn malignant
The one that is not a neoplasm
- A pseudocyst is far more common than any of these and follows pancreatitis. The most common location is the lesser sac, anterior to the pancreas and posterior to the stomach
- History decides: pancreatitis makes a pseudocyst likely, its absence makes a cystic neoplasm more likely
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PANCREAS
Endocrine Tumours
Islet cell tumours
- Arise from the islet cells and may be functional or nonfunctional, benign adenoma or malignant
- The most common functioning islet cell tumour is insulinoma, followed by gastrinoma
- Functional tumours present early because of their hormone effects, so they are usually small and hard to see
- Typically well defined and hypoechoic to the surrounding parenchyma
- Insulinoma presents with the Whipple triad: hypoglycaemic symptoms, a low measured blood sugar, and relief with intravenous glucose
- Gastrinoma produces Zollinger-Ellison syndrome, gastric acid hypersecretion with recurrent peptic ulcers and diarrhoea. About 60 percent are malignant and many are multiple or extrapancreatic
Adenocarcinoma
- The most common primary neoplasm of the pancreas
- Most arise in the head, presenting with painless jaundice from common duct obstruction
- Hypoechoic, ill defined mass that obstructs both the bile duct and the pancreatic duct, giving the double duct sign
Phlegmon
- An inflammatory process spreading along fascial pathways, causing diffuse inflammatory oedema of soft tissue that may proceed to necrosis and suppuration
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Card 31 · Pancreas: Neoplastic Pathology
Front
Sonographic Findings
- Most common appearance is a hypoechoic mass in the head of the pancreas
- Poorly defined focal mass with an irregular border
- Focal enlargement and displacement of normal pancreatic parenchyma
- Secondary enlargement of the common duct from edema or tumor invasion of the head
Associated Signs
- Double duct sign: coexisting dilation of the common bile duct and the pancreatic duct
- Courvoisier gallbladder: painlessly enlarged palpable gallbladder caused by a pancreatic head mass obstructing the CBD
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PANCREAS
Adenocarcinoma: Clinical & Search Pattern
Clinical Presentation
- Painless jaundice is the classic presentation of a head mass obstructing the CBD
- Weight loss and anorexia are common
- Ampullary adenocarcinomas carry a better prognosis than pancreatic adenocarcinoma
Search Pattern
- Identify the focal hypoechoic mass and document its region: head, body, or tail
- When the mass is in the head, look for CBD and pancreatic duct dilation
- Evaluate the gallbladder for painless distention (Courvoisier)
- Survey the liver for metastatic disease and assess regional lymph nodes
Trick: A hypoechoic head mass with the double duct sign and a distended, non-tender gallbladder should raise concern for pancreatic adenocarcinoma.
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Card 32 · Gastrointestinal Tract: Normal
Front
Stomach and duodenum
- Stomach in three parts: the fundus superiorly, the body forming the central axis, the pylorus distally
- Duodenum in four segments: superior, descending, transverse, ascending
Small bowel and colon
- Valvulae conniventes: large mucosal folds projecting into the small bowel lumen that slow the passage of food and increase absorption. Seen as linear echoes about 3 to 5 mm apart
- Haustra: the sacculations that give the colon its segmented appearance
- The vermiform appendix is a remnant of the apex of the cecum. It sits under McBurney point, the midpoint of a line from the right anterosuperior iliac spine to the umbilicus
Blood supply
- The celiac, superior mesenteric, and inferior mesenteric arteries supply both small and large intestine
- The celiac axis reaches the duodenum through its right gastric, gastroduodenal, and superior pancreaticoduodenal branches
- Varices may arise from the gastroesophageal vessels
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GI TRACT
Wall & Technique
Wall layers
- The bowel wall has five layers. The odd numbered layers, first, third, and fifth, are echogenic; the even numbered layers, second and fourth, are hypoechoic
- Average total thickness is about 3 mm when distended and 5 mm when undistended
Landmarks
- The gastroesophageal junction is seen on the sagittal scan just left of midline as a target or bull eye, anterior to the aorta, posterior to the left lobe of the liver, and inferior to the hemidiaphragm
- The duodenum outlines readily with water ingestion or a change in patient position
Technique and limits
- Intraluminal air produces an echogenic shadow that stops the beam, which is why much of the tract is difficult to assess
- The small bowel is usually not resolved beyond the valvulae conniventes
- Digestion and absorption are the primary functions of the tract
- Peristalsis is the discriminator: bowel changes shape under gentle transducer pressure while lymph nodes hold theirs
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Card 33 · Gastrointestinal Tract: Upper Tract Pathology
Front
Gastric masses
- Leiomyoma is the most common tumor of the stomach
- Gastric carcinoma is the fifth leading cause of cancer and the third leading cause of cancer death
- A polyp is a protruding, space occupying epithelial lesion within the stomach
Other gastric findings
- Gastric bezoar: an intragastric mass made of accumulated ingested material
- Duplication cyst criteria, all three required: lined with alimentary tract epithelium, a well developed muscular wall, and continuity with the stomach
Trick: A thickened hypoechoic wall around an echogenic lumen is the target or pseudokidney appearance. It flags bowel wall pathology without naming the cause.
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Obstruction
- Small bowel obstruction shows dilation of the loops proximal to the site of obstruction
- Fluid filled loops transmit sound, so an obstructed bowel is often easier to image than a normal one
- Paralytic ileus dilates bowel without a mechanical obstructing point
Other lesions
- Meckel diverticulum: a pouchlike herniation through the muscular wall of a tubular organ
- Lymphomatous involvement of the intestinal wall can produce a pseudokidney or hydronephrotic pseudokidney appearance
- Diverticulum: an outpouching of the wall, most often colonic
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Card 34 · Gastrointestinal Tract: Appendix & Lower Tract
Front
Acute appendicitis
- Results from luminal obstruction and inflammation, leading to ischemia of the vermiform appendix
- Presents with pain and rebound tenderness, usually localized over the right lower quadrant
- Wall edema measures greater than 2 mm thick
- Asymmetric wall thickening raises the possibility of perforation
Scanning it
- High frequency linear transducer with graded compression over the point of maximum tenderness
- A normal appendix compresses. An inflamed appendix does not
- An appendicolith appears as an echogenic focus with posterior shadowing
- Follow the blind ending tube to its tip; a normal tip does not exclude disease if the base was not seen
Trick: Compressibility is the whole test. If it flattens under the transducer, it is not an inflamed appendix.
