color atlas of ultrasound anatomy [2 ed.]

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Standard Planes for Abdominal Scanning … p. 2 Upper abdominal longitudinal scan, center Lower abdominal longitudinal scan, center … p. 2/3 Upper abdominal longitudinal scan, right side Upper abdominal longitudinal scan, left side … p. 4/5 Upper abdominal transverse scan, center Lower abdominal transverse scan, center … p. 6/7 Upper abdominal transverse scan, right side Upper abdominal transverse scan, left side … p. 8/9 Longitudinal flank scan, right side Longitudinal flank scan, left side … p. 10/11 Transverse flank scan, right side Transverse flank scan, left side … p. 12/13

Note: The number key for the diagrams is on the fold-out flap inside the back cover.

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Scanning Planes

2

Upper abdominal longitudinal scan, center

Lower abdominal longitudinal scan, center

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Standard Planes for Abdominal Scanning

40

3

73

20

5

7

1

85

80

89

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Scanning Planes

4

Upper abdominal longitudinal scan, right side

Upper abdominal longitudinal scan, left side

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Standard Planes for Abdominal Scanning

5

30 20

76 60

21

40 70

61 50

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Scanning Planes

6

Upper abdominal transverse scan, center

Lower abdominal transverse scan, center

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Standard Planes for Abdominal Scanning

7

7 70

40

20

1

10

50

90 61

60

80 97 89

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97

85

97

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Scanning Planes

8

Upper abdominal transverse scan, right side

Upper abdominal transverse scan, left side

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Standard Planes for Abdominal Scanning

9

21 40 10

19

20

70

7 1

50

90 61

60

19 1

10 20

50

90 60

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70 7

61

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Scanning Planes

10

Longitudinal flank scan, right side

Longitudinal flank scan, left side

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Standard Planes for Abdominal Scanning

11

20 60

21 70

61

50

50 61

20

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Scanning Planes

12

Transverse flank scan, right side

Transverse flank scan, left side

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Standard Planes for Abdominal Scanning

13

20 60 10 90

21 19 7

1 40

61

70

50

50 70

61

40 7

1

90 60

20

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Aorta and Vena Cava in Suprarenal Transverse Sections, Including the Renal Vessels … p. 16 1 2 3 4 5 6 7 8 9 10

Passage of aorta and vena cava through diaphragm Left gastric artery Celiac trunk Celiac trunk Hepatic artery Splenic artery Superior mesenteric artery Superior mesenteric artery Superior mesenteric artery and splenic vein Left renal vein and right renal artery

Aorta and Vena Cava in Infrarenal Transverse Sections … p. 26 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Infrarenal aorta and vena cava Infrarenal aorta and vena cava Infrarenal aorta and vena cava Infrarenal aorta, vena cava, superior mesenteric artery and vein Infrarenal aorta and vena cava Aortic bifurcation Iliac arteries Confluence of iliac veins Iliac vessels Iliac vessels Iliac vessels Iliac vessels Left iliac vessels Left iliac vessels

Splenic Artery and Vein in Longitudinal Sections … p. 40

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25 26 27 28 29 30

Aorta Splenic vein and left gastric artery Splenic artery and vein, celiac trunk Splenic artery and vein, celiac trunk Splenic artery and vein, renal artery and vein Splenic artery and vein, renal artery and vein

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Hepatic Artery in Longitudinal Sections … p. 46

31 32 33 34

Celiac trunk Hepatic artery and splenic vein Hepatic artery and superior mesenteric vein Hepatic artery and portal vein

Renal Artery and Vein in Longitudinal Sections … p. 50

35 36 37 38

Aorta Right renal artery and left renal vein Vena cava and right renal artery Right renal artery and right renal vein

Right Renal Artery and Vein in Transverse Sections … p. 54

39 40 41 42

Opening of renal vein Renal vein Renal vein at hilum, renal artery Renal artery

Left Renal Artery and Vein in Longitudinal Sections … p. 58

43 44 45 46



Vena cava Right renal artery and left renal vein Aorta and left renal vein Left renal vessels, splenic artery and vein Vessels of the Porta Hepatis in Longitudinal Sections … p. 62

47 48 49 50 51 52

Portal vein, vena cava, right renal artery Portal vein, vena cava, right renal artery, and bile duct Portal vein, vena cava, and bile duct Portal vein and hepatic artery Hepatic artery, superior mesenteric vein Hepatic artery, superior mesenteric artery, and splenic vein

Vessels of the Porta Hepatis in Transverse Sections … p. 68

53 54 55 56

Hepatic artery, portal vein, vena cava Hepatic artery, bile duct, portal vein Bile duct, gallbladder, vena cava Bile duct, gallbladder, superior mesenteric vein

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1  Vessels

16

1 Passage of aorta and vena cava through diaphragm

2 Left gastric artery

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Aorta and Vena Cava in Suprarenal Transverse Sections, Incl. the Renal Vessels

24

17

21

70 23 10

1

96

20 90

Just below the diaphragm, the vena cava is surrounded by liver tissue. The aorta lies directly behind the gastroesophageal junction, often making the vessel more difficult to scan.

24

21

23

96

6 1

10 20 90

The left gastric artery is identified as a small-caliber vessel cranial to the celiac trunk.

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1  Vessels

18

3 Celiac trunk

4 Celiac trunk

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Aorta and Vena Cava in Suprarenal Transverse Sections, Incl. the Renal Vessels

19

24 21

22 17

6

3

96

70

43

1

10 20 90

After arising from the aorta, the celiac trunk runs a short distance to the left.

21 22 3 17

10

1

43

70 18

96 20 90

The proximal part of the celiac trunk also turns slightly downward in most cases.

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1  Vessels

20

5 Hepatic artery

6 Splenic artery

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Aorta and Vena Cava in Suprarenal Transverse Sections, Incl. the Renal Vessels

21

21 22

4 17 10

20

43

3

18

1 96

90

The celiac trunk runs slightly to the right, giving rise to the hepatic artery.

21 22

4

3

17 10

96

5

43

1 18

20 90

The splenic artery branches from the celiac trunk at a right angle.

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1  Vessels

22

7 Superior mesenteric artery

8 Superior mesenteric artery

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Aorta and Vena Cava in Suprarenal Transverse Sections, Incl. the Renal Vessels

23

21 5

4

22

7

18

17

1

96

43 18

10

20

90

61

The superior mesenteric artery arises just below the celiac trunk and runs parallel to the aorta.

21 22 18 36

10

43

7

4

1

96

18

20 90

61

The root of the superior mesenteric artery is usually surrounded by an echodense fat pad.

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1  Vessels

24

9 Superior mesenteric artery and splenic vein

10

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Left renal vein and right renal artery

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Aorta and Vena Cava in Suprarenal Transverse Sections, Incl. the Renal Vessels

21

43

42

7

18 36 20

25

8

15

1

10

9 61

90

The aorta, the superior mesenteric artery, and the splenic vein crossing over the superior mesenteric artery provide landmarks for identifying the head of the pancreas.

21

43 42

76 20

36

7

18 8

1

15

10

90

The left renal vein is physiologically compressed between the aorta and the superior mesenteric artery. It is slightly congested proximal to the compression site.

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1  Vessels

26

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11

Infrarenal aorta and vena cava

12

Infrarenal aorta and vena cava

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Aorta and Vena Cava in Infrarenal Transverse Sections

27

21

41 76

43

7

18

1

8

15

36 10

94

90

The vena cava is easily compressible with the transducer, and it bears impressions from adjacent organs.

70 21

42 41

19

7

1 94

94

36 10 90

The aorta has a circular cross section, whereas the vena cava is somewhat flattened.

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1  Vessels

28

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13

Infrarenal aorta and vena cava

14

Infrarenal aorta, vena cava, and superior mesenteric artery and vein

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Aorta and Vena Cava in Infrarenal Transverse Sections

21

70

76 19

41 94

29

7 1

10

94

90

The caliber of the vena cava varies with the pulse and respirations. The diameter of the aorta measures 2.5 cm in its cranial portion, 2.0 cm in its caudal portion.

19

7 1

10

90

Together with the aorta and vena cava, the superior mesenteric artery and vein form a typical four-vessel pattern in a low transverse scan through the upper abdomen.

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1  Vessels

30

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15

Infrarenal aorta and vena cava

16

Aortic bifurcation

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Aorta and Vena Cava in Infrarenal Transverse Sections

31

1

10

90

While the aorta and vena cava are relatively far apart in the upper abdomen, they converge at the level of the promontory, coming very close together.

10

2

2

90

94

The aorta divides into the common iliac arteries at the level of the L4 vertebral body, above the promontory.

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1  Vessels

32

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17

Iliac arteries

18

Confluence of iliac veins

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Aorta and Vena Cava in Infrarenal Transverse Sections

2

33

2

10

90

94

The aortic bifurcation is located slightly above the confluence of the iliac veins.

2

16

16

2

90 94

The confluence of the iliac veins lies approximately at the level of the umbilicus.

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1  Vessels

34

19

Iliac vessels

20 Iliac vessels

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Aorta and Vena Cava in Infrarenal Transverse Sections

35

2 2

16

16 90

The iliac arteries are first anterior and then lateral to the iliac veins.

2 16

16

2

90

The iliac vessels follow the concavity of the lesser pelvis to the femoral arteries.

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1  Vessels

36

21 Iliac vessels

22 Iliac vessels

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Aorta and Vena Cava in Infrarenal Transverse Sections

37

2 2

16

16 90

In serial transverse scans down the iliac vessels, the sections of the vessels are seen to move laterally and posteriorly.

2 16

2 16 90

The iliac vessels are more difficult to scan at lower levels due to intervening bowel gas.

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1  Vessels

38

23 Left iliac vessels

24 Left iliac vessels

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Aorta and Vena Cava in Infrarenal Transverse Sections

2

39

95

16

97

The iliac veins run dorsomedial to the iliac arteries in the lesser pelvis.

