DIAGNOSTIC ULTRASONOGRAPHY

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DIAGNOSTIC ULTRASONOGRAPHY

• CHAPTER 23

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PRINCIPLES OF ULTRASOUND

• The use of sound waves beyond the audible
  frequency ( gt 20,000 Hz) for diagnostic purposes.
• Can be used for therapeutic purposes by using
  larger and continuous dosages as in
• Generation of heat- treatment of low back pain,
  muscle strains, promote tissue regereration, kill
  malignant cells.
• To pulverize kidney stones, gallstones.

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PRINCIPLES OF ULTRASOUND

• Sound waves are generated by the TRANSDUCER- the
  gizmo holding a piezoelectric crystal that
  changes electrical current into sound waves and
  vice versa.
• Sound waves are generated, reflected off of
  tissues and echo back, and are picked up by the
  transducer (piezoelectric crystal) and converted
  to electrical activity.

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PRINCIPLES OF ULTRASOUND

• The image that is generated is dependent upon the
  time it takes the sound waves to return to the
  transducer.
• The return time is a reflection of the distance
  the tissue is from the transducer and the degree
  to which the sound waves are reflected by that
  tissue (organ vs. bone vs. fat vs. fluid).

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HAZARDS OF DIAGNOSTIC ULTRASOUND

• In short, for diagnostic ultrasound, there are
  none.
• Ultrasound for longer periods of time than are
  used in diagnostic ultrasound can generate
  sufficient heat as to be harmful.
• And in higher frequencies (gt100,000 Hz) can cause
  cavitation.

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METHODS OF UULTRASOUND

• 1) PULSE-ECHO
• 2) DOPPLER

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PULSE-ECHO METHOD

• 2 TYPES
• A MODE - amplitude modulation echoes are
  displayed in graphic form, such as in an
  echocardiogram.
• B MODE - brightness modulation echoes are
  displayed as different intensities of brightness,
  giving a 2-dimensional cross-sectional image
  (picture, if you will). Can be static or
  dynamic (real-time).

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DOPPLER METHOD

• Sound waves bounced off of different objects have
  different frequencies.
• With doppler ultrasound, these different
  frequencies are transformed into audible sounds,
  of different frequency.
• The different frequencies can also be mapped to
  give a visual representation as well as an
  audible one.

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DOPPLER METHOD

• USES
• Flow through arteries and veins- to assess
  patency of arterial grafts, obstruction to flow
  by thrombi, atherosclerosis, etc.- arterial flow
  can often be heard in cases where it can not be
  palpated.
• Opening and closing of cardiac valves and flow
  through them- valvular stenosis, regurg.

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DOPPLER METHOD

• OBSTETRICAL USES
• Doppler stethoscope- to detect a fetal heart beat
  episodically, or continuously as in labor.
• Assessment of placental function / fetal growth
  evaluates flow through the umbilical artery and
  vein, looks for differentials in flow

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DOPPLER METHOD

• COLOR FLOW IMAGING
• A type of doppler study.
• Asseses whether blood flow is laminar (the usual
  way) or turbulent (the abnormal way).
• Useful in cardiac valvular regurgitation
  identification of a false lumen in aortic
  dissection congenital heart defects such as
  patent ductus arteriosus, atrial and venticular
  septal defects, which would appear as turbulent
  flow.

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DOPPLER METHOD

• DUPLEX SCANNING
• Uses both real-time imaging and doppler flow
  together.
• Useful in evaluating a variety of vascular
  problems aneurysms, atheroscerotic plaques.

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APPLICATIONS OF ULTRASOUND

• CEREBRAL CIRCULATION
• CAROTID ARTERY
• GYNECOLOGIC / OBSTETRIC
• TRANSVAGINAL / TRANSABDOMINAL
• TRANSRECTAL / TRANSTHORACIC / TRANSESOPHAGEAL
• STRESS ECHOCARDIOGRAM
• ECHOENCEPHALOGRAM
• BREAST
• BLADDER

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CEREBRAL CIRCULATION

• Measures blood flow in the cerebral circulation,
  particularly in the
• 1) Middle, anterior, and posterior cerebral
  arteries.
• 2) Distal internal carotid.
• 3) Basilar artery.
• Often combined with doppler duplex ultrasound and
  arteriography.

