ULTRASOUND

Ultrasound

Sound Navigation & Ranging (SONAR)

was the source of WWII

imaging modality based on the pulse-echo principle

uses high frequency sound waves

waves travel through the body and are reflected variably on the different types tissue and
encounter grayscale

Gray scale

is the image seen in the monitor (black and white)

Sound

also known as Acoustic

propagation of energy by mechanical wave through matter

requires an medium for transmission

Vacuum – absence of matter

Waves

energy transfer through cyclical variations

(2) CLASSIFICATIONS OF WAVES

Mechanical

needs medium in order to propagate

transverse – perpendicular direction

Electromagnetic

does not need a medium

electromagnetic wave – travels through a medium

longitudinal – same direction

(4) SOUND VARIABLES - PDTD

Pressure – concentration of force

Density – concentration of medium particles

SOUND RANGES:
Infrasound below human audible 0 – 20 Hz
Audible can be heard 20 Hz – 20 kHz
Ultrasound above human audible more than 20 kHz
2 – 10 MHz for diagnostic
Diagnostic Ultrasound
imaging
Temperature – warming of particles from absorption of wave energy

Distance – particle displacement with weight

Frequency

Hertz / Hz

rate of occurrence

use to measure sound

Hertz = # of cycles/second

Pathway of Ultrasound

Electrical Energy–Sound Energy–Electrical Energy

Velocity

speed of sound

rate at which a wave travels through a medium

sounds travels fastest – solid

sounds travels slowest – gas

Low frequency – Long wavelength

High frequency – Short wavelength

Hz – sound frequency

dB (decibel) – sound intensity

TISSUE SOUND WAVES

air 331 m/sec
lungs 500 m/sec
fat 1440 m/sec
water 1495 m/sec
brain 1510 m/sec
soft tissues 1540 m/sec
liver, kidney, blood 1560 m/sec
muscle 1570 m/sec
bone 4080 m/sec

1540 m/sec

average sound velocity in human body

Wavelength

physical distance between cyclical wave peak within a medium

* determined by frequency and velocity

Amplitude

Volts

height of wave

strength, volume or size of the physical quantity

Power

Watts

rate at which energy is transferred

Intensity

equals to concentration of energy

Attenuation

progressive weakening of sound beam with depth of tissue

total propagation loss decrease in intensity & amplitude due to weight interaction in the medium

ATTENUATION RATE dB/

TISSUE
cm – MHz
Soft tissue 0.5
Muscle 1
BL 0.125
 ADVANTAGES OF ULTRASOUND

low cost of equipment

no ionizing radiation

scanning can be performed at any place

detects blood flow, cardiac and fatal movement

portable equipment

aids in biopsy and drainage procedure

DISADVANTAGES OF ULTRASOUND

Aqueous Gel Mineral Oil

1. Viscosity up down
2. Easier to clean check x
3. Dries out check x
4. Damage clothing x check
operator dependent

inability of sound to cross and interface with gas or bone

presence of fat produce poor image

* 1inch of penetration = 1MHz – 1dB

Jacques & Pierre Curie

piezoelectric

KT Dussik

performed the first ultrasound of the brain

Fontanels:

Posterior – 18 months

Anterior – 3 – 4 months
GD Ludwig & FW Struthers

first to establish the use of pulse-echo technique for medical diagnostic imaging

(3) SOUND WAVE INTERACTION OF MEDIA

1. REFLECTION

phenomenon of causing a propagative wave to change direction such that some of the wave
energy does not continue to propagate forward reduction of the portion of the Ultrasound beam
back to its source

foundation of diagnostic ultrasound

(2) Factors that Affect Reflection

Acoustic Impedance = Rayls

describes the reflection of sound at an interface

is the product of tissue density and velocity of sound in the material

used to determine what percentage of the incident wave will be transmitted and what percentage
will be reflected at an acoustic interface

Impedance Matching

refers to any process that lessens the reflectivity of sound

Coupling Agent

refers to materials applied to lessen the reflectivity of sound

prevents air gap between the face of the transducer and the skin of the patient

EXAMPLE OF COUPLING AGENT

Beam Angle of Incidence

higher angle = lower reflection

lower angle = higher reflection

PERCENTAGE OF REFLECTION AT TISSUE INTERFACE

Air 99.9
Bone/Muscle 80
Brain 44
Water 0.64

(3) TYPES OF REFLECTION

Specular – smooth surface

Back Scattering – rough surface

Rayleigh-Tyndall Scattering – small structures

REFRACTION

bending of the beam at an interface of 2 media

cause spatial resolution

produce gray-scale appearance

determined by Snell’s Law

Snell’s Law

predicts amount of refraction

refraction is considered an artefact which can cause objects to be drawn at the wrong location or
not even drawn at all

ABSORPTION

process of converting sound to heat energy within the medium

occurs when energy in the sound beam is captured by the tissue

heat in body easily spread and dissipates

dominant factor in attenuation

(3) CHARACTERISTICS OF ULTRASOUND BEAM

a. proximal portion
b. near field
Fresnel Beam c. coherent
d. highly-collimated
e. zone shallower than the natural focus
a. where beam reaches its min. diameter
Transition Point or Natural Focus b. distance at which the waves become
synchronous
a. distal portion
b. far field
Fraunhofer Beam
c. divergent beam
d. region deeper than the natural focus

