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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5802_Библиотеки_им_академика_М_И_Перельмана.pdf
Upper abdominal
16
Age range in years Male
cm (mean ± SD)
Female
cm (mean ± SD)
30–39 9.52 ± 1.29 8.88 ± 1.28
40–49 9.38 ± 1.48 8.92 ± 1.54
50–59 8.83 ± 1.33 8.25 ± 1.39
60–69 8.99 ± 1.61 8.66 ± 1.50
70–79 8.60 ± 1.62 8.25 ± 1.54
80–89 7.90 ± 1.85 7.59 ± 1.53
Spleen size with sex, gender and race in collegiate athletes
Height
(m)
Female 1.46 22.3 9.9
Male 1.84 25.9 11.3
African American 1.82 26.4 9.8
White 1.75 23.8 10.8
Measurement of area: View the spleen in the longitudinal axis, in deep
inspiration. The interface between the lung and spleen serves as the
transverse diameter, and the longitudinal diameter is measured from
here to the splenic tip. The diagonal diameter is measured from this
lateral spleen-lung interface to the medial spleen margin. The crosssectional area is calculated as follows:
BMI
(kg/m
2
)
Length of spleen
(cm)
Diagonal
(Transverse2 + Longitudinal2)/2
√
Normal
Transverse diameter 5.5 ± 1.4
Longitudinal diameter 5.8 ± 1.8
Diagonal diameter 3.7 ± 1.0
Diameter cm (mean ± SD)
Spleen
Alternatively, the spleen index (SI) can be used as a quantitative marker
of splenic volume.
2
SI (cm
) = transverse diameter (cm) × vertical diameter (cm)
By using a grading system, pathological splenic entities may be deemed
more or less likely.
Grade 0 = normal 0–30 cm
moderate 61–90 cm
2
, grade III = marked 91–120 cm2, and grade IV =
2
, grade I = mild 31–60 cm2, grade II =
marked massive >120 and massive > 150. No ofcial grade V.
FURTHER READING
Benter T, Kluhs L, Teichgraber U. Sonography of the spleen. J
Ultrasound Med. 2011; 30:1281–1293.
Frank K, Linhart P, Kortsik C, Wohlenberg H. Sonography in
determination of spleen size: Standard dimensions in healthy
adults. Ultraschall in Med. 1986; 7:134–137.
Hosey RG, Mattacola CG, Kriss V. Ultrasound assessment of spleen
size in collegiate athletes. Br J Sports Med. 2006; 40:251–254.
Ishibashi H, Higuchi N, Shimamura R, et al. Sonographic
assessment and grading of spleen size. J Clin Ultrasound. 1991;
19:21–25.
Loftus WK, Metreweli C. Normal splenic size in a Chinese
population. J Ultrasound Med. 1997; 16:345–347.
Niederau C, Sonnenberg A, Muller JE, Erckenbrecht JF, Scholten
T, Fritsch WP. Sonographic measurements of the normal
liver, spleen, pancreas, and portal vein. Radiology. 1983;
149:537–540.
Rosenberg HK, Markowitz RI, Kolberg H, Park C, Hubbard A, Bell
RD. Normal splenic size in infants and children: Sonographic
measurements. AJR Am J Roentgenol. 1991; 157:119–121.
17
Upper abdominal
18
Pancreas
PREPARATION
Patient should fast for 6–8 hours prior to examination.
POSITION
Supine.
TRANSDUCER
2.0–6.0 MHz curvilinear transducer.
METHOD
If the pancreas is obscured by air, visualization may be improved by
drinking 500 ml of water in the right decubitus position. The water
bolus outlines the pancreatic head. Longitudinal and transverse images
are obtained using the upper abdominal blood vessels as landmarks.
The pancreatic head is measured above the inferior vena cava.
The pancreatic neck is measured over the superior mesenteric vein.
The pancreatic body is measured over the superior mesenteric artery.
APPEARANCE
The pancreas should appear homogenous with a reectivity greater
than or equal to the adjacent liver. Variations in reectivity relate to
the degree of fatty inltration. After 60 years of age, fat accumulation
in pancreatic tissues is common and reectivity therefore increases.
