Untitled

• Covers abdominal and general ultrasound registry review topics

Introduction to Abdominal Imaging

• When learning anatomy and physiology, location in relation to other organs is important
• Consider parenchymal divisions/components, and landmarks
• It is important to consider vasculature
• Size and appearance should be noted
• Be aware of any variants
• The basic function should be understood

Relational Anatomy

• Anterior/superficial is towards the front, or closer to the top
• Posterior/deep is towards the back, or closer to the bottom
• Superior/cephalad is towards the head
• Inferior/caudal is towards the feet
• Medial is closer to the middle
• Lateral is closer to the sides
• Proximal is closer to the origination
• Distal is closer to termination

Basic Abdominal Anatomy

• The peritoneum is a closed sac containing major internal organs
• Intraperitoneal organs are inside the peritoneum, and covered by a visceral peritoneum and parietal peritoneum
• Parietal is the outer sac
• Visceral is the organs' "skin"
• The greater sac is a larger space
• The lesser sac (omental bursa) is found between the pancreas and stomach
• Gallbladder, liver, ovaries, stomach, spleen and some bowel intraperitoneal organs

Intraperitoneal Cavities

• Spaces that can collect fluid, such as ascites, are found in the intraperitoneal cavities
• Exudate is malignant ascites; transudate is benign
• Subphrenic space is inferior to the diaphragm, between the diaphragm and the liver/spleen
• Subhepatic space is inferior to the liver, the right posterior subhepatic space is the Morison's pouch (liver/kidney)
• The lesser sac lies between the pancreas and stomach
• Paracolic gutters are the lateral sides of the abdomen, next to the colon
• Retropubic space, also known as the space of Retzius, is anterior to the bladder
• Anterior CDS in females lies between the bladder and uterus, and does not exist in males
• Posterior CDS in females lies between the uterus and rectum
• in males, the posterior CDS lies between the bladder and rectum
• Retroperitoneal organs lie under peritoneum, covered anteriorly by the peritoneum
• The anterior pararenal space contains the pancreas, duodenum, ascending and descending colon, and lymph nodes
• The perirenal space includes the kidney, adrenal glands, and ureter
• Posterior pararenal space is comprised of fat
• The great vessel compartment contains the IVC, aorta, and lymph nodes

Abdominal Pathology

• Pathology categories include diffuse, focal benign, infections, obstruction, trauma and cancer
• Diffuse pathology is all over the organ, affecting cells and their function, abnormal labs, and produces symptoms
• Focal benign pathology includes cysts/tumors and does not necessarily affect organ function, making it asymptomatic
• Infections include acute infections producing fever, leukocytosis (elevated WBC), and pain
• Chronic infections do not show symptoms of infection, but can cause organ damage like diffuse infections
• Organs with ducts or collecting systems can have blockages (gallbladder, biliary, pancreas, urinary)
• Obstruction can cause pain and elevated labs/enzymes, with dilated tubes proximal to the blockage visually
• Trauma (hemorrhage, hematoma, rupture, laceration, fracture) is all bleeding, can cause decreased hematocrit/hemoglobin, dropping BP, with a history of trauma or surgery
• Cancer symptoms can vary, but may include risk factors, tumor markers, and invasion

Liver Anatomy

• Liver facts include that it is intraperitoneal (except for the bare area) and covered by the Glisson capsule
• Liver has three main lobes: right, left, and caudate
• The liver metabolizes materials, eliminates waste, and makes bile
• Portal triads consist of portal vein, hepatic artery, and bile duct and go to a hepatocyte
• Intersegmental/hepatic indicates between segments and separates them with fissures, hepatic veins, ligaments, and/or the gallbladder
• Intrasegmental/hepatic indicates inside segments/liver, without Portal veins, bile ducts, or hepatic artery dividing the segments
• Liver division is done by Couinaud classification
• Caudate lobe (segment 1 of Couinaud) is separated from the left lobe by the ligamentum venosum and bordered posteriorly by the IVC
• Ligaments appear as an echogenic band on sono
• The ligamentum is formed by the closure of blood vessels
• Ligamentum venosum in utero is the ductus venosus
• The Ligamentum teres (AKA round ligament) in utero is the umbilical vein, and can be found inside the falciform ligament
• Portal vein and hepatic artery supply the liver
• 70% of its blood is supplied by the MPV
• MPV and proper hepatic artery enter at porta hepatis traveling hepatopetally
• Portal vein are minimally phasic and have steady flow
• Hepatic arteries have low resistance
• Both are intrasegmental with branches matching segments
• Hepatic veins drain into right atrium and travel hepatofugally
• Hepatic veins are intersegmental, situated between and splitting segments