(2) ULTRASOUND RESOLUTION

Axial / Depth

ability to separate 2 objects, one lying on top of the other

Lateral / Azimuthal

ability to separate 2 objects lying side by side

MODES OF SONOGRAPHY

Equipments
A-mode (Amplitude)

simplest type of ultrasound

echoes are displayed as spikes projectingfrom the baseline

B-mode (Binary/Brightness)

incorporated in real-time

series of receive echoes from a tomographic image

provide grayscale to different amplitudes of returning echoes

C-mode (Constant)

constant depth

used in Doppler

M-mode

single acoustic line is repeatedly transmitted in the same direction

represented by dots moving back & forth

used in echocardiography

REAL-TIME

presently used in ultrasound

ultrasound lines transmitted, recorded, processed, displayed as to appear intact and continues with
time (moving image)

DOPPLERS

use principles of shift in reflected sound frequency produced from moving structures

used in arterial / nervous flow studies / blood flow studies

3D US – no movement
4D US – with real-time

Echocardiography

ultrasound study of the heart

DOPPLER EFFECT

apparent shift in frequency in any interrogating wave caused by relative motion between the
observer and the target

(3) TYPES OF DOPPLER

Color Doppler

Continuous Wave Doppler – employs 2 piezoelectric materials

Pulse Doppler

(3) MAIN PARTS OF ULTRASOUND MACHINE

Transducer/Probe

Control Console

brain of ultrasound machine

computer and CPU

TV Monitor

image display system

TRANSDUCER / PROBE

heart of the ultrasound machine

device that converts one form of energy into another

electropotetial energy – mechanical vibrations – electropotential energy

 FUNCTION:

Transmitter of sound

Receiver of reflected echoes

DIFFERENT PARTS OF TRANSDUCER

Connector / Coaxial Cable

Provides electrical impulse

Plastic Housing

Provides protection and structural support for internal parts

Acoustic Insulator

Prevents sound from passing into housing

Backing Block

Shortens the sonic pulse for the second fraction

Dampens vibration to prime transducer for its second fraction

Materials used:

Tungsten

Rubber

Resin

Live Electrode

Absorbs sound waves transmitted back to the transducer

Ground Electrode

Protects the patient from electric shock

Quarter wave matching layer (QWML)

Layer of material located in front of the transducer used to transmit ultrasound more
efficiently to the patient

Face (water-tite)

Protective acoustic window designed to match the crystal and transmits the ultrasound
beam

Crystal Element
 Active part

Contains / possesses Piezoelectric effect

PIEZOELECTRIC EFFECT
Fundamental physical principle for all medical ultrasound
Phenomenon of mechanical deformation which results when an electric field (voltage) is
applied to certain crystal materials
Mechanically deform crystals produces the sound echoes

TYPES OF PIEZOELECTRIC EFFECT

Poling
Process of making materials piezoelectric

PZT

Lead, Zirconate, Titanate

Commonly used materials for transducer crystals

Manufactured by heating a ceramic in a strong magnetic field causing the alignment of

dipoles

Ferroelectrics
Artificial piezoelectric materials

ULTRASOUND CONTROL CONSOLE

Responsible for image production

Storage system

Contains the CPU

Brain of the ultrasound machine

CPU does calculations for data processing, forms image displayed in monitor, stores
processed data in discss

Computer

Contains :

Microprocessor

Memory amplifiers
 Power supply

CONTROLS IN THE ULTRASOUND MACHINE

Gain
image density
STC / TGC

Sensitivity, Time, Control

Time Gain Compensator

For picture balance

Freeze

cessation of motion

For stop and start

Zoom

image magnification

Steering

redirection of the beam

Measurements (Caliper)

Distance

Volume = LxWxHx0.5223

Weight – for solid and liquid

Marker

probe position

Body Parts

Probe Position

Menu

Display

Menus – parts to be examined

Display – single or dual, multiple

Ex. 2 kidneys for picture

 Modes

B mode – gray scale, real time, receives echoes

M mode – echocardiography

ELECTRONIC STEERING – move the images

TRANSDUCER FREQUENCIES
3.5 MHz – deep structure
5-7 MHz – superficial structure
10-12 MHz – high resolution scanning / better detail

DEEP STRUCTURE (3.5 MH)

Brain

Chest

Lungs

Heart

Liver

Gall bladder

Stomach

Spleen

Pancreas

Kidney

SUPERFICIAL STRUCTURE (5-7 MHz)

Parotid d. Breast

Eyeball e. Testes

Thyroid

TYPES OF PROBE / TRANSDUCER

Linear (Flat)
5-7MHz
Superficial
Convex (Curve)

thoracic & abdomen

 intercostals scanning

Radial

POSITIONS OF THE PROBE

Longitudinal

Transverse

Oblique

IMAGE TRANSFER OF THE BODY AT THE PERSONALITY OF THE OBJECT

Printer – uses heat sensitive paper
Video disk – Flash drive, SD

(2) ULTRASOUND ARTIFACT

LOCATIONAL ARTIFACTS
Refraction
Lateral displacement of normal anatomy from normal position

