Table Of ContentReal-time Ultrasound Imaging
in the Abdomen
Real-time Ultrasound Imaging
in the Abdotnen
M. Leon Skolnick, M. D.
Associate Professor of Radiology
University of Pittsburgh
School of Medicine
Director of Ultrasound Laboratories
Presbyterian-University Hospital
Pittsburgh, Pennsylvania
With 386 Illustrations
Springer-Verlag
New York Heidelberg Berlin
M. Leon Skolnick, M.D.
Associate Professor of Radiology
University of Pittsburgh
School of Medicine
Pittsburgh, Pennsylvania 15261 U.S.A.
Sponsoring Editor: Larry W. Carter
Production and Design: Berta Steiner
Library of Congress Cataloging in Publication Data
Skolnick, M. Leon.
Real·time ultrasound imaging in the abdomen.
Bibliography: p.
Includes index.
1. Abdomen-Radiography. 2. Diagnosis,
Ultrasonic. I. Title. [DNLM: 1. Ultra
sonics-Diagnostic use. 2. Abdomen.
WI 900 S628rJ
RC944.S56 617'.5507543 81-5740
AACR2
© 1981 by Springer-Verlag New York Inc.
Softcover reprint of the hardcover 1st edition 1981
All rights reserved. No part of this book may be translated or reproduced in any form
without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New
York 10010, U.S.A.
The use of general descriptive names, trade names, trademarks, etc. in this publica
tion, even if the former are not especially identified, is not to be taken as a sign
that such names, as understood by the Trade Marks and Merchandise Marks Act,
may accordingly be used freely by anyone.
9 8 7 6 5 432 1
ISBN-13: 978-1-4612-5921-3 e-ISBN-13: 978-1-4612-5919-0
DOl: 10.1007/978-1-4612-5919-0
Dedications
To the memory of my father) Samuel) who inspired me to write this
book) and to my family-Irene) David) Karen) and Eric-who encour
aged and supported me through these endeavors
Contents
1 Advantages of Real-time Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Instrumentation........................................... 13
3 Scanning Techniques and Anatomic Considerations . . . . . . . . . . . . 39
4 Kidney................................................... 59
5 Liver and Spleen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6 Biliary System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. III
7 Pancreas.................................................. 139
8 Retroperitoneum.......................................... 165
9 Intra- and Extraluminal Fluid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 191
10 Invasive Ultrasonography .................................. , 213
Index.................... ..... ............. ....... .... ... 235
vii
Preface
Diagnostic ultrasound is changing dramatically because of the development
of a variety of high resolution real-time scanning instruments. Until recently
the standard instrument was the articulated arm contact scanner. Real-time
scanners were viewed as adjunct instruments for specific and limited pur
poses. The roles are reversing with real-time instruments more frequently
accepted as the primary diagnostic tool and the contact scanner becoming the
ancillary instrument for use mainly for viewing a large field that cannot be
scanned with real-time instruments.
Two recent editorials stated that real-time instruments were used as the
sole diagnostic instrument for between 80% [Cooperberg (2)] and 98%
[Bartrum and Crow (1)] of their abdominal examinations.
This book introduces the reader to the field of real-time scanning in the
abdomen. It presupposes an understanding of basic physical concepts of
ultrasound, the appearance of both normal and pathologic conditions as
produced by static articulated arm contact scanning, and a familiarity with
the techniques of contact scanning. It is designed to acquaint the reader with
the spectrum of real-time instrumentation, provide a basic understanding of
the physics of ultrasound as related to these instruments, emphasize the
special skills required in the use of this equipment, and describe applications
of real-time scanning for various parts of the abdomen. While numerous
illustrations of both normal and pathologic anatomy are shown, the book is an
all-inclusive study of abdominal pathology as demonstrated by real-time
imaging.
Obstetrics and gynecology were intentionally omitted from this work. I
believe that these subjects are sufficiently broad that adequate coverage
would require publication in a separate book. The adrenal gland was ex
cluded because our experience with real-time studies of this organ was quite
limited.