Liver variants

• Reidel's lobe is an extension of the right lobe over the right kidney, which may cause false-positive results
• To distinguish it from hepatomegaly, the left lobe should be checked for enlargement
• Papillary process is an inferior extension of the caudate lobe
• Normal liver measures up to 15cm along the mid-hepatic line (dome to inferior tip), and is slightly more echogenic compared to the kidney
• MPV diameter should be less than or equal to 13 millimeters

Diffuse Liver Pathology

• Symptomatic diffuse pathology includes infection or cancer
• Diffuse liver diseases cause issues with function, so think liver enzymes (ALT, ALP, AST)
• ALT is alanine transaminase
• ALP is alkaline phosphatase
• AST is aspartate transaminase
• Elevated bilirubin is jaundice
• The liver conjugates bilirubin, so pre-liver is unconjugated and liver/after is conjugated
• Indirect (unconjugated) type means it has not yet gone through the liver and commonly caused by RBC hemolysis
• Direct (conjugated) type means it’s acute liver disease, hepatitis, or biliary obstruction
• Total bilirubin usually means it's liver disease/failure
• The progression of liver disease determines the severity of symptoms and labs: fatty (hepatic steatosis) can lead to chronic steatohepatitis > chronic disease/cirrhosis
• Cirrhosis leads to liver cell death/fibrosis, then portal hypertension/varices
• Fatty liver infiltration (hepatic steatosis) is the most common diffuse liver disease and most likely reason for elevated Liver Function Tests (LFTs) where hepatocytes (liver cells) fill with fatty deposits
• Can also be a sign of metabolic syndrome leading to steatohepatitis-chronic liver disease and fibrosis Symptoms include elevated LFTs, no symptoms
• On ultrasound, the liver will appear echogenic/dense with poor transmission (high attenuation) and poor visualization of vasculature
• Focal fatty infiltration appears echogenic with a patch of fatty liver and no mass effect
• Focal fatty sparing shows as a hypoechoic area with a patch of normal liver that’s most commonly located next to the gallbladder or porta hepatis (no mass effect)
• Cirrhosis is liver cell death, fibrosis, and liver failure, with the most common cause being alcoholism
• Symptoms include poor liver function (elevated Liver Function Tests (LFTs), jaundice (elevated total or direct bilirubin), fatigue, weight loss, and/or diarrhea
• On ultrasound, the liver has a heterogeneous/coarse texture, a small right lobe, an enlarged caudate lobe, nodular surface, and ascites
• The nodular surface is best seen using a higher frequency linear array
• Micronodular cirrhosis is when smaller nodules are caused by alcoholism
• Macronodular cirrhosis has nodules larger than 1cm and are caused by hepatitis
• Sequela/progression of disease includes portal hypertension with increased risk of Hepatocellular Carcinoma (HCC), and should be evaluated for signs of portal hypertension, portal vein thrombosis, and HCC
• Most common cause of portal hypertension is cirrhosis
• Shows increased pressure on the portal system, redirecting blood flow away from the liver
• Blood flow will only happen into lower pressure, but increased pressure of liver disease resists flow coming into it
• Flow drawn to other channels with lower pressure, so blood backs up into veins that drain into the PV (splenic vein, coronary / left gastric vein)
• These will dilate, forming varices or venous collaterals
• Share same clinical findings as advanced cirrhosis, and may exhibit caput medusa (superficial abdomen veins) and GI bleeding
• On ultrasound, Hepatofugal PV flow, dilated MPV >13mm, abdominal varices = dilated venous collaterals near spleen, stomach, and esophagus, abnormal splenic vein flow, splenomegaly, recanalized paraumbilical vein