Results in an object appearing displace from its true position

Reverberation

Caused by sound bouncing between multiple structures

Ex. Bladder

Multipath

incorrect depth of structure

Mirror Image

oblique incidence of a specular reflection

*Specular reflection

reflection from a smooth surface

Ex. Diaphragm

ATTENUATION ARTIFACTS
Applied for different structure
Useful in ultrasound
1. Shadowing

absent through transmission

dark / black appearance

E.g. stone, calcification

2. Enhancement

better through transmission

bright appearance

E.g. cysts

Ex. Urinary Bladder

- have a fluid inside the structure

Telerad – connections

Transcriptor – script

PACS – Computer Screen & Computer Console

BIOLOGIC EFFECTS OF ULTRASOUND

1. Heat

attenuation produces heat

2. Cavitation

rare that produces cavities

ULTRASOUND IMAGES

Polyps

Endometrial

Cervical

Nabothian cyst

Cervical

Cervical cancer

Ovary
Follicle

Stroma

Sides, fundal, posterior

OVARIAN PATHOLOGIES

Polycystic ovary

Rosary bead; infertility

Cysts

Benign (simple)

Malignant (complex)

Tumors

Endometrioma – chocolate cyst

Hydrosaphinx – dilated tubes

CRANIAL ULTRASOUND

5-7 MHz

Open fontanelle

Brain parenchyma – bleed / tumor

Ventricles – hydrocephalus

SALIVARY GLANDS

Parotid & submandibular

5-7 MHz; linear probe

Sialosis

Sialoadenitis

Cyst

Tumor – adenoma
BREAST ULTRASOUND

5-7 MHz; linear

Clock positions; axilla

Zones

Retroareolar

Periareolar

Middle

Peripheral

Depth

Superficial

Inermediate

Deep

BREAST PATHOLOGIES

Fibroadenoma

Fibrocysts

Carcinoma

THORACIC ULTRASOUND

3-5 MHz; curved

Intercostal scanning

Detect pleural effusion

Detect large lung tumors

Cardiac evaluation

Pericardial effusion

THYROID GLAND ULTRASOUND

5-7 MHz; linear

+ carotid artery, jugular vein, muscle, lymph nodes

2 lobes; connecting bridge = Isthmus

Pathologies of Thyroid Gland

Thyroiditis – enlarged; tender

Goiter – enlarged

Cyst – colloid

Tumor

BLIGHTED OVUM

Anembryonic pregnancy

(+) gestational sac

(-) fetal pole

Patient with vaginal bleeding

Sac with no fetus

ASCITES

Excessive abdominal fluid

Anechoic

ECTOPIC PREGNANCY

Fetus outside the uterus

Normal / thick endometrium

Adnexal mass / fetus

Fluid in cul de sac

PATIENT PREPARATION in ULTRASOUND
NONE

Cranial ultrasound

Neck ultrasound

Thoracic ultrasound

Breast ultrasound

Ultrasound of the kidneys

Liver ultrasound

Splenic ultrasound

FASTING

0-3 year old – NPO for 3 hours

need fasting

gall bladder

pancreas

BLADDER DISTENTION

Pelvic Ultrasound

transthoracic

let the patient take 6-8 glasses of water

remind the patient not to urinate prior exam

EMPTY BLADDER

let the patient urinate

transvaginal ultrasound

transrectal ultrasound

ULTRASOUND EXAMINATION
Cranial

Brain

Ventricles

Head

Parotid gland

Submandibular gland

Neck

Thyroid Gland

Blood Vessels

main artery – carotid

main vein – jugular

Lymph nodes

Breast

Mammary gland

Axilla

Thoracic

Pleural Infusion

not detective for lung tumors

Pericardial Infusion

surrounding the heart

CT SCAN – lung tumors

Abdomen

Full Abdomen
liver

billary tree

gall bladder

stomach

pancreas

spleen

KUB

bowels

pelvic organs

Female:

uterus

ovaries

urinary bladder

Male:

prostate gland

urinary bladder

Upper Abdominal

liver

billary tree

pancreas

spleen

stomach

Hepatobillary Tree

liver

billary tree

gall bladder
Lower Abdominal

Female

KUB

uterus

ovaries

urinary bladder

Male

KUB

prostate gland

VII. Pelvic

3 methods:

transabdominal

transvaginal

transrectal

VIII. Others

optic nerve

lense

fluid – aqueous humor

scrotal

inguinal

superficial – skin

penis

CROSS-SECTIONAL VIEW

Right Ventral
liver

billary tree

gall bladder

Right Dorsal

ascending colon

right kidney

vena cava

Left Ventral

heart

stomach

Left Dorsal

aorta

spleen

pancreas

left kidney

descending colon

Dorsal

rectum

Mid-Dorsal

uterus

ovaries

spine

Mid-Ventral

urinary bladder

LIVER
Located at right ventral
Pyramid-like shape
 Apex points to the right axilla
Base points to the hip

Lobes
Right lobe
Left lobe
Extends in the following region:
Medial
Lateral
Caudate
Quadrate

