Guidelines, Policies and Statements D5 Statement on Abdominal Scanning
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1 Guidelines, Policies and Statements D5 Statement on Abdominal Scanning Disclaimer and Copyright The ASUM Standards of Practice Board have made every effort to ensure that this Guideline/Policy/Statement is accurate and reflects best practice at the time at which they are issued. The information provided in this document is of a general nature only and is not intended as a substitute for medical or legal advice. The Society, employees and members do not accept any liability for the consequences of any inaccurate or misleading data/opinions or statements issued by ASUM. Approved Guidelines may be distributed freely with the permission of ASUM asum@asum.com.au. Page 1 of 6 01/16
2 Guidelines, Policies and Statements D5 Statement on Abdominal Scanning August 1991, Reaffirmed May 1997, Revised September 1999 March Introduction 1.1. The following comments apply to ultrasound in adults and are directed towards the range of pathology expected in adults These comments may be used as a general guide when scanning children and infants provided that appropriate allowance is made for the anatomical differences between adults and children Ultrasonic investigation of the abdomen is usually conducted to answer a specific clinical question. For example: Are there gallstones? Is the prominent aortic pulsation due to aneurysm? Is there evidence of parenchymal liver disease? Why are the liver function tests deranged? 2. Equipment 2.1. Equipment for abdominal scanning should be high quality real-time apparatus, less than 10 years old, which meets accreditation standards 2.2. Curved linear and sector transducers with variable focal zones are preferred. The frequency should be in the MHz range. 3. Guide To The Abdominal Ultrasound Survey 3.1. Although the study should be directed to answering the clinical question, a general examination of the abdomen is conducted to detect alternate causes for the presenting patient signs and symptoms. This survey of the abdomen is usually restricted to the upper abdominal organs. Scanning of the lower abdomen should be obtained if departmental protocol directs this When assessing a particular organ in the abdomen with ultrasound, the organ should be thoroughly scanned from one border to the other in a minimum of two orthogonal planes. Archived images are obtained in standard planes to document a normal study, and specific views are taken to illustrate detected pathology. When an abnormality is found, the following basic sonography rules apply: quantify abnormality in two planes, assess echogencity, borders, echotexture and vascularity / hemodynamics Pancreas Transverse and longitudinal scanning is required, particularly of the head, body, tail and uncinate process. Page 2 of 6 01/16
3 Comment on: The degree of visualisation particularly if suboptimal Size of the head, body and tail Parenchymal texture Focal lesions: including soft tissue masses, cysts, and calcification Pancreatic duct; calibre, contour and stones. Assess CBD size at pancreatic head Gall Bladder Peripancreatic lesions; collections, solid masses, lymphadenopathy and cysts Demonstrate in at least two planes with patient in supine or decubitus position To assess mobility of gall bladder lesion or findings, also scan with the patient in erect position Comment on: Intraluminal lesions; number, size, posterior shadowing, mobility and echogenicity. Wall thickness (versus degree of distension) or mass assess wall continuity posterior to mass and presence of vascularity. Presence of mural gas, mural oedema, calcification or comet tail artifact. Distension - physiological, pathological Point tenderness with probe pressure and release Extrahepatic Bile Duct Pericholecystic collections / echogenicity changes eg: fatty sparing Attempt to demonstrate the full length of the common bile duct and common hepatic duct Comment on: Duct diameter luminal measurement, at level of portal vein bifurcation (MHD) and more distally (CBD). If there is duct dilatation - degree and extent of dilatation, level of obstruction, regularity of caliber, assess for duct wall thickness Intraluminal lesions - number, size, echogenicity, posterior shadowing, and mobility within duct. If solid luminal contents assess for wall disruption and/or vascularity of mass. Page 3 of 6 01/16
4 Liver Longitudinal and transverse views are usually sufficient. Intercostals views may be required in the technically difficult patient Comment on: Adequacy of visualisation of the whole of the liver Overall size, caudate lobe size, contour/size changes due to mass/surgery. Borders/Liver surface - smooth, irregular. If irregular macro- or micro-nodular cirrhosis. Parenchymal echogenicity, texture and attenuation Focal lesions; number, size, location echo characteristics segmental location required. Intrahepatic bile ducts Hepatic & Portal veins size, patency, hemodynamics (direction and velocity of flow in PV) Perihepatic collections Right pleural space Spleen Measure size Comment on: Parenchyma - texture and echogenicity, vascularity post trauma or with abnormality Focal lesions - number, size, location, echo characteristics, presence of splenunculus Perisplenic collections, collateral veins, splenic vein patency and direction of flow Left pleural space Kidneys Measure size - measure bipolar distance Comment on: Contour Parenchyma - echogenicity cortex and medulla, cortico-medullary differentiation Page 4 of 6 01/16
5 Focal masses - number, size, location, cystic or solid, vascularity, exclude invasion into renal vein Collecting systems - hydronephrosis, prominent extrarenal pelvis, dilated ureter, intraluminal lesions, urothelial thickening, exclude focal nephronia/pyonephrosis in UTI s Peri-renal and para-renal collections and masses Adrenal Glands Visualisation should be attempted. However the adrenal glands are not usually seen in the adult group Comment on: Size and texture if enlarged Focal masses: cystic, solid, bilateral, unilateral, vascularity Upper Abdominal Vasculature Demonstration of the upper abdominal vasculature is a key requirement in abdominal scanning. The degree of ultrasonic interrogation will depend on the clinical indication for the scan The following vessels should be visualized, and assessed for patency and haemodynamics as clinically indicated: Aorta exclude aneurysm, atherosclerosis, para-aortic lymphadenopathy, confirm patency Coeliac axis - exclude aneurysm, atherosclerosis, para-aortic lymphadenopathy, confirm patency Superior mesenteric artery - exclude aneurysm, atherosclerosis, confirm patency Right & Left renal vein patency in association with mass, acute renal failure, hepato-renal syndrome Inferior vena cava assess size, patency, phasicity, pre-caval nodes. Splenic vein assess patency, direction of flow. Superior mesenteric vein - assess patency, direction of flow. Main portal vein and its 2 proximal branches Right & Left Portal veins assess size, assess patency, direction of flow. Exclude recanalised Umbilical Vein in patients with chronic liver disease. Splenic artery - exclude aneurysm, atherosclerosis, confirm patency. Page 5 of 6 01/16
6 Hepatic artery - exclude aneurysm, atherosclerosis, confirm patency. Replaced right hepatic artery (common variant) - exclude aneurysm, atherosclerosis, confirm patency Hepatic veins - assess size, patency, phasicity/compliance Aorta Size: measure the outer AP diameter of the aorta ( Males : < 3cm NAD; Females: < 2.5 cm) Comment on: Aneurysmal dilatation & patency Calcification, plaques and thrombus Para-aortic masses; size number location Peritoneal Cavity Confirm / Exclude Ascites comment on maximum depth of collection Comment on: Loculated collections; size, site, echo characteristics, vascularity Peritoneal masses; size, vascularity and site Bowel wall: thickness, dilatation, peristalsis, identify gut layer involved in abnormality ie: mucosal/mural etc Assess the appendix. Page 6 of 6 01/16
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