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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 139
rI
r
r
Pancreas
Duodenum
Gallbladder • Longitudinal Image
Sagittal Plane • Transabdominal Anterior Approach •
Second Patient Position/Left Lateral Decubitus
11. LONG AXIS image of the gallbladder.
Anterior
Superio
Portal
vein
Liver
Posterior
Labeled: GB SAG LONG AXIS
Gallbladder • Axial Image
Transverse Plane • Transabdominal Anterior Approach •
Second Patient Position/Left Lateral Decubitus
12. Axial image of the GALLBLADDER FUNDUS.
Anterior
Liver
Right Left
nferio
Gallbladde
long axis
Gallbladder
fundus
Inferior
vena cava
Posterior
Left
renal
vein
Labeled: GB TRV FUNDUS
140 PART III Abdominal Scanning Protocols
Anterior
n
Diaphragm
Posterior
Anterior
Required Images When the Gallbladder and Biliary Tract are Part of Another Study
Gallbladder • Longitudinal Image
Sagittal Plane • Transabdominal Anterior Approach
1. LONG AXIS image of the gallbladder.
Portal vein
Liver
Gallbladder
Small bowel
Through
transmissio
Superior
Inferior
vena cava
Posterior
Inferior
Labeled: GB SAG LONG AXIS
Gallbladder • Axial Image
Transverse Plane • Transabdominal Anterior Approach
2. Axial image of the GALLBLADDER FUNDUS.
Gallbladder
fundus
Liver
Inferior
vena cava
Sidewall
shadow
LeftRight
Labeled: GB TRV FUNDUS
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 141
Posterior
Gallbladder
Posterior
Anterior
Biliary Tract • Longitudinal Images
Sagittal Plane • Transabdominal Anterior Approach
NOTE: Common duct images can be magnified to aide physician
interpretation.
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.
3. Longitudinal image of the COMMON HEPATIC DUCT (CHD).
Common
hepatic duct
Superior
Portal vein
Liver
Anterior
Inferior
vena cava
Labeled: SAG CHD
4. 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).
Common
bile duct
Superior
Liver
Inferior
Hepatic artery
Duodenum
Inferior
Portal vein
Labeled: SAG CBD
Hepatic artery
142 PART III Abdominal Scanning Protocols
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.
5. Same image as 4 without calipers.
Labeled: SAG CBD
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 143
Review Questions
Answers on page 629.
1. The long axis of the gallbladder is visualized in
a) a transverse scanning plane.
b) either transverse, sagittal, or coronal scanning planes depending
on its position.
c) a sagittal scanning plane.
d) longitudinal scanning planes.
2. What can help in the evaluation of the retroduodenal portion of
the CBD?
a) use water to displace the bowel gas.
b) glucagon.
c) intercostal, left lateral decubitus approach.
d) use a sharp transducer angle right laterally from the midline.
3. In a sagittal scanning plane at the level of the porta hepatis the
portal vein will be
a) seen in long axis.
b) seen in short axis.
c) anterior to the common duct.
d) anterior to the hepatic artery.
4. Different patient positions are used when evaluating the
gallbladder because
a) it distinguishes certain abnormalities from each other.
b) single position evaluation is not enough confirmation.
c) of the variability of the position of the gallbladder.
d) it unfolds the gallbladder.
5. _________________describes a folded gallbladder fundus.
a) segmental contraction.
b) Santorini’s fold.
c) biliary bend.
d) Phrygian cap.
6. The long axis view of the common duct is seen
a) in an oblique sagittal scanning plane.
b) in an oblique transverse scanning plane.
c) posterior to the long axis of the hepatic artery.
d) posterior to the axial sections of the portal vein.
7. The gallbladder tends to lie in the
a) retroperitoneum.
b) midepigastrium.
c) area between the right medial angle of the ribs and the superior
pole of the right kidney.
d) area just inferior to the level of the costal margin.
8. The CBD is located to the hepatic artery.
a) left lateral.
b) right lateral.
c) inferomedially.
d) posterior.
144 PART III Abdominal Scanning Protocols
9. The cystic duct connects the
a) common hepatic and CBDs.
b) common duct and pancreatic duct.
c) common duct and gallbladder neck.
d) gallbladder neck and body.
10. The spiral valve
a) closes when the gallbladder is full of bile.
b) regulates the flow of bile from the gallbladder.
c) is the tortuous connection of the gallbladder and cystic duct.
d) is the tortuous connection of the gallbladder and common duct.
11. The proximal portion of the common duct is
a) called the CBD.
b) appears traversed when viewed at the level of the porta hepatis
in a sagittal plane.
c) called the CHD.
d) appears traversed when viewed at the level of the pancreas head
in a sagittal scanning plane.
12. The distal portion of the common duct is
a) called the CBD.
b) appears traversed when viewed at the level of the porta hepatis
in a sagittal plane.
c) called the CHD.
d) appears traversed when viewed at the level of the pancreas head
in a sagittal scanning plane.
13. The common duct usually lies at a right angle to the costal margin.
a) true.
b) false.
14. The gallbladder serves as a storage site for bile and is variable in size
according to the amount of bile it is storing.
a) true.
b) false.
15. The CHD is considered normal in size up to
a) 2 mm.
b) 4 mm.
c) 6 mm.
d) 8 mm.