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CAROTID ARTERY SCANS

• Atherosclerosis is associated with thickening of
  the intima of the artery.
• Risk of cardiovascular disease and stroke is
  proportional to the thickness of the intima,
  which is a reflection of the degree of
  atherosclerosis.
• Useful for screening both symptomatic patients
  who may need surgical intervention and
  asymptomatic patients who may need prevntive
  measures.

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GYNECOLOGIC ULTRASOUND

• Uterus- size, shape (bicornuate), presence of
  masses within (fibroids, neoplasms).
• Ovary- presence of masses, cysts, neoplasms.
• Tubes- hydrosalpinx, pyosalpinx in PID, ectopic
  pregnancy.

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RIGHT OVARY
BENIGN CYSTIC TERATOMA
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OBSTETRICAL ULTRASOUND

• Confirmation of intrauterine pregnancy, presence
  of ectopic pregnancy, of fetuses.
• Position of fetus(es), placenta (previa).
• Guidance for amniocentesis.
• Evaluation of fetal growth, gestational age.
• Evaluation of amniotic fluid volume.
• Structural / congenital abnormalities of the
  fetus.

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ECTOPIC PREGNANCY
UTERUS SOLID MASS WITHIN NO GESTATIONAL SAC
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ECTOPIC PREGNANCY
ADNEXA CYSTIC MASS, BETA HCG 17,000
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COLOR DOPPLER (FLOW)STUDY
INCREASED FLOW
ECTOPIC PREGNANCY
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TWIN GESTATION
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OB (FETAL) ULTRASOUND
26 WEEK FETUS CONGENITAL POLYCYSTIC KIDNEYS
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23 YOF AT 20 WEEKS GESTATION
FETAL HYDROTHORAX (BILATERAL PLEURAL EFFUSIONS)
AND ASCITES, C/W HYDROPS FETALIS
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23 YOF AT 20 WEEKS GESTATION
FETAL HYDROTHORAX (BILATERAL PLEURAL EFFUSIONS)
AND ASCITES, C/W HYDROPS FETALIS
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OLIGOHYDRAMNIOS
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OB SCAN - OMPHALOCOEL
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OB SCAN - OMPHALOCOEL
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PLAIN FILM - OMPHALOCOEL
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TRANSVAGINAL ULTRASOUND

• Transducer placed in the vagina.
• USEFUL FOR
• Evaluation of follicular development, ovulation.
• Ruling out ectopic pregnancy.
• Evaluation of endometrial thickness in the
  assessment of post-menopausal bleeding, need for
  biopsy.
• Incompetent cervix.

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BICORNUATE UTERUS
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SAME BICORNUATE UTERUS
GESTATIONAL SAC
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SAME BICORNUATE UTERUS
OTHER HORN FLUID-FILLED ONLY
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TRANSVAGINAL SCAN
UTERUS COMPLEX, CYSTIC MASS WITHIN THE
UTERUS DDx CYSTIC POLYP, ENDOMETRIAL
Ca, ENDOMETRIAL HYPERPLASIA
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TRANSVAGINAL SCAN
On this image performed during sonohysterography,
two masses, one polypoid and another more
broad-based, extending from the endometrial
lining are evident.
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ULTRASOUND LEFT OVARY
HEMORRHAGIC CYST
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SAME PATIENT
HEMORRHAGIC CYST RESOLVED
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ABDOMINAL ULTRASOUND

• Often the 1st test used to evaluate abdominal
  pathology (or 2nd, behind a KUB).
• Or complementary to other studies such as
  radionuclide studies, CT, MRI, X-Ray/Contrast
  studies, etc. No radiation, cheaper.
• Needle-guided biopsies, paracentesis.
• Examples appendicitis, cholelithiasis, aortic
  aneurysms, cysts / masses / tumors / abscesses /
  ascites.