Gall Bladder fossa

separates Right & Left lobe
Lies in Gall bladder
Falciform ligament
separates lateral & medial portions of left lobe

Right Clavicular line – 12cm

Midsagittal line – 5 cm
*If > 5cm – enlargement

Angles: Acute
Location: RUQ
Borders: Smooth

8 Segements of Liver
Divided by Intrahepatic ducts

Parenchymal Echogenicity (PE)

description of an organ

U/S appearance of Liver Parenchyma

Medium level echo

Px Prep: None
Probe Frequency: 3.5 MHz Curved/Convex

Liver Pathologies
Diffuse  ↓ in PE
Acute Hepatitis – Low level echo
 Diffuse ↑ in PE (Differential Diagnosis)

Fatty Liver – most common

Cirrhosis – fibrotic changes in the liver
Chronic Hepatitis – calcifications
Metabolic Disease
Copper disorder/ Copper Metabolism disorder
Neoplasm
Hepatic Cyst
Simple
Complex – more complex, more malignant
Hepatic Abscess – rounded, internal dirty shadowing
Tumors
Benign – macrocalcification
Malignant – microcalcification
Tuberculosis of Liver – parenchymal calcification
Hepatomegaly
Obtuse angulation
Round borders
Enlarged liver
U/S findings (3):
Extension to the left
Rounding of borders
Severe hepatomegaly
Flattening of right kidney
>12cm – increase clavicular span
>5cm – increase MSL

BILIARY TREE
Right Intrahepatic Ducts – Right lobe
Left Intrahepatic Ducts – Left lobe
Common Hepatic Duct (CHD)
Cystic Duct (CD) – Proceeds to Gall Bladder
Common Bile Duct/Main Bile Duct – proceed into Duodenum
Up to 7mm

Bile Duct – Echogenic duct; anechoic interior

Px Prep: Fasting
Probe: 3.5 MHz Curve/Convex

Pathologies of the Biliary Tree

Biliary Ectasia – dilated bile ducts
Caused by obstruction
Presence of stone
Stenosis – narrowing
Stricture – abrupt narrowing
Tumor/neoplasm
Cholangitis – inflammation of Biliary Tree
U/S appearance:
 Dilated ducts w/ thick walls
Choledocholithiasis – stone in the bile duct
Hyperechoic
Rounded
PSS
Bile Duct cyst – cyst in wall
Tumors

Pathologies of Gall Bladder

Acute Cystitis – inflammation of Gall Bladder
Thick walls
GB is dilated
Presence of stones
*3mm – GB normal thickness
Chronic Cholecystitis
GB is contracted
Thick walls
Presence of stone
Cholecystolithiasis – gall stone
If not imapacted, mobile
Polyp – differentiated w/ tumor
Medium to low level echo
Fixed; attached to walls
No PSS

Sludge – thickened bile

Echogenic
Low level echo
Medium level echo
Solidified sludge ball
Find intraluminal echoes
Cholesterolosis – strawberry Gall Bladder
Comet-tail feature
Rokitansky-Aschoff bodies
Tumors
Cholangiocarcinoma – cancer in bile ducts

PANCREAS – located at LUQ; retroperitoneal

Parts:
Head – 3 cm
– C-loop of Duodenum
Body – 2 cm
Tail – 1cm
– Hilum of Spleen
2 Ducts of Pancreas
Wirsung – major duct; echogenic line
Santorini – minor duct; not visualized

U/S Appearance
Pacreatic Parenchyma – more echogenic than liver

Px Prep: Fasting w/ laxative

*Rationale: Obscured when stomach is full w/ food

Probe Freq: 3.5 MHz Curve/Convex

Pathologies of Pancreas
Annular Pancreas – congenital anomaly where the Pancreas surrounds the Duodenum
Pancreatitis – pancreas swells
Acute Pancreatitis
↑size, ↓ echogenicity
Dilate
Chronic Pancreatitis
↓size, ↑ echogenicity
Contraction
Hyperechoic
Calcificatio (+)
Pancreatic cyst
Phlegmon – fluid collection/ no capsule
Pseudocyst - colletion of pancreatic fluid w/ a capsule
Pancreatic abscess – ovoid w/ internal dirty shadowing

Trauma
Pancreatic contusion – bruise
Pacreatic hematoma – collection of blood
Pacreatic laceration – tear
Pancreatic fracture
Pancreatic tumor
Benign
Malignant
Adenocarcinoma – most common malignant cancer

SPLEEN – located at LUQ

Posterior to the Stomach
Ovoid
Prone to trauma
Up to 12 cm – diameter

Splenic Index (SI) – way of measuring Spleen

L x W x AP x vol = 480
>480 – enlarged Spleen

Px Prep: None
Probe Freq: 3.5 Curve/Convex

U/S Appearance of Spleen

Isoechoic to Liver
Medium level echo
Above left kidney

Pathologies
Splenomegaly
> 480
> 12 cm
Cause by infection
E.g. AIDS, Malaria (enlarge Spleen)
Tumors
Leukemia – cancer of blood
Lymphoma – cancer of lymph nodes
Metabolic disorder
Vascular anomalies
Splenic Trauma
Contusion
Hematoma
Laceration
Fracture
Splenosis – congenital anomaly; autotransplantation of Splenic tissue after trauma
Asplenia – absence of Spleen
Polysplenia – more than 1 spleen