Treatment of Portal Hypertension

• TIPSS transjugular intrahepatic portosystemic shunt creates a communication or a bridge between PV and HV, decompressing the portal vein and normalizing flow
• the right portal vein (proximal) goes to the right hepatic vein (distal)
• If successful, flow will be hepatopetal at the proximal anastomosis (RPV) and hepatofugal at the distal anastomosis (RHV)
• Obstruction of the PV is most commonly caused by tumors or lymphadenopathy
• Thrombosis may be caused by increased liver resistance due to HCC, mets, portal hypertension, or increased clotting factors (pregnancy, oral contraceptives, surgery)
• Symptoms can include pain, elevated LFTs, hypovolemia, nausea, and/or vomiting
• On ultrasound, thrombois of PV or cavernous transformation is apparent which leads to periportal collaterals and small vessels around the portal vein to reroute blood around the clot into the liver
• Different than portosystemic collaterals, as portal hypertension collaterals reroute blood away from the liver, while cavernous transformation reroutes blood back into the liver Budd-Chiari Syndrome has occlusion of hepatic veins and possibly IVC with clinical indication of elevated Liver Function Tests
• Leads to congestion, eventual liver necrosis, the caudate lobe enlarges to compensate as it drains directly into the IVC
• Show hepatomegaly on Sono with absent flow from hepatic veins and enlarged caudate lobe
• Infection types are known as acute hepatitis or abscess
• Major difference: Hepatitis is a diffuse infection so LFT’s will always be abnormal, an abscess is focal so liver function tests may be normal
• Diffuse labs and fever = whole organ infection "acute -itis"
• Fever and focal findings= abscess

Hepatitis

• Hepatitis A and B are the most common types of Hepatitis
• Hepatitis C is most likely the cause of needing liver transplantation
• "-itis" means inflammation or infection, will become chronic if liver is damaged. -Acute -itis is active infection, while solid organ acute -itis usually are clinical diagnosis
• Acute Hepatitis is most commonly Hepatitis A, transmitted fecal-orally
• When acute, patient will have clinical findings of fever, non-obstructive jaundice (elevated direct bilirubin), and elevated LFTs, but Sono may be normal
• Chronic Hepatitis is most commonly Hepatitis C, transmitted via bodily fluids
• There are no clinical finding except when it causes evidence of decreased in liver function
• Sono may have signs of fibrosis or cirrhosis

Abscesses

• Patients will show with clinical signs of infection (fever,pain,leukocyosis)
• All abscesses may focal complexed cysts, so clinical and Sono findings will be important
• A Hydatid abscess is caused by echinococcal Parasite which creates water-lily sign / Daughter cysts and Membranes which create decrease GI functions
• An amebic abscess is caused by a parasite from water which creates GI, causing diarrhea
• Pyogenic abscess is caused Pyo by Bacteria from other infection, surgery creating possible need of surgery
• Candida/Fungal abscess is caused by Candida albicans in Immunocompromised patient showing target lesions
• Focal masses can be benign/non-endocrine, asymptomatic, ormalignant, symptomatic
• Cysts, are benign and mostly asymptomatic, Associated with PKD
• Patient may have pain if Hemorrhagic and display anechoic, complex with posterior enhancement through Sono
• Cavernous hemangioma, most common benign, is an Echogenic solid mass
• Hepatocellular Adenoma is associated with oral contraceptives, may be echogenic
• Lipoma, made of fat, is Hyperechoic
• Focal Nodular Hyperplasia, 2nd most common benign liver tumor, is a stealth lesion as it soechoic to liver tissue and has central scar with vascularity
• A Hematoma is "Bleeding" can occur through trauma or surgery
• Can take the Intraparenchymal hematoma: within the organ/liver, being more focal
• Can also present as Subcapsular: hematoma around the liver, like free fluid
• Clinical indications includes trauma or Biopsy History, loss of hematocrit/pain
• Appears Anechoic to echogenic through Sono depending on age
• Cancers are common with Weight loss, fatigue, and may or may not be jaundice if obstructive
• Hepatocellular Carcinoma( HCC aka hepatoma) can happen in a chronic liver/cirrhosis/hepatitis and is primary, tested by looking for tumor markers(AFP) that appears solid mass on Sono and/or ascites
• Metastasis, most common cancer found in liver, is found by LFTs, pain/jaundice
• Appears as several solid Hypoechoic breast/ lung/ cancer/lymph and Target solid tumors on lung and colon

