Diagnostic Ultrasound - Abdomen and Pelvis
Kidneys – Normal peak systolic velocity (PSV) 75-125 cm/s, not more than 180 cm/s □ > 200 cm/s is abnormal – Resistive index (RI) is (peak systolic velocity - end diastolic velocity)/peak systolic velocity; normal < 0.7 – Pulsatility index (PI) is (peak systolic velocity - end diastole velocity)/mean velocity, normal < 1.8 • Renal veins ○ Normal caliber 4-9 mm ○ Formed from tributaries that coalesce at renal hilum ○ Right renal vein is relatively short and drains directly into IVC ○ Left renal vein receives left adrenal vein from above and left gonadal vein from below ○ Left renal vein crosses midline between aorta and superior mesenteric artery ○ Spectral Doppler – Normal PSV 18-33 cm/s – Spectral Doppler in right renal vein mirrors pulsatility in IVC – Spectral Doppler in left renal vein may show only slight variability of velocities consequent upon cardiac and respiratory activity Size • Bipolar length is found by rotating transducer around its vertical axis such that the longest craniocaudal length can be identified • Normal size between 10-15 cm • Volume measurements ○ May be more accurate, but is time consuming ○ 3D ellipsoidal formula can be used for volume estimation – Length x AP diameter x transverse diameter x 0.5 ○ Consistency and changes in volume over time more important ANATOMY IMAGING ISSUES Imaging Recommendations • Right kidney ○ Liver used as acoustic window ○ Transducer placed in subcostal or intercostal position ○ Varying degree of respiration is useful ○ Raising patient's right side and scanning laterally/posterolaterally may be useful • Left kidney ○ More difficult to visualize due to bowel gas from small bowel and splenic flexure ○ Usually easier to search for left kidney using posterolateral approach with left side raised ○ Full right lateral decubitus with pillow under right flank and left arm extended above head may be useful in difficult cases – Spleen can be used as acoustic window for imaging upper pole of left kidney ○ Posterior approach – Useful for intervention procedures (renal biopsy, nephrostomy) – Image quality may be impaired by thick paraspinal muscles and ribs shadowing • Renal arteries ○ Origins best seen from midline anterior approach ○ Right renal artery can usually be followed from origin to kidney ○ Left renal artery often requires posterolateral coronal transducer scanning position for visualization • Renal veins ○ Best seen on transverse scan from anterior approach ○ May also be seen on coronal scan from posterolateral coronal Key Concepts • Accessory renal vessels ○ Must be accounted for in planning surgery (e.g., resection, transplantation) ○ Often are best seen using multidetector row CT, magnetic resonance angiogram, or digital subtraction angiography rather than ultrasound EMBRYOLOGY Embryologic Events • Congenital anomalies of renal number, position, structure, and form are very common ○ Often accompanied by anomalies of other systems ○ VATER acronym: Vertebral, anorectal, tracheoesophageal, radial ray, renal ○ Congenital absence of kidney ○ Anomalies of position (ectopia) are common ○ Anomalies of structure – Congenitally large septum of Bertin (lobar dysmorphism); asymptomatic – Fetal lobulations (lobation), single or multiple indentations of lateral renal contours – Partial duplication: Commonly results in enlarged kidney with 2 separate hila, 2 ureters (may join downstream or join bladder separately); duplex kidney = bifid renal pelvis, single ureter Anatomy: Abdomen 45
Kidneys Anatomy: Abdomen KIDNEYS IN SITU Inferior phrenic vessels Right adrenal vein Renal veins Left inferior adrenal vessels Left gonadal vein Right gonadal vein Superior mesenteric artery Gonadal arteries Inferior mesenteric artery Renal artery Renal vein Renal pelvis Capsule (incised & peeled back) (Top) The kidneys are retroperitoneal organs that lie lateral to the psoas and "on" the quadratus lumborum muscles. The oblique course of the psoas muscles results in the lower pole of the kidney lying lateral to the upper pole. The right kidney usually lies 1-2 cm lower than the left, due to inferior displacement by the liver. The adrenal glands lie above and medial to the kidneys, separated by a layer of fat and connective tissue. The peritoneum covers much of the anterior surface of the kidneys. The right kidney abuts the liver and the hepatic flexure of the colon and duodenum, while the left kidney is in close contact with the pancreas (tail), spleen, and splenic flexure. (Bottom) The fibrous capsule is stripped off with difficulty. Subcapsular hematomas do not spread far along the surface of the kidney, but compress the renal parenchyma, unlike most perirenal collections. 46