KIDNEY – located both sides of spine

T12 to L3
Bean-shape
Size
Length: 9-14cm
Width: 5-7 cm
AP: 4-5 cm

3 Portions of Kidney
Upper Pole
Midpelvis
Lower Pole

Excursion – movement of Kidneys during respiration

U/S Appearance of Kidney

Renal Parenchyma – Low level echo
 Renal Sinus – Hyperechoic
Composed of several parts:
Calyces
Infundibulum
Renal Arteries
Renal Nerves
Renal Veins

Px Prep: None
Probe Freq: 3.5 MHz Curve/Convex

Renal Pathologies
Renal Parenchymal Disease
Diffuse ↑ in PE
Renal Cyst
Renal Tumor
Angiomyolipoma – most common tumor in Kidney; tumor in blood vessel, muscle, fats
Hydronephrosis
Enlarged kidney size w/ dilated calyces
Pyonephrosis – Calyces filled w/ pus
Nephrolithiasis/ Renal Calculus/ Renal Stone – stone in kidney
Nephrocalcinosis – renal parenchyma becomes Heperechoic
Ectopic Kidney – abnormal location of kidney; sometimes seen in pelvic cavity
Horseshoe Kidney – congenital anomaly connection of upper and lower pole of Kidney

URETERS – located both sides of spine

Not fully visualized
8 mm (diameter)
Urine – anechoic

Ureteral Ectasia – dialted

Stones
Strictures
Stenosis
Tumor

URINARY BLADDER – midline pelvic cavity

Up to 5 mm – wall thickness

Common Diseases of Urinary Bladder

Cystitis – inflammation
U/S findings
Thickened wall w/ irregular borders
Bladder Diverticulum – out pouching
 Bladder tumors
Malignant – most common
– Silent Hematuria – manifestations
Cystolithiasis – stone in the bladder

BLOOD VESSELS – serves as landmarks

Walls – echogenic
Blood – anechoic

Cross-sectional view:
Aorta – more rounder w/ thicken wall
Vena Cava – oblong shape; almost collapsed

Aorta – left side of spine

Vena Cava – right side of spine
PORTAL Veno System – anterior to upper portion of Aorta & Inferior Vena Cava

Branches of Abdominal Aorta

Abdominal Aorta
Celiac Artery
Left Gastric artery – not visualized
Splenic artery – seen in U/S
Hepatic artery – seen in U/S
Superior Mesenteric artery
Right Renal artery
Left Renal artery
Inferior Mesenteric artery
Common Iliac artery
Right Common Iliac artery
Left Common Iliac Artery

Pulsation – rhythmic movement of Aorta

Branches of Inferior Vena Cava

Inferior Vena Cava
Intrahepatic veins – seen in U/S
Right Renal vein
Left Renal vein
Common Iliac vein
Right Iliac vein
Left Iliac vein
Portal Veno System
Intrahepatic Portal vein
Gastric vein
Splenic vein
Superior Mesenteric vein
Inferior Mesenteric vein – attachment on bowel
Pathologies of Blood Vessel
Atherosclerosis – thickening of walls w/ irregular internal borders
Aneurysm – focal dilatation of the blood vessel wall due to weakness
3 basic types:
Fusiform
Sac like
Berry – special type of sac
Dissection – abnormal blood flow w/ the layers of blood vessel wall
Blood must flow in lumen

THYROID GLAND
Located in anterior neck
Appearance: 2 lobes (R&L) divided each by upper pole & lower pole

Size of each Lobe

L: 3-4 cm
W: 2-3 cm
AP: 1-2 cm

Isthmus – bridge between R&L lobes of thyroid gland

Thickness: up to 3 mm

*Thyroid gland moves upward when swallowing

Px Prep: None
Probe: Flat/Linear (5-7 MHz)

U/S Appearance
Thyroid Parenchyma
Isoechoic to Liver
Medium Level Echo

Pathologies of Thyroid Gland

Goiter (Thyromegaly) – Enlarged thyroid gland
Hyperthyroidism
Heat intolerance
Increase metabolism
Exophthalmos – bulging eyes
Hypothyroidism
Cold intolerance
Decrease metabolism
Feel sleepy
Thyroiditis – inflammation of thyroid gland
Enlarged size with tenderness
Thyroid cyst
Colloid cyst – most common
 Tumors
Adenoma – most common Benign tumor (macrocalcifications)
Adenocarcinoma – Malignant tumor (microcalcifications)

MAMMARY GLAND
Puberty: starts to enlarge
Old: sagging

Parts:
Nipple – external opening
Areola – light colored (virgin)
– dark (w/ baby)
Tail – contains lymph nodes

Px Prep: None
Probe: Linear/Flat (5-7 MHz)
*For smaller lesions to detect better scanning resolution use (10-12 MHz)

Clock Position – better scanning resolution

Quadrants:
Upper Outer – most common site of breast cancer
Upper Inner
Lower Outer
Lower Inner
Zones:
Retro-areolar zone – behind nipple and areola
Peri-areolar zone – surrounds the nipple
Middle zone – mid
Peripheral Zone – outermost