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Inflammatory disease
- Crohn disease is regional enteritis, a recurrent granulomatous inflammatory disease affecting the terminal ileum, the colon, or both, at any level
- Inflamed segments show wall thickening with loss of the normal five layer pattern
Appendiceal and peritoneal
- Mucocele of the appendix: gross enlargement of the appendix from accumulation of mucoid substance within the lumen
- Pseudomyxoma peritonei: mucinous material distributed through the peritoneal cavity
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Card 35 · Peritoneal Cavity & Abdominal Wall: Anatomy
Front
Two layers, two sacs
- The parietal peritoneum lines the walls of the cavity; the visceral peritoneum covers the abdominal organs
- The general peritoneal cavity is the greater sac
- The lesser sac, or omental bursa, is the peritoneal recess posterior to the stomach
- The cavity contains the greater and lesser omentum, the mesenteries, the ligaments, and the fluid spaces
Why the attachments matter
- The peritoneal attachments to the walls and organs determine where abnormal fluid can collect and how it moves
- Because of the coronary ligament attachments, a collection in the right posterior subphrenic space cannot extend between the bare area of the liver and the diaphragm
- The bare area is delineated by the right superior and inferior coronary ligaments, which separate the posterior subphrenic space from the right superior subhepatic space, Morison pouch
- Ligaments on the right of the liver form the subphrenic and subhepatic spaces
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PERITONEUM
Fluid & Collections
Pelvic compartments
- The retrovesical space is divided by the uterus into an anterior vesicouterine recess and a posterior rectouterine sac, the pouch of Douglas
- The pouch of Douglas is the most dependent part of the peritoneal cavity in the supine patient, so free fluid gathers there
Ascites
- Ascites is the accumulation of serous fluid in the peritoneal cavity
- Simple ascites is anechoic and shifts with position; inflammatory or malignant ascites tends to carry internal echoes, septations, or matted bowel
- The hepatorenal recess, Morison pouch, is a dependent space where small volumes collect first
Abscess
- An abscess is a cavity formed by necrosis within solid tissue, or a circumscribed collection of purulent material
- A gas containing abscess shows bright reflectors with dirty shadowing and reverberation
- Named collections to look for: lesser sac, subphrenic, subcapsular, biloma
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Card 36 · Peritoneal Cavity & Abdominal Wall: Pathology
Front
PERITONEUM
Mesentery & Omentum
How masses behave
- A mass in the mesentery or omentum may be cystic or solid; a mass within the peritoneum tends to show an infiltrative pattern
- With an omental mass, at least one third are malignant, and secondary neoplasms outnumber primary
- In the mesentery, a benign primary tumor is more common than a malignant one, secondary neoplasms still outnumber primary, and a cystic mass is more common than a solid one
Named lesions
- Lymphoma presents as a uniformly thick, hypoechoic, band shaped structure following the convexity of the anterior and lateral abdominal wall, the omental band
- Secondary tumors and lymphoma are the neoplasms that most commonly involve the peritoneum and mesentery
- Urachal cyst: incomplete regression of the urachus during development
- Urinoma: an encapsulated collection of urine from closed renal injury, surgery, or an obstructing lesion
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PERITONEUM
Abdominal Wall
Wall lesions
- Lesions of the superficial abdominal wall include inflammatory lesions, hematomas, neoplasms, hernias, and postsurgical lesions
- Rectus sheath hematoma: an acute or chronic collection of blood lying within the rectus muscle or between the muscle and its sheath
- Lymphocele: a fluid collection appearing after surgery in the pelvis, retroperitoneum, or recess cavities
- Neoplasms of the wall include lipomas, desmoid tumors, and metastases
Hernia
- An abdominal hernia is the protrusion of a peritoneal lined sac through a defect in the weakened abdominal wall
- Scan the defect at rest and during Valsalva, since a reducible hernia may only appear on strain
Trick: A hernia is a moving diagnosis. If the patient does not strain, a reducible sac stays hidden and the study reads normal.
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Card 37 · Urinary System: Normal
Front
Location & Coverings
- Retroperitoneal, paired organs
- Three coverings from inner to outer: fibrous true capsule, perinephric (perirenal) fat, and Gerota's fascia
- Hilum transmits renal artery, renal vein, and ureter
Parenchyma & Sinus
- Parenchyma = renal cortex plus renal medulla
- Medullary (renal) pyramids are triangular structures within the medulla
- Columns of Bertin are cortical tissue extending between pyramids
- Central renal sinus contains fat, calyces, pelvis, and vessels
Vasculature
- Renal artery divides into about 5 segmental branches
- Renal vein drains into the IVC
Function
- Filter blood, produce urine, and maintain homeostasis
- Urine drains calyces to renal pelvis to ureter to bladder
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KIDNEY
Sonographic Appearance
Size
- Normal adult kidney typically greater than 8 cm in longitudinal length
- Average length 10 to 12 cm
- Measure bipolar (pole to pole) long axis length
Echogenicity
- Normal cortex is hypoechoic to or isoechoic with adjacent liver or spleen
- Cortex should measure more than 1 cm in thickness
- Medullary pyramids appear as triangular hypoechoic areas
- Renal sinus is the brightest region (echogenic fat)
Scanning
- Right kidney: use liver as an acoustic window
- Left kidney: use spleen as an acoustic window
- Slight decubitus rolls the liver anterior to the right kidney for better access
- Document renal echogenicity compared with liver and spleen
Bladder
- Anechoic when distended with homogeneously echogenic wall
- Wall uniform in thickness, less than 3 mm when well distended
- Color Doppler shows ureteral jets entering from the trigone at the posterolateral bladder base
Renal Function Labs
- BUN and creatinine are the standard renal function labs
- Both are elevated in renal failure
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Card 38 · Urinary System: Congenital Variants & Pseudotumors
Front
Normal variants that mimic mass
- Column of Bertin: a prominent invagination of cortex located at varying depths within the medullary substance. It is cortex, so it is isoechoic to cortex and continuous with it
- Dromedary hump: a bulge of cortical tissue on the lateral surface, usually of the left kidney
- Junctional parenchymal defect: a triangular echogenic area, typically anterior and superior
- Sinus lipomatosis: deposition of fat in the renal sinus with parenchymal atrophy
Telling variant from tumour
- A variant is isoechoic to normal cortex, continuous with it, and does not distort the outer contour
- A true mass distorts the contour, differs in echogenicity, and displaces rather than continues the parenchyma
- A hypertrophied column does not exceed 3 cm, indents the sinus laterally, and stays continuous with the cortex
Trick: A pseudotumour is made of the same tissue it sits in. If it matches cortex exactly, it probably is cortex.