CHAPTER 7 Gallbladder and Biliary Tract Scanning Protocol 145
16. What is the normal diameter of the gallbladder wall?
a) < 0.5 mm
b) > 1.0 cm
c) < 3 mm
d) > 5 mm
17. The gallbladder is described in three major sections:
a) head, neck, body.
b) head, neck, fundus.
c) left, middle, right.
d) superior, medial, lateral.
18. The biliary system has three main functions. Which of the
following is not a function?
a) transports bile to the gallbladder.
b) stores bile.
c) transports bile to aid in digestion of fat.
d) stores enzymes.
19. The biliary ducts are subdivided into intrahepatic and extrahepatic
ducts.
a) true.
b) false.
20. A fold in the gallbladder fundus is called the Phrygian cap.
a) true.
b) false.
21. Intrahepatic bile ducts are not routinely visualized on ultrasound.
a) true.
b) false.
22. The gallbladder is an intraperitoneal organ.
a) true.
b) false.
Common hepatic artery
Proper hepatic artery
ry
Righ
Location of Pancreas
Stomach
Common hepatic duct
Cystic duct
Common bile duct
Gastroduodenal artery
Right adrenal gland
Gallbladder
Right kidney
Duodenum
Head
Proper hepatic artery
Portal
vein
Body
Neck
Uncinate
process
IVC
Pancreas Anatomy
Portal vein
Aorta
Common hepatic artery
Spleen
Tail
Main pancreatic duct
Superior mesenteric artery
Superior mesenteric vein
Celiac trunk
Splenic artery
Left adrenal gland
Left kidney
Common
hepatic duct
Cystic duct
t adrenal gland
Gallbladder
Common bile duct
Gastroduodenal
artery
Right kidney
Duodenum
IVC
Portal splenic confluence
Aorta
Stomach
Spleen
Celiac trunk
Splenic artery
Left adrenal gland
Splenic vein
Left kidney
Inferior mesenteric vein
Left renal vein
Superior mesenteric arte
Superior mesenteric vein
CHAPTER 8
Pancreas Scanning Protocol
Betty Bates Tempkin
Key Words
Common bile duct (CBD)
Endocrine
Exocrine
Gastroduodenal artery
Pancreas body
Pancreas head
Pancreas neck
Pancreas tail
Pancreas uncinate process
Objectives
At the end of this chapter, you will be able to:
• Define the key words.
• Distinguish the sonographic appearance of the pancreas and the
terms used to describe it.
• Describe the transducer options for scanning the pancreas.
• List the various suggested breathing techniques for patients when
scanning the pancreas.
• List the suggested patient positions (and options) when scanning
the pancreas.
• Describe the patient prep for a pancreas study.
• Distinguish normal variants of the pancreas.
• Name the survey steps and explain how to evaluate the entire
length, width, and depth of the pancreas.
• Explain the order and exact locations to take representative
images of the pancreas.
• Answer the review questions at the end of the chapter.
Portal splenic confluence
Portal vein
Retroperitoneal
Santorini’s duct
Splenic vein
Superior mesenteric artery
Superior mesenteric vein
Wirsung’s duct
Overview
Location
• The pancreas is retroperitoneal (located in the retroperitoneum, the
portion of abdominopelvic cavity posterior to the peritoneal sac).
It extends from the second portion of the duodenum, across the
midline, to the hilum of the spleen.
• The descriptive portions of the pancreas are located as follows:
(a) Head: The portion of pancreas immediately anterior to the
inferior vena cava; between the medial curve of the second
147
148 PART III Abdominal Scanning Protocols
portion of the duodenum and the superior mesenteric vein.
Its lateral border is marked anteriorly by the gastroduodenal
artery and posteriorly by the common bile duct (CBD).
(b) Uncinate process: A medial extension of the head that lies
directly posterior to the superior mesenteric vein. It has been
known to extend as far left as the aorta.
(c) Neck: The portion of pancreas directly anterior to the superior
mesenteric vein.
(d) Body: The portion of pancreas that extends left lateral from
the neck and lies between the posterior wall of the antrum of
the stomach and the superior mesenteric artery. Its left lateral
border is generally described as not definite.
(e) Tail: The portion of pancreas that typically lies posterior to
the stomach, between the left lateral edge of the spine and the
hilum of the spleen.
Anatomy
• The pancreas is a nonencapsulated multilobular gland. Its blood
supply is from the superior mesenteric artery, splenic artery, and
gastroduodenal artery. Venous drainage is through splenic and
superior mesenteric vein tributaries.
• Wirsung’s duct, the main pancreatic duct, extends the length of
the pancreas and enlarges toward the head up to 3 mm. It meets
with the common bile duct at the pancreas head, and joined
together or separately, the ducts enter the second portion of the
duodenum.
• Santorini’s duct is a normal variant that serves as an accessory
pancreatic duct from the anterior portion of the pancreas head. It
enters the duodenum superior to and separate from Wirsung’s duct
and the common bile duct.
• The size, shape, and lie of the pancreas vary somewhat. The size
decreases with age. The shape has been compared to a dumbbell,
sausage, and a comma with the larger segment representing the
head. The lie or orientation of the pancreas has varying degrees of
horizontal oblique.
• The normal adult pancreas is 15 to 20|cm in length.
• The anterior to posterior dimensions of the head range from 2.0
to 3.0|cm.
• The anterior to posterior dimensions of the neck range from 1.5
to 2.5|cm.
• The anterior to posterior dimensions of the body range from 1.5
to 2.5|cm.
• The anterior to posterior dimensions of the tail range from 1.0 to
2.0|cm.