Measurements are relative, and structural abnormalities are more
important than absolute dimensions.
MEASUREMENTS
Transverse
anteroposterior diameter (mm)
Pancreatic head 19–25
Pancreatic body 15–20
Pancreatic tail 20–25
Pancreas
Axial view through the pancreas at the conuence of the splenic vein and superior
mesenteric vein. The head, neck, and body are measured on this view.
FURTHER READING
Glaser J, Stienecker K. Pancreas and aging: A study using
ultrasonography. Gerontology. 2000; 46:93–96.
Pirri C, Cui XW, De Molo C, Ignee A, Schreiber-Dietrich DG,
Dietrich CF. The pancreatic head is larger than often assumed.
ZGastroenterol. 2013; 51:390–394.
Sienz M, Ignee A, Dietrich CF. Reference values in abdominal
ultrasound: Biliopancreatic system and spleen. Z Gastroenterol.
2011; 49:845–870.
Sirli R, Sporea I. Ultrasound examination of the normal pancreas.
Med Ultrason. 2010; 12:62–65.
19
Upper abdominal
20
Pancreatic duct (adult)
PREPARATION
None.
POSITION
Supine.
TRANSDUCER
2.0–5.0 MHz curvilinear transducer.
METHOD
The long axis of the pancreas should be determined. The duct in the
region of the head–neck and body is obtained in the transverse/oblique
planes. The diameter of the duct is taken as the distance between the
inner layers of the anterior and posterior walls.
APPEARANCE
The duct appears as a low reective tubular structure with reective
walls. The lumen of the pancreatic duct is usually largest in the head of
the pancreas and gradually decreases distally.
MEASUREMENTS
Normal pancreatic duct diameter (mm)
Range Mean
Head/neck 2.8–3.3 3
Proximal body 2.0–2.4 2.1
Distal body 1.0–1.7 1.6
The size of the pancreatic duct increases with age, with the upper limit
of normal estimated at 3 mm. Administration of secretin causes pancreatic duct dilatation in normal subjects, but has no effect on dilatation caused by chronic pancreatitis and may be used to distinguish
these two entities. The diameter of the pancreatic duct can increase
during deep inspiration in adults without pancreatic disease, up to 1.3
mm when compared with images obtained at end-expiration.
Pancreatic duct (adult)
Transverse image of the pancreas to measure the anteroposterior diameter of the
pancreatic duct in the proximal aspect of the body.
21
FURTHER READING
Glaser J, Hogemann B, Krummenerl T, Schneider M, Hultsch E,
van Husen N, Gerlach U. Sonographic imaging of the pancreatic
duct. New diagnostic possibilities using secretin stimulation.
Digestive Dis Sci. 1987; 32:1075–1081.
Hadidi A. Pancreatic duct diameter: Sonographic measurement in
normal subjects. J Clin Ultrasound. 1983; 11:17–22.
Sienz M, Ignee A, Dietrich CF. Reference values in abdominal
ultrasound—biliopancreatic system and spleen. Z Gastroenterol.
2011; 49:845–870.
Wachsberg RH. Respiratory variation of the diameter of the
pancreatic duct on sonography. AJR Am J Roentgenol. 2000;
175:1459–1461.
Upper abdominal
22
Adrenal glands (adult)
PREPARATION
None.
POSITION
Supine.
TRANSDUCER
2.0–6.0 MHz curvilinear transducer.
METHOD
Anterior transverse images in quiet respiration. The entire gland is not
likely to be seen in a single plane of imaging due to the shape of the
gland (triangular or crescentic).
The right adrenal gland is best imaged with the patient supine or left
lateral decubitus using an intercostal or subcostal approach in the midanterior axillary line.
The left adrenal gland is more difcult to see, often due to gas within
the stomach. A right lateral decubitus position, using an intercostal
approach in the mid- or posterior axillary line, is favored. If a thin
patient is imaged supine with deep inspiration, the left adrenal may be
seen posterior to the splenic vein.
APPEARANCE
Variable, but an adrenal mass appears as a homogeneous area with a
distinct capsule.