80

2

77 16

95

97

The iliac veins are always medial to the arteries at the level of the inguinal ligament.

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1  Vessels

40

25 Aorta

26 Splenic artery and left gastric artery

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Splenic Artery and Vein in Longitudinal Sections

41

40 18

21

15

4 96 1 90

Because the celiac trunk runs slightly to the left initially, often it is not displayed in a longitudinal scan centered over the aorta.

40 18 7 5 15

21 6 96

1

90

The left gastric artery runs cranially between the common hepatic artery and splenic artery. It is often difficult to define.

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1  Vessels

42

27 Splenic artery and vein, celiac trunk

28 Splenic artery and vein, celiac trunk

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Splenic Artery and Vein in Longitudinal Sections

43

40 18

5 6

21

15

7

96 1

90

The celiac trunk divides into the left gastric artery, common hepatic artery, and splenic artery.

40 21

5

18 15

6 3

9

96 1

The curved course of the celiac trunk and splenic artery explains why both vessels appear in the same sagittal section.

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1  Vessels

44

29 Splenic artery and vein, renal artery and vein

30 Splenic artery and vein, renal artery and vein

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Splenic Artery and Vein in Longitudinal Sections

45

43 5

21

18 15

6

9

96

74

1

The splenic artery turns left and runs posteriorly with the splenic vein to the hilum of the spleen.

21

5 18

43

15

70 9

Longitudinal scan on the left side shows the typical appearance of the large splenic and renal veins and the smaller splenic and renal arteries.

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1  Vessels

46

31

Celiac trunk

32 Hepatic artery and splenic vein

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Hepatic Artery in Longitudinal Sections

47

70 40 20

18 7

3 1

The origin of the celiac trunk and its division into branches are subject to numerous variations.

70

40 18 4 20

1

The hepatic artery turns upward and to the right and runs along the inferior border of the liver toward the porta hepatis.

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1  Vessels

48

33 Hepatic artery and superior mesenteric vein

34 Hepatic artery and portal vein

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Hepatic Artery in Longitudinal Sections

49

70

40 19 20

15

4 8

90

A longitudinal scan between the aorta and vena cava typically displays sections of four vessels: the hepatic artery, venous confluence, left renal vein, and right renal artery.

41

4 17 20 10

8

96

A longitudinal scan over the vena cava displays four typical vascular sections: the vena cava, portal vein, hepatic artery, and renal artery.

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1  Vessels

50

35 Aorta

36 Right renal artery and left renal vein

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Renal Artery and Vein in Longitudinal Sections

40

21 5

51

7

18 15

3 1

The left renal vein runs between the aorta and superior mesenteric artery, where it is subject to physiologic compression.

21 24 19

17

15 8

17

90

The section of the right renal artery can be identified between the aorta and vena cava. Just above the renal artery are the left renal vein and a longitudinal section of the superior mesenteric vein.

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1  Vessels

52

37 Vena cava and right renal artery

38 Right renal artery and right renal vein

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Renal Artery and Vein in Longitudinal Sections

53

20

17

8

10

The right renal artery usually impresses the posterior surface of the vena cava, although variants may occur.

20 30

8 17

92

14

8

The renal veins are often more than twice the diameter of the renal arteries.

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1  Vessels

54

39 Opening of renal vein

40 Renal vein

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Right Renal Artery and Vein in Transverse Sections

20

55

76

30

1 10

14

90

69 95

The opening of the right renal vein at the vena cava can be clearly defined above the kidney in most subjects.

20

30 76 10 14

1

60

95

90

In serial transverse scans down the vena cava, the oval cross section of the renal vein separates from the vena cava and moves laterally toward the kidney.

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1  Vessels

56

41

Renal vein at hilum, renal artery

42 Renal artery

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Right Renal Artery and Vein in Transverse Sections

20

57

30 76 10

14

1

8

60 90

95

The renal artery follows the same course as the renal vein, but at a slightly more caudal level.

20 30 76 10 60

8

1

95

90

The renal arteries are located posterior and caudal to the renal veins.

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1  Vessels

58

43 Vena cava

44 Right renal artery and left renal vein

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Left Renal Artery and Vein in Longitudinal Sections

59

21 4

17

40

17 8

10

90 90

The right renal artery passes behind the vena cava, impressing its posterior surface.

40 21

4

18

19 15

8 96 90

The scan plane cuts the left renal vein and right renal artery between the aorta and vena cava.

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1  Vessels

60

45 Aorta and left renal vein

46 Left renal vessels, splenic artery and vein

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Left Renal Artery and Vein in Longitudinal Sections

61

18 40

21

15

7

5 1 90

The left renal vein runs between the aorta and superior mesenteric artery.

21

40 5

18 9

15

The left renal vessels are often difficult to scan because of overlying air.

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1  Vessels

62

47 Portal vein, vena cava, right renal artery

48 Portal vein, vena cava, right renal artery, and bile duct

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Vessels of the Porta Hepatis in Longitudinal Sections

63

40

20

36 4

12

17

10 8

The triad of the portal vein, vena cava, and right renal artery provides a typical landmark in the upper abdominal longitudinal scan.

20

40 36 4

12

17

10 8

When the triad of the portal vein, vena cava, and right renal artery is identified, the scan will usually include a longitudinal section of the bile duct.

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1  Vessels

64

49 Portal vein, vena cava, and bile duct

50 Portal vein and hepatic artery

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Vessels of the Porta Hepatis in Longitudinal Sections

65

40

20 36 12

4

17 10 8

The bile duct enters the head of the pancreas anterior to the vena cava.

45

20 4

40

17

10 8

The portal vein and hepatic artery run side-by-side posterior to the head of the pancreas.

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1  Vessels

66

51 Hepatic artery, superior mesenteric vein

52 Hepatic artery, superior mesenteric artery, and splenic vein

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Vessels of the Porta Hepatis in Longitudinal Sections

67

70 19

40 4

15

45

20

8

When the mesenteric vein is viewed in longitudinal section, typically the scan will also display the hepatic artery cranially and the right renal artery and left renal vein posteriorly.

70

40 7

18

20 4

15

1

When the superior mesenteric artery is viewed in longitudinal section, typically the scan will also show the hepatic artery, splenic vein, and left renal vein.

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1  Vessels

68

53 Hepatic artery, portal vein, vena cava

54 Hepatic artery, bile duct, portal vein

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Vessels of the Porta Hepatis in Transverse Sections

24

20

69

21

12 3 17

4 36

17

1 10

96 90

The portal vein runs between the vena cava and hepatic artery.

21 24

20

5 36

3

4

17 10

1 96 90

The hepatic artery runs cephalad into the porta hepatis.

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1  Vessels

70

55 Bile duct, gallbladder, vena cava

56 Bile duct, gallbladder, superior mesenteric vein

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Vessels of the Porta Hepatis in Transverse Sections

22

71

21

24

20 30

40 36

70

18

10 1

96 90

The bile duct is identified medial to the gallbladder and anterior to the vena cava.

21

24 22 40 30

36 10

7

19

1

96

20 90

The bile duct runs parallel to the superior mesenteric vein for a short distance, then turns laterally to the right toward the papilla.

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Liver in Longitudinal Sections … p. 74 57 58 59 60 61 62 63 64 65 66 67 68 69 70

Left lobe of liver, lateral segment, subsegments II and III Left lobe of liver, ligamentum teres, boundary between lateral and medial segments Left lobe of liver, ligamentum teres, boundary between lateral and medial segments Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe Medial segment, subsegment IV, quadrate lobe Gallbladder, portal vein, vena cava, boundary between medial and anterior segments Middle hepatic vein, boundary between medial and anterior segments Anterior segment, subsegments VIII and V Right hepatic vein, boundary between anterior and posterior segments Posterior segment, subsegments VII and VI Posterior segment, lateral portions of liver, kidney

Left Portions of the Liver in Transverse Sections … p. 88 71 72 73 74 75 76 77 78

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Left lobe of liver, lateral segment, heart Left lobe of liver, lateral segment, heart Left lobe of liver, lateral segment, hepatic veins Left lobe of liver, lateral segment, caudate lobe Left lobe of liver, lateral segment, caudate lobe Left lobe of liver, lateral segment, left portal vein branch Left lobe of liver, lateral segment, ligamentum teres Left lobe of liver, subsegment III, ligamentum teres

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Central Portions of the Liver in Transverse Sections … p. 96 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96

Medial and anterior hepatic segments, opening of hepatic veins Medial and anterior hepatic segments, opening of hepatic veins Medial and anterior hepatic segments, hepatic veins, caudate lobe Medial and anterior hepatic segments, hepatic veins, caudate lobe Medial and anterior hepatic segments, caudate lobe Medial and anterior hepatic segments, left portal vein branch, caudate lobe Medial and anterior hepatic segments, left portal vein branch, caudate lobe Medial and anterior hepatic segments, left portal vein branch, caudate lobe Medial and anterior hepatic segments, bifurcation of portal vein Medial and anterior hepatic segments, bifurcation of portal vein Medial and anterior hepatic segments, right portal vein branch Medial and anterior hepatic segments, right and left portal vein branches Medial and anterior hepatic segments, right and left portal vein branches Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, portal vein Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, portal vein Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, gallbladder Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, gallbladder Inferior border of liver, kidney, gallbladder, ligamentum teres

Right Portions of the Liver in Transverse Sections … p. 114 97 98 99 100

Posterior segment, upper subsegment Posterior segment, portal vein Posterior segment, caudal subsegment, kidney Posterior segment, inferior border

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2  Liver

74

57 Left lobe of liver, lateral segment, subsegments II and III

58 Left lobe of liver, ligamentum teres, boundary between lateral and medial segments

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Liver in Longitudinal Sections

II

75

III 21, 26 70 94 18 43

The liver is divided into a left and a right lobe on anatomical criteria. The left lobe corresponds to the lateral segment; the right lobe consists of the medial, anterior, and posterior segments.