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GALLBLADDER GALLSTONE, WALL THICKENING
CHOLECYSTITIS
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SAME PATIENT COMMON BILE DUCT ENLARGED
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ABDOMINAL SONOGRAM
A thickened gall bladder wall is noted, with some
pericholecystic fluid and shadowing echogenic
foci likely representing stones
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APPENDICITIS
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TRANSRECTAL ULTRASOUND

• Primarily for evaluation of the prostate- size,
  shape, etc., to evaluate for BPH, prostate
  cancer.
• Used after evaluation by DRE (digital rectal
  exam) and PSA (prostate-specific antigen).
• Used in needle-guided biopsies, implantation of
  radioactive seeds for treatment of malignancy of
  the prostate.

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TRANSTHORACIC ECHOCARDIOGAPHY

• USEFUL IN THE EVALUATION OF
• Valvular defects, chamber size.
• Structural abnormalities- patent ductus, atrial
  and ventricular septal defects.
• Pleural effusion, cardiac tamponade.
• Color imaging can detect flow laminar vs.
  turbulent.
• Some changes in coronary flow.
• ECG sometimes done simultaneously.

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TRANSESOPHAGEAL ULTRASOUND

• Generates an image unimpeded by the lungs and
  chest-wall structures.
• Especially good visualization of the left atrium
  and aortic root.
• Examples infective endocarditis, aortic
  dissection, cardiac origin of an arterial embolus
  such as atrial fib. much better than TTE.
• RISKS bleeding, aspiration, perforation,
  arrhythmias.

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ECHOENCEPHALOGRAM

• Ultrasound can not penetrate bone.
• Limited use in the adult.
• This modality is most useful for imaging the
  newborn as the skull (sutures) have not
  completely fused.
• Useful for evaluating mostly, things that shift
  the midline, hydrocephalus, size of the cerebral
  ventricles, intracranial hemorrhage in the
  newborn.

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ECHOENCEPHALOGRAM
ANEURYSM OF THE VEIN OF GALEN, WHICH IS REALLY
AN A-V FISTULA
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SAME PATIENT - ANGIOGRAM
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1 DAY OLD INFANT W/ HEART FAILURE
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1 DAY OLD INFANT W/ HEART FAILURE
Head ultrasound shows a cystic mass, posterior to
the third ventricle. The mass is continuous with
the dilated straight sinus.
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1 DAY OLD INFANT W/ HEART FAILURE
Doppler examination shows pulsatile high flow in
the cystic mass.
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THORACIC SONOGRAMS

• Limited utility due to the lack of penetration of
  ultrasound by air.
• Can detect pleural fluid, abscess, malposition of
  the diaphragm.

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ULTRASOUND OF THE BREAST

• Usually done adjunctively with or as a follow-up
  to mammography.
• Differentiates between solid and cystic lesions.
• Helpful in women w/ dense breasts as glandular
  tissue and malignancy both show up white on
  mammogram. On ultrasound, malignancy appears
  black.
• Used to guide needle biopsy and to place a
  surgical clip to mark the area for future
  treatment.

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MAMMOGRAM
PALPABLE MASS
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BREAST ULTRASOUND
PALPABLE MASS, CYSTIC ON ULTRASOUND
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BONE SONOGRAMS

• Primary use is as a screening tool for
  osteoporosis, looking at the heel, as healthy
  bone echoes sound waves faster than does
  osteoporotic bone.
• Also used for congenital hip dysplasia
  (dislocation).

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BLADDER ULTRASOUND

• Used to determine volume of urine.
• Main purpose is to determine urine volume without
  having to catheterize the bladder, avoiding the
  risk of infection.
• Image of the bladder is matched to an image on
  the screen corresponding to a pre-calculated
  volume.

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Compression U/S - LLE Noncompressibility of
common femoral vein with echogenic thrombus
within the vein lumen consistent with chronic
DVT.
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POLYCYSTIC KIDNEY DISEASE
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18 YOM W/ TESTICULAR MASS
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18 YOM W/ TESTICULAR MASS
EPIDERMOID CYST OF THE TESTICLE
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ULTRASOUND-GUIDED NEEDLE BIOPSY OF THE LIVER