Sonographic Nomenclature

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3.3 Sonographic Nomenclature

Intra-abdominal lymph nodes: 5 scans (celiac, superior and inferior mesenteric groups, parietal retroperitoneal, and portal)

Gastrointestinal tract: Document according to findings. A complete workup should be documented by 9 scans: – Stomach: Fornix, body, antrum – Colon: Ileocecal; ascending, transverse and descending colon; sigmoid colon;

rectum

Genital organs: 2 scans each (uterus + adnexa or prostate + seminal vesicle; testicular scans may be added if required)

Urinary tract: 6 scans (renal pelvis and ureteropelvic junction on both sides, site where the ureter crosses over the iliac vessels on both sides, bladder transverse with prevesical ureter, bladder longitudinal)

Adrenal glands: 2 scans.

3.3 Sonographic Nomenclature

Note: When reporting sonographic findings, use proper nomenclature and try to

avoid using terms drawn from radiology.

The report consists of an accurate description of findings and the diagnosis. Structures not adequately visualized are described as such in the report.

Criteria for evaluating findings: It is important to evaluate the location, size,

shape, margins, relations, internal echo pattern, consistency, and dynamics (of moving structures). Tenderness to pressure, compressibility, and movement with respiratory excursions should also be assessed.

Examples of terms used in ultrasound reporting (listed alphabetically):

Acoustic enhancement

Acoustic shadow (Fig. 64b)

Coarse (coarse granularity)

Defect

Density

Distribution

Echogenicity (Fig. 64): Hypoechoic, anechoic, echogenic, isoechoic, hyperechoic; internal echoes

Heterogeneous

Homogeneous

Intensity

Internal echo pattern

Irregular

Lesion

Loose (rarefied) echo texture

Margins

Nonhomogeneous

Nonuniform

Normal-appearing

Regular

Sharp

Spacing

Structure (structural defect)

Uniform

Documentation and Reporting

3.3 Sonographic Nomenclature

Documentation and Reporting

Fig. 64a–d Examples of various internal echo patterns. a Echogenic pattern (arrow). b Hyperechoic (very echogenic) pattern with an acoustic shadow (S). c Hypoechoic pattern (arrows). d Anechoic pattern (C)

Individual echo characteristics and echo patterns

Table 8.Individual echoes and echo patterns

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Individual echoes Echo pattern

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Intensity

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Intense (high-level echoes in a dense arrangement)

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Echogenic, hyperechoic (Fig. 64a)

Scant (low-level echoes spaced far apart) Hypoechoic (Fig. 64c)

None (devoid of echoes) Anechoic (Fig. 64b)

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Distribution

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Uniform

yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy

Homogeneous

Nonuniform Nonhomogeneous

4.2 Sonographic Measurements

4 Function Studies

4.1 Basic Principles

As well as static examinations that yield morphologic findings, functional ultrasound studies can also be done. Since they involve the assessment of dynamic phenomena, these tests significantly expand our diagnostic capabilities by supplying information on organ functions.

The following tests have proved useful in routine situations :

Measurement of gallbladder contractions

Measurement of gastric emptying (p. 50)

Residual urine determination (p. 51)

Diuresis urography (p. 52).

4.2 Sonographic Measurements

Gallbladder Contractions

..............................................................................................................

Indications:

Suspected cystic duct obstruction

Prior to litholysis

Prior to lithotripsy

Measurement:

With a planimetry unit: Measure the maximum longitudinal area by scanning points around the gallbladder circumference (Figs.

65 and 66).

Function Studies

Fig. 65 Gallbladder planimetry for determining maximum longitudinal area

Fig. 66 Sonographic gallbladder planimetry for determining maximum longitudinal area. L = liver, GB = gallbladder

4.2 Sonographic Measurements

Without a planimetry unit : Measure the three greatest diameters in two planes and multiply them (length q depth q width) to calculate the gallbladder volume using the formula for an ellipsoid (sonographic residual urine determination; see Fig.

Test meal: A large, fatty, nonstandardized breakfast or a standardized beverage

69).

(e.g., 350 mL of cocoa).

Procedure:

The gallbladder is measured in the fasted patient (see above).

Function Studies

The patient consumes a fatty breakfast (e.g., rolls with butter and cheese, 1 egg, and 1 cup of hot chocolate).

The measurements are repeated at intervals of approximately 10 min.

Findings:

More than a 50 % decrease in gallbladder volume indicates a significant contraction. Gallbladder contractions are maximal at 30–45 min.

Contractions are absent or deficient in patients with cholecystitis, cystic duct obstruction, hepatic cirrhosis, diabetes mellitus, pregnancy, or celiac disease.

Gastric Emptying

..............................................................................................................

Indications: Detection of impaired gastric motility, which may occur in diabetic

neuropathy, nondiabetic neuropathy, and systemic diseases.

Measurement: Cross-sectional area of the antrum in the aortomesenteric plane

(Figs.

67 and 68).

Fig. 67 Antral planimetry in the aortomesenteric plane

Test meal : Tea

Procedure:

The fasted patient is examined in the morning in the sitting or standing position.

Antral planimetry is carried out in the aortomesenteric plane.

The patient drinks 300 mL of unsweetened tea with a straw.

Antral planimetry is repeated at 5 min intervals.

Findings: Determine the time required for the maximum antral area measured

after ingestion of tea to return to the initial area measured before ingestion of tea:

Normal value : 25 min.

A value of 40 min or more signifies impaired gastric emptying.

4.2 Sonographic Measurements

Fig. 68 Sonographic antral planimetry. VMS = superior mesenteric vein, L = liver, AO = aorta, AN = antrum

Residual Urine Determination

..............................................................................................................

Indications: Determination of residual urine.

Measurement: Calculate bladder volume using the formula for an ellipsoid

(see below).

Procedure:

Have the patient empty the bladder completely.

Measure the residual urine volume sonographically using the formula (Fig. 69): volume (mL) = width (cm) q depth (cm) q length (cm) q 0.5.

Function Studies

Fig. 69a, b a Measurement in transverse section. W = width, D = depth. b Measurement in sagittal section. L = length

Findings:

A residual urine volume I 50 mL is still within the normal range.

Bear in mind that the residual urine values calculated for small volumes are too large, and that those calculated for large volumes are too small.

4.2 Sonographic Measurements

Diuresis Urography

..............................................................................................................

Indications: Detection of subpelvic stenosis.

Measurement: Transverse diameter of the anechoic separation of the renal sinus

echo complex (Fig.

Test substance : Furosemide

Procedure:

Measure the transverse diameter of the central echo complex at the widest

Function Studies

point (Fig.

Administer 20 mg of furosemide by i.v. bolus.

Repeat the measurement at 5 min and 15 min.

Findings:

In a normal examination, the separation of the central echo complex measured

70).

71).

at 15 min is less than the separation measured at 5 min.

If the separation increases or shows no change, an obstructive subpelvic stenosis should be suspected.

Fig. 70 Measurement of the separation of the renal sinus echo complex

Fig. 71 Sonographic measurement. ++ = separation of central echo complex, K = kidney

5.1 Fine-Needle Aspiration Biopsy (FNAB)

5 Interventional Ultrasound

5.1 Fine-Needle Aspiration Biopsy (FNAB)

Preparations and Technique

..............................................................................................................

Setup (Fig. 72): The supplies include sterile drapes and gloves.

Prerequisites:

Adequate coagulation: Quick PT i 70 %, platelets i 100 000/mm3. Factor analy- sis (e.g., factor XIII) may be indicated in patients with a hematologic systemic disease.

Secure informed consent.

Confirm a safe puncture route.

Fig. 72 Materials for fine-needle aspiration biopsy: 1 Syringe, needle, razor, local anesthesia.

2 Syringe with citrate. 3 Angiomed core needles.

Otto needles 0.8 mm,

0.95 mm, 1.2 mm, or 4 glass slides with a formalin-filled Eppendorf tube

Interventional Ultrasound

Technique with a FNAB transducer (Fig. 73):

To maintain asepsis, the transducer must be sterilized (e.g., by placing it in disinfectant solution), and it may be necessary to line the guide channel of the biopsy transducer with sterile film. An antiseptic spray can be used as the ultrasound coupling medium.

Visualize the target lesion (Figs. 74a, 75a).

Mark the puncture route (Figs. 74b, 75b).

Measure the depth of needle insertion (Figs. 74b, 75b).

Anesthetize the puncture site.

Swiftly advance the biopsy needle along the designated path under sonographic guidance.

Remove the inner stylet, and visually check the position of the needle tip echo at the target site (Figs.

Apply gentle suction and rotate the core needle to sample material for cytohis-

74b, 75c).

tologic analysis.

5.1 Fine-Needle Aspiration Biopsy (FNAB)

Interventional Ultrasound

Fig. 73a–c Ultrasound-guided percutaneous FNAB

5.1 Fine-Needle Aspiration Biopsy (FNAB)

Fig. 74a, b Fine-needle aspiration biopsy. a Rounded, hypoechoic intrasplenic mass (TU). b The lesion is visualized, here using a linear transducer with a central biopsy channel. The needle path is marked on the screen. The insertion depth is measured (arrow), and the posi tion of the tip echo at the target site (arrow) is checked. S = spleen

Interventional Ultrasound

abc

Fig. 75a–c FNAB. a Elliptical, hypoechoic mass (TU) in the region of the right adrenal gland. L = liver. b The mass is visualized, the needle path is marked, and the depth is measured (arrowhead). c The position of the tip echo at the target site (arrow) is checked

5.1 Fine-Needle Aspiration Biopsy (FNAB)

Preparation of the sample:

Expel the material (mixed with citrate) onto a glass slide.

Transfer larger tissue particles into a formalin-filled Eppendorf tube.

Spread out and air-dry the cytologic sample.

Liquid samples should undergo cytologic and bacteriologic analysis (Fig. 76).

Interventional Ultrasound

abc

Fig. 76a–c Therapeutic fine-needle aspiration and drainage. a Rounded, sharply circumscribed intrasplenic mass with a nonhomogeneous internal echo pattern. b Diagnostic fine-needle aspiration yielded abscess material. Arrow: needle tip echo. c The abscess material (140 mL) was therapeutically evacuated at the same sitting. S = spleen, A = abscess

Indications and Guidelines for Specific Organs

..............................................................................................................

Liver:

Indications: Investigation of diffuse and focal abnormalities.

Note: With superficial lesions, make sure the lesion is biopsied through normal

liver tissue.

Spleen:

Indications: Abscess, primary focal lesions (Figs. 74, 76).

Note: The spleen is a very vascular organ, and strict criteria should be applied

in patient selection.

Pancreas:

Indication: Carcinoma

Note: It is unnecessary to establish a preoperative histologic diagnosis for inde-

terminate pancreatic masses that are localized and operable.

FNAB of a pancreatic mass is unnecessary if diagnostic imaging indicates a malignant tumor and operative treatment is planned.

Adrenal gland:

Indication: Indeterminate mass lesion (Fig. 75).

Caution: Before puncturing an adrenal mass, first exclude pheochromocytoma

clinically and by laboratory tests.

Lymph nodes :

Indications: Malignant lymphoma, metastasis, reactive lymphadenopathy.

Limitations: FNAB is inadequate in most cases for the evaluation of a suspected malignant lymphoma; surgical lymphadenectomy is usually required.

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