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CHAPTER 8 Pancreas Scanning Protocol 169
8. The tail of the pancreas is
a) anterior to the SMA, left renal vein, and left kidney; posterior to
the stomach.
b) anterior to the splenic vein, left renal vein, and left kidney; pos-
terior to the stomach.
c) lateral to the splenic artery, posterior to the splenic vein and
stomach.
d) just lateral to the spleen, anterior to the splenic vein, and poste-
rior to the stomach.
9. A standard alternative approach for scanning the pancreas tail is
a) intercostal scanning.
b) subcostal scanning.
c) an anterior approach.
d) a posterior approach.
10. The exocrine function of the pancreas is
a) accessory storage of bile.
b) to produce the hormones insulin and cortisone.
c) to produce the hormone insulin.
d) to aid digestion in conjunction with the biliary system.
11. What structure is identified at the anterior aspect of the head of the
pancreas?
a) Common bile duct.
b) Common hepatic artery.
c) Gastroduodenal artery.
d) Splenic vein.
12. Which portion of the pancreas is the least commonly visualized by
ultrasound?
a) Uncinate process.
b) Body.
c) Neck.
d) Tail.
13. What is the relationship of the pancreas to the superior mesenteric
vein?
a) Posterior to the tail.
b) Posterior to the neck.
c) Lateral to the tail.
d) Superior to the body.
14. Which part(s) of the pancreas does the duodenum encircle?
a) Head.
b) Body.
c) Neck.
d) All of the above.
15. The tail of the pancreas is in contact with which structure(s)?
a) Left kidney.
b) Splenic flexure of the colon.
c) Spleen.
d) All of the above.
Hepatic artery
Superior mesenteric artery
Quadratus lumborum
Right adrenal gland
Right renal artery
Celiac trunk
Left renal vein
Left renal artery
Left adrenal gland
Splenic artery
Right renal vein
Right kidney
Psoas
Ureter
Medullary pyramids
Minor calyces
Major calyces
IVC
Aorta
Bladder
Spleen
Left kidney
Quadratus lumborum
Psoas
Ureter
Renal artery
Renal vein
Hilum
Renal pelvis
Renal sinus
Renal capsule
Cortex (parenchyma)
Figure 9-1 Top, Location of urinary system. Bottom, Kidney anatomy.
Ureter
Renal Scanning Protocol
Betty Bates Tempkin
Key Words
Adrenal gland
Arcuate vessels
Collecting system
Columns of Bertin
Gerota’s fascia
Heterogeneous
Homogeneous
Hypoechoic
Infundibulum
Inner medulla
Major calyces
Medullary pyramid
Minor calyces
Morison’s pouch
Nephron
Perinephric space
Psoas muscle
Quadratus lumborum muscle
Renal capsule
Renal cortex
Renal hilum
Renal parenchyma
Renal pelvis
Renal sinus
Retroperitoneum
True capsule
Ureter
CHAPTER 9
Objectives
At the end of this chapter, you will be able to:
• Define the key words.
• Distinguish the sonographic appearance of the kidneys and
urinary system and the terms used to describe them.
• Describe the transducer options for scanning the kidneys.
• List the various suggested breathing techniques for patients when
scanning the kidneys.
• List the suggested patient positions (and options) when scanning
the kidneys.
• Describe the patient prep for a renal study.
• Distinguish normal renal variants.
• Name the survey steps and explain how to evaluate the entire
length, width, and depth of the aorta and its branches.
• Explain the order and exact locations to take representative
images of the kidneys.
• Answer the review questions at the end of the chapter.
Overview
Location
• The kidneys lie in the retroperitoneum (portion of abdominopelvic
cavity posterior to the peritoneal sac) in the abdomen on each side of
the spine, anterior to the psoas and quadratus lumborum muscles
171
172 PART III Abdominal Scanning Protocols
in the area between the twelfth thoracic and fourth lumbar vertebrae. The psoas muscle is posterior and medial to the kidneys. The
quadratus lumborum muscle is posterior and lateral to the kidneys.
• The right kidney is normally situated lower than the left kidney.
• The right kidney is posteroinferior to the liver and gallbladder.
• The left kidney is inferior and medial to the spleen.
• Located immediately superior, anterior, and medial to each kidney
is an adrenal gland.
Anatomy
• The kidneys are described as having a superior and inferior pole,
medial and lateral margins, and an anterior and posterior surface.
• The kidneys are encapsulated by a fibrous renal or true capsule.”
• Fat surrounds the encapsulated kidneys in the perinephric or
perirenal space (part of the retroperitoneal space within the
renal fascia that contains the kidney, perirenal fat, adrenal gland,
and proximal ureter).