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KIDNEY
Congenital Anomalies
Fusion and position
- Horseshoe kidney is the most common anomaly of renal fusion. Fusion of the lower poles occurs in 96 percent of cases, the ureters pass anterior to the parenchyma, and the blood supply varies
- Renal ectopia: a kidney not in its usual position within the renal fascia
- Renal hypoplasia: incomplete development, usually with fewer than five calyces
- The isthmus lies anterior to the spine and can be mistaken for a solid pelvic mass or enlarged nodes
Duplication
- Incomplete or partial duplication is the most frequently occurring congenital anomaly in the neonate: two collecting systems and two ureters, with a single ureter entering the bladder
- Complete duplication is rarer, with two separate systems each having its own ureter reaching the bladder
- The Weigert-Meyer rule: in a double ureter, the ureter draining the upper pole opens below and medial to the one from the lower pole
- At the mid pole in transverse the duplex sinus is faceless, two echogenic sinus regions split by parenchyma with no single central pelvis. Two ureteral jets on one side confirm complete duplication
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Card 39 · Urinary System: Vasculature & Doppler
Front
Arterial anatomy
- The renal arteries are lateral branches of the aorta arising just inferior to the superior mesenteric artery
- The artery divides into segmental, then interlobar arteries running between pyramids, then arcuate arteries arching over the bases of the pyramids, then interlobular arteries into the cortex
- At least 30 percent of people have accessory renal arteries
Venous anatomy
- Five to six veins join to form each main renal vein, emerging from the hilum anterior to the renal artery
- The left renal vein crosses anterior to the aorta and posterior to the superior mesenteric artery
The nephron
- The renal corpuscle is a capillary network, the glomerulus, surrounded by Bowman capsule
- Blood enters through an afferent arteriole and leaves through an efferent arteriole
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Normal waveform
- The main renal artery is nonresistive, with significant diastolic flow, usually 30 to 50 percent of peak systole
- Continuous diastolic flow provides continuous perfusion of the kidney
- Spectral broadening occurs in both systole and diastole
- Segmental, interlobar, and arcuate arteries show a similar pattern with progressively dampened, lower velocity flow toward the periphery
- The normal intrarenal waveform has a rapid systolic upstroke and an early systolic peak
Resistive index
- Calculated from peak systolic and end diastolic velocity
- Normal peak systolic velocity is under 160 cm per second and the normal resistive index is 0.70 or less
- A raised RI is nonspecific and points to medical renal disease, obstruction, or transplant dysfunction rather than any single cause
Practical limits
- Renal artery stenosis is hard to exclude in a native kidney because the origin and full course are difficult to see
- Occlusion can only be declared when the artery is unquestionably imaged, and collaterals can be mistaken for a patent vessel
- Stenosis criteria: PSV above 180 cm per second at the narrowing, a downstream tardus and parvus waveform with acceleration time under 0.1 second, and a smaller kidney
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Card 40 · Urinary System: Bladder & Ureter
Front
Ureteral anatomy
- The renal pelvis divides into two or three major calyces, each dividing into two or three minor calyces
- Three constrictions occur along the ureter: where it leaves the renal pelvis, where it crosses the pelvic brim, and where it pierces the bladder wall
- Those three points are where calculi lodge, which is why they are worth knowing by position
Ureteral jets
- Colour Doppler shows urine entering the bladder from each ureteral orifice
- Present and symmetric jets argue against complete obstruction on that side
- Absence of a jet is suggestive but not diagnostic, since jets are intermittent
- Jets run upward and toward the opposite side, entering from the posterolateral bladder floor
Ureterocele
- Cystic dilatation of the distal ureter within the bladder, seen as a thin walled cyst at the trigone
- Associated with the upper pole moiety of a duplicated system
- Shows a cobra head appearance on sagittal view of the bladder base
- An ectopic ureterocele is commoner in females and usually arises from the upper pole ureter of a complete duplication, inserting low near the bladder neck
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Bladder masses
- Transitional cell carcinoma accounts for 90 percent of malignancies involving the renal pelvis, ureter, and bladder
- It appears as an irregular, immobile projection from the wall, and colour flow within it separates a tumour from adherent clot
- Blood clot moves with position change; tumour does not
Wall changes
- Diffuse wall thickening follows chronic outlet obstruction, producing trabeculation and diverticula
- A diverticulum is an outpouching connected by a neck, best shown by scanning through the connection
- Measure wall thickness only on a reasonably distended bladder, since an empty bladder always looks thick
- A diverticulum has no muscular layer, so stasis, recurrent infection, and stones are common inside it
Postvoid residual
- Measured in three dimensions and multiplied by 0.52 for an ellipsoid volume
- A significant residual supports outlet obstruction and explains upstream dilatation
- A residual under 20 mL is normal in an adult
Cystitis
- The wall may be normal at first, then hypoechoic and thickened as inflammation continues, and finally echogenic and fibrotic in chronic disease
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Card 41 · Urinary System: Cystic & Obstructive
Front
Definition
- Dilation of the renal collecting system
- Formal systems include SFU Grades I to IV and RAD I to V; also described descriptively as mild, moderate, severe
Sonographic Findings
- Anechoic distension of the renal pelvis and calyces
- Mild: distension of the renal pelvis
- Moderate: pelvis and calyces dilate further with ballooning
- Severe: marked dilation with cortical thinning
Simple Renal Cyst (Bosniak I)
- Round or oval, anechoic with no internal echoes
- Thin, well-defined walls with sharp interface to parenchyma
- Posterior acoustic enhancement (through transmission)
- No color flow within the mass
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Autosomal Dominant Polycystic Kidney Disease
- Previously known as adult polycystic kidney disease
- Presents with hypertension, flank pain, and progressive renal failure
Sonographic Findings
- Bilateral enlarged kidneys containing numerous cortical renal cysts
- Cysts vary in size and may distort the normal renal contour
- Associated hepatic cysts may be present
Distinguishing from Simple Cysts
- Multiple bilateral cysts with kidney enlargement, not a solitary lesion
- Progressive replacement of normal parenchyma
- Screen the liver for associated cysts
Trick: Bilateral, numerous, and enlarged kidneys with liver cysts points to ADPKD rather than incidental simple cysts.
