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Diagnostic Ultrasound

Diagnostic Ultrasound. Strengths of Ultrasonography. Determining origin of an abdominal mass Evaluation of organ parenchyma Liver, spleen, kidneys, adrenals, pancreas, intestines, prostate, bladder, heart Fetal viability Real time scanning – see movement/motion

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Diagnostic Ultrasound

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  1. Diagnostic Ultrasound Dr.sai krishna

  2. Strengths of Ultrasonography • Determining origin of an abdominal mass • Evaluation of organ parenchyma • Liver, spleen, kidneys, adrenals, pancreas, intestines, prostate, bladder, heart • Fetal viability • Real time scanning – see movement/motion • Performing fine needle aspiration/ biopsy Dr.sai krishna

  3. Weaknesses of Ultrasonography: • Ultrasound can’t penetrate gas or bone • Can’t assess intestinal gas patterns • Can’t evaluate some extra abdominal structures (i.e. spine) • Equipment can be expensive • Diagnostic success is user dependent • Must know anatomy very well Dr.sai krishna

  4. Technical considerations: • Lesions can be missed in - incorrect transducer - improper TGC settings - poor screen contrast - brightly lit room • Use appropriate frequency Highest frequency transducer appropriate first later lower frequency Dr.sai krishna

  5. Appropriate Pressure • use the lowest power setting possible to have high quality image. • If Obese , emaciated , Gas filled leads to images of poor quality. • Cant pass thru Air so clip the hair coat. • Tranquilization needed in biopsies Dr.sai krishna

  6. Patient positioning • Abdominal scanning: -Dorsal recumbency -V shaped tough -Head towards the machine -Dominant hand scanning & non dominant hand on control panel Dr.sai krishna

  7. Two planes: Longitudinal Transverse oblique can be used in producing diagnostic images. Use as many views with as many angles possible. Dr.sai krishna

  8. Abdominal ultrasound Dr.sai krishna

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  11. Diaphragm Dr.sai krishna

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  16. Basic rules for UltraSonography • Always scan in dim lighted room • Always remove hair • Always position the animal in consistent orientation. • Always position the image on screen with proper orientation Dr.sai krishna

  17. Slowly perform Scan • All structures should be identified • Always scan each organ in two planes • Consistently use same technique • Perform the exam with consistency Dr.sai krishna

  18. General Abdomen: For small dogs and cats, a 7.5/10 MHz sector, linear or curved array transducer is used. For larger dogs, 5 MHz transducers are usually adequate In some giant breed dogs 3.5 MHz may be required. Dr.sai krishna

  19. LiverspleenleftkidneyL.nodes Rt.abdominal wall Urinary bladder Genital tract Rt.kidney Pancreas duodenum ORDER OF EXAMINATION Dr.sai krishna

  20. Free abdominal fluid: • Free abdominal fluid is seen as anechoic angular or triangular areas between abdominal structures. • If a large amount of free fluid is present, the abdominal structures will be separated by large anechoic areas, and the small intestine attached to a highly echogenic mesentery is seen floating freely in the fluid. Protein-losing diseases, such hepatopathy, nephropathy or enteritis, portal hypertension, or increased pressure in the caudal vena cava secondary to right-sided heart failure Dr.sai krishna

  21. Cysts typically have a thin, well defined wall, with anechoic content, edge shadowing and distant enhancement. • Intra-abdominal masses: Tumours such as lipoma may present as homogenous hyperechoic masses or have a more mixed internal structure. A classic abscess has a thick and irregular wall with a centre of variable echogenicity Dr.sai krishna

  22. Diaphragmatic and abdominal hernias: Loss of the curvilinear appearance of the diaphragm, the presence of liver or other abdominal structures close to the heart, and pleural or abdominal effusion are typical signs. • An intercostal approach using a parasternal window. Dr.sai krishna

  23. Abdominal ultrasound • Liver Indications: Abnormality in x-ray Metastasis Ascites Elevated liver enzymes Biopsy Parenchyma Gallbladder Portal veins Hepatic veins Diaphragm Dr.sai krishna

  24. Due to the location of the liver within the ribcage, a curvilinear transducer is very helpful to allow full penetration of the ultrasound beam. • Transducer frequency of 7-10 MHz should be sufficient. • Both subxiphoid and right intracostal windows should be used for complete evaluation of the liver and gallbladder. • By using the ribcage to mark the extent of the normal caudal hepatic margin an assessment of marked microhepatia and/or hepatomegaly can be made. Dr.sai krishna

  25. Start with cross sectional view. • Place transducer near the xyphoid process • Scan to the patients right and back to the left • Angle the probe as needed to visualise all of the liver. • Apply fair amount of pressure to expel the gas. then move to longitudinal section • Compare the echogenicity of the liver with the surrounding fat (hepatic lipidosis). Dr.sai krishna

  26. What to examine? Texture Echogenicity Liver , central vessels , gall bladder , cystic and common bile duct. Dr.sai krishna

  27. Normal Liver is: Homogenous with hepatic & Portal veins & caudal vena cava Portal veins with echogenic walls(due to adjacent fat) . Hepatic veins with out walls. Dr.sai krishna

  28. The line of the diaphragm is seen at the bottom of the scan. • The right lobes are displayed on the operator’s left and the left lobes on the right. Dr.sai krishna