• Gerota’s fascia is a fibrous sheath that encloses each kidney, peri-
nephric fat, and adrenal gland.
• Normal adult kidneys measure 9 to 12|cm long, 2.5 to 3.5|cm thick,
and 4 to 5|cm wide.
• Each kidney is composed of two distinct areas, the renal sinus and
renal parenchyma:
I. Renal sinus: consists of the renal hilum and collecting system:
A. Renal hilum:
1. Medial opening into the renal sinus at the mid portion of
the kidney.
2. Through it passes the renal arteries, veins, nerves, lym-
phatic vessels, and ureter.
B. Collecting system: consists of the infundibulum and renal
pelvis:
1. The infundibulum is composed of minor and major
calyces:
a. 8 to 18 minor calyces, which receive urine from the
medullary pyramids (Figure 9-1).
b. 2 or 3 major calyces, which receive urine from the
minor calyces then dump it into the renal pelvis.
2. The renal pelvis is a urine reservoir formed by the
expanded superior end of the ureter. It receives urine
from the major calyces before it is transported down the
ureter to the urinary bladder.
II. Renal parenchyma: consists of the inner medulla and outer
cortex:
A. Inner medulla:
1. 8 to 18 medullary pyramids that pass urine to the minor
calyces in the renal pelvis. The bases of the pyramids form
Renal pelvis
Renal column of Bertin
Cortex
Medullary
pyramid
Minor
calyces
Blood vessel
entering renal
parenchyma
CHAPTER 9 Renal Scanning Protocol 173
Renal
parenchyma
Renal
artery
Renal
vein
Renal
sinus
Ureter
Major calyces
Figure 9-2 Section of internal kidney anatomy. Observe how the ureter begins in the kidney as the
renal pelvis. Notice how the number of medullary pyramids equals the number of minor calyces. Note
the columns of Bertin separating each medullary pyramid.
a margin with the renal cortex. The apices of the pyramids
project into the bottom or side of the renal sinus and into
the minor calyces. The pyramids are separated from each
other by bands of cortical tissue referred to as the col-
umns of Bertin, which extend inward to the renal sinus
(Figure 9-2).
B. Outer cortex: The outer renal cortex lies between the
medulla and outer renal capsule. It contains millions of
nephrons; the microscopic functional units of the kidney
that form urine.
Physiology
• As part of the excretory system, kidneys function to get rid of meta-
bolic wastes.
• Kidneys purify the blood by excreting urine (excess water, salt,
toxins).
Sonographic Appearance
• As seen in the following transverse scanning plane image of an
axial section of the midportion of the right kidney, the overall
sonographic appearance of the normal adult kidney is described
as heterogeneous (mixed echo pattern) due to the contrast in
174 PART III Abdominal Scanning Protocols
tL
Anterior
ssel
pyramid
appearance of the renal cortex and renal sinus. The renal cortex
appears midgray and homogeneous (uniform echo pattern) with
a smooth contour, whereas the renal sinus presents as bright with
irregular borders and, in this case, interrupted with anechoic,
urine-filled medullary pyramids and blood-filled vessel.
Medullary
pyramid
Liver
Medullary
pyramid
Righ
Renal
cortex
Renal
sinus
Medullary
(Courtesy Ultrasoundpaedia.com.)
Posterior
eft
Blood
ve
Renal
hilum
Renal
capsule
As this image demonstrates, the kidneys are easily identified by
the highly reflective appearance of the surrounding renal capsule.
It appears as a bright, thin continuous line seen along the periphery of the kidney, adjacent to the renal cortex. This image also
shows why the kidney (cortex) is described as hypoechoic (less
echogenic) compared to the adjacent normal liver.
• Since the orientation of each kidney is vertically obliqued in
the body; therefore, longitudinal and long axis views are seen in
oblique sagittal scanning planes and oblique coronal scanning
planes as demonstrated in the image on the facing page, which
was taken in a coronal oblique scanning plane; it shows the long
axis of a normal left kidney. Notice how the longitudinal section
of the kidney appears elliptical in shape. Observe how the bases
of the anechoic, urine-filled medullary pyramids form a margin
with the renal cortex. In some cases, the arcuate vessels can be
visualized at this corticomedullary junction as bright, echogenic
dots. Note how the renal sinus appears highly reflective with variable contour due to the fat it contains.