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Card 42 · Urinary System: Masses & Stones
Front
Clinical
- Renal colic, hematuria, oliguria, urinary tract infection
Sonographic Findings
- Echogenic focus that produces posterior acoustic shadowing
- Twinkle sign seen posterior to the calculus on color Doppler
- May cause upstream hydronephrosis if obstructing
Pitfall
- Prominent renal sinus fat, mesenteric fat, and bowel gas can appear as an indistinct echogenic focus with questionable shadowing
- Twinkle artifact helps confirm a true stone
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KIDNEY
Solid Renal Masses
Renal Cell Carcinoma
- Solid mass on the kidney, hypoechoic, isoechoic, or hyperechoic
- Can have a complex cystic appearance
- Consider RCC, oncocytoma, angiomyolipoma, transitional cell carcinoma, and secondary neoplasms when a solid mass is detected
Angiomyolipoma
- Benign fat-containing tumor of the kidney
- Classically well defined and markedly hyperechoic (fat)
- A small hyperechoic RCC can mimic it
Mimic to Exclude
- Hypertrophied column of Bertin is a normal variant that can mimic a mass
- Confirm continuity with adjacent cortex and matching echogenicity
Trick: A well-defined hyperechoic renal mass suggests angiomyolipoma, but RCC can also appear hyperechoic, so correlate and follow up.
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Card 43 · Urinary System: Infection
Front
Acute pyelonephritis
- Bacterial infection of the renal parenchyma, usually ascending from the lower tract
- The kidney is often normal on ultrasound, which is the single most important point
- When abnormal: enlargement, loss of corticomedullary differentiation, and focal hypoechoic or hyperechoic areas of oedema
- Presents with fever, flank pain, and leukocytosis
- Renal infection is a spectrum: pyelonephritis, then focal bacterial nephritis, then abscess. A perinephric abscess arises by direct extension
Complications
- Renal abscess, pyonephrosis, xanthogranulomatous pyelonephritis, emphysematous pyelonephritis, and chronic pyelonephritis
- Focal bacterial nephritis shows a slightly hyperechoic, avascular focal area on colour Doppler
Pyonephrosis
- Pus within an obstructed collecting system
- Dilated collecting system containing low level echoes or a debris fluid level
- A surgical emergency, and the reason debris in a dilated system is never dismissed
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Emphysematous pyelonephritis
- Gas forming infection of the parenchyma
- Occurs almost exclusively in diabetic and immunocompromised patients
- Fever, flank pain, and leukocytosis
- Bright echogenic foci with dirty shadowing and reverberation, which can obscure the kidney entirely
- E. coli is the usual organism, and severe cases can need emergency nephrectomy
Xanthogranulomatous pyelonephritis
- Chronic infection associated with obstruction and a staghorn calculus
- The kidney enlarges and loses function, with dilated calyces replaced by inflammatory tissue
- The kidney is enlarged, with dilated calyces replaced by cystic inflammatory spaces around the stone
- Peripelvic fibrosis can stop the staghorn calculus from shadowing
Chronic pyelonephritis
- Repeated infection produces a small, scarred kidney with an irregular echogenic cortex and loss of corticomedullary differentiation
Trick: A bright kidney full of gas in a diabetic patient is emphysematous until proven otherwise. Do not read the shadowing as bowel.