III II 73

21 98 45

42 74

93, 94

18

On functional criteria, the lateral and medial segments belong to the left lobe of the liver while the anterior and posterior segments belong to the right lobe.

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2  Liver

76

59 Left lobe of liver, ligamentum teres, boundary between lateral and medial segments

60 Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe

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Liver in Longitudinal Sections

77

II 21

III

73

42 98

5 7

3

74

18

15

1 90

The lateral segment is composed of subsegment II cranially and subsegment III caudally.

21

III

II

93

24 70

25

11 23

92

93 I

17

92

10 96

The boundary between the lateral and medial segments, i.e., between the anatomical left and right lobes of the liver, is the left hepatic vein.

Block_engl_02.indd 77

25.08.2011 14:09:40

2  Liver

78

61 Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe

62 Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe

Block_engl_02.indd 78

25.08.2011 14:09:40

Liver in Longitudinal Sections

IV

21

79

24

17 4

11 23

I

41

17

25

10

90

The caudate lobe corresponds to subsegment I of the medial segment and is located lateral and anterior to the vena cava. Most of the medial segment consists of subsegment IV.

24

20 IV

22

17 17

11

41

23 I 10

90

The boundary between the lateral and medial segments, i.e., between the anatomical left and right lobes of the liver, is the ligamentum teres.

Block_engl_02.indd 79

25.08.2011 14:09:41

2  Liver

80

63 Left hepatic vein, ligamentum teres, boundary between lateral and medial segments, caudate lobe

64 Medial segment, subsegment IV, quadrate lobe

Block_engl_02.indd 80

25.08.2011 14:09:41

Liver in Longitudinal Sections

81

24

IV 17

41 17 10

90

Ligamentum teres (the obliterated umbilical vein) extends from the left portal vein branch to the anterior inferior border of the liver.

20 22 IV 17 17 96

93 10

The caudal part of the medial segment, the quadrate lobe, is situated between ligamentum teres and the gallbladder. The quadrate lobe is part of subsegment IV.

Block_engl_02.indd 81

25.08.2011 14:09:41

2  Liver

82

65 Gallbladder, portal vein, vena cava, boundary between medial and anterior segments

66 Middle hepatic vein, boundary between medial and anterior segments

Block_engl_02.indd 82

25.08.2011 14:09:41

Liver in Longitudinal Sections

27

83

22 IV 30 17

10

93 94

The plane of the gallbladder and vena cava forms the boundary plane between the medial and anterior segments of the liver.

20

12 17 10

10 14

The middle hepatic vein marks the boundary between the medial and anterior segments in the cranial part of the liver.

Block_engl_02.indd 83

25.08.2011 14:09:41

2  Liver

84

67 Anterior segment, subsegments VIII and V

68 Right hepatic vein, boundary between anterior and posterior segments

Block_engl_02.indd 84

25.08.2011 14:09:42

Liver in Longitudinal Sections

28

VIII

85

V

12

17

14

96

78

The anterior segment consists of subsegment VIII cranially and subsegment V caudally.

12 17

13 96

The right hepatic vein and the division of the right portal vein branch mark the boundary plane between the anterior and posterior segments.

Block_engl_02.indd 85

25.08.2011 14:09:42

2  Liver

86

69 Posterior segment, subsegments VII and VI

70 Posterior segment, lateral portions of liver, kidney

Block_engl_02.indd 86

25.08.2011 14:09:42

Liver in Longitudinal Sections

VII

29

87

VI

96

The posterior segment consists of subsegment VII cranially and subsegment VI caudally.

17

29

VI

VII

60

65

The right lobe of the liver is highly variable in its caudal extent.

Block_engl_02.indd 87

25.08.2011 14:09:42

2  Liver

88

71 Left lobe of liver, lateral segment, heart

72 Left lobe of liver, lateral segment, heart

Block_engl_02.indd 88

25.08.2011 14:09:42

Left Portions of the Liver in Transverse Sections

26

89

II 96

98

The left lobe of the liver is in close proximity to the heart, separated from it only by the diaphragm.

26

II

96

97

The anatomical left lobe of the liver corresponds to the lateral hepatic segment.

Block_engl_02.indd 89

25.08.2011 14:09:43

2  Liver

90

73 Left lobe of liver, lateral segment, hepatic veins

74

Block_engl_02.indd 90

Left lobe of liver, lateral segment, caudate lobe

25.08.2011 14:09:43

Left Portions of the Liver in Transverse Sections

91

27 IV 28 VIII

26 II

12 13 29 VII

11 23

25 I

71

10 96

The left hepatic vein marks the boundary between the lateral and medial hepatic segments.

27 IV 11

12 28 VIII 10

26 II

25 23

I

71 93 94

The cranial part of the lateral hepatic segment is designated as subsegment II.

Block_engl_02.indd 91

25.08.2011 14:09:43

2  Liver

92

75 Left lobe of liver, lateral segment, caudate lobe

76 Left lobe of liver, lateral segment, left portal vein branch

Block_engl_02.indd 92

25.08.2011 14:09:43

Left Portions of the Liver in Transverse Sections

93

26 II

27 IV

11 11

12 17

28 VIII

71

23 I

94

74

10

93 1

96

The caudate lobe is considered a separate entity, designated as subsegment I.

27 IV

26 II 17 72

4

93,94

17 43

15 10 96

1

18

In scanning down the left lobe of the liver, the left branch of the portal vein marks the boundary between the cranial and caudal subsegments of the lobe.

Block_engl_02.indd 93

25.08.2011 14:09:43

2  Liver

94

77 Left lobe of liver, lateral segment, ligamentum teres

78 Left lobe of liver, subsegment III, ligamentum teres

Block_engl_02.indd 94

25.08.2011 14:09:43

Left Portions of the Liver in Transverse Sections

95

26 II 27, 22 IV 72

24

45

17 4

42 17

18 7

10

96

93 94

43

15

1

Ligamentum teres arises directly from the left portal vein branch and runs forward and downward.

26 III

24 27, 22 IV

70

15

93, 94

10 1

Ligamentum teres presents a triangular or polygonal shape in cross section. It marks the boundary between subsegment III and the quadrate lobe, which is designated as subsegment IVb.

Block_engl_02.indd 95

25.08.2011 14:09:44

2  Liver

96

79 Medial and anterior hepatic segments, opening of hepatic veins

80 Medial and anterior hepatic segments, opening of hepatic veins

Block_engl_02.indd 96

25.08.2011 14:09:44

Central Portions of the Liver in Transverse Sections

97

VIII IV

II

20

21

10 96

The hepatic veins converge and enter the vena cava just below the diaphragm.

II

VIII

IV

94

13 12 11

VII

10

96

The opening of the hepatic veins at the vena cava forms a typical stellate pattern in transverse section.

Block_engl_02.indd 97

25.08.2011 14:09:44

2  Liver

98

81 Medial and anterior hepatic segments, hepatic veins, caudate lobe

82 Medial and anterior hepatic segments, hepatic veins, caudate lobe

Block_engl_02.indd 98

25.08.2011 14:09:44

Central Portions of the Liver in Transverse Sections

VIII

13

VII

99

II

IV

11

25

12

71

23 I

10

96

The upper pole of the caudate lobe extends to a point just below the opening of the hepatic veins into the vena cava.

IV

VIII

II 11

13

25

12 23 I

VII

71

93

10 93

The three hepatic veins define the boundaries between the lateral, medial, anterior, and posterior segments of the liver.

Block_engl_02.indd 99

25.08.2011 14:09:45

2  Liver

100

83 Medial and anterior hepatic segments, caudate lobe

84 Medial and anterior hepatic segments, left portal vein branch, caudate lobe

Block_engl_02.indd 100

25.08.2011 14:09:45

Central Portions of the Liver in Transverse Sections

VIII

11

IV

12

II

25

13

101

71

23 I

93

10

VII

94

Ligamentum venosum separates the caudate lobe from subsegment II of the lateral hepatic segment.

11

IV

VIII 12 13

17

II

25

23 I

72

10 VII

1 96 90

The caudate lobe of the liver is designated as subsegment I.

Block_engl_02.indd 101

25.08.2011 14:09:45

2  Liver

102

85 Medial and anterior hepatic segments, left portal vein branch, caudate lobe

86 Medial and anterior hepatic segments, left portal vein branch, caudate lobe

Block_engl_02.indd 102

25.08.2011 14:09:45

Central Portions of the Liver in Transverse Sections

II

IV

VIII

103

11 12

17 72

23 I

13 10

1 96

VII

90

The caudate lobe is interposed between the vena cava and left portal vein branch.

II IV

VIII

11

12 17

VII

17 3 1

10 96 90

The upper subsegments of the lateral and medial hepatic segments are designated as subsegment II and subsegment IVa, respectively.

Block_engl_02.indd 103

25.08.2011 14:09:45

2  Liver

104

87 Medial and anterior hepatic segments, bifurcation of portal vein

88 Medial and anterior hepatic segments, bifurcation of portal vein

Block_engl_02.indd 104

25.08.2011 14:09:46

Central Portions of the Liver in Transverse Sections

105

II IV

VIII

11

17 12

4

17

7 10

1

96

VII 90

The upper subsegments of the anterior and posterior hepatic segments are designated as subsegments VIII and VII.

II

IV

VIII

11

17

12 17

4 10

VII

7

5 43

1 96 90

The bifurcation of the portal vein is located just anterior to the vena cava.

Block_engl_02.indd 105

25.08.2011 14:09:46

2  Liver

106

89 Medial and anterior hepatic segments, right portal vein branch

90 Medial and anterior hepatic segments, right and left portal vein branches

Block_engl_02.indd 106

25.08.2011 14:09:46

Central Portions of the Liver in Transverse Sections

107

IV

VIII

II 17

12

11 4

17

7 10 VII

5

43

1 96 90

The division of the portal vein into right and left branches marks the approximate boundary between the upper and lower subsegments.

II VIII

IV

17

4

17

7

18

43

15 10

1

VII 90

The division of the portal vein into right and left branches shows an antler-like configuration on ultrasound.

Block_engl_02.indd 107

25.08.2011 14:09:46

2  Liver

108

91 Medial and anterior hepatic segments, right and left portal vein branches

92 Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, portal vein

Block_engl_02.indd 108

25.08.2011 14:09:46

Central Portions of the Liver in Transverse Sections

IV

VIII

109

II

17

22 17 7

15

10

43 18

1

VII 90

The right portal vein branch initially runs slightly caudally from the bifurcation.

22 V

24

III

IV

70 18

17 10

7

43

15 1

9

VI 90

Ligamentum teres marks the boundary plane between the right and left lobes of the liver.

Block_engl_02.indd 109

25.08.2011 14:09:47

2  Liver

110

93 Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, portal vein

94 Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, gallbladder

Block_engl_02.indd 110

25.08.2011 14:09:47

Central Portions of the Liver in Transverse Sections

111

III V

24 22 IV

70 18 43

10 VI

7

1

14

90

The lower subsegments of the lateral, medial, anterior, and posterior hepatic segments are designated, respectively, subsegments III, IVb, V, and VI.

22 IV

V

III 24

30 VI

76

14

10

70

42 19

94 1

The gallbladder and ligamentum teres form the boundary structures of the quadrate lobe in transverse section.

Block_engl_02.indd 111

25.08.2011 14:09:47

2  Liver

112

95 Medial and anterior hepatic segments, quadrate lobe, ligamentum teres, gallbladder

96 Inferior border of liver, kidney, gallbladder, ligamentum teres

Block_engl_02.indd 112

25.08.2011 14:09:47

Central Portions of the Liver in Transverse Sections

III

24 V

22 IV 30

73 76

17 VI

113

42 19

41

10 1

14

The vena cava–gallbladder plane marks the boundary between the right and left lobes of the liver based on functional criteria.

22 IV

V

III

24 77

30 VI 94

60

The shape of the inferior hepatic border is influenced by the kidney, the gallbladder, and the groove for ligamentum teres.

Block_engl_02.indd 113

25.08.2011 14:09:48

2  Liver

114

97 Posterior segment, upper subsegment

98 Posterior segment, portal vein

Block_engl_02.indd 114

25.08.2011 14:09:48

Right Portions of the Liver in Transverse Sections

115

VIII, 28 VII, 29

12

13

11 10

96

The upper subsegment of the posterior hepatic segment is designated as subsegment VII.

77

17

20, 29

10

96

The right portal vein branch marks the approximate boundary between subsegment VII cranially and subsegment V caudally.

Block_engl_02.indd 115

25.08.2011 14:09:48

2  Liver

116

99 Posterior segment, lower subsegment, kidney

100 Posterior segment, inferior border

Block_engl_02.indd 116

25.08.2011 14:09:48

Right Portions of the Liver in Transverse Sections

117

29 VI

77 14

60

10

The lower subsegment of the posterior hepatic segment is designated as subsegment VI.

29 VI 77 8

10

60

The right lobe of the liver is highly variable in its inferior extent.

Block_engl_02.indd 117

25.08.2011 14:09:48

Gallbladder in Upper Abdominal Transverse Scans from Above Downward … p. 120 101 102 103 104 105 106

Right branch of the portal vein, ligamentum venosum Portal vein, ligamentum venosum Neck of the gallbladder Junction of the neck and body of the gallbladder Body of the gallbladder Gallbladder fundus

Gallbladder in Upper Abdominal Longitudinal Scans from Left to Right … p. 126 107 108 109 110 111 112

Vena cava, duodenum, portal vein bifurcation Body of the gallbladder, portal vein bifurcation Gallbladder, portal vein Gallbladder, portal vein Gallbladder, portal vein, right kidney Gallbladder fundus, right kidney

Gallbladder in Transverse Flank Scans from Above Downward … p. 132

113 114 115 116

Gallbladder neck, duodenum, right kidney Gallbladder neck, small bowel, right kidney Gallbladder body, small bowel, right kidney Gallbladder fundus, small bowel

Gallbladder in Longitudinal Flank Scans from Posterior to Anterior … p. 136 117 118 119 120

Block_engl_03.indd 118

Right kidney, liver Gallbladder, liver Gallbladder, liver Gallbladder, liver

25.08.2011 14:10:07

Details of Gallbladder … p. 140 121 Regions of the gallbladder, Heister valves 122 Layered structure of the gallbladder wall Bile Ducts in Upper Abdominal Transverse Scans From Above Downward … p. 142 123 124 125 126 127 128

Common duct, hepatic artery, splenic vein Common duct, hepatic artery, splenic vein Common duct, hepatic artery Common duct, hepatic artery Common duct, hepatic artery Common duct, head of pancreas

Bile Ducts in Upper Abdominal Longitudinal Scans from Right to Left … p. 148 129 130 131 132

Common duct, portal vein, hepatic artery Common duct, hepatic artery, portal vein Common duct, hepatic artery, portal vein Common duct, head of pancreas

Block_engl_03.indd 119

25.08.2011 14:10:07

3  Gallbladder

120

101 Right branch of the portal vein, ligamentum venosum

102 Portal vein, ligamentum venosum

Block_engl_03.indd 120

25.08.2011 14:10:07

Gallbladder in Upper Abdominal Transverse Scans from Above Downward

20

121

73

*

4

17

96

10

The interlobar fissure (*) anterior to the right branch of the portal vein is the key landmark for locating the gallbladder.

20 37 17

76 10

1

The gallbladder neck is located just caudal to the right portal vein branch and interlobar fissure.

Block_engl_03.indd 121

25.08.2011 14:10:08

3  Gallbladder

122

103 Neck of the gallbladder

104 Junction of the neck and body of the gallbladder

Block_engl_03.indd 122

25.08.2011 14:10:08

Gallbladder in Upper Abdominal Transverse Scans from Above Downward

123

76

33

19

20 10

1

The duodenum is located medial to the neck of the gallbladder.

20 32

76

40

19

1

10

90

The duodenal bulb can be consistently identified on the free peritoneal side of the body or neck of the gallbladder.

Block_engl_03.indd 123

25.08.2011 14:10:08

3  Gallbladder

124

105 Body of the gallbladder

106 Gallbladder fundus

Block_engl_03.indd 124

25.08.2011 14:10:08

Gallbladder in Upper Abdominal Transverse Scans from Above Downward

32

20

76

125

92

10

60

The duodenum passes between the body of the gallbladder and the vena cava.

93 31

20

60

The gallbladder fundus may extend almost to the anterior wall of the trunk, or it may be situated very deeply behind the liver.

Block_engl_03.indd 125

25.08.2011 14:10:09

3  Gallbladder

126

107 Vena cava, duodenum, portal vein bifurcation

108 Body of the gallbladder, portal vein bifurcation

Block_engl_03.indd 126

25.08.2011 14:10:09

Gallbladder in Upper Abdominal Longitudinal Scans from Left to Right

20

127

73

17 17

76

10

The vena cava, the portal vein bifurcation, and the echogenic band of the interlobar fissure are the principal landmarks for locating the gallbladder in longitudinal scans.

20 17 30 17 10

76

The duodenum is located posterior to the gallbladder and caudal to the right colic flexure.

Block_engl_03.indd 127

25.08.2011 14:10:09

3  Gallbladder

128

109 Gallbladder, portal vein

110

Block_engl_03.indd 128

Gallbladder, portal vein

25.08.2011 14:10:09

Gallbladder in Upper Abdominal Longitudinal Scans from Left to Right

129

20 17 30

76

17 10

The shape and location of the gallbladder are highly variable. But the gallbladder neck is always located in the porta hepatis, caudal to the right branch of the portal vein.

20

30 17

76

10

The healthy gallbladder is a fluid-filled organ, usually pear-shaped, that does not contain internal echoes.

Block_engl_03.indd 129

25.08.2011 14:10:09

3  Gallbladder

130

Block_engl_03.indd 130

111

Gallbladder, portal vein, right kidney

112

Gallbladder fundus, right kidney

25.08.2011 14:10:09

Gallbladder in Upper Abdominal Longitudinal Scans from Left to Right

131

20 30 77

17

60

A variable-sized piece of liver is interposed between the gallbladder and kidney.

20

30

14 60

The gallbladder always borders directly on the right kidney, but it may appear separate from the kidney when scanned through its lateral portion.

Block_engl_03.indd 131

25.08.2011 14:10:10

3  Gallbladder

132

Block_engl_03.indd 132

113

Gallbladder neck, duodenum, right kidney

114

Gallbladder neck, small bowel, right kidney

25.08.2011 14:10:10

Gallbladder in Transverse Flank Scans from Above Downward

133

60 20 14 33 76

The gallbladder neck is identified at the level of the kidney in a high lateral transverse scan.

60 20

95 77

32

A scan through the gallbladder from the lateral side typically displays the triad of the gallbladder, kidney, and liver.

Block_engl_03.indd 133

25.08.2011 14:10:10

3  Gallbladder

134

Block_engl_03.indd 134

115

Gallbladder body, small bowel, right kidney

116

Gallbladder fundus, small bowel

25.08.2011 14:10:10

Gallbladder in Transverse Flank Scans from Above Downward

135

60 20

95

77 32

The gallbladder is often obscured by bowel gas when scanned from the lateral side.

60

95

20

77 31

The gallbladder fundus may extend downward for some distance.

Block_engl_03.indd 135

25.08.2011 14:10:10

3  Gallbladder

136

Block_engl_03.indd 136

117

Right kidney, liver

118

Gallbladder, liver

25.08.2011 14:10:11

Gallbladder in Longitudinal Flank Scans from Posterior to Anterior

137

20 60

The kidney is the key landmark for locating the gallbladder in the lateral longitudinal scan.

20

30

The gallbladder is consistently displayed anterior to the right kidney.

Block_engl_03.indd 137

25.08.2011 14:10:11

3  Gallbladder

138

119

Gallbladder, liver

120 Gallbladder, liver

Block_engl_03.indd 138

25.08.2011 14:10:11

Gallbladder in Longitudinal Flank Scans from Posterior to Anterior

139

20

30

The gallbladder directly abuts the liver posteriorly.

20

30

In most cases the gallbladder can be completely surveyed in a series of lateral longitudinal scans.

Block_engl_03.indd 139

25.08.2011 14:10:11

3  Gallbladder

140

121 Regions of the gallbladder, Heister valves

122 Layered structure of the gallbladder wall

Block_engl_03.indd 140

25.08.2011 14:10:11

Details of Gallbladder

141

78 20

33

31

34 32

17

94

60 20

35 14

The Heister valves and gallbladder neck can often be clearly identified in a longitudinal scan over the gallbladder.

78

20 94

30 76 94

The anterior wall of the gallbladder displays three distinct layers. Usually its posterior wall is poorly delineated from the duodenum.

Block_engl_03.indd 141

25.08.2011 14:10:11

3  Gallbladder

142

123 Common duct, hepatic artery, splenic vein

124 Common duct, hepatic artery, splenic vein

Block_engl_03.indd 142

25.08.2011 14:10:12

Bile Ducts in Upper Abdominal Transverse Scans From Above Downward

21

4

36

143

18 1 10 20 90

The common duct is located just anterior to the portal vein.

21

4 7

18 36 20

10

1 96 90

An upper abdominal longitudinal scan over the porta hepatis displays a longitudinal section of the common duct and a cross section of the hepatic artery.

Block_engl_03.indd 143

25.08.2011 14:10:12

3  Gallbladder

144

125 Common duct, hepatic artery

126 Common duct, hepatic artery

Block_engl_03.indd 144

25.08.2011 14:10:12

Bile Ducts in Upper Abdominal Transverse Scans From Above Downward

21 36

145

7

4

1

10 96 20

90

A portion of the common duct runs parallel and anterior to the vena cava.

18

21

7

4 20

36

10

1 96

90

In most cases the common duct can be clearly traced into the head of the pancreas.

Block_engl_03.indd 145

25.08.2011 14:10:12

3  Gallbladder

146

127 Common duct, hepatic artery

128 Common duct, head of pancreas

Block_engl_03.indd 146

25.08.2011 14:10:12

Bile Ducts in Upper Abdominal Transverse Scans From Above Downward

147

21 4

15

30

1 10

36

90

20

The common duct and hepatic artery are initially parallel to each other in the porta hepatis. The common duct is lateral, the artery medial.

21 30

20

76

36

41

19 7

10 1

90

Below the porta hepatis, the common duct runs downward while the hepatic artery curves into the field from the medial side.

Block_engl_03.indd 147

25.08.2011 14:10:13

3  Gallbladder

148

129 Common duct, portal vein, hepatic artery

130 Common duct, hepatic artery, portal vein

Block_engl_03.indd 148

25.08.2011 14:10:13

Bile Ducts in Upper Abdominal Longitudinal Scans from Right to Left

93

4

36

149

17

10

20

The common duct appears anterior and slightly lateral to the vena cava.

20

36 4

17 10 8

The common duct angles slightly toward the lateral side as it descends.

Block_engl_03.indd 149

25.08.2011 14:10:13

3  Gallbladder

150

131

Common duct, hepatic artery, portal vein

132 Common duct, head of pancreas

Block_engl_03.indd 150

25.08.2011 14:10:13

Bile Ducts in Upper Abdominal Longitudinal Scans from Right to Left

151

20 4

36

17

8

10

In most cases the rounded cross section of the common duct can be clearly identified above the pancreatic head.

20 36

41

10

8

The common duct is clearly visible anterior to the vena cava at the level of the pancreatic head.

Block_engl_03.indd 151

25.08.2011 14:10:13

Pancreas in Longitudinal Sections … p. 154 133 134 135 136 137 138 139 140 141 142 143 144

Duodenum lateral to head of pancreas Head of pancreas, bile duct Head of pancreas, bile duct Head of pancreas, hilar vessels, vena cava Head of pancreas, superior mesenteric vein, uncinate process Head of pancreas, superior mesenteric vein, uncinate process Body of pancreas, splenic vein Body of pancreas, splenic vein, superior mesenteric artery, aorta Body of pancreas, splenic vein Tail of pancreas, splenic artery and vein, renal artery and vein Tail of pancreas, splenic artery and vein, renal artery and vein Tail of pancreas

Head of the Pancreas in Transverse Sections … p. 166 145 146 147 148

Section cranial to head of pancreas, vena cava, splenic vein Head of pancreas, vena cava, superior mesenteric vein Head of pancreas, vena cava, superior mesenteric vein, uncinate process, common bile duct Head of pancreas, vena cava, superior mesenteric vein, uncinate process, gallbladder

Body of the Pancreas in Transverse Sections … p. 170 149 150 151 152

Block_engl_04.indd 152

Scan cranial to body of pancreas, celiac trunk Body of pancreas, splenic vein Body of pancreas, splenic vein, superior mesenteric artery, aorta Left renal artery and vein, superior mesenteric artery and vein, aorta

25.08.2011 14:10:30

Tail of the Pancreas in Transverse Sections … p. 174 153 154 155 156

Tail of pancreas, splenic artery Tail of pancreas, splenic vein Tail of pancreas, gas in stomach Tail of pancreas

Transsplenic View of the Tail of the Pancreas in Longitudinal Sections … p. 178 157 158 159 160

Scan posterior to tail of pancreas, spleen, kidney Spleen, tail of pancreas, kidney Spleen, tail of pancreas, kidney Scan anterior to tail of pancreas, spleen, stomach

Transsplenic View of the Tail of the Pancreas in Transverse Sections … p. 182 161 Spleen, tail of pancreas, kidney 162 Spleen, tail of pancreas, kidney Details of the Pancreas … p. 184 163 Transverse scan of pancreatic duct 164 Longitudinal scan of pancreatic duct

Block_engl_04.indd 153

25.08.2011 14:10:30

4  Pancreas

154

133 Duodenum lateral to head of pancreas

134 Head of pancreas, bile duct

Block_engl_04.indd 154

25.08.2011 14:10:30

Pancreas in Longitudinal Sections

73

20

17

155

76

36

The head of the pancreas lies in the duodenal loop of the duodenum and is bounded laterally by the duodenum.

20

73 41

4 17

36 10

The bile duct, hepatic artery, and portal vein are located cranial to the head of the pancreas.

Block_engl_04.indd 155

25.08.2011 14:10:30

4  Pancreas

156

135 Head of pancreas, bile duct

136 Head of pancreas, hilar vessels, vena cava

Block_engl_04.indd 156

25.08.2011 14:10:30

Pancreas in Longitudinal Sections

73

22

4 17

23

157

41

36

10

The bile duct runs posteriorly in the head of the pancreas to the papilla, which usually cannot be visualized with ultrasound.

70 22 4

41

17 10 8 90 92

The head of the pancreas lies against the anterior surface of the vena cava and is bordered cranially by the main trunk of the portal vein.

Block_engl_04.indd 157

25.08.2011 14:10:30

4  Pancreas

158

137 Head of pancreas, superior mesenteric vein, uncinate process

138

Block_engl_04.indd 158

Head of pancreas, superior mesenteric vein, uncinate process

25.08.2011 14:10:31

Pancreas in Longitudinal Sections

22

41

19

4 44

17 23

10

159

94

8 90

The uncinate process runs posteriorly around the mesenteric vein, coming between that vessel and the vena cava.

22 4 10

41 19

44

94

8

90

The superior mesenteric vein marks the boundary between the head and body of the pancreas.

Block_engl_04.indd 159

25.08.2011 14:10:31

4  Pancreas

160

139 Body of pancreas, splenic vein

140 ody of pancreas, splenic vein, superior mesenteric artery, aorta

Block_engl_04.indd 160

25.08.2011 14:10:31

Pancreas in Longitudinal Sections

161

42

22 4

18

19

96 1

90

The body of the pancreas is the narrowest part of the organ in its ventrodorsal dimension.

70 21 3 1

42 18

7

15

90

The celiac trunk is cranially adjacent to the body of the pancreas. The splenic vein and body of the pancreas cross over the superior mesenteric artery.

Block_engl_04.indd 161

25.08.2011 14:10:31

4  Pancreas

162

141

Body of pancreas, splenic vein

142 Tail of pancreas, splenic artery and vein, renal artery and vein

Block_engl_04.indd 162

25.08.2011 14:10:31

Pancreas in Longitudinal Sections

163

70 21

42

6

9

15

18

5

The left margin of the aorta marks the junction between the body and tail of the pancreas.

21

6

43 5 9

18 15

A longitudinal scan at the junction of the body and tail of the pancreas displays four vessels in cross section: the splenic artery, splenic vein, renal artery, and renal vein.

Block_engl_04.indd 163

25.08.2011 14:10:32

4  Pancreas

164

143 Tail of pancreas, splenic artery and vein, renal artery and vein

144 Tail of pancreas

Block_engl_04.indd 164

25.08.2011 14:10:32

Pancreas in Longitudinal Sections

165

21 43 74

6

5

18 9

15

The tail of the pancreas often has a plump appearance in cross section.

21

43

15

The tail of the pancreas can be completely visualized in an anterior scan only if acoustic conditions are good.

Block_engl_04.indd 165

25.08.2011 14:10:32

4  Pancreas

166

145 Section cranial to head of pancreas, vena cava, splenic vein

146 Head of pancreas, vena cava, superior mesenteric vein

Block_engl_04.indd 166

25.08.2011 14:10:32

Head of the Pancreas in Transverse Sections

167

21 42

22 18 20

10

43

1

90

The body of the pancreas overlies the superior mesenteric vein. All parts of the gland that lie to the right of the superior mesenteric vein are designated as the head of the pancreas.

21 22

36

20

41 19 44 10

94

1

60 90

The uncinate process extends between the vena cava and superior mesenteric vein.

Block_engl_04.indd 167

25.08.2011 14:10:32

4  Pancreas

168

147 Head of pancreas, vena cava, superior mesenteric vein, uncinate process, common bile duct

148 Head of pancreas, vena cava, superior mesenteric vein, uncinate process, gallbladder

Block_engl_04.indd 168

25.08.2011 14:10:32

Head of the Pancreas in Transverse Sections

169

21 22 41

30 36

20

10

19

1

60

94

90

The common bile duct is visible at the right border of the pancreatic head in transverse section.

21

22 30

41

20

19 44

36

60

70

10

1

94

90

The head of the pancreas lies between the liver, gallbladder, vena cava, and superior mesenteric vein.

Block_engl_04.indd 169

25.08.2011 14:10:33

4  Pancreas

170

149 Scan cranial to body of pancreas, celiac trunk

150 Body of pancreas, splenic vein

Block_engl_04.indd 170

25.08.2011 14:10:33

Body of the Pancreas in Transverse Sections

171

70 21 43 17

3

4 10

5 94

1

90

The body of the pancreas is bounded cranially by the celiac trunk and its two branches, the hepatic artery and splenic artery.

21

4 17

41

42 7

36 10

70

1

5

43

90

The borders of the healthy pancreas form a continuous outline from head to body to tail.

Block_engl_04.indd 171

25.08.2011 14:10:33

4  Pancreas

172

151 Body of pancreas, splenic vein, superior mesenteric artery, aorta

152 Left renal artery and vein, superior mesenteric artery and vein, aorta

Block_engl_04.indd 172

25.08.2011 14:10:33

Body of the Pancreas in Transverse Sections

21

173

70 42

45 41

7

44

18

43

1

10

90

The splenic vein is the landmark for locating the pancreas. The superior mesenteric artery lies between the splenic vein and the aorta, appearing as an echo-free spot surrounded by bright echoes.

21

7

70 18

1

10

15 9

90

When the renal vessels are displayed in a transverse scan, usually the pancreas is no longer visualized.

Block_engl_04.indd 173

25.08.2011 14:10:33

4  Pancreas

174

153 Tail of pancreas, splenic artery

154 Tail of pancreas, splenic vein

Block_engl_04.indd 174

25.08.2011 14:10:33

Tail of the Pancreas in Transverse Sections

175

21 5 94

10

1

43

90

The tail of the pancreas is located well posteriorly, on the left side of the aorta.

21 4

94 3 18

10

43

1

90

The tail of the pancreas is angled sharply posterior from the body and extends a variable distance between the stomach and the upper renal pole toward the splenic hilum.

Block_engl_04.indd 175

25.08.2011 14:10:34

4  Pancreas

176

155 Tail of pancreas, gas in stomach

156 Tail of pancreas

Block_engl_04.indd 176

25.08.2011 14:10:34

Tail of the Pancreas in Transverse Sections

21

42

70

18

45

10

177

1

94

43

90

The junction between the body and tail of the pancreas is located at the level of the left aortic margin.

70 42

18 10

1

43

94

90

The tail of the pancreas is the most difficult part of the gland to evaluate with ultrasound.

Block_engl_04.indd 177

25.08.2011 14:10:34

4  Pancreas

178

157 Scan posterior to tail of pancreas, spleen, kidney

158 Spleen, tail of pancreas, kidney

Block_engl_04.indd 178

25.08.2011 14:10:34

Transsplenic View of the Tail of the Pancreas in Longitudinal Sections

179

50

61

The tail of the pancreas is scanned intercostally through the spleen. Kidney and spleen serve as landmarks.

50

43

61 18

The tail of the pancreas is located in the splenic hilum between the spleen and the kidney.

Block_engl_04.indd 179

25.08.2011 14:10:34

4  Pancreas

180

159 Spleen, tail of pancreas, kidney

160 Scan anterior to tail of pancreas, spleen, stomach

Block_engl_04.indd 180

25.08.2011 14:10:34

Transsplenic View of the Tail of the Pancreas in Longitudinal Sections

181

79

50

94

43 18 15

Interference from bowel gas is often encountered caudal to the tail of the pancreas.

18

50

70

The stomach is a source of numerous artifacts anterior to the tail of the pancreas.

Block_engl_04.indd 181

25.08.2011 14:10:34

4  Pancreas

182

161 Spleen, tail of pancreas, kidney

162 Spleen, tail of pancreas, kidney

Block_engl_04.indd 182

25.08.2011 14:10:35

Transsplenic View of the Tail of the Pancreas in Transverse Sections

50

18

183

61

70 15 43 94

In transverse sections as well, the spleen is used as an acoustic window for scanning the tail of the pancreas.

70 43 94

15 61

The tail of the pancreas lies in an angle between the spleen and the kidney.

Block_engl_04.indd 183

25.08.2011 14:10:35

4  Pancreas

184

163 Transverse scan of pancreatic duct

164 Longitudinal scan of pancreatic duct

Block_engl_04.indd 184

25.08.2011 14:10:35

Details of the Pancreas

24

185

21 70

22

30 20 41

45

42

19

94 43

44

The pancreatic duct has a variable course. It usually runs in the ventrocranial part of the parenchyma, appearing sonographically as two parallel echogenic lines.

24 94

70 20

21 94 45 42 5

18

In this plane the pancreatic duct appears as a fine, tubular structure with a luminal diameter up to 3 mm. It is located slightly anterior to the center of the gland.

Block_engl_04.indd 185

25.08.2011 14:10:35

Block_engl_05.indd 186

25.08.2011 14:10:49

Longitudinal Flank Scans of the Spleen … p. 188 165 166 167 168

Spleen, kidney Splenic hilum, splenic vein Spleen, stomach Spleen, stomach

Transverse Flank Scans of the Spleen … p. 192 169 170 171 172

Spleen, kidney, stomach Spleen, kidney, pancreas Spleen, stomach Spleen, small bowel

Details of the Spleen … p. 196 173 Accessory spleen 174 Accessory spleen

Block_engl_05.indd 187

25.08.2011 14:10:49

5  Spleen

188

165 Spleen, kidney

166 Splenic hilum, splenic vein

Block_engl_05.indd 188

25.08.2011 14:10:49

Longitudinal Flank Scans of the Spleen

189

79

50

61

The spleen is identified in the longitudinal flank scan as a rounded triangle between the upper renal pole and the diaphragm.

50 94 18

96

A flank scan at the level of the hilum displays the spleen in its greatest longitudinal dimension.

Block_engl_05.indd 189

25.08.2011 14:10:50

5  Spleen

190

167 Spleen, stomach

168 Spleen, stomach

Block_engl_05.indd 190

25.08.2011 14:10:50

Longitudinal Flank Scans of the Spleen

191

94 18

50 71

96

The spleen lies against the stomach anteriorly and medially.

50

71

94 96

The spleen exhibits a typical crescent shape in an anterior flank scan.

Block_engl_05.indd 191

25.08.2011 14:10:50

5  Spleen

192

169 Spleen, kidney, stomach

170 Spleen, kidney, pancreas

Block_engl_05.indd 192

25.08.2011 14:10:50

Transverse Flank Scans of the Spleen

92

193

50

70

94

61 43

A high transverse flank scan demonstrates the typical triad of the spleen, kidney, and stomach.

92 70

50

94 43

61

18

The tail of the pancreas can usually be identified in the splenic hilum next to the splenic vessels.

Block_engl_05.indd 193

25.08.2011 14:10:50

5  Spleen

194

171 Spleen, stomach

172 Spleen, small bowel

Block_engl_05.indd 194

25.08.2011 14:10:50

Transverse Flank Scans of the Spleen

195

70 50 92 92

18

94

61

The spleen may be deeply lobulated by septa.

50

92

92 77 61

Loops of small bowel are located medial to the lower pole of the spleen.

Block_engl_05.indd 195

25.08.2011 14:10:51

5  Spleen

196

173 Accessory spleen

174

Block_engl_05.indd 196

Accessory spleen

25.08.2011 14:10:51

Details of the Spleen

197

50 51

18

Accessory spleens are most commonly found in the hilar region.

50

51

94 61

An accessory spleen is occasionally found at the lower pole.

Block_engl_05.indd 197

25.08.2011 14:10:51

Longitundinal Flank Scans of the Right Kidney from Posterior to Anterior … p. 200 175 176 177 178

Kidney, liver, psoas muscle Kidney, liver, psoas muscle Kidney, liver, psoas muscle Kidney, right renal vein

Transverse Flank Scans of the Right Kidney from Above Downward … p. 204 179 180 181 182

Kidney, liver Kidney, liver, right renal vein Kidney, liver Kidney, liver

Upper Abdominal Longitudinal Scans of the Right Kidney from Right to Left … p. 208 183 184 185 186

Kidney, liver Kidney, liver Kidney, liver, renal cyst Kidney, liver, renal cyst

Upper Abdominal Transverse Scans of the Right Kidney from Above Downward … p. 212 187 188 189 190

Block_engl_06.indd 198

Kidney, right renal vein, vena cava Kidney, right renal vein, vena cava, right renal artery Kidneys, right renal artery Kidney, spleen, psoas muscle

25.08.2011 14:11:06

Longitudinal Flank Scans of the Left Kidney from Posterior to Anterior … p. 216 191 192 193 194

Kidney, spleen, psoas muscle Kidney, spleen, psoas muscle Kidney, spleen, psoas muscle Kidney, renal vein, spleen, aorta

Transverse Flank Scans of the Left Kidney from Above Downward … p. 220 195 196 197 198

Kidney, spleen, stomach Kidney, left renal artery, spleen, stomach Kidney, right colic flexure Kidney, right colic flexure

Details of the Kidneys … p. 224 199 Medullary pyramids 200 Collecting system

Block_engl_06.indd 199

25.08.2011 14:11:06

6  Kidneys

200

175 Kidney, liver, psoas muscle

176 Kidney, liver, psoas muscle

Block_engl_06.indd 200

25.08.2011 14:11:06

Longitundinal Flank Scans of the Right Kidney from Posterior to Anterior

201

20 60

95

90

The right kidney is clearly demonstrated through the acoustic window of the liver.

60

95

90

The kidneys slide downward along the lumbar muscles during respiratory excursions.

Block_engl_06.indd 201

25.08.2011 14:11:06

6  Kidneys

202

177 Kidney, liver, psoas muscle

178 Kidney, right renal vein

Block_engl_06.indd 202

25.08.2011 14:11:06

Longitundinal Flank Scans of the Right Kidney from Posterior to Anterior

203

20

60

95

The summation of portions of the pelvicalyceal system, blood vessels, lymphatics, fatty tissue, and renal sinus form an echogenic complex at the center of the kidney.

20

60 14 95

The fibrous renal capsule cannot be visualized with ultrasound.

Block_engl_06.indd 203

25.08.2011 14:11:06

6  Kidneys

204

179 Kidney, liver

180 Kidney, liver, right renal vein

Block_engl_06.indd 204

25.08.2011 14:11:07

Transverse Flank Scans of the Right Kidney from Above Downward

205

20 92

92

60

92

The right kidney occupies a posterior site in the angle between the spinal column, muscles, and right lobe of the liver.

20

92

60

14

1

90

Generally the renal hilar vessels can be clearly defined.

Block_engl_06.indd 205

25.08.2011 14:11:07

6  Kidneys

206

181 Kidney, liver

182 Kidney, liver

Block_engl_06.indd 206

25.08.2011 14:11:07

Transverse Flank Scans of the Right Kidney from Above Downward

207

20 92 60

1 95

The psoas muscle is located medial to the kidney.

20

92

60

95

77

1

In most cases the right kidney can be clearly visualized as far as its upper pole when scanned from the lateral side.

Block_engl_06.indd 207

25.08.2011 14:11:07

6  Kidneys

208

183 Kidney, liver

184 Kidney, liver

Block_engl_06.indd 208

25.08.2011 14:11:07

Upper Abdominal Longitudinal Scans of the Right Kidney from Right to Left

209

20

60

Unlike the left kidney, the right kidney can be clearly visualized from the anterior side using the liver as an acoustic window.

20

60 78

The lower pole of the kidney is often obscured by overlying bowel gas.

Block_engl_06.indd 209

25.08.2011 14:11:08

6  Kidneys

210

185 Kidney, liver, *renal cyst

186 Kidney, liver, *renal cyst

Block_engl_06.indd 210

25.08.2011 14:11:08

Upper Abdominal Longitudinal Scans of the Right Kidney from Right to Left

211

20

* 60

Renal cysts are common, irrelevant incidental findings.

20

* 60

An anterior scan will often display the entire right kidney in thin patients.

Block_engl_06.indd 211

25.08.2011 14:11:08

6  Kidneys

212

187 Kidney, right renal vein, vena cava

188 Kidney, right renal vein, vena cava, right renal artery

Block_engl_06.indd 212

25.08.2011 14:11:08

Upper Abdominal Transverse Scans of the Right Kidney from Above Downward

213

20

10

14 60

90

The renal vein enters the vena cava at the level of the renal upper pole.

20

14

8

10

60 90

The renal artery is located posterior and superior to the renal vein, which is noticeably larger than the artery in most patients.

Block_engl_06.indd 213

25.08.2011 14:11:08

6  Kidneys

214

189 Kidneys, right renal artery

190 Kidney, spleen, psoas muscle

Block_engl_06.indd 214

25.08.2011 14:11:09

Upper Abdominal Transverse Scans of the Right Kidney from Above Downward

215

20

77

8 60

95 90

The kidney slides downward on the psoas muscle during inspiration.

20 92 60

77 95 90

The right lobe of the liver extends a variable distance over the right kidney.

Block_engl_06.indd 215

25.08.2011 14:11:09

6  Kidneys

216

191 Kidney, spleen, psoas muscle

192 Kidney, spleen, psoas muscle

Block_engl_06.indd 216

25.08.2011 14:11:09

Longitudinal Flank Scans of the Left Kidney from Posterior to Anterior

50

217

79 61 95

A good acoustic window is not available for scanning the left kidney.

79

50

61

95

The spleen extends laterally to the approximate center of the left kidney.

Block_engl_06.indd 217

25.08.2011 14:11:09

6  Kidneys

218

193 Kidney, spleen, psoas muscle

194 Kidney, renal vein, spleen, aorta

Block_engl_06.indd 218

25.08.2011 14:11:09

Longitudinal Flank Scans of the Left Kidney from Posterior to Anterior

79

50

65

219

94

61

95

The lower half of the left kidney is covered laterally by the descending colon and left colic flexure.

50

79

61

94

15

9 77

1

The aorta appears farthest from the transducer in a longitudinal scan from the left flank.

Block_engl_06.indd 219

25.08.2011 14:11:10

6  Kidneys

220

195 Kidney, spleen, stomach

196 Kidney, left renal artery, spleen, stomach

Block_engl_06.indd 220

25.08.2011 14:11:10

Transverse Flank Scans of the Left Kidney from Above Downward

50

221

92

92

61

70

The ribs are an obstacle to scanning the left kidney through the spleen.

61

50

92 9 70

The renal vessels are often clearly visualized on the left side.

Block_engl_06.indd 221

25.08.2011 14:11:10

6  Kidneys

222

197 Kidney, right colic flexure

198 Kidney, right colic flexure

Block_engl_06.indd 222

25.08.2011 14:11:10

Transverse Flank Scans of the Left Kidney from Above Downward

78

223

61

The lower pole of the left kidney is often difficult to define.

78 61

95

Because the kidney moves with respiratory excursions, it can be fully visualized in most cases despite being partially obscured by bowel gas and ribs.

Block_engl_06.indd 223

25.08.2011 14:11:10

6  Kidneys

224

199 Medullary pyramids

200 Collecting system

Block_engl_06.indd 224

25.08.2011 14:11:11

Details of the Kidneys

225

20 64 64

62

63 65

63

60 95

An imaginary line joining the bases of the hypoechoic medullary pyramids forms a dividing line between the cortical and medullary tissue in the ultrasound image.

20

78

62 64

64 94

65

95

Intense diuresis has caused a bandlike or stellate fluid collection to appear in the renal pelvis.

Block_engl_06.indd 225

25.08.2011 14:11:11

Block_engl_07.indd 226

25.08.2011 14:11:26

Upper Abdominal Longitudinal Scans of the Right Adrenal Gland from Right to Left … p. 228 201 202 203 204

Kidney, liver Kidney, liver Adrenal gland, liver Adrenal gland, vena cava, renal artery

Upper Abdominal Transverse Scans of the Right Adrenal Gland from Below Upward … p. 232 205 206 207 208

Kidney, vena cava Kidney, renal vein, vena cava Renal vein, vena cava Adrenal gland, vena cava

Longitudinal Flank Scans of the Left Adrenal Gland from Back to Front … p. 236 209 210 211 212

Kidney, spleen Adrenal gland, kidney, spleen Adrenal gland, kidney, spleen Spleen, tail of pancreas

Details of the Adrenal Glands … p. 240 213 Layers of adrenal gland 214 Layers of adrenal gland

Block_engl_07.indd 227

25.08.2011 14:11:26

7  Adrenal Glands

228

201 Kidney, liver

202 Kidney, liver

Block_engl_07.indd 228

25.08.2011 14:11:26

Upper Abdominal Longitudinal Scans of the Right Adrenal Gland from Right to Left

229

20

60

95 96

The right adrenal gland is located at the level of the upper renal pole, medial and anterior to the right kidney.

20

60

95 96

In an upper abdominal longitudinal scan from the anterior aspect, the kidney is used as a landmark for locating the right adrenal gland.

Block_engl_07.indd 229

25.08.2011 14:11:26

7  Adrenal Glands

230

203 Adrenal gland, liver

204 Adrenal gland, vena cava, renal artery

Block_engl_07.indd 230

25.08.2011 14:11:26

Upper Abdominal Longitudinal Scans of the Right Adrenal Gland from Right to Left

231

20

69 96

In a scan across the kidney from right to left, when the upper renal pole is just disappearing from the image the region of the right adrenal gland has been located.

20

10

69

96

The right adrenal gland extends behind the vena cava, above the renal vessels.

Block_engl_07.indd 231

25.08.2011 14:11:27

7  Adrenal Glands

232

205 Kidney, vena cava

206 Kidney, renal vein, vena cava

Block_engl_07.indd 232

25.08.2011 14:11:27

Upper Abdominal Transverse Scans of the Right Adrenal Gland from Below Upward

20

233

30 76 10 1

60

90

The landmarks for identifying the right adrenal gland region in transverse section are the kidney, the inferior surface of the liver, and the vena cava.

20

30 77 14

10 1

60

90

The adrenal region is located above the renal hilar vessels.

Block_engl_07.indd 233

25.08.2011 14:11:27

7  Adrenal Glands

234

207 Renal vein, vena cava

208 Adrenal gland, vena cava

Block_engl_07.indd 234

25.08.2011 14:11:27

Upper Abdominal Transverse Scans of the Right Adrenal Gland from Below Upward

235

20

77 10

14

1

90

The right adrenal gland is identified just above the renal pole, lateral and posterior to the vena cava.

20 77 10 1 69 90

The right adrenal gland appears as a narrow, triangular, hypoechoic structure with an echodense rim.

Block_engl_07.indd 235

25.08.2011 14:11:27

7  Adrenal Glands

236

209 Kidney, spleen

210 Adrenal gland, kidney, spleen

Block_engl_07.indd 236

25.08.2011 14:11:27

Longitudinal Flank Scans of the Left Adrenal Gland from Back to Front

94

79

50

237

94

61

The left adrenal gland is usually more difficult to locate than the right adrenal gland.

50

61 94

69

The left adrenal gland is identified between the upper renal pole, spleen, and aorta.

Block_engl_07.indd 237

25.08.2011 14:11:27

7  Adrenal Glands

238

211

Adrenal gland, kidney, spleen

212 Spleen, tail of pancreas

Block_engl_07.indd 238

25.08.2011 14:11:28

Longitudinal Flank Scans of the Left Adrenal Gland from Back to Front

239

50 94 61 43

69

The left adrenal gland is frequently crescent-shaped.

94

50

18

43

70

96

1

The left adrenal gland often extends relatively far downward toward the renal hilum.

Block_engl_07.indd 239

25.08.2011 14:11:28

7  Adrenal Glands

240

213 Layers of adrenal gland

214 Layers of adrenal gland

Block_engl_07.indd 240

25.08.2011 14:11:28

Details of the Adrenal Glands

20

241

41

4 17 10

10

8

69 90

The adrenal gland is seen to consist of three layers: two echodense outer layers and a hypoechoic middle layer.

10

69

The adrenal cortex is hypoechoic, and the medulla is hyperechoic.

Block_engl_07.indd 241

25.08.2011 14:11:28

Block_engl_08.indd 242

25.08.2011 14:11:42

Upper Abdominal Transverse Scans of the Gastric Cardia from Above Downward … p. 244 215 216 217 218

Esophagus, aorta, liver Cardia, aorta, liver Cardia, gastric body, aorta, liver Gastric body, aorta, liver

Upper Abdominal Longitudinal Scans of the Stomach from Right to Left … p. 248 219 220 221 222

Esophagus, aorta, liver Esophagus, aorta, liver Cardia, liver Gastric body, liver

Stomach in Upper Abdominal Longitudinal Scans from Left to Right … p. 252 223 224 225 226 227 228 229 230

Gastric body, liver Antrum, liver, pancreas Antrum, liver, pancreas Antrum, liver, pancreas Antrum, liver, duodenum Antrum, duodenal bulb, pylorus Duodenum, gallbladder, liver Gallbladder, liver

Upper Abdominal Transverse Scans of the Antrum and Duodenum from Above Downward … p. 260 231 232 233 234

Antrum, liver, pancreas Antrum, duodenum, liver, pancreas, gallbladder Antrum, duodenum, liver, pancreas, gallbladder Antrum, gallbladder

Details of the Stomach … p. 264 235 236 237 238

Layers of gastric wall Layers of gastric wall Gastric folds Gastric folds

Block_engl_08.indd 243

25.08.2011 14:11:42

8  Stomach

244

215 Esophagus, aorta, liver

216 Cardia, aorta, liver

Block_engl_08.indd 244

25.08.2011 14:11:42

Upper Abdominal Transverse Scans of the Gastric Cardia from Above Downward

245

* esophagus

21

12

* 10

71 96

1

96

94

The gastroesophageal junction is identified between the liver, aorta, and crura of the diaphragm.

21

12 74 10

72 1

96 96 90

94

The cardia opens into a sharply tapered triangular structure when viewed in transverse section.

Block_engl_08.indd 245

25.08.2011 14:11:42

8  Stomach

246

217 Cardia, gastric body, aorta, liver

218 Gastric body, aorta, liver

Block_engl_08.indd 246

25.08.2011 14:11:43

Upper Abdominal Transverse Scans of the Gastric Cardia from Above Downward

247

21 12 72 10 1

90

Next to the cardia, the gastric body presents a seemingly chaotic pattern of solid, liquid and gaseous material.

21

17 17

10

1 72

20 90

Below the cardia, the gastric body borders directly on the aorta.

Block_engl_08.indd 247

25.08.2011 14:11:43

8  Stomach

248

219 Esophagus, aorta, liver

220 Esophagus, aorta, liver

Block_engl_08.indd 248

25.08.2011 14:11:43

Upper Abdominal Longitudinal Scans of the Stomach from Right to Left

249

* esophagus 22 96

6 96

*

1

The abdominal esophagus is identified just to the right of, and anterior to, the aorta.

* esophagus 22 96

3

96

*

1 90

The esophagus and cardia are located between the liver and aorta in an upper abdominal longitudinal scan.

Block_engl_08.indd 249

25.08.2011 14:11:43

8  Stomach

250

221 Cardia, liver

222 Gastric body, liver

Block_engl_08.indd 250

25.08.2011 14:11:44

Upper Abdominal Longitudinal Scans of the Stomach from Right to Left

96

251

21

72 74

The cardia and body of the stomach are located and identified by first defining the gastroesophageal junction.

21 96

72

In subjects who have not been specially prepared, the gastric body presents a heterogeneous echo pattern located behind the left lobe of the liver.

Block_engl_08.indd 251

25.08.2011 14:11:44

8  Stomach

252

223 Gastric body, liver

224 Antrum, liver, pancreas

Block_engl_08.indd 252

25.08.2011 14:11:44

Stomach in Upper Abdominal Longitudinal Scans from Left to Right

253

21

72

The gastric body is consistently located behind the left lobe of the liver.

21

73 42 5

The appearance of the stomach depends on its degree of distention.

Block_engl_08.indd 253

25.08.2011 14:11:44

8  Stomach

254

225 Antrum, liver, pancreas

226 Antrum, liver, pancreas

Block_engl_08.indd 254

25.08.2011 14:11:45

Stomach in Upper Abdominal Longitudinal Scans from Left to Right

255

21 73 42 5

Generally the fluid-filled stomach can be clearly visualized with ultrasound.

21 45

73

42 19

A longitudinal scan at the center of the upper abdomen displays the triad of the stomach, liver, and pancreas.

Block_engl_08.indd 255

25.08.2011 14:11:45

8  Stomach

256

227 Antrum, liver, duodenum

228 Antrum, duodenal bulb, *pylorus

Block_engl_08.indd 256

25.08.2011 14:11:45

Stomach in Upper Abdominal Longitudinal Scans from Left to Right

257

21 73

4 17

75

10

The typical target pattern of the gastric antrum is seen most clearly in a longitudinal scan at the inferior border of the liver.

22 73

75

*

A definite thickening of the muscularis marks the location of the pylorus.

Block_engl_08.indd 257

25.08.2011 14:11:45

8  Stomach

258

229 Duodenum, gallbladder, liver

230 Gallbladder, liver

Block_engl_08.indd 258

25.08.2011 14:11:46

Stomach in Upper Abdominal Longitudinal Scans from Left to Right

259

22

30 76

The descending duodenum is imaged posterior to the gallbladder.

22

30

Bowel gas often produces artifacts in the gallbladder region.

Block_engl_08.indd 259

25.08.2011 14:11:46

8  Stomach

260

231 Antrum, liver, pancreas

232 Antrum, duodenum, liver, pancreas, gallbladder

Block_engl_08.indd 260

25.08.2011 14:11:46

Upper Abdom. Transv. Scans of the Antrum and Duodenum from Above Downward

261

21 24

73 42

20 41

19

30 10

1

The pancreas lies against the posterior surface of the stomach.

20

21

24

73 75

30

41

10

45

19

42

1

The antrum extends to the right, coming between the pancreas and liver. It is difficult to visualize at that location.

Block_engl_08.indd 261

25.08.2011 14:11:46

8  Stomach

262

233 Antrum, duodenum, liver, pancreas, gallbladder

234 Antrum, gallbladder

Block_engl_08.indd 262

25.08.2011 14:11:47

Upper Abdom. Transv. Scans of the Antrum and Duodenum from Above Downward

20 22

21

24

73

76

30

263

42

11

45 41 1

10

The second part of the duodenum lies between the liver, gallbladder, vena cava, and head of pancreas.

22 21 73

30 76 20

The antrum often extends quite far downward, especially when the stomach is full and the subject is standing upright.

Block_engl_08.indd 263

25.08.2011 14:11:47

8  Stomach

264

235 Layers of gastric wall

236 Layers of gastric wall

Block_engl_08.indd 264

25.08.2011 14:11:47

Details of the Stomach

265

21

73

With a high-resolution device and favorable scanning conditions, five layers can be distinguished in the gastric wall.

21

73

A scan through the antrum is best for differentiating the layers of the gastric wall.

Block_engl_08.indd 265

25.08.2011 14:11:47

8  Stomach

266

237 Gastric folds

238 Gastric folds

Block_engl_08.indd 266

25.08.2011 14:11:47

Details of the Stomach

21

267

73

90

The rugal folds of the stomach are demonstrated most clearly in the fasted state.

21 73

94

In an upper abdominal transverse scan, the gastric folds produce a confusing pattern in which numerous wall layers are seen.

Block_engl_08.indd 267

25.08.2011 14:11:48

Block_engl_09.indd 268

25.08.2011 14:12:00

Bladder in Longitudinal Sections … p. 270 239 240 241 242

Bladder, prostate, rectum Bladder, ureteral orifice, prostate, rectum Bladder, rectum Bladder, bowel

Details of the Bladder … p. 274 243 Bladder, ureteral orifices 244 Bladder, inflow of urine

Block_