CHAPTER 9 Renal Scanning Protocol 175
Lateral
Medullary
rior
Anterior
Posterior
LT
RT
Renal
cortex
Spleen
Superior
Medullary
pyramid
Medial
(Courtesy the University of Virginia’s Imaging Center, Charlottesville, Virginia.)
• The image below shows an axial section of the mid portion of the
right kidney taken in a transverse scanning plane. The renal cortex
appears homogeneous, with midgray echoes that are hypoechoic
relative to the normal liver. Observe how axial sections of the kidney appear rounded and broken medially by the renal hilum. In
this case, we can observe an anechoic, long section of the right
renal vein exiting the renal hilum on its course to the inferior vena
cava (IVC). Note the anechoic medullary pyramid. The pyramids
appear anechoic or hypoechoic relative to the renal cortex depending on the amount of urine they contain. The pyramids as well as
the infundibulum and renal pelvis are only visualized when they
contain urine. The ureters are not normally visualized. This image
also demonstrates Morison’s pouch, a peritoneal space that appears
as a bright curvilinear line between the right kidney and the liver.
This space is important as it is a potential site for abnormal collection of fluid.
pyramids
Infe
Renal
capsule
Renal
sinus
Medullary
pyramid
Right
Mid portion
right kidney
Morison’s
pouch
Renal
capsule
Liver
Inferior
vena cava
Left
Right
renal vein
Cortex
Sinus
176 PART III Abdominal Scanning Protocols
Normal Variants
• Dromedary humps:
• Cortical bulge(s) on the lateral border of the kidney that appear
the same as normal renal cortex.
• Hypertrophied column of Bertin:
• Enlarged columns of renal cortex that vary in size and indent
the renal sinus.
• They appear the same as normal renal cortex.
• Double collecting system:
• The renal sinus is divided by a hypertrophied column of Bertin.
• The appearance is the same as normal renal cortex and two
normal renal sinuses.
• Horseshoe kidney:
• The kidneys are connected, usually at the lower poles.
• Except for their connection, the kidneys appear otherwise
normal.
• Renal ectopia:
• One or both kidneys may be found outside the normal renal
fossa.
• Other locations include the lower portion of the abdominal or
pelvic cavities, and in rare cases they may be found in the intrathoracic area. Except for the location, the kidney(s) appears
otherwise normal.
Preparation
Patient Prep
• None.
Transducer
• 3.0 MHz or 3.5 MHz.
• 5.0 for very thin patients.
Breathing Technique
• Deep, held inspiration. Deep inspiration causes the kidneys to
descend, making them easier to visualize sonographically.
NOTE: Different breathing techniques should be used whenever the
suggested breathing technique does not produce the desired results.
Patient Position
Right Kidney
• Supine.
• Left posterior oblique, left lateral decubitus, and prone as needed.
CHAPTER 9 Renal Scanning Protocol 177
Patient’s right (RT)
Patient’s left (LT)
Left Kidney
• Right lateral decubitus.
• Prone as needed.
NOTE: Different patient positions should be used whenever the suggested position does not produce the desired results.
Renal Survey Steps
Right Kidney • Longitudinal Survey
Sagittal Plane • Transabdominal Anterior Approach
1. Begin scanning with the transducer perpendicular, just inferior to
the most lateral edge of the right costal margin.
2. Have the patient take in a deep breath and hold it. The longitudinal section of the kidney should come into view. If the kidney is
not seen here, move the transducer small degrees in medial and
inferior sections with the patient holding his or her breath, until
the kidney is identified.
LT
RT
NOTE: Deep inspiration causes the kidneys to descend, making them
easier to visualize sonographically.
178 PART III Abdominal Scanning Protocols
3. When the kidney is located, very slightly twist/rotate the transducer first one way, then the other (to oblique the scanning plane
according to the vertical oblique lie of the right kidney) to resolve
the long axis of the right kidney.
4. Once the long axis is determined, very slightly rock the transducer
superior to inferior while slowly sliding the transducer medially,
scanning through the kidney until you are beyond it.
Evaluate the perirenal region as you scan through it.
5. Move the transducer back onto the kidney. Slowly rocking and
sliding scan right lateral, through and beyond the kidney.
Evaluate the perirenal region as you scan through it.
LT
RT
LT
RT
NOTE: The longitudinal survey of the right kidney can be performed
from a coronal plane, right lateral approach. This approach can be performed with the patient supine, but it is usually easier to scan with the
patient in a left lateral decubitus position.
1. Begin scanning with the transducer perpendicular, midcoronal
plane, just superior to the iliac crest. Have the patient take in
a deep breath and hold it as you move or angle the transducer
superior to inferior or scan intercostally if necessary to locate
the kidney.