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Card 44 · Urinary System: Medical Renal Disease
Front
KIDNEY
Parenchymal Disease
The sonographic pattern
- Medical renal disease is the general term for parenchymal disease affecting the nephrons rather than a mass or obstruction
- The hallmark is increased cortical echogenicity, judged against the adjacent liver or spleen
- Normal cortex is less echogenic than liver. Cortex equal to or brighter than liver is abnormal
- The pyramids stand out against the bright cortex early in disease, then differentiation is lost as it progresses
- The strict criterion is cortex equal to or brighter than the adjacent liver or spleen, and cortex equal to the renal sinus in the same image
Grading by comparison
- Compare cortex to liver on the right and cortex to spleen on the left in the same image, so gain settings apply to both
The limitation
- The pattern is nonspecific. It says the nephrons are diseased, not which disease it is
Two patterns
- Type I brightens the cortex but preserves or exaggerates the corticomedullary junction. Type II distorts anatomy and obliterates that junction, focally or diffusely
- Some acute conditions do the opposite, enlarging the kidneys with decreased echogenicity from interstitial edema, as in acute renal vein thrombosis, acute pyelonephritis, and acute rejection
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KIDNEY
Chronic Renal Failure
Causes of the bright kidney
- Glomerulonephritis, acute tubular necrosis, diabetic nephropathy, HIV nephropathy, and interstitial nephritis
- HIV nephropathy classically gives markedly echogenic kidneys that stay normal in size or enlarge
- Acute tubular necrosis is the most common medical cause of acute renal failure, giving bilaterally enlarged kidneys with hyperechoic pyramids
- Nephrocalcinosis: the medullary form makes the pyramids brighter than the cortex, usually from hyperparathyroidism or renal tubular acidosis. The cortical form spares them
Chronic renal failure
- The kidneys become small with a thin, echogenic cortex and loss of corticomedullary differentiation
- Size is the discriminator: a bright large kidney suggests acute or infiltrative disease, a bright small kidney suggests chronic end stage disease
- Acquired cystic disease develops in long term dialysis patients and carries an increased risk of renal cell carcinoma
Laboratory correlation
- BUN is the concentration of urea nitrogen in blood, the end product of cellular metabolism
- Hematuria is blood cells in the urine and can accompany early renal disease
- Leukocytes appear with inflammation, infection, or tissue necrosis anywhere in the urinary tract
- Serum creatinine is more specific and more sensitive than BUN for renal impairment
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Card 45 · Urinary System: Transplant & Trauma
Front
The transplant
- Placed extraperitoneally in the iliac fossa, so it is superficial and imaged with a higher frequency transducer than a native kidney
- Baseline size, cortical echogenicity, collecting system, and resistive index are recorded so later studies have something to compare against
Fluid collections by timing
- Hematoma: immediately postoperative
- Urinoma: early, within days to weeks, from a leak at the ureteric anastomosis
- Lymphocele: weeks to months later, typically medial to the graft, often septated
- Abscess: any time, with debris, gas, and clinical sepsis
Dysfunction
- A rising resistive index with graft enlargement and loss of corticomedullary differentiation suggests rejection, but the finding is nonspecific and biopsy decides
- Acute rejection can present as an enlarged graft with decreased parenchymal echogenicity from interstitial edema
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Renal trauma
- Ranges from contusion, through laceration, to a shattered kidney and pedicle injury
- Subcapsular haematoma conforms to the capsule and flattens the parenchyma; perinephric haematoma spreads into the perirenal space
- Appearance varies with age. An acute haematoma is usually echogenic and may look complex, becoming more anechoic as the clot lyses
- Colour Doppler assesses perfusion, since a devascularized kidney can look structurally intact
Metastases
- Metastases to the kidneys are relatively common and occur late in the disease course
- Bilateral in about one third of cases and multiple in more than half
- The common primaries are carcinoma of the lung or breast, and renal cell carcinoma of the contralateral kidney
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Card 46 · Retroperitoneum: Spaces & Adrenal Anatomy
Front
Boundaries
- The retroperitoneal space lies between the posterior parietal peritoneum and the posterior abdominal wall muscles, extending from the diaphragm to the pelvis
- Laterally it reaches the extraperitoneal fat planes within the transversalis fascia; medially it encloses the great vessels
Three compartments
- Perirenal space: the kidney, the adrenal, and perirenal fat
- Anterior pararenal space: the duodenum, the pancreas, and the ascending and transverse colon
- Posterior pararenal space: the iliopsoas muscle, the ureter, and branches of the IVC and aorta with their lymphatics
Node bearing areas
- Two major lymph node bearing areas: the iliac and hypogastric nodes within the pelvis, and the para-aortic group in the upper retroperitoneum
- The prevesical space runs from the pubis to the anterior margin of the bladder; the presacral space lies between the rectum and the fascia over the sacrum
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RETROPERITONEUM
Adrenal Anatomy
Position and shape
- The right adrenal sits more superior to the kidney; the left sits more medial to it
- The right adrenal has a comma or triangular shape in the transaxial plane
- A single vein drains each gland: the right into the IVC, the left into the left renal vein
How to find them
- Right: scan longitudinally through the right lobe of the liver, perpendicular to the linear right crus of the diaphragm
- Left: harder because of stomach gas. Place the patient right lateral decubitus, scan along the posterior axillary line using the spleen and left kidney as a window, in deep inspiration
- Recognize retroperitoneal fat as separate from the liver, the crus, the gland, and the great vessel
Pitfalls that mimic the gland
- Right crus of the diaphragm, the second portion of the duodenum, the gastroesophageal junction, medial lobulations of the spleen, splenic vasculature, the body and tail of the pancreas, and the fourth portion of the duodenum
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Card 47 · Retroperitoneum: Adrenal Pathology
Front
RETROPERITONEUM
Cortical Syndromes
What each part secretes
- Cortex: mineralocorticoids, chiefly aldosterone, which regulate electrolyte and water balance; glucocorticoids, chiefly cortisol, which drive carbohydrate metabolism and damp inflammation; and small amounts of androgens and estrogens
- Medulla: epinephrine and norepinephrine
- The cortex is controlled by ACTH from the pituitary
The syndromes
- Addison disease: adrenocortical insufficiency with cortical atrophy. Hypotension, weakness, fatigue, loss of appetite and weight, and a characteristic bronzing of the skin. Prognosis is good on steroid replacement
- Conn syndrome: aldosteronism from excess aldosterone, present in about 0.5 percent of patients with sustained hypertension, usually from a cortical adenoma measuring 0.5 to 3 cm with contralateral adrenal atrophy. Muscle weakness, hypertension, abnormal electrocardiogram
- Adrenogenital syndrome: excess sex hormones and adrenal androgens, from a tumor or from hyperplasia, producing virilization
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RETROPERITONEUM
Adrenal Masses
Tumors
- Benign nonfunctioning adenoma is the most common primary adrenal tumor
- The adrenal glands are the fourth most common site in the body for metastasis, after the lung, the liver, and the bones
- Pheochromocytoma arises from the pheochromocytes of the medulla and secretes epinephrine and norepinephrine in excessive quantities
- Neuroblastoma is the most common adrenal malignancy of childhood and the most common tumor of infancy, representing about 30 percent of all neonatal tumors
Non neoplastic
- Adrenal hemorrhage is most common in neonates after a traumatic delivery with stress, asphyxia, or septicemia. The gland may return to normal size with focal areas of calcification
- Adrenal cysts appear as anechoic lesions with through transmission in the suprarenal location
Trick: A suprarenal mass is not automatically adrenal. Prove it is separate from the kidney, the crus, and the bowel before naming it.