Pediatric Liver Tumors

• Hepatoblastoma is an increased risk of HCC and present in Beckwith-Wiedemann syndrome
• May show elevated AFP through testing and similar Sono appearance
• Liver Transplants are common to recover Hepatits patients
• Normal liver's have livers Dopplers(same as nativelivers Hep.v and arteries
• Hepatic arteries go heaptopetal with phasic and pulsatile movement Hepatic Arterys go hepatopedal with low resistance
• Portal veins also Hepatic veins can get high flow after and elevated RI.
• May have Rejection do to heaptopetal and lower flow in PV.
• Infarction can occur through or with liver transplantation is caused by hepoechoic blockage do to emobolilsm
• Ultrasounds can also guide liver biopsies to test tissue
• to avoid complications of abnormal and or clotting
• The core gauge will range 14-20 to get the best sample
• Ultrasound will assess liver and patients position is best to avoid bleed.
• 90 angle perpendicular scanning helps image the needle clearly
• When bleeding, the site should be assess after to ensure no risk of complication
• Flows through the liver for better visualization to access the vascularity and needle

Gallbladder and Biliary Anatomy

• The gallbladder intraperitoneal and stores and concentrates bile that’s transported through ducts
• Cholecystokinin (from duodenum) makes the gallbladder contract, releasing bile into the system
• Proximal flow of the biliary tree indicates where it is coming from and distal indicates where it is going
• Intrahepatic biliary radicles (part of portal triads) drain into right and left hepatic ducts (RHD,LHD)
• RHD and LHD turn into CHD, where CHD connects to cystic duct to become Extrahepatic

Biliary ducts

• Cystic duct contains spiral valves of Heister which only allow into GB until GB is is contracted (with cholecystokinin)
• The Cystic ducts is located in the neck which also connects CBD to the bile flow connecting to the Sphincter of oddi controlling the flow of the duodenum
• Flow goes Liver Biliary radicles R/L HD - CHD -cystic -GB - cystic -CBD -Ampulla
• The vascular supply: Cystic artery (branch of right hepatic artery)
• Inner to Outer layers: Mucosa, Fibromuscular, Serosa

Gallbladder Pathology

• Variants consist of the phrygian cap (fold of fundus), the hartmann pouch (outpouching in neck), and the junctional fold( fold in neck)
• It is important to have 6 hours without eating so it be easily seen though Sono
• Normal wall should be over 3 mm which is found Sagittarius
• Gb should be smaller than 4 cm to the transverse plane
• CBD normal under 6 mm while up to only 10 mm if cholecystectomy
• Patients may have increased mm every decade ( 8 yrs or 8 mm) The cystic dust can also be seen posterior to the CBD Sono findings will be present only when tubes have disease irritation/blocking/infection irritating is usually the result of stone
• This may cause pain and not be seen unless obstruction
• May have abnormal lab and conjugated bile/jaundice
• infection may caused by obstructions, as it is more common during the case of blockage with similar symptoms except fever

Abcesses

• Asymptomatic result of Incidental abnormalities in the GB wall
• Polyps are is commonly from Cholesterol and less than 10 mm from the GB and result to umbrella conditions from cholesterolorist
• Sono display and non mobile projecting from Inner-Lumen
• The adenomyomatosis presents as the formation of musculars layers forming little pockets like Rokitanasky Aschoff
• Cholesterol is usually stuck here and can be displayed through the Comet tail due though focal findings
• With Porcelain Gb its calcified and is considered a to have increase risk of stones
• Sono, as well, show Shadowing due to its mild effects
• The Gallbladder sludge is aka viscid bile and caused by Biliary stasis

Billary conditions

• Seen can be seen Icu total parention and or hypercalermia
• It appear through flow being Level dependent echoses can be easily seen
• Tumoractive is when fluid has been settled into sludge balls that can be movable (need to move patient!)
• The hepatilization results from isooechioc liver text
• symptonatic Gb and biliary disease starts with cholithiasis
• Bilirary stones may result in stones
• May be commonly seen in Gb fundus
• Display as RUQ pain collic/nausiea//vomiting

GB symptoms

• Hyporecoich,may come with shadownig
• Wes wall can be seen with stones
• The patients mobility should be documented
• Patients require some form of movement ( supline and LLD)
• Cholecoliths occur through the ducts
• Lab values are needed more due to obstructed or synponmatic disease
• Distal CBD is more likely to occur and must be dilate first
• mirzzin is when you lodge stone in cystic duct
• And press on the CBD
• Obstructive disease Is located on the distal end
• The sono should follow some signs like Parallel tube,double duck as well should be considered
• Intraheptic signs should be abornonmal and no color flow