The adrenal gland cortex tends to be hypoechoic and the medulla may
sometimes be seen as a thin hyperechoic stripe, particularly in younger
patients with a resultant “trilaminar” appearance.
The visualization of normal adrenal glands is variable and dependent
on operator experience; 78.5%–92% on the right and 44%–71% on
the left.
The left gland tends to be more crescentic and the right more triangular, but shapes are variable.
Adrenal glands (adult)
The normal right adrenal gland in an adult with measurement of the length of a limb
demonstrated.
MEASUREMENTS
Thickness 0.2–0.8 cm
Length 4–6 cm
Width 2–3 cm
23
FURTHER READING
Kim KW, Kim JK, Choi HJ. Sonography of the adrenal glands in the
adult. J Clin Ultrasound. 2012; 40:357–363.
Marchal G, Gelin J, Verbeken E, Baert A, Lauwerijns J. High
resolution real-time sonography of the adrenals glands: A routine
examination? J Ultrasound Med. 1986; 5:65–68
Yeh HC. Sonography of the adrenal glands: Normal glands and
small masses. AJR Am J Roentgenol. 1980; 135:1167–1177.
Zappasodi F, Derchi LE, Rizzato G. Ultrasonography of the normal
adrenal glands: Study using linear array real-time equipment. Br
J Radiol. 1986; 59:759–764.
Upper abdominal
24
Diaphragm
PREPARATION
None.
POSITION
Supine.
TRANSDUCER
2.0–6.0 MHz curvilinear transducer.
METHOD
Performed from a subcostal position, in a longitudinal plane. A cursor
is placed at the position of the dome of either the left or right hemidiaphragm at end tidal volume, and then marked at full inspiration. If
forced expiration is used, the dome of the diaphragm may not be visible.
APPEARANCE
The thin, high-reective diaphragmatic curve is readily identied.
MEASUREMENTS
Diaphragm paralysis is demonstrated on B-Mode ultrasound by absent
or minimal thickening (< 20%) during inspiration.
Diaphragm
thickness
Normal (quiet) inspiration 2.8 mm 2.2 cm
Deep inspiration 4 mm or more 5.4 cm male
M-Mode ultrasound has been shown to be more accurate and reproducible for assessing hemidiaphragmatic movement. Excursions are
larger in men. Lower limits are shown below.
Men Women
Quiet breathing 1 cm 0.9 cm
Voluntary snifng 1.8 cm 1.6 cm
Deep breathing 4.7 cm 3.7 cm
Diaphragm
movement
4.0 cm female
Diaphragm
A cursor is
placed at the
position of the
dome of the right
hemidiaphragm at
end tidal volume,
and then marked at
full inspiration with
a second cursor.
FURTHER READING
Baria MR, Shahgholi L, Sorenson EJ, Harper CJ, Lim KG,
Strommen JA, Mottram CD, Boon AJ. B-Mode ultrasound
assessment of diaphragm structure and function in patients with
COPD. Chest. 2014; 146:680– 685.
Boussuges A, Gole Y, Blanc P. Diaphragmatic motion studied by
M-mode ultrasonography: Methods, reproducibility, and normal
values. Chest. 2009; 135:391– 400.
Harris RS, Giovannetti M, Kim BK. Normal ventilatory movement
of the right hemidiaphragm studied by ultrasonography and
pneumotachograph. Radiology. 1983; 146:141–144.
Houston JG, Morris AD, Howie CA, Reid JL, McMillan N.
Technical report: Quantitative assessment of diaphragmatic
movement—A reproducible method using ultrasound. Clin
Radiol.1992; 46:40–47.
Smargiassi A, Inchingolo R, Soldati G, Copetti R, Marchetti G,
Zanforlin A, Giannuzzi R, Testa A, Nardini S, Valente S. The
role of chest ultrasonography in the management of respiratory
diseases: Document II. Multidiscip Respir Med. 2013; 8:55.
Testa A, Soldati G, Giannuzzi R, Berardi S, Portale G, Gentiloni
Silveri N. Ultrasound M-Mode assessment of diaphragmatic
kinetics by anterior transverse scanning in healthy subjects.
Ultrasound Med Biol. 2011; 37:44–52
25