- Page 16 and 17: TABLE OF CONTENTS VASCULAR CONDITIO
- Page 18 and 19: TABLE OF CONTENTS 562 Perigraft Flu
- Page 20 and 21: TABLE OF CONTENTS 906 Hyperechoic G
- Page 22 and 23: Diagnostic Ultrasound
- Page 24 and 25: PART I SECTION 1 Abdomen Liver 4 Bi
- Page 26 and 27: Liver ○ Appear as echolucent defe
- Page 28 and 29: Liver Coronary ligament HEPATIC ATT
- Page 30 and 31: Liver Segment 8 HEPATIC SEGMENTS Se
- Page 32 and 33: Liver Rectus abdominis muscle LEFT
- Page 34 and 35: Liver Abdominal muscle LEFT LOBE OF
- Page 36 and 37: Liver Anterior right portal vein RI
- Page 38 and 39: Liver PORTA HEPATIS Anatomy: Abdome
- Page 40 and 41: Liver Inferior liver margin OTHER V
- Page 42 and 43: Biliary System • Harmonic imaging
- Page 44 and 45: Biliary System Left hepatic duct Ri
- Page 46 and 47: Biliary System Right rectus muscle
- Page 48 and 49: Biliary System COMMON BILE DUCT Ana
- Page 50 and 51: Biliary System LEFT INTRAHEPATIC DU
- Page 52 and 53: Spleen SPLEEN ANATOMY AND HISTOLOGY
- Page 54 and 55: Spleen Fat in splenic hilum Left he
- Page 56 and 57: Spleen SPLENIC VESSELS Anatomy: Abd
- Page 58 and 59: Spleen Splenosis ANATOMICAL VARIANT
- Page 60 and 61: Pancreas PANCREAS IN SITU Anatomy:
- Page 62 and 63: Pancreas PANCREAS, TRANSVERSE VIEW
- Page 64 and 65: Pancreas Left lobe of liver PANCREA
- Page 68 and 69: Kidneys KIDNEY ARTERIES AND INTERIO
- Page 70 and 71: Kidneys RENAL FASCIA AND PERIRENAL
- Page 72 and 73: Kidneys Right hemidiaphragm RIGHT K
- Page 74 and 75: Kidneys RIGHT KIDNEY, CT CORRELATIO
- Page 76 and 77: Kidneys Right erector spinae muscle
- Page 78 and 79: Kidneys RIGHT INTRARENAL ARTERY AND
- Page 80 and 81: Kidneys LEFT KIDNEY, CT CORRELATION
- Page 82 and 83: Kidneys LEFT KIDNEY, CT CORRELATION
- Page 84 and 85: Kidneys Subcutaneous fat Left latis
- Page 86 and 87: Kidneys LEFT MAIN RENAL ARTERY AND
- Page 88 and 89: Kidneys Right lobe of liver MULTIPL
- Page 90 and 91: Bowel - Forms an incomplete ring in
- Page 92 and 93: Bowel Falciform ligament STOMACH AN
- Page 94 and 95: Bowel SMALL INTESTINE Anatomy: Abdo
- Page 96 and 97: Bowel Abdominal wall STOMACH Anatom
- Page 98 and 99: Bowel Rectus muscle SMALL BOWEL Ana
- Page 100 and 101: Bowel Abdominal wall musculature Ce
- Page 102 and 103: Bowel LARGE BOWEL Abdominal wall mu
- Page 104 and 105: Bowel Urinary bladder RECTOSIGMOID
- Page 106 and 107: Abdominal Lymph Nodes RETROPERITONE
- Page 108 and 109: Abdominal Lymph Nodes LYMPHANGIOGRA
- Page 110 and 111: Peritoneal Spaces and Structures PE
- Page 112 and 113: Peritoneal Spaces and Structures PE
- Page 114 and 115: Peritoneal Spaces and Structures Li
Kidneys<br />
Anatomy: <strong>Abdomen</strong><br />
KIDNEYS IN SITU<br />
Inferior phrenic vessels<br />
Right adrenal vein<br />
Renal veins<br />
Left inferior adrenal vessels<br />
Left gonadal vein<br />
Right gonadal vein<br />
Superior mesenteric artery<br />
Gonadal arteries<br />
Inferior mesenteric artery<br />
Renal artery<br />
Renal vein<br />
Renal pelvis<br />
Capsule (incised & peeled<br />
back)<br />
(Top) The kidneys are retroperitoneal organs that lie lateral to the psoas <strong>and</strong> "on" the quadratus lumborum muscles. The oblique course<br />
of the psoas muscles results in the lower pole of the kidney lying lateral to the upper pole. The right kidney usually lies 1-2 cm lower<br />
than the left, due to inferior displacement by the liver. The adrenal gl<strong>and</strong>s lie above <strong>and</strong> medial to the kidneys, separated by a layer of<br />
fat <strong>and</strong> connective tissue. The peritoneum covers much of the anterior surface of the kidneys. The right kidney abuts the liver <strong>and</strong> the<br />
hepatic flexure of the colon <strong>and</strong> duodenum, while the left kidney is in close contact with the pancreas (tail), spleen, <strong>and</strong> splenic flexure.<br />
(Bottom) The fibrous capsule is stripped off with difficulty. Subcapsular hematomas do not spread far along the surface of the kidney,<br />
but compress the renal parenchyma, unlike most perirenal collections.<br />
46