Unless otherwise noted, all of the ultrasound images in this book are
printed so that: 1) on transverse scans, the right side (R) of the subject
is on the viewer's left; and (2) on sagittal scans, the direction of the subject's
head (H) is on the viewer's left.
ix
x
REFERENCES
1. Bartrum R], Crow HC: Real-time ultrasound: Its role in abdominal examinations.
Radiology 133:823-824, 1979
2. Cooperberg P: Real-time ultrasound of the abdomen: Clinical usefulness and limita
tions. Appl Radiology, p. 130, November-December, 1980
Acknowledgments
The WTiting and producing of a book involves many people in addition to
the author. Several persons who have been especially vital to the success
of this project and whom I wish to individually acknowledge and thank for
their efforts are: Janice French, my devoted secretary, for typing and or
ganizing the manuscript; Denise Basara, Abbe Greenberg, and Lois Galen
tine, our excellent technologists who worked with me in performing the
ultrasound examinations; Jon Coulter and Ron Filer, for the artwork;
Norman Rabinovitz and his staff for photographic support; and Larry Carter,
Berta Steiner, and Ute Bujard of Springer-Verlag for producing this volume.
M. Leon Skolnick, M.D.
Pittsburgh, Pennsylvania
xi
1
Advantages of Real-time Imaging
1. Static Versus Real-time Imaging over the patient's skin. The plane through
2. Why is Real-time Imaging Important? which the image is obtained depends upon
A. Demonstration of Organs in Motion the orientation of the arm and can only be
Respiratory changed by varying the arm position (Fig.
Vascular 1.1). Images produced by contact scanners
Bowel cover a larger field of view and usually are
Fetal of higher resolution than those produced by
B. Abdominal Surveying real-time instruments. Image quality pro
C. Optimizing Beam Orientation to duced by contact scanning greatly depends
Organs upon the skill of the operator since the trans
D. Vascular Identification ducer must be manually moved over the
E. Differentiation of Solid from Cystic patient to form an image. Thus, image qual
Masses ity can vary from scan to scan. In addition,
F. Continuous Scanning of Organ Vol since each image takes several seconds to
ume form, highest resolution images are obtained
G. Imaging Difficult-to-reach Regions during suspended respiration. Improper
3. Recording Real-time Images: Philosophi scanning techniques, especially during com
cal Considerations pound scanning, can introduce artifacts into
4. Limitations of Real-time Imaging the images, which if not appreciated by the
physician or technologist may lead to incor
rect interpretation of the images (Fig. 1.2).
In real-time systems, image formation is
automatic, and new images are continuously
1. STATIC VERSUS REAL·TIME produced many times per second. The trans
IMAGING ducer assembly can be freely moved over the
patient to produce images in any axis, and
images can be produced as the transducer is
There are two basic types of ultrasound im being moved (Fig. 1.3). Organs can be dis
aging instrumentation: those producing played in motion and patients need not sus
static images and those producing images in pend respiration during the scanning pro
motion (real-time or dynamic imaging). cedure. Since the equipment automatically
The articulated arm contact scanner is produces each new image in the same way
the main type of instrument used to produce as the previous one, image quality is con
static images. Such images are formed as the sistent from image to image and is not de
operator manually moves a transducer at pendent upon operator skill (Table 1.1).
tached to a multijointed (articulated) arm It is much easier to train a person to op-
I
2 Advantages of Real-time Imaging
Fig. 1.1. To change the plane
of the scan (solid or
dotted arrows) in the
articulated arm contact
scanner, the entire arm
assembly (A) and sup
port carriage (C) must
be rotated.
A B
Fig. 1.2. Artifacts introduced by improper scanning techniques. Transverse scans through right
upper abdomen showing a mass (M) in gallbladder (G). R, right side of patient.
A Single sweep scan. Mass identified as gallstone because of acoustic shadow (Sh) cast
by mass. B Compound scan. Acoustic shadow not seen because compounding move
ments of transducer allow ultrasound beam to reach tissues behind gallbladder with
out being shadowed by mass. Mass can be mistaken for polyp in gallbladder.
Description:Diagnostic ultrasound is changing dramatically because of the development of a variety of high resolution real-time scanning instruments. Until recently the standard instrument was the articulated arm contact scanner. Real-time scanners were viewed as adjunct instruments for specific and limited pur