Depth:
Superficial
Intermediate
Deep

Pathologies:
Mastitis – inflammation of breast
Enlarged mammary gland
 Breast cyst
Breast Abscess
Tumor
Breast carcinoma – malignant
Breast adenocarcinoma – benign
Gynecomastia – enlargement of the breast in males due to liver problems or drugs and
hormone imbalance

PROSTATE GLAND
Located inferior to the urinary bladder in male pelvic cavity
Size (L x W x AP x vol) = 20-24 grams

4 Zones
Peripheral zone
Transitional zone
Central zone
Periurethral zone

U/S appearance of Prostate Gland

Medium level echo
Isoechoic to liver

Methods of Scanning
Transabdominal (3.5 MHz)
Px Prep: Bladder distention
Transrectal (5-7 MHz) – more accurate
Px Prep: Empty bladder

Pathologies of Prostate Gland

Prostatomegaly – enlarged prostate gland
> 24 gms
Hypertrophy
Hyperplasia
Heterogeneous echogenicity – PE
Prostatitis – inflammation of prostate gland
Enlarged size with tenderness
Heterogeneousechogenicity
Prostatic hypertrophy / hyperplasia
Prostatic cyst
Prostatic adenomas
Abscess – very rare
Tumors
Benign
Malignant
Concretions – calcifications in Prostate gland

SCROTUM
 3mm - normal scrotal skin thickness
Contains 2 sacs
Sac contents:
Testes (2) - R&L occupies most of the scrotum
Epididymis (2)
Spermatic cord

Epididymis – enlargement at each end; dumbbell shape

Testes – R&L occupy most of the scrotum

Size
L: 3-4 cm
W: 2-3 cm
AP: 1-3 cm

U/S appearance of Scrotum

Isoechoic to liver
Medium level echo

Scrotal U/S
Px Prep: None
Probe: Linear/ Flat (5-7 MHz)

Pathologies of Scrotum
Cryptorchidism (Undescended testis/Cryptochism)
1 testis
Orchitis – inflammation of testis
Enlargement of testis w/ heterogeneous echogenicity
Epididymitis
Testicular cyst
Testicular abscess
Tumors in testis – most likely malignant
Punctate – small calcifications (<5mm)
Hydrocele – testis floats in water / excessive fluid
*Red – indicates water
*Black – indicates tumor
Findings: Anechoic (> Water in scrotal sac)
Varicocele – dilated vein
Serpiginous lucencies

Normal diameter = 2.5 mm

*If > 2.5 mm/0.25 cm – dilated vein Epididymitis – inflammation of epididymis head
enlarged epididymis w/ heterogeneous echogenicity
dumbbell like
Epididymal cyst
Epididymoorchitis – inflammation of testis and epididymis
Tumor
Seminoma – most common tumor in testis
UTERUS
Located at pelvic cavity
Posterior to the Urinary Bladder
Pear-shape

Position of uterus
Anteverted – anterior portion
Anteflexed – anterior and flexed
Retroverted – Posterior portion
Retroflexed – posterior and flexed

*Size of uterus depends on age

>50 yo – size of uterus decrease

Uterine to Cervix ratio

Infant (<2yo) 1/3 2/3
Young virgin ½ ½
Multipara 2/3 1/3

U/S appearance of Uterus

Isoechoic to liver
Medium level echo

L: 6-10 cm – normal size in adults

L: 3-5 cm – postmenopausal

ENDOMETRIUM
Echogenic
Medium to high level echo

*Thickness depending on the menstrual phase

4-8 mm – Proliferative phase (after menstruation)
8-14 mm – Secretory phase
Up to 4 mm – Postmenopausal
Cervix
4 cm – normal length

Ovaries
Up to 3 cm in size
Location
Sides of uterus – most common
Near the fundus
Posterior to uterus

Appearance of ovary
 Rectangular sometime
Stroma – Parynchema of ovary
Follicles – rounded lucencies
*2.4 cm – size of mature follicles during ovulation

Methods of Scanning:
Transabdominal (Curve/Convex 3.5 MHz)
Px Prep: Bladder distention
Transvaginal (5-7 MHz)
Px Prep: Empty Bladder
If virgin,
Transrectal (5-7 MHz)
Px Prep: Empty Bladder

*Fallopian tubes – cannot be visualized

Pathologies
Uterine Didelphy
2 bodies of uterus
Adenomyosis
Enlarged uterus
Thickened wall w/ no focal lesions
Myoma Uteri (Uterine Myoma/Fibroids)
Benign tumors in uterus

4 Types of Myoma
Subserosal Myoma
Intramural Myoma – inside the muscular layer
Submucosal Myoma – endometrium
Cervical Myoma – cervix

Endometrial Hyperplasia
Thickened endometrium
Endometrial cyst
Endometrial Polyp
Echogenic
Medium to low level echo
*Hysterosonography – for detection of Polyp
Fluid in endometrial cavity
Nabothian –cyst in cervix
Cervicitis – inflammation of cervix
Cervical cancer – tumor in cervix
Enlarged cervix w/ irregular borders
Heterogenous echogenicity

