Sonographic Examination

OBJECTIVES
Objectives of sonography are;
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To learn the normal cross sectional anatomy & structural details (normal sonographic findings of the patient). To find out the abnormalities observed on sonographic examination. To co-relate the sonographic examination findings with physical examination To confirm the diagnosis sonographically To categorize the trauma patients as per organ trauma score as first line assessment To diagnose and to plan sonographic management in selected patients To find out innovations in both clinical & sonographic examinations

! ! ! ! ! !

Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

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SONOGRAPHIC EXAMINATION IN GENERAL

Muhammad Shuja Tahir, FRCS (Eden), FCPS Pak (Hon)

Sonographic examination is performed with the help of an ultrasound machine. It can be performed for most of the body parts but requires different probes and machines. It used to be performed by specialists of the field during last few decades. Now a days, most of the doctors are able to perform sonography on their own with reasonably accurate interpretation. The skill can further be improved if the sonography is learnt at earlier stage (during student years) as it has become an essential part of diagnostic work up. The time has come that medical students start learning sonographic examination as adjuvant to clinical examination. It should be performed in a structured manner so that omissions can be avoided. It has reasonably high sensitivity and specificity. It has much higher accuracy rate. It achieves nearly 100% accuracy when combined with clinical examination. INTRODUCTION AND COUNSELING One must introduce him/herself to the patient and should plan whether the patient will go to the ultrasound examination room or the examination will be conducted
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on the bedside in the ward (in case of a serious and heamodynamically unstable patients. The patient should be informed about the mechanics of the examination so that patient clearly knows what exactly is going to happen to him/her, which of the body parts are to be uncovered and how much and for how long. One should be very polite and decent during the examination. The examination is conducted at an appropriate and comfortable room temperature. The contact gel is applied to the area to be examined sonographically. Never forget to clean and cover the uncovered parts of patients at the end of examination. The patient is informed about completion of examination. SPECIAL INTERVIEW Relevant history should be asked from the patient so that the sonographic examination is conducted objectively. History of Jaundice, pain in epigastrium or right hypochondrium, nausea, vomiting, abdominal pain, distension or trauma should be asked. History of last menstrual period, menstrual abnormalities (Amenorrhea, heavy menstrual bleeding) should be noted. History of abdominal masses should be asked. Dysuria, pain in lumber area and haematuria are also noted if present. EXPOSURE AND POSITION Elective examination is conducted in ultrasound examination room. The patient is asked to lie down on the examination couch. The patient should preferably wear the hospital gown after removing the shirt to facilitate the sonographic examination and to avoid soiling of

clothes with jelly. The patient lies in supine position on the couch and the abdomen is exposed from lower chest to the lower abdomen. The thighs and genatalia remain covered. Patient is shifted to right or left lateral positions as required for examination. Emergency, trauma or serious haemodynamically and unstable patients who can not be shifted to ultrasound room are examined on the bedside by bringing the machine to the side of the bed. No special preparation is required for most of the conditions. Gall bladder examination is done on a fasting patient and pelvic examination is conducted on patient with full urinary bladder. The sonographic examination is performed in a methodical and structured form to avoid missing important observations. SONOGRAPHIC EXAMINATION The machine is checked for normal functioning. Its computer attachments are checked for accepting photographs. Printer and its papers are checked and one is ready for conducting

Normal abdominal sonography

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sonography. The jelly is put over the probe and examination is started in a well organized and structured manner. It is started from right hypochondrium. The probe is moved from right hypochondrium to epigastrium and then to left hypochondrium. ABDOMEN AND PELVIS These patients usually don't require any special preparation normally. The patients who present for biliary examination should be fasting for 612 hours so that the gall bladder is distended at the time of examination. The pelvic examination is performed with full bladder. The pelvic organs are better examined in the presence of distended urinary bladder. One should know the patient's problem before a fruitful examination is conducted. BILIARY SONOGRAPHY It is performed for the diagnosis of following conditions; ! Cholecystitis ! Cholelithiasis ! Choledocholithiasis

The gall bladder is recognized and seen. Its photograph is taken. Cystic duct, hepatic ducts common hepatic duct and common hepatic duct and common bile duct and intra hepatic biliary ducts are examined. Abnormalities of biliary tree are noted and photographs are taken of stones or any other solid mass present in gall bladder or biliary tree. The examination is conducted in both longitudinal and transverse views. When sonographic examination of gall bladder is done on a fasting patient, the stones show as hyperechoic shadow. The mass has a posterior acoustic shadow confirming the diagnosis. Thick walled gall bladder with other suggestive features is seen in cholecystitis. Sonographic Murphys test is positive when gentle examination of gall bladder is so painful as to stop breathing momentarily. It is seen in acute cholecystitis or empyema of gall bladder. The hyperechoic shadow of billiary stones seen in jaundiced patients in common bile duct is called choledocholithiases. It is usually

Abdominal and pelvic sonography

Cholelithiasis

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associated with dilated proximal billiary canaliculi to suggest obstructive jaundice. Presence of stones in the gall bladder help to simplify the diagnosis in a patient having severe colic. Small stone or even gravel can be picked up on sonography. LIVER Sonographic examination of liver helps in diagnosis and assessment of extent of liver problem. Liver (Cross sectional anatomy ) is examined from front, lateral and posterior aspect for parenchymal inspection. Abnormalities are noted. Size of liver is assessed. Presence or absence of ascities is noted. The liver parenchyma is normally grey on scanning. It shows intra hepatic billiary ducts, intra hepatic portal tributaries and intra hepatic arterial tributaries. The liver parenchyma changes to hyper echoic form in cases of liver damage and resulting fibrosis in case of post hepatitis-C cirrhosis (Chronic liver disease).