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Card 48 · Retroperitoneum: Nodes, Masses & Collections
Front
RETROPERITONEUM
Lymph Nodes
Where and how to look
- The nodes lie along the lateral and anterior margins of the aorta and the IVC, so scan supine or decubitus
- Always examine in two planes; enlarged nodes should be reproducible in both projections
- A left coronal view using the left kidney as a window reaches the para-aortic group
The patterns
- Rounded, focal, echo poor lesions, 1 to 3 cm and larger
- Confluent echo poor masses, which often displace the kidney laterally
- A mantle of nodes in the paraspinal location
- A floating aorta, displaced anteriorly by the enlarged nodes
- The mesenteric sandwich sign, anterior and posterior nodal masses surrounding the mesenteric vessels
Node or bowel
- Nodes hold their shape under gentle transducer pressure and transmit sound homogeneously
- Bowel changes with peristalsis, shows dense central mucosal echoes, and often shadows from air within the wall
Trick: Use color flow before calling a lesion a node. A vessel in cross section looks exactly like one.
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RETROPERITONEUM
Masses & Collections
Tumors
- Lymphoma is the most common primary retroperitoneal tumor
- Metastatic disease can occur anywhere in the retroperitoneum, arriving hematogenously, through the lymphatics, or by direct extension
- Evaluate splenic size and the splenic hilum in any patient with lymphadenopathy
Fluid collections
- Urinoma: a walled off collection of extravasated urine, developing spontaneously or after trauma, surgery, or subacute to chronic urinary obstruction
- Retroperitoneal hemorrhage: seen with trauma, vasculitis, bleeding diathesis, a leaking aortic aneurysm, or a bleeding neoplasm
Fibrosis
- Retroperitoneal fibrosis, Ormond disease, is an idiopathic condition characterized by thick sheets of fibrous tissue in the retroperitoneal cavity
- It encases the great vessels and the ureters, so hydronephrosis is often the presenting finding
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Card 49 · Thyroid & Parathyroid: Normal
Front
THYROID
Anatomy & Sonographic Appearance
Location & Shape
- Located in the anteroinferior neck, inferior to the thyroid cartilage
- Right and left lobes connected across the midline by the isthmus
- The lobes are normally equal in size, with a wide range of variability; a pyramidal lobe (superior extension of the isthmus) is a normal variant
- Isthmus normally measures between 2 and 6 mm in the AP dimension
Sonographic Appearance
- Fine, homogeneous echotexture
- Slightly more echogenic than the surrounding musculature
- Thin echogenic thyroid capsule
Transverse Landmarks
- Trachea in the midline, posterior to the isthmus
- Common carotid artery and internal jugular vein lateral to each lobe
- Longus colli muscle posterior to the thyroid
- Strap muscles (sternohyoid, sternothyroid, thyrohyoid, omohyoid) anterior; sternocleidomastoid anterolateral
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THYROID
Technique, Physiology & Parathyroid
Patient & Transducer
- Supine with a pillow or pad under both shoulders for moderate neck hyperextension
- High-frequency linear array transducer, 7 to 15 MHz
- Select the highest frequency that still penetrates
- Scan each lobe in transverse and sagittal planes
Thyroid Physiology & Labs
- Follicular cells produce thyroxine (T4) and triiodothyronine (T3); iodine required
- Parafollicular (C) cells secrete calcitonin
- TSH from the pituitary regulates thyroid hormone output
- Labs typically show elevated TSH with low T3 and T4 in primary hypothyroidism, and the opposite pattern in hyperthyroidism
Parathyroid Glands
- Endocrine glands located on the posterior surface of the thyroid
- Most people have four parathyroid glands, though 3 to 5 glands is not uncommon
- Normal parathyroid gland measures about 5 to 6 mm
- Secrete parathyroid hormone (PTH), the principal regulator of calcium homeostasis
- Normal glands are usually too small to identify on ultrasound
Trick: Thyroid is more echogenic than the adjacent strap muscles. If the gland looks darker than the straps, think diffuse thyroid disease.
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Card 50 · Thyroid: Diffuse Disease
Front
THYROID
Goiter & Graves Disease
Goiter
- Diffuse enlargement of the thyroid gland, with or without palpable nodules
- Isthmus exceeding 1 cm in the AP plane suggests enlargement
- Diffusely heterogeneous echotexture; may show focal scarring, ischemia, necrosis, or cyst formation
- Multinodular goiter is a common cause of diffuse enlargement
Graves Disease
- Most common cause of hyperthyroidism; autoimmune, more common in women
- Diffusely enlarged, hyperplastic gland
- Marked hypervascularity on color Doppler termed the "thyroid inferno"
- Labs: high T3 and T4, low TSH
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THYROID
Hashimoto Thyroiditis
Hashimoto Thyroiditis
- Chronic lymphocytic thyroiditis; autoimmune, most common cause of hypothyroidism
- More common in women
- Mild enlargement of the gland initially, with later atrophy
- Diffusely heterogeneous, hypoechoic echotexture
- Multiple, ill-defined hypoechoic regions separated by echogenic fibrous bands
Clinical Correlation
- Preexisting Hashimoto disease is a known risk factor for thyroid lymphoma
- Labs typically show low T3 and T4 with elevated TSH
Trick: Both Graves and Hashimoto can look diffusely hypoechoic. Add color Doppler: Hashimoto vascularity is variable and typically less than the Graves inferno.