*Intrauterine device filled with Barium – anechoic

Hydrosalphinx – dilated fallopian tube filled w/ fluid
Pyosalphinx – dilated fallopian tube filled w/ pus
 Ovarian cyst – most common
Simpler – more benign
More complex – more malignant
Polycystic Ovary (< 1cm)
Multiple subcentimeter follicle lucencies
Peripherally located
Rosary bead appearance

*Cul de Sac – pouch in pelvic cavity

Trophoblastic Disease – abnormal pregnancy

– hypertrophi chorionic villi
Hydatidiform mole (H-mole)
Benign type
Snowstorm/vesicular pattern of endometrium
Invasive mole – penetrates walls of uterus
Partial mole – mole w/ fetus
Choriocarcinoma
Malignant type

ABORTION
– Termination of pregnancy before the 27 weeks Age of Gestation (AOG)
Induced Abortion – w/ manipulation
Spontaneous Abortion – w/o manipulation
Incomplete Abortion – thick endometrium
Complete Abortion – normal uterus in U/S

Ectopic Pregnancy – abnormal location of fetus

– outside uterus
Locations:
Fallopian tube – most common location
Abdominal cavity
Ovary

U/S findings:
Normal uterus
Adnexal mass
Fluid in the culde sac

FETAL EVALUATION

Months
st
1 Trimester – first 3 months
nd
2 Trimester
rd
3 Trimester
Age of Gestation – count in weeks
37 – 40 weeks – term for pregnancy (full term)

< 37 – PreT/Premature
> 40 – Post/Post mature

Last Menstrual Period (LMP)

G_P_ (_-_-_-_)
F PAL
Gravida - # of pregnancy
st
Primigravida – 1 pregnancy
Nulligravida – none
Multigravida – > 1 pregnancy
Parity - # of deliveries
st
Primipara – 1 delivery
Nullipara - none
Multipara
F – # of full term
P – Premature
A – Abortion
L – Live

Number – # of fetus
Viability – death or alive (yes or no)

Fetal Presentation
Cephalic – normal
head near cervix
Breech – buttocks near cervix
Transverse lie – horizontal position
Footling – foot near cervix

Biometry – measurement of life

st
1 trimester are shown
Gestational Sac (GS) – anechoic
Crown Rumplength (CRL) – vertex to butt
nd
2 & 3rd Trimester
Biparietal Diameter (BPD) – parietal to parietal
Cephalic Index (CI) – measure the longest and widest diameter of skull
Femoral Length (FL) – measures femoral length
Abdominal Circumference (AC) – axial view of stomach
– J-shape of portal vein
 – Ellipse
Estimated Fetal Weight (EFW) – base on percentile

*BPD, FL, AC – computer automatically gives EFW

th
10 Percentile – small baby or Small for Gestational Age (SGA)
th
90 percentile – Large for Gestational Age (LGA)
Mother may be diabetic
th
50 percentile – average

FETAL SPINE – either R or L

Fetal Heart Rate (FHR) – use M-mode (beats/min)

Check regular rate & rhythm
Placenta – disc shape (echogenic)
High lying – normal location
Low Lying – caudad tip of placenta to the Os is <4 cm
Marginal Placenta/Placenta Previa Partialis – abnormal; touching the Os
Partial Complete/ Placenta Previa Totalis –

Placenta – filled w/ blood vessel

Patient will bleed

Amniotic Fluid Volume (AFV) (5-20)

Fluid surrounds the fetus
< 4cm (measurement) – abnormal
> 12cm (depth) – abnormal
– measures quadrants of fluid

4 Quadrant indices = 5-20

Oligohydramnios – decrease amniotic fluid volume (<5)
Developed due to GUT problems
Hormohydramnios / Normohydramnios – normal (5-20)
Polyhydramnios – increase (>20)
Developed due to GIT problems

Fetal Anatomy (FA)

Sinologist checks from head to toe
Umbilical cord – 2 arteries; 1 vein
Cord coil – Umbilical cord surrounds neck of fetus
Sex
Turtle sign – male
 Hamburger sign – female
Colonic grading
I, II, III (term)
Head
encephalocele
Hydrocephalus
Cleft lip
Chest
Pneumothorax
Diaphragmatic hernia

Abdomen
Omphalocele
Gastroschisis
Hydronephrosis
Gut obstruction

Limbs
Hypoplasia
Dwarfism
Gigantism

Biophysical Profile (BPP)

Checks the status of fetus
2 score is normal
0 is abnormal
Fetal Breathing (FB) – Checked if lungs contracting/expanding
Fetal Movement (FM)
Fetal Tone (FT) - arms and legs extending/flexing
Amniotic Fluid Index (AFI)
Non Stress Test (NST)
Total = 10

*If no NST, perfect score is 8.

Maternal Uterine Walls

Checked if uterus is normal, or if there is myoma
Maternal Cervix – 4cm (normal length) – competent
<4cm – incompetent
Maternal ovaries – checked if there is cyst

Maternal UB
Single Live Intrauterine Pregnancy (SLIP)
Fetal Death in Utero (FDU)

Congenital Scanning – check fetus if there is congenital anomaly e.g. cleft

Feature of Colon
 Will tell what semester
Colonic Index (CI)

GENERAL RULES FOR PATIENT PREP IN ULTRASOUND:

Fasting w/ Laxatives – If Gall Bladder & Pancreas are included
Bladder Distention – if Urinary Bladder is included
Empty Bladder – When using Transvaginal & Transrectal probes.

