Abdominal (Quick Guide)

Objectives

  1. Understand the normal anatomy of the contents of the abdomen
  2. Know which organs and pathologies are visible with each of the ultrasound views used in abdominal ultrasonography
  3. Understand the utility of ultrasound as an abdominal imaging modality and know when and how it should be used
  4. Be able to recognize several abdominal pathologies with ultrasound
  • Abdominal preset
  • Phased array or curvilinear transducer
  • Patient in supine position
  • Three views to address
    • Right Upper Quadrant
    • Left Upper Quadrant
    • Biliary & Portal Vein

Take a moment to review the abdominal contents shown in the figures. Pay particular attention to the organs that we will focus on throughout this chapter: liver, gallbladder, common bile duct, portal vein, spleen, and appendix.

Remember that you will be scanning 3D anatomy! Do your best to visualize the anatomy as you are scanning.

Although this image is 2D, remember that you will be scanning 3D anatomy! Do your best to visualize the anatomy as you are scanning.

The following are indications for using abdominal US:

  • Abdominal pain
  • Screening asymptomatic patients
  • Liver disease
  • Abdominal trauma
  • To avoid exposure to ionizing radiation, particularly in pediatric and pregnant patients

It’s always best to treat the abdominal exam as a supplement – not a replacement – for a physical exam!

Right Upper Quadrant

Probe position

  • Place the transducer along the patient’s right mid-axillary line at about the 9th or 10th intercostal space
  • Indicator pointed up toward the patient’s head, obtain a longitudinal image

Identify 

  • Diaphragm
  • Liver
  • Right Kidney
  • Morison’s Pouch
  • Having the patient bend their knees and raise the right arm will open the rib cage to allow for a more spacious scan
  • Fanning the probe from superior to inferior will scan the entire liver and kidney
  • Any black, anechoic space between the liver and kidney may indicate fluid in Morison’s pouch.
  • Mirror image artifact gives the false appearance of liver above the diaphragm. In reality, it’s just an ultrasound artifact that indicates air in the right lung.
    • If you don’t see the mirror artifact, there might be lung pathology. See the pulmonary exam for more details.

Left Upper Quadrant

Probe position

  • Place the transducer along the patient’s left posterior-axillary line at about the 7th to 8th intercostal space
  • Indicator pointed up toward the patient’s head

Identify 

  • Diaphragm
  • Spleen
  • Left Kidney
  • Left Lung
  • Having the patient bend their knees and raise the left arm will open the rib cage to allow for a more spacious scan
  • Placing your “knuckles to the bed” is key to obtaining this image
    • This view is more posterior and superior than most think
  • Angling or sliding the transducer superiorly to analyze the space above the diaphragm allows for inspection of fluid in the pleural space

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Biliary & Portal Vein

Probe position

  • The gallbladder can be difficult to find. It is a mobile organ. Sitting up, rolling over, or even standing may bring the gallbladder into view.
  • Generally, begin with (1) subcostal. If gallbladder not visualized, move to (2) epigastric. If still not visualized, move laterally into the (3) intercostal view.
  • Pointing the indicator to the left shoulder = transverse gallbladder.
  • Pointing the indicator to the right shoulder = sagittal gallbladder.
  • Once you’ve found the gallbladder, make sure to record both transverse and sagittal views

Identify 

  • Gallbladder
    • Appears at the medial border of the right hepatic lobe at the liver hilum
  • Cystic duct
    • Trace until if becomes the common bile duct, appearing as a tube behind the hepatic artery and portal vein
  • Having the patient bend their knees and raise the right arm will open the rib cage to allow for a more spacious scan
  • Repositioning the patient to the left lateral decubitus position can bring the gallbladder away from the ribcage and can additionally demonstrate mobility of the gallstones or sludge
  • The gallbladder is best visualized with US after the patient has fasted for 8 hours because fasting distends the gallbladder and reduces bowel gas

[potential for images here]