How I do it: Ultrasound of the Abdomen

Summary

This video script provides a detailed guide on performing abdominal ultrasounds, focusing on various liver, gallbladder, pancreas, and kidney imaging techniques. It explains the correct scanning techniques for different parts of the abdomen, including the subxiphoid and intercostal windows. The script emphasizes proper probe placement and sweeping motions to capture essential images of the liver lobes, gallbladder, pancreas, and kidneys, ensuring complete organ evaluation and pathology detection. It also covers advanced methods, such as imaging the pancreas and gallbladder in various positions and ensuring thorough examination for conditions like stones and dilatation.

Takeaways

• 😀 Proper abdominal ultrasound technique starts with imaging the left lobe of the liver using a subxiphoid approach.
• 😀 Sweep through the left lobe, starting laterally, progressing medially to capture key structures like the aorta, IVC, and caudate lobe.
• 😀 For the right lobe, angle the probe beneath the rib, starting at the dome and sweeping down to capture parenchyma, hepatic veins, and portal veins.
• 😀 In a transverse view, make sure to sweep through the left and right lobes entirely, checking for anatomy and pathology.
• 😀 The intercostal window can be used to improve imaging of the liver by angling the probe between rib spaces for better views.
• 😀 Gallbladder imaging can be done via subcostal and intercostal windows, ensuring proper alignment of the probe to capture both sagittal and transverse views.
• 😀 The left side of the patient should be used for better access to the spleen and kidney, ensuring full organ sweeps for pathology detection.
• 😀 The pancreas is best imaged using a subxiphoid approach, angling the probe counterclockwise to capture a sagittal image with the splenic vein as a landmark.
• 😀 When imaging the pancreas, identify structures like the pancreatic duct, CBD, and GDA, ensuring to sweep through the entire pancreas for clear images.
• 😀 For the kidneys, use a right lateral decubitus position and an oblique transducer angle to capture both sagittal and transverse images for complete evaluation.

Q & A

What is the first step in performing an abdominal ultrasound on the left lobe of the liver?

The first step is to approach the left lobe of the liver subxiphoid and sweep all the way out through the left lobe, starting with the lateral view.

How do you differentiate between the hepatic veins and portal veins in the liver?

The hepatic veins have less echogenic walls compared to the portal veins, and they enter directly into the inferior vena cava (IVC), which is another distinguishing feature.

What should be done if any ductal dilatation is suspected during the ultrasound of the liver?

If ductal dilatation is suspected, the best place to look is at the level of the portal veins, where the portal system may show signs of dilatation.

What is the key to ensuring you don’t miss any anatomy or pathology while scanning the liver?

You need to sweep through the entire liver, both longitudinally and transversely, to ensure that no areas or potential issues are overlooked.

What is the best approach to image the right lobe of the liver?

The right lobe of the liver should be approached slightly obliquely, angling the probe under the rib, and starting from the dome of the right lobe, sequentially taking images as you sweep down.

How should you position the probe when imaging the gallbladder?

The probe should be positioned subcostally and may be slightly oblique to the body to fully open up and visualize the gallbladder.

What additional step should be taken to check for stones in the neck of the gallbladder?

To check for stones in the neck of the gallbladder, you should have the patient turn onto their left side, which will bring the gallbladder forward and help reveal any stones in the neck.

How can you differentiate between the hepatic artery and the common bile duct (CBD) during an ultrasound?

You can differentiate them by turning on color Doppler: if the vessel fills with color, it is the hepatic artery; if it does not, it is the CBD.

What is the recommended method for imaging the pancreas?

The pancreas should be imaged from a subxiphoid approach with the probe angled down to use the left lobe of the liver as a window. Slight counterclockwise rotation of the transducer helps to achieve a sagittal view.

Why is it difficult to visualize the entire tail of the pancreas?

The tail of the pancreas dives deep and may be difficult to visualize fully during an ultrasound, which is why imaging is usually focused on the head and uncinate process.

What landmarks should you look for when imaging the spleen?

When imaging the spleen, you should focus on the rib space on the left side of the patient, sweeping through the spleen completely in sagittal and transverse planes.