Cranial
Px Prep: None
Transducer: Transvaginal Probe (5-7 MHz)
Px Position:
Px in supine position.
 Look for anterior fontanel and cover parts that are not examined.
Probe on anatomy:
Place on anterior fontanel.

Neck (Thyroid Gland)

Px Prep: None
Transducer: Flat/Linear (5-7 MHz)
Px Position:
Put pillow under Px’s shoulder
Hyperextend the neck, cover the rest of the body.
Probe:
Place on the anterior neck.

Parotid & Submandibular Gland

Px Prep: None
Transducer: Flat/Linear (5-7 MHz)
Px Position: Supine
Probe:
Turn Px’s head to the left
Put probe under the right ear for the right parotid gland.
Turn Px’s head to the right
Put probe under left ear for the left parotid gland.
For the L&R submandibular gland, place probe under the L&R mandible

Breast
Px Prep: None
Transducer: Flat/Linear (5-7 MHz)
Px Position:
Let Px remove the upper clothing, including the bra.
Right breast: Put pillow under the right hemithorax.
Arms placed upwards in the same side.
Cover the part that is not examined.
Probe:
On the breast (12 o’clock, 3 o’clock, 6 o’clock, 9 o’clock)

Thoracic (Lungs and Heart)

Px Prep: None
Transducer: Curve/Convex (3.5 MHz)
Px Position:
Px in sitting position w/ its back facing the sonographer.
Remove the upper clothing.
Cross legs & let Px hug the pillow.
Bend the head & flex forward.
Probe on anatomy:
Right or left hemithorax (Intercostal scanning – wide field of view)

Whole Abdominal
Px Prep: Fasting with Bladder Distention
Transducer: Curve/Convex (3.5 MHz)
Px Position:
Arms placed upwards
Cover the lover portion of the body not examined
Probe on anatomy:
RUQ (Liver, biliary tree, gall bladder)
LUQ (Pancreas, stomach, spleen)
Pelvic organs

Upper Abdominal
Px. Prep: Fasting w/ laxative
Transducer: Curve/Convex (3.5 MHz)
Px Position:
Pxin supine position
Arms upwards
Raise upper clothing
Cover parts not examined.
Probe:
RUQ (Liver, biliary tree, gall bladder)
LUQ (Pancreas, stomach, spleen)

Lower Abdomen
Px Prep: Bladder Distention
Trandsucer: Curve/Convex (3.5 MHz)
Px Position:
Supine
Arms upwards
Raise upper clothing
Cover parts not to be examined
Probe on anatomy:
Lower center – Bladder, prostate gland (supine), kidneys (prone)

Hepatobiliary
Px Prep: Fasting
Transducer: Curve/Convex (3.5 MHz)
Px Position:
Supine, arms upwards, raise upper clothing & cover parts not to be examined.
Probe on anatomy:
RUQ (Liver, Biliary Tree, Gall Bladder)

Pelvic (Transabdominal)
Px Prep: Bladder Distention
Transducer: Curve/Convex (3.5 MHz)
Px Position:
 Supine
Arms upwards
Raise upper clothing
Cover parts not to be examined.
Probe on anatomy:
Hypogastric region: Uterus, Ovaries, & Bladder

Pelvic (Transvaginal)
Px Prep: Empty Bladder
Transducer: Transvaginal probe
Px Position:
Remove lower clothes including underwear
Place pillow under the hips/pelvis
Arms at sides
Put Px in Lithotomy position, cover upper part not be examined
Put KY jelly at the tip of probe, cover with condom. Put jelly again then insert.

Pelvic (Transrectal)
Px Prep: Empty Bladder
Transducer: Transrectal probe
Px Position:
Place Px in supine position
Remove the lower clothing including underwear. Cover parts not to be examined.
Put KY jelly on the tip of the probe, cover with condom. Put jelly again, cover with
condom, and then put with jelly again.
Probe on anatomy:
Insert in anus in a circular pattern

Scrotal
Px Prep: None
Transducer: Flat/Linear (5-7 MHz)
Px Position:
Px in supine position. Let Px remove the lower clothing including underwear.
Give Px a tissue paper, let him hold his penis in a cephalad direction.
Probe on anatomy:
Scrotum

st
Fetal Evaluation (1 Trimester) (Transvaginal)
Px Prep: Empty Bladder
Transducer: Transvaginal probe (5-7 MHz)
Px Position:
Remove lower clothes including underwear
Place pillow under the hips/pelvis
Arms at sides
Put Px in Lithotomy position, cover upper part not be examined
Put KY jelly at the tip of probe, cover with condom. Put jelly again then insert.

nd rd
Fetal Evaluation (2 & 3 Trimester) (Transabdominal)
Px Prep: Empty Bladder
Transducer: Curve/Convex (3.5 MHz)
Px Position:
Supine
Arms upwards
Raise upper clothing
Cover parts not to be examined.
Probe on anatomy: