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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5782_Библиотеки_им_академика_М_И_Перельмана.pdf
CHAPTER 9 Renal Scanning Protocol 199
Review Questions
Answers on page 629.
1. In most cases, the long axis of the left kidney is most easily resolved
from which scanning plane?
a) Coronal transverse scanning plane
b) Transabdominal sagittal oblique scanning plane
c) Coronal scanning plane
d) Coronal oblique scanning plane
2. The overall sonographic appearance of the kidneys can be
described as
a) hyperechoic relative to the liver.
b) heterogeneous.
c) hypoechoic relative to the liver.
d) highly reflective.
3. The sonographic appearance of normal renal cortex is
a) hyperechoic relative to the liver.
b) heterogeneous.
c) hypoechoic relative to the liver.
d) highly reflective.
4. The sonographic appearance of the normal renal sinus is
a) homogeneous.
b) heterogeneous.
c) hypoechoic relative to the liver.
d) highly reflective.
5. The medullary pyramids are
a) not sonographically distinguishable.
b) abnormal if visualized sonographically.
c) hypoechoic or anechoic relative to renal cortex depending on
the amount of urine they contain.
d) referred to as the major and minor calyces.
6. The renal pelvis
a) is formed by the expanded superior end of the ureter where it
divides into the medullary pyramids; not visualized sonographically
when collapsed.
b) is another term for the renal hilum.
c) is formed by the expanded superior end of the ureter where it
divides into the infundibula; not visualized sonographically
when collapsed.
d) can be visualized sonographically at the corticomedullary
junction when urine-filled.
7. The normal contour of the kidney
a) can be seen indenting the renal sinus.
b) appears smooth and even on ultrasound.
c) is formed by the arcuate vessels.
d) appears hypoechoic relative to renal cortex.
200 PART III Abdominal Scanning Protocols
8. The infundibula
a) can be seen sonographically at the corticomedullary junction as
bright dots.
b) appears sonographically as triangular or round anechoic urine-
filled structures in the cortex.
c) surrounds the renal sinus.
d) are the major and minor calyces.
9. The psoas and quadratus lumborum muscles
a) appear sonographically as the low-gray structures posterior to
the kidneys.
b) form the bright interface between the right kidney and the liver.
c) are support structures for the kidney that are not appreciated
sonographically.
d) are the low-gray structures seen directly inferior to the kidneys.
10. Which sentence describes the normal echogenicity of the renal
cortex?
a) The normal kidney is never isoechoic with the liver.
b) The kidney is normally hyperechoic in comparison to the spleen
and liver.
c) The normal kidney echogenicity is frequently isoechoic with the
liver and spleen
d) The echogenicity of the kidney varies and should not be com-
pared to the liver.
11. The normal range in size of the kidney is _________________.
a) 4 to 7 cm
b) 7 to 9 cm
c) 9 to 14 cm
d) 13 to 17 cm
12. Which sentence is true regarding the normal anatomy of the
kidneys?
a) The kidneys are retroperitoneal in location.
b) The right kidney is located slightly superior compared to the
left.
c) The superomedial aspect of the right kidney does not come in
contact with the adrenal gland.
d) Each kidney is perfectly aligned on either side of the spine.
13. Periodic ureteral “jets” are a sign of ___________________________.
a) ureteral stone
b) ureteral spasm
c) ureteral compression
d) normality
14. Which of the following is not part of the urinary tract?
a) Kidneys
b) Uterus
c) Ureters
d) Urinary bladder
15. Label the following:
16. Label the following:
LT
CHAPTER 9 Renal Scanning Protocol 201
RT
17. Label the following:
Superior mesenteric artery
Superior mesenteric vein
Hepatic arter
Celiac trunk
Left adrenal gland
Portal vein
Duodenum
y
Pancreas
IVC
Stomach
Aorta
Splenic artery
Spleen
Splenic vein
Left kidney
Inferior mesenteric vein
Left renal vein
Spleen Anatomy
CHAPTER 10
Spleen Scanning Protocol
Betty Bates Tempkin
Key Words
Accessory spleen
Anemia
Asplenia
Hematopoiesis
Intraperitoneal
Lymphatic tissue
Objectives
At the end of this chapter, you will be able to:
• Define the key words.
• Distinguish the sonographic appearance of the spleen and the
terms used to describe it.
• Describe the transducer options for scanning the spleen.
• List the various suggested breathing techniques for patients when
scanning the spleen.
• List the suggested patient positions (and options) when scanning
the spleen.
• Describe the patient prep for a splenic study.
• Distinguish normal variants of the spleen.
• Name the survey steps and explain how to evaluate the entire
length, width, and depth of the spleen.
• Explain the order and exact locations to take representative
images of the spleen.
• Answer the review questions at the end of the chapter.
Portal-splenic confluence
Reticuloendothelial system
Splenic artery
Splenic flexure
Splenic hilum
Splenic vein
Overview
Location
• Except for its medial hilum, the spleen is intraperitoneal (enclosed
in the sac formed by the parietal peritoneum) in the posterolateral
section of the left upper quadrant (or left hypochondrium), beneath
the ninth to eleventh intercostal spaces.
• The spleen lies posterior and lateral to the tail of the pancreas, fundus
and body of the stomach, and posterior to the splenic flexure (sharp
bend between the transverse and descending colon in the left upper
quadrant, anterior to the spleen).
203
204 PART III Abdominal Scanning Protocols
Longitudinal section Axial section
• The medial portion of the spleen is superior and lateral to the left
kidney.
• The spleen lies inferior and adjacent to the diaphragm, putting it
in close proximity to the left pleural cavity.
Anatomy
• The size of the spleen is variable, but is considered normal when it
appears about the same size as the adjacent left kidney. Generally, it
should be no longer than 12 or 13 cm and no deeper (anteroposteriorly) than 7 or 8 cm. The correct measurement caliper placement
is demonstrated in Figure 10-1.
• The shape of the spleen is variable, but it is basically ovoid and
may resemble a half moon or crescent. Thus, its superoposterior
surface (adjacent to the diaphragm) is convex and smooth and
its inferomedial surface (in contact with the stomach, left kidney,
splenic flexure, pancreas tail) is concave and indented or nodulous.
The splenic hilum (entry and exit route for the arterial, venous,
and lymphatic vessels and nerves) is located within this concavity. Note that if the spleen becomes enlarged, it loses its concave
appearance and becomes more round.
• The splenic vein exits the hilum and heads across the body toward
the midline, running behind (posterior to) the tail and body of the
pancreas to join the superior mesenteric vein at a point just posterior to the pancreas neck to form the portal vein. This location is
commonly referred to as the portal-splenic confluence.
• The spleen receives blood from the splenic artery that branches
from the celiac trunk of the abdominal aorta and runs left lateral
and just superior to the body and tail of the pancreas, to enter the
splenic hilum. In many cases, the artery may divide into two or
three smaller branches before entering the spleen.
Length
Figure 10-1 Spleen Measurements. Correct caliper placement for measuring the spleen.
Width
Depth
Width
CHAPTER 10 Spleen Scanning Protocol 205
Physiology
• Although not essential to life, the spleen filters foreign material
from the blood and forms antibodies.
• The spleen is a large mass of lymphatic tissue (reticular connective
tissue) that is part of the reticuloendothelial system, an essential
part of the immune system. It is composed of phagocytic cells capable of consuming substances, such as bacteria and viruses, making them incapable of causing harm to the body. They also engulf
old cells and abnormal cells, clearing the body of their harmful
presence.
• The spleen also breaks down hemoglobin, is a blood reservoir, and
is important for hematopoiesis (red blood cell formation) in the
fetus or when there is severe anemia (marked loss of the number of
red blood cells produced in bone marrow; symptoms may include
fatigue, shortness of breath, irregular heartbeat).