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  31. Echogenecity: • Hepatic echogenicity must be assessed only in comparison with neighbouring organs at the same depth and preferably within the same image. • Compare with left kid (less) & spleen(more) . Hyperechoic , Hypoechoic , Mixed echoic Diffused , Focal Dr.sai krishna

  32. Diffusely hypoechoic liver: • vessels appear more prominent with their hyperechoic walls in greater contrast to the surrounding hypoechoic parenchyma. • Differential diagnoses for this appearance include lymphoma (and other multicentric round cell neoplasms), congestion and acute hepatitis. Dr.sai krishna

  33. Diffusely hyperechoic liver: • Indistinctness of the vessel walls (border effacement). • Differential diagnoses for generalized hyperechogenicity include vacuolar diseases, fibrosis(cirrhosis) & lymphoma. • Vacuolar diseases include hyperadrenocorticism, hypothyroidism, non-specific hepatopathies and fatty infiltration. Dr.sai krishna

  34. Diffusely mixed echoic liver: • A mixed pattern may be caused by a single type of infiltration mixed with normal parenchyma, or by more than one form of infiltration Dr.sai krishna

  35. Differential diagnoses include infiltrative neoplasia , such as lymphoma or mast cell tumour, and histiocytic diseases. • Patchy mixed patterns are seen with advanced fibrosis (cirrhosis), hepatocutaneous syndrome and feline amyloidosis . • The classic appearance of cirrhosis is a hyperechoic parenchyma with hypoechoic regenerative nodules, free peritoneal fluid, small overall size and irregular liver margins. Dr.sai krishna

  36. Feline amyloidosis is characterized by a coarse, patchy mixed echogenicity with hyperechoic specks and hypoechoic foci. • Hepatocutaneous syndrome is associated with mucocutaneous ulcerative lesions and liver failure. The ultrasonographic appearance is a Swiss cheese pattern with hypoechoic regenerative nodules and surrounding regions of hepatocyte collapse Dr.sai krishna

  37. Focal changes in echogenicity: • Nodules are very common in older dogs • Both benign and malignant nodules can be hypoechoic, mixed or hyperechoic. • Benign nodular hyperplasia, metastatic nodules, haematomas and primary liver neoplasia. Dr.sai krishna

  38. An outer hypoechoic area surrounding a hyperechoic centre is more commonly seen with, but is not unique to, metastatic neoplasia. • Feline biliary cystadenomas are hyperechoic with small to large cavitated (anechoic) portions. • Haemangiosarcoma, fibrosarcoma, leiomyosarcoma and extra-skeletal osteosarcoma. Dr.sai krishna

  39. Changes in liver contour and architecture: • Interruption of the regular hepatic architecture, deviation of adjacent vascular structures and bulging of the hepatic margins are indicative of a mass lesion. • Differential diagnoses include neoplasia, benign nodular hyperplasia, haematoma, abscess, granuloma, cyst and torsion. Dr.sai krishna

  40. Microhepatica: • Where there appears to be reduced liver volume . • Where there is little space between the liver and intestine, that the liver size is small. • Cirrhosis & portosystemic shunt. • The liver is small and is usually poorly vascularised. The abnormal shunting vessel may be seen relatively easily in portosystemic shunt with smooth, sharp edges. • cirrhotic nodules present, which are isoechoic and are not easily identified but liver margins are often rounded and irregular Dr.sai krishna

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  42. Diffuse necrosis and cirrhosis in a dog. Dr.sai krishna

  43. Biliary disease: Gall bladder: It is usually anechoic and ovoid in shape with a tapered neck. The intraparenchymal ducts are not usually seen unless dilated and they can then be differentiated from the hepatic vessels by their branching pattern and tortuous appearance. Chronic cholangitis: Cases of long standing cholangitis or cholangiohepatitis the wall of the gall bladder may be quite hyperechoic or even thickened. Dr.sai krishna

  44. Chronic cholangitis Gall bladder wall is thickened and hyperechoic. Dr.sai krishna

  45. Obstructive disease: • Cholelithiasis As hyperechoic structures casting a strong acoustic shadow. Bile duct this may be dilated and tortuous • Mural causes : inflammation or occasionally neoplasia The bile duct carcinomas may be seen as an echogenic mass within the dilated and obstructed ducts. Dr.sai krishna

  46. Bile duct within which hyperechoic calculi can be seen Cholelithiasis Dr.sai krishna

  47. Spleen: • The head of the spleen is often located within the ribcage in the cranial left dorsal abdomen in dogs so left intercostal approach may be necessary to fully evaluate the spleen. • The entire spleen in the cat is caudal to the ribcage and can be fully evaluated from a ventral approach. • The spleen should be uniform in echogenicity. • The splenic veins are visualized at the splenic hilus and for a short distance within the parenchyma. The splenic veins can be evaluated with colour Doppler ultrasonography for assessment of blood flow Dr.sai krishna

  48. Dog Cat Dr.sai krishna

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  50. Doppler ultrasonography interrogation of splenic vein blood flow is important for evaluation of splenic torsion, thrombosis and certain mass lesions. • As the spleen is superficial avoid excessive pressure on the transducer as this may result in it not being readily seen. In most cases (including large dogs) a 7.5 MHz transducer is more than adequate to image this well. Dr.sai krishna

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