Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 129
2. Once the gallbladder is identified, find its long axis. This can
be accomplished by slightly twisting/rotating the transducer first
one way, then the other, to oblique the scanning plane according to the lie of the gallbladder. Occasionally, no oblique is
necessary.
NOTE: If the long axis of the gallbladder cannot be resolved in the sagittal plane, rotate the transducer 90 degrees into the transverse scanning
plane. Remember that gallbladder lie is variable and the scanning plane
must be adjusted accordingly.
3. Assuming the long axis is identified in the sagittal plane, begin the
survey by very slightly rocking the transducer from right to left,
sweeping through both side margins of the gallbladder while at the
same time very slowly sliding inferiorly through and beyond the
fundus.
LT
RT
4. Continue rocking and sliding and move the transducer back onto
the fundus, then very slowly rock and slide superiorly, surveying
through and beyond the gallbladder body and neck.
LT
RT
130 PART III Abdominal Scanning Protocols
Gallbladder • Axial Survey
Transverse Plane • Transabdominal Anterior Approach •
First Patient Position
1. Relocate the gallbladder long axis in the sagittal plane. Move inferiorly to view the fundus then very slowly rotate the transducer 90
degrees into the transverse plane. A round or oval axial section of
the fundus will come into view.
RT
2. Very slightly rock the transducer superior to inferior and at the
same time slowly slide inferiorly, through and beyond the fundus.
LT
LT
RT
3. Continue rocking and slide the transducer superiorly back onto
the fundus and continue scanning up through the body and neck
until you are beyond the gallbladder.
LT
RT
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 131
Biliary Tract • Longitudinal Survey
Sagittal Plane • Transabdominal Anterior Approach •
First Patient Position
1. Begin scanning by relocating the long axis of the gallbladder. Identify the neck, main lobar fissure, and portal vein. Look for a small,
anechoic, longitudinal section of the common duct just anterior to
the portal vein. It may be necessary to very slightly twist/rotate the
transducer, first one way, then the other to oblique the scanning
plane according to the lie of the duct and to resolve its long axis.
NOTE: The common duct usually lies at a right angle to the costal
margin.
NOTE: In a sagittal oblique plane, at the level of the porta hepatis, the
portal vein will be traversed, seen as round or oval, in a short axis/axial
section. Just inferior to this level, the portal vein appears longitudinal as
it runs posterior and parallel to the common duct.
2. Barely rock the transducer right to left, sweeping through both
sides of the common duct and at the same time very slowly slide
the transducer slightly superior and right lateral to survey through
and beyond the margin of the proximal portion of the duct. The
distance moved is very small.
NOTE: Notice the appearance of the small, anechoic, axial section of
the hepatic artery running between the long sections of the duct and
the portal vein.
LT
RT
3. Move the transducer just inferior, back onto the duct then return
to the level of the gallbladder neck and main lobar fissure.
4. Continue the survey by barely rocking the transducer right to left
and at the same time very slowly slide the transducer slightly inferior
and medial to scan through and beyond the distal portion of the
duct at the level of the head of the pancreas. The distance moved
is very small.
132 PART III Abdominal Scanning Protocols
Remain at this level to begin the axial survey of the duct.
RT
NOTE: The distal portion of the duct or CBD can be difficult to visualize
for the short distance that it runs behind the duodenum due to overlying
bowel gas. When this occurs, continue to scan through the duodenum
and pick up the duct again just on the other side of the duodenum or
at the head of the pancreas. To visualize this retroduodenal portion of
the duct, some institutions have patients drink enough water to fill the
duodenum. The water displaces the bowel gas and serves as an acoustic
“window” to view the duct.
LT
Biliary Tract • Axial Survey
Transverse Plane • Transabdominal Anterior Approach •
First Patient Position
NOTE: Because of the small diameter of the common duct, a complete
axial survey can be difficult. Therefore, when measurements are within
normal limits it is acceptable to evaluate the axial sections of the proximal portion of the duct (the CHD) at the level of the GB neck and
the distal portion of the duct (the CBD) at the level of the head of the
pancreas.
1. While still in the sagittal plane relocate the long axis of the common bile duct (CBD) at the level of the head of the pancreas. Very
slowly rotate the transducer 90 degrees into the transverse plane.
Look for the small, round, anechoic section of the CBD within
the posterolateral portion of the pancreas head. In most cases, the
small axial section of the gastroduodenal artery can also be identified anterior to the CBD in the anterolateral portion of the pancreas head.
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 133
2. Return to the sagittal plane and relocate the long axis view of the
gallbladder neck. Move the transducer slightly superior to the neck
and a longitudinal section of the common hepatic duct (CHD)
anterior to the portal vein should come into view. Resolve the long
axis of the duct then very slowly rotate the transducer 90 degrees
into the transverse plane. Look for the small, round, anechoic section of the CHD anterior to the portal vein.
LT
RT
Gallbladder • Longitudinal Survey
Sagittal Plane • Transabdominal Anterior Approach •
Second Patient Position
Second Patient Position: Left Lateral Decubitus
Follow the same survey steps used for the first patient position for longitudinal and axial gallbladder surveys and longitudinal and axial
surveys of the common duct.
Gallbladder and Biliary Tract Required Images
NOTE: The required images are a small representation of what a sonog-
rapher visualizes during a study. Therefore, the images should provide
the interpreting physician with the most telling and technically accurate
information available.
Gallbladder • Longitudinal Images
Sagittal Plane • Transabdominal Anterior Approach •
First Patient Position/Supine
NOTE: The gallbladder must be documented in two different patient
positions.
134 PART III Abdominal Scanning Protocols
r
GallbladderLiver
Inferior
Gallbladder
1. LONG AXIS image of the gallbladder.
Gallbladder
neck
Hepatic
artery
Superior Inferior
Portal
vein
Anterior
Gallbladde
fundus
Gallbladder
body
Cystic duct
Posterior
Labeled: GB SAG LONG AXIS
NOTE: In many cases gallbladder definition is sacrificed to achieve the
long axis. Therefore, additional longitudinal images of the gallbladder
fundus, body, and neck should be documented.
2. Longitudinal image of the GALLBLADDER FUNDUS and BODY.
fundus/body
Anterior
Liver
Superior
Labeled: GB SAG FUNDUS/BODY
Posterior
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 135
Inferior
Gallbladder neck
Pancreas
Duodenum
3. Longitudinal image of the GALLBLADDER NECK.
Hepatic artery
Common
hepatic duct
Superior
Portal
vein
Anterior
Liver
Posterior
Labeled: GB SAG NECK
NOTE: The area where the neck of the gallbladder joins the cystic duct
is described as the spiral valve due to its tortuous appearance. This reference is to appearance only because there is no valvular action.
Gallbladder • Axial Images
Transverse Plane • Transabdominal Anterior Approach •
First Patient Position/Supine
4. Axial image of the GALLBLADDER FUNDUS.
Cystic
duct
Liver
Right Left
Gallbladder
fundus
Labeled: GB TRV FUNDUS
Anterior
Posterior
Inferior
vena cava
Left
renal
vein
136 PART III Abdominal Scanning Protocols
Aorta
Duodenum
5. Axial image of the GALLBLADDER BODY.
Duodenum
Liver
Right Left
Gallbladder
body
Increased
posterior
through
transmission
vena cava
Anterior
Inferior
Posterior
Labeled: GB TRV BODY
6. Axial image of the GALLBLADDER NECK.
Anterior
Right Left
Portal
vein
Liver
Posterior
Pancreas
Spine
Right renal
artery
Pancreas
Gallbladder
neck
Labeled: GB TRV NECK
7. Axial image of the GALLBLADDER with anterior wall measurement.
Labeled: GB ANT WALL MS
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 137
Inferior
Hepatic
NOTE: Gallbladder wall thickness is typically evaluated from the shortaxis. Measure the anterior wall at its most narrow point. Remember to
keep the transducer perpendicular to the gallbladder wall for an accurate measurement.
Biliary Tract • Longitudinal Images
Sagittal Plane • Transabdominal Anterior Approach •
First Patient Position
NOTE: Images of the common duct may be taken in the second patient
position if the duct was better visualized in that position during the
survey. Also, common duct images can be magnified to aide physician
interpretation.
NOTE: As a general rule, CHD measurements are only required when
the CBD measurement is abnormal.
NOTE: The longitudinal image of the CHD can be omitted if the duct
was well visualized on the longitudinal image of the gallbladder neck or
long axis gallbladder images.
8. Longitudinal image of the COMMON HEPATIC DUCT (CHD).
Common
hepatic duct
Superior
Liver
Diaphragm
Anterior
Inferior
vena cava
Posterior
Labeled: SAG CHD
artery
Portal vein
Gallbladder
138 PART III Abdominal Scanning Protocols
Anterior
9. Longitudinal image of the COMMON BILE DUCT (CBD) with
anterior to posterior measurement (from interior margin of anterior wall
to interior margin of posterior wall).
Superior
Hepatic
artery
Liver
Portal vein
Common
bile duct
Posterior
Inferior
Bowel
Labeled: SAG CHD
NOTE: Notice how the measurement of the CBD is at the widest margins of the lumen. Sometimes Doppler is helpful to differentiate the CBD
and hepatic artery. Axial images and measurements are not required for
the CHD and CBD unless the longitudinal CBD measurement exceeds
the normal limit.
10. Same image as 9 without calipers.
Labeled: SAG CHD