Sonographic Appearance
• The normal adult spleen appears homogeneous, with medium-
level echoes and even texture that is described as isosonic or
slightly hypoechoic when compared to the normal liver, and
hyperechoic relative to kidney parenchyma. In some cases, small
vascular branches can be seen interspersed within the spleen. They
appear as anechoic, round or tubular structures. Arterial walls usually appear brighter than venous walls; however, the larger venous
structures can clearly be distinguished from the smaller arterial
branches at the level of the splenic hilum. Occasionally, small,
bright reflections may be visualized throughout the spleen that
represent calcified granulomatous inclusions or calcifications of
small arterial walls.
• The orientation of the spleen 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 following page. This normal
spleen appears crescent in shape and hyperechoic compared to
the adjacent left kidney. Notice the spleen’s smooth outer convexity and its relationship to the diaphragm and pleural space
superiorly.
206 PART III Abdominal Scanning Protocols
Medial
rior
Lateral
Medial
r
LT
RT
Superior
Pleural
space
Diaphragm
Lateral
Spleen
Infe
Left Kidney
• Axial sections of the spleen are visualized in transverse scanning
planes. The following is a transverse scanning plane image from a
left lateral approach. It demonstrates an axial section of the spleen
that includes the splenic hilum. Note the normal homogeneous
appearance and even texture of the spleen.
LT
RT
Anterior
Spleen
Posterio
Splenic
hilum
Diaphragm
Normal Variants
• Accessory spleen:
• Splenic tissue found separate from the organ, most often at the
splenic hilum. Sonographic appearance is the same as normal
splenic tissue.
• Asplenia:
• Rare absence of the spleen, often associated with congestive
heart disease.
CHAPTER 10 Spleen Scanning Protocol 207
Preparation
Patient Prep
• None.
Transducer
• 5.0 MHz for intercostal or lateral subcostal scanning
approaches.
• 3.0 or 3.5 MHz for anterior or posterior scanning approaches.
Breathing Technique
• Deep, held inspiration. Deep inspiration causes the spleen to
descend, making it 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 lateral decubitus.
• Supine, sitting semierect to erect, and prone as needed.
NOTE: Different patient positions should be used whenever the suggested position does not produce the desired results.
Spleen Survey Steps
Spleen • Longitudinal Survey
Coronal Plane • Left Lateral Approach
NOTE: Although this approach can be performed with the patient
supine, it is generally easier with the patient in the right lateral decubitus position. Imaging quality might be improved by placing a sponge or
rolled towel under the patient’s right side to open up the rib spaces on
the patient’s left.
NOTE: Rib shadows are a consequence of intercostal scanning and may
obscure part of the spleen. In most cases, angling the transducer within
the intercostal space toward the unseen area or moving to an adjacent
rib space will aid visualization.
208 PART III Abdominal Scanning Protocols
1. Begin scanning with the transducer perpendicular, midcoronal
plane, in the most inferior intercostal space. Have the patient take in
a deep breath and hold it. The superior and inferior margins of the
spleen will usually come into view. How much of the normal spleen
you see, however, will depend on its shape and the patient’s body
habitus. If the spleen is not seen in the inferior intercostal space,
move the transducer to the adjacent superior intercostal space(s).
2. When the spleen is located, very slowly rotate/twist the transducer,
first one way then the other, to slightly oblique the scanning plane
according to the lie of the spleen and to resolve its long axis.
Notice the diaphragm and adjacent pleural space superiorly and
the left kidney and perinephric space inferiorly. The splenic hilum
may also be visualized medially. Very slightly rotating/twisting the
transducer can help resolve the hilar structures.
3. While visualizing the long axis of the spleen, slightly move or angle
the transducer within the intercostal space toward the patient’s front,
scanning through and beyond the anterior portion of the spleen.
4. Move the transducer back onto the long axis of the spleen. While
visualizing the long axis, slightly move or angle the transducer
within the intercostal space toward the patient’s back, scanning
through and beyond the posterior portion of the spleen.