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Card 51 · Thyroid: Nodules & Parathyroid
Front
THYROID
Nodules & Papillary Carcinoma
Nodule Basics
- Nodules may be cystic, solid, or complex
- Simple anechoic cysts and colloid cysts (with echogenic focus and comet-tail) are typically benign
- Follicular adenoma is the most common benign thyroid neoplasm; well-encapsulated solid mass
- Any suspicious cystic or complex mass may require FNA biopsy
Suspicious (Malignant) Features
- Solitary, solid mass that is markedly hypoechoic compared with the gland
- Taller-than-wide shape
- Internal microcalcifications (psammoma bodies)
- Irregular margins
- Marked internal vascularity
Papillary Carcinoma
- Most common thyroid malignancy, approximately 70% of thyroid cancers
- Classically hypoechoic solid mass with microcalcifications
- May spread to cervical lymph nodes
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PARATHYROID
Parathyroid Adenoma
Parathyroid Adenoma
- Benign solid mass and the most common cause of primary hyperparathyroidism
- Appears as a hypoechoic mass adjacent to or posterior to the thyroid gland
- Usually solitary; most often near the lower pole
- Normal parathyroid glands are typically not visualized
Primary Hyperparathyroidism
- Elevated serum calcium
- Elevated PTH
- Most often caused by a parathyroid adenoma; less commonly parathyroid hyperplasia or, rarely, parathyroid carcinoma
Secondary Hyperparathyroidism
- Associated with chronic renal failure and vitamin D deficiency
- Elevated PTH with low calcium
- May demonstrate enlargement of all four parathyroid glands
Trick: A hypoechoic mass hugging the posterior thyroid in a patient with high calcium and high PTH is a parathyroid adenoma until proven otherwise.
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Card 52 · Thyroid: Carcinoma Subtypes & Neck Masses
Front
The suspicious pattern
- A solid mass that is markedly hypoechoic, with irregular margins, and taller than wide
- Microcalcifications are tiny punctate echogenic foci under 2 mm, usually without acoustic shadowing
- Colour Doppler may show increased vascularity with a disorganized internal flow pattern
- Sonography can demonstrate inflammatory, benign, and malignant conditions but cannot reliably tell them apart, so suspicious nodules go to fine needle aspiration under ultrasound guidance
The subtypes
- Papillary: the most common, spreads through lymphatics to cervical nodes, associated with microcalcifications
- Follicular: spreads haematogenously; cytology cannot distinguish adenoma from carcinoma, so it needs excision
- Medullary: arises from parafollicular C cells, secretes calcitonin, associated with MEN syndromes
- Anaplastic: elderly patients, rapidly growing, poor prognosis
Thyroid lymphoma
- Primarily non Hodgkin, and almost always arising in a gland with pre-existing Hashimoto thyroiditis. A large hypoechoic lobulated solid mass with poor internal vascularity, in an older woman with a rapidly growing neck mass
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Cervical nodes
- A normal node is oval with a bright fatty hilum and hilar flow
- Suspicious features are a rounded shape, loss of the hilum, cystic change, calcification, and peripheral rather than hilar vascularity
- Cervical node metastases are present in 20 to 50 percent of papillary carcinomas at diagnosis
- A normal node stays under 1 cm in short axis, is oval, and keeps a thin symmetric cortex with hilar flow
Developmental cysts
- Thyroglossal duct cyst: midline, at or below the hyoid, mostly paediatric with 90 percent found before age 10
- Branchial cleft cyst: lateral, anterior to the sternocleidomastoid, near the mandibular angle
- Cystic hygroma: multiloculated, posterior triangle, usually presenting in infancy
Landmarks
- The longus colli muscle lies posterior to each lobe and is the landmark that keeps a posterior nodule from being called extrathyroidal
- The isthmus bridges the lobes anterior to the trachea
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Card 53 · Scrotum & Testes: Normal
Front
Testis
- Paired ovoid organs suspended within the scrotum
- Covered by the tunica albuginea, a dense fibrous capsule
- Tunica vaginalis is a double serous layer (parietal and visceral) covering the testis and epididymis; a potential space between the layers is where hydroceles form
- Mediastinum testis appears as an echogenic band located along the posterolateral aspect of the testis
Epididymis and vas deferens
- Three parts: head, body, and tail
- Head lies superior to the upper pole of the testis; body and tail course posteriorly along the testis
- Echogenicity is similar to or slightly less than the adjacent testis
- The epididymal tail continues as the vas (ductus) deferens
Scrotal wall and spermatic cord
- Dartos muscle divides the scrotum into two compartments; the cremaster muscle provides thermoregulation
- Spermatic cord contents: vas deferens, testicular artery, cremasteric artery, artery to the vas, pampiniform plexus, lymphatics, and nerves
Vascular supply
- Testicular artery branches into capsular artery, then centripetal artery, then recurrent rami
- Cremasteric and deferential arteries accompany the testicular artery within the spermatic cord
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SCROTUM
Sonographic Technique
Transducer
- High frequency linear array transducer is preferred for scrotal imaging
- Very high frequency probes (7 to 15 MHz) are typical for smaller superficial structures such as the scrotum
Patient and protocol
- Patient is imaged supine with the scrotum supported
- Each testis is evaluated in transverse and sagittal planes
- Obtain a transverse image of the right and left testes together for side by side comparison in both gray scale and color Doppler
- Include images of the epididymal head superior to the testis and follow the body and tail posteriorly
Doppler evaluation
- Color and pulsed Doppler flow within each testicle and epididymis should be symmetric
- Match color and spectral settings on the contralateral side before comparing
- Perform the Valsalva maneuver when a varicocele is suspected
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Card 54 · Scrotum & Testes: Detailed Anatomy & Cryptorchidism
Front
Coverings and structures
- The tunica albuginea is the fibrous capsule directly investing the testis; it invaginates to form the mediastinum testis
- The rete testis sits at the hilum, where the mediastinum resides
- A potential space lies between the visceral and parietal layers of the tunica vaginalis. This is the space in which a hydrocele, pyocele, or hematocele develops
- In the adult each testis is about 3 to 5 cm long, 2 to 4 cm wide, and 3 cm high
Epididymis
- A tubular structure of 6 to 7 cm, beginning superiorly at the head and coursing posterolateral to the testis through body and tail
- The head is the largest and most consistently visualized portion, isoechoic or slightly hypoechoic to testis with a coarser echotexture
Vessels
- The right and left testicular arteries arise from the abdominal aorta just below the level of the renal arteries
- Venous drainage passes through the veins of the pampiniform plexus
Appendages
- The appendix testis and appendix epididymis sit at the upper pole. Either can torse and mimic torsion, showing a small hypoechoic paratesticular mass with increased peripheral flow
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Undescended testis
- Cryptorchidism describes a testis that has not descended into the scrotum and cannot be brought there by external manipulation
- Most lie in the inguinal canal, where ultrasound finds them readily. An intraabdominal testis is often impossible to locate sonographically and needs CT or MRI
- The undescended testis is usually smaller and slightly less echogenic than its descended partner
Why it matters
- Carries 2.5 to 8 times the malignancy risk of a normally descended testis
- Also associated with infertility
- Surgical treatment, freeing the testis and implanting it in the scrotum, is orchiopexy. It does not remove the malignancy risk
Tubular ectasia
- Tubular ectasia of the rete testis is an uncommon benign condition, associated with a spermatocele, an epididymal or testicular cyst, or other epididymal obstruction on the same side
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Card 55 · Scrotum & Testes: Pathology
Front
SCROTUM
Inflammatory & Torsion
Epididymitis and epididymo-orchitis
- Most common cause of acute scrotal pain in adults
- Inflamed epididymis appears enlarged, hypoechoic, or heterogeneous
- Hyperemic flow within the epididymis and/or testis on color Doppler
- Associated findings include a hypoechoic testis with orchitis, thickened scrotal wall, and reactive hydrocele
Testicular torsion
- Most common cause of acute scrotal pain in adolescents
- Early stages may show a normal sonographic appearance
- After 4 to 6 hours the testis becomes swollen and hypoechoic
- Color Doppler shows decreased or absent intratesticular flow compared with the contralateral testis
- Paratesticular flow may be increased around the abnormal testis
Trick: Always set color Doppler on the asymptomatic side first, then apply identical settings to the painful side so a true flow difference is not hidden by scanner adjustments.