The liver may show mixed echopattern, discrete opacities or masses with increased vascularity in case of primary liver tumour such as Hepatoma. The liver may show tears of different size (length and depth) following liver trauma. Sonographic examination helps in assessing the liver injury score. It also helps in regular monitoring of trauma patients who are managed nonoperatively. Sonographic examination is per formed regularly, daily or even twice or three times a

Normal Liver ultrasound

It may show isolated hyperechoic mass or multiple masses in cases of secondary tumours (deposits) in liver when primary tumour is somewhere else in the body. Liver may show isolated hypoechoic area or multiple hypoechoic areas in the liver in cases of various types of liver abscesses (Amoebic or pyogenic). Multiple hypoechoic areas (Multiple unilocular or multilocular cystic areas) are seen in cases of hydated cysts of liver.

Hydatid cyst liver

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day. Sonographic assessment may be required in case of haemodynamically compromised patients. SONOGRAPHY FOR ASCITES Sonography reveals this problem easily. The presence of fluid (even very small amount) can be diagnosed. The intra peritoneal fluid may be present in pelvis or in the peritoneal cavity.

SPLEEN The spleen is nearly of the same size as of the kidney (1x3x5 inches). The parenchyma is appreciated and noted. All abnormalities of spleen are noted and photographs are taken for record. It can be seen on sonographic examination which reveals its anatomical landmarks clearly. The size can be measured. Any sign of injury, tear, hematoma, cystic mass or abscesses can be diagnosed. The sonography helps in monitoring of splenic injury in patients on (NOM) non operative management. Sonographic injury grading can also done.

Ascites on ultrasound examination

STOMACH Normally an empty stomach cannot be visualized on sonographic examination. It can be seen when filled with fluids. The diseased stomach may reveal complex mass if it is present in the stomach. Gastric outlet obstruction can be diagnosed as large amount of fluid keeps the stomach distended even after few hours fasting. PANCREAS The pancreas is seen normally when the probe lies over epigastrium. It can be easily appreciated when enlarged and inflamed or when a tumour, cyst or psuedocyst of pancreas is present.

Rupture spleen on sonography

APPENDICITIS When appendix is infected, sonography helps to confirm the diagnosis. The probe is put at Mac Burneys point in right iliac fossa and moderate degree of pressure is exerted. The appendix is seen, fecolith may be seen or inflammatory mass with bull's eye appearance is seen. Sometimes free fluid around appendix is seen.

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ureteric area. Presence of hydronephrosis or hydroureter indicates the diagnosis. Right lumber area is examined in both longitudinal and transverse views. Right kidney, right diaphragm upper part of right ureter and right side of large gut are seen. Intra peritoneal fluid (Ascities), blood and leaked intestinal secretions are seen. Left lumber area is examined in the similar fashion in both views. Left kidney, diaphragm, stomach, left large gut and spleen are seen. Fluid collection under the diaphragm or peritoneal cavity is seen. The supra pubic and umbilical areas are examined. Distended bladder is seen then other intra peritoneal viscera are seen. Uterus and ovaries are seen in female patients. Normal uterus usually has empty cavity. Normal ovaries show differently during changing period of menstrual cycle. During midcycle, follicles are seen. The ovaries are smaller and atrophic in old menopausal women. INTERVENTIONAL SONOGRAPHY It is microinvasive method of treatment in the patients with trauma or deep abscess such as

Appendicitis on sonography

Loops of small bowel may be seen adherent to the appendix. Sonographic MacBurneys test is positive when minor pressure at MacBurneys point causes severe pain at right iliac fossa. KIDNEY Ultrasonography helps in differentiating between different causes of acute abdominal emergencies such as; The sonography shows abnormal findings of urinary tract. It shows presence of stone or any other cause of obstruction in the renal or

Normal kidney on ultrasound examination

Core needle biopsy under ultrasound guidance

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LUMP Sonography is helpful in improving the diagnosis of a lump which may be present either subcutaneously or deep in the body. It may be related to viscera or abdominal wall or peritoneal, thoracic or pelvic cavity. Correct size of the lump can be measured in various dimensions. Nature of lump can be assessed. Whether it is solid, cystic or of mixed type of tissues. It further helps to assess the nature of adjacent tissues and helps to verify any abnormality present or associated with the lump. RESPIRATORY SYSTEM (CHEST) Sonography for respiratory system is performed occasionally when there is strong suspicion of fluid or blood collection in the pleural cavity. It does not help in assessment of normal respiratory functions or anatomy of thorax.

Focused Abdominal Scan for Trauma (FAST)

liver abscess, subphrenic abscess, breast abscess perinephric abscess and pelvic abscess. Sono-graphic guided biopsy from primary, secondary or metastatic deposits can be obtained with precision and higher accuracy. FOCUSED ABDOMINAL SCAN FOR TRAUMA F.A.S.T Ultrasound guided aspiration or drainage of haematoma or abscess can be performed with minimum trouble to patient. FAST has almost replaced diagnostic peritoneal lavage to detect haemoperitoneum. Ultrasound has made a lot of impact in the management of seriously injured patients. Intra peritoneal or intrathoracic collection and haemorhage can be detected easily in severely injured patient who is not fit for any other diagnostic procedure.

Ultrasound examination for pleural effusion

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SONOGRAPHIC EXAMINATION IN GENERAL

Preparation How to prepare a patient for sonography of; Gall bladder Kidneys Bladder Uterus Prostate What is F.A.S.T? How liver abscess is drained under ultrasound guidance? Cleaning the patient Covering the patient Counseling

F.A.S.T Intervention

Completion

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