Common GB Symptoms

• Gb enlarged is obstruction of distal GB.
• The distal should always be known while identifying that it over 4 cm
• Courvoiuser GB, enlarged GB do to pancreases do to pancreases Head mass
• There could be an Infection, patients should be sick
• Acute causes includes mursphy sigh fevers and elevated levels
• Thickened Gb should be noted with fluid while display sludge Gangrenous cholecutis shows erosion from eroded walls of GB
• Emoyema is a supperatiive mass on the gallbladder
• Empysema air has bacterial air and increase risk form dibetics
• should should Reverboration can be seen with champagne signs
• Arcalcus shows no stones
• The chlangioits shows elevated symptoms
• Most likely is by an abstructured stones Charconct triad shows pain
• The sclerosis Is the main complicaation
• This can cause increases in cardias
• Pneumobiliia

Cancer - Gallbladder

• most common tumor suspects when polyps are over 1 cm
• patient shows weightless loss and possible jaundies
• sono - shows nonobile along the wall over 1 cm Choangioarconoma most commonly found in the head of the liver and most cases result is Klatskin tumor Most cases are found on the bifurcation
• Clinical and sono is most of result In weight loss and Jaundice

Congential issues in infants

• Born wirth it. The patients can be alive or dead that will result to death if to much harm occurs.
• Billiary artersia-Narrowing or absence of biliary tree. Only seen in newborns/infants. Not compatible with life Clincial- newornjaundice/liver failure

Pancreas

• Fact, retriopertioneal anterior pararenal space
• exocrine gland, enzyme created by acinar cells

Pancrease

• Pancrease is located retropereitoneally
• Exo created out side, create the exocrine which the body is uses, and Endo is located in the blood with exocrinr system,
• Pancrease use homronies insulin/ glucigon and somostatni There is a MP and ACessory
• MP aka is wirsung
• the Accessory aka Santorini:
• Gasduinal, splatic artery supplies the blood
• Adult panacareace appears Ecinocic and the pediartc is the Hypoic echo
• Panceeatic duct is normal with being 2mm when see perpencualr from LOB
• Gda located at the Anterior Head CbD - is posterior

Variants

• divisum short main duct in inc risk
• Annular can wraps around

Pathologies acute (pancreatitis)

• Most from gal stones
• Amylase rises first but lipase is over the 72hours most specific Sono ( Hypo, pseudocysts , duatal ( vascular comp) ( spinlic vien thombrois artery Phelmon is non enapsualrated with fluid
• pusedo cyctis has encapsulates and in acute or chroinc Repeat bouts Dammaged Alcohol abuses Pain jaundice sono, hyperchoic cysts Most comond cause by paercreatic head, can't pass
• Wipple procedure

Renal

• retitoneon,
• cortex / meddula=nethroin filters wants waste-
• sinus= collecting systen-urin
• Artieries= paenthima
• Renol Artery= Segmentol Interloper
• Minor. Caylix .major. caylix
• renal peleiss uterere jureto vesiticular function

###Anatomical

• Corter forms outer hupoochie/ normal is over 10 ml medullla uppopehoic
• coulmes brrin colrtical
• sins are hyperchoic for calyces is seen fluid distantion

Pathology of Kidney

• Parenchyma- functi,
• compriomois- tumors/cys
• uraninalyis present condtiuion
• pyria/ baceria herria/potreuria.

Kidney Symptoms and Treatment

• acure kideny injury. moist common acute tubiualr is is increased elevation bun/creatinine. hyperten
• small, kidneys small or thin corticimedulary differenation

Kidney conditions, etc

• polycistic renakl disease bilateral/
• aquired renal cystic/ caused by renal hemodialysis
• Compare and contart renla dysases renal arety stenus. renla veein thromoisi
• transplation of the abronanl tissue ,
• upj obstruction mostly common congential location to peds
• dilation of enll pelvis, hydorenohrosis
• dilation if bladder uthreter hydronephrosis

Adrenal Glands

• Facts include Retroperitoneal is suprerenals with Gerota fascia enclosed from the Kidneys
• Endocrine gland is controolled pitatirty
• Anatoomically, they are supported by suppornrenal
• moist poserot juts to the big vessels supoeramodial ro Kidnsye the can have normal adult which visualizes pediatric pyrimdm The adrenal medila has cartiol/ aderogena. And cotxisner has edpiderneoghprinee the homrone
• Adersone = adreno carticol
• Patiuey wull send more. Acutr

Adrendal pathology

• Addisons has autoimmunodeffects.
• and then they are senf for Adrens, the hormones . but the body will be Adrenla l Insufficiency
• Hupetemsion and low sdouim. Hich

I think. Tumors can be symptoms