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SCROTUM
Fluid, Vascular & Mass
Hydrocele, hematocele, and pyocele
- Hydrocele is a fluid filled collection located between the two layers of the tunica vaginalis, sonographically anechoic surrounding the testis
- Hematocele = blood, pyocele = pus, in the same potential space; usually complex with septations and debris
Varicocele
- Caused by incompetent valves within the pampiniform plexus
- Veins measuring 3 mm or larger in diameter are considered varicose
- Occurs most often on the left side
- Distension increases with the Valsalva maneuver
Testicular carcinoma
- Most testicular tumors are well defined hypoechoic intratesticular masses
- Larger tumors may be poorly marginated or appear heterogeneous
Testicular microlithiasis
- Multiple bright, nonshadowing echogenic foci scattered throughout the testis
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Card 56 · Scrotum & Testes: Testicular Tumors
Front
The governing rule
- Extratesticular masses are usually benign; intratesticular masses are more likely malignant
- That single distinction drives the whole scan, so establish whether a mass is inside or outside the tunica albuginea first
- Testicular cancer is uncommon overall but is the most common malignancy in men aged 15 to 35
Germ cell tumours
- Testicular tumours divide into germ cell and non germ cell types
- Germ cell tumours are associated with elevated human chorionic gonadotropin and alpha fetoprotein
- Seminoma: homogeneous, hypoechoic, with a smooth border
- Embryonal cell carcinoma: heterogeneous and less well circumscribed, with areas of increased echogenicity from calcification, haemorrhage, or fibrosis, and possible cystic components
- Teratoma: heterogeneous with well defined borders, and may contain dense foci that shadow
- Germ cell tumours are about 95 percent of testicular tumours and are usually malignant. Non germ cell (stromal) tumours are generally benign
- Teratomas tend to be benign in children and malignant in adults
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Secondary tumours
- Malignant lymphoma makes up 1 to 7 percent of testicular tumours and is the most common bilateral secondary testicular neoplasm in men over 60
- Leukaemic infiltration is the equivalent in children
- Bilateral or diffuse involvement in an older man points away from a primary germ cell tumour
Microlithiasis
- Multiple bright, nonshadowing foci scattered throughout the testis
- The absence of shadowing is what separates it from coarse calcification
- More than five microliths on any single image is considered abnormal
- Associated with cryptorchidism, Klinefelter syndrome, infertility, testicular atrophy, and an increased risk of germ cell tumour, so annual follow up is advised
Scanning for a tumour
- Compare both testes in the same image at identical settings, since a subtle echogenicity difference is easier to see side by side than alone
- Any focal intratesticular lesion is treated as malignant until proven otherwise
Trick: Inside the testis, assume malignant. Outside it, assume benign. Then look for what disproves you.
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Card 57 · Scrotum & Testes: Extratesticular Masses & Fluid
Front
SCROTUM
Fluid Collections
The tunica vaginalis space
- Hydrocele: serous fluid, the most common cause of painless scrotal swelling. May be idiopathic but is commonly associated with epididymo-orchitis and torsion
- Pyocele: a collection of pus, from untreated infection or an abscess rupturing into the space
- Hematocele: blood, usually post traumatic, appearing complex with septations as it organizes
Varicocele
- Abnormal dilatation of the veins of the pampiniform plexus within the spermatic cord
- Usually caused by incompetent venous valves within the spermatic vein
- Dilated tubular structures over 2 mm that enlarge with Valsalva and standing
- More common on the left. A new right sided varicocele raises the possibility of a retroperitoneal mass
- The left side predominates because the left spermatic vein joins the left renal vein at a steep angle, and that vein can be compressed between the aorta and the SMA
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SCROTUM
Extratesticular Masses
Cysts
- Cysts are benign fluid collections that may lie within the testis or in the extratesticular structures. Most scrotal cysts are extratesticular
- Spermatocele: contains spermatozoa, arises at the epididymal head, and may show low level internal echoes
- Epididymal cyst: contains clear serous fluid and may arise anywhere along the epididymis
Solid extratesticular lesions
- Adenomatoid tumour: a benign solid extratesticular mass arising in the epididymis
- Sperm granuloma: a chronic inflammatory reaction to extravasation of spermatozoa, seen most often after vasectomy
Hernia
- Bowel, omentum, or other structures may herniate into the scrotum
- Peristalsis within the scrotal contents settles the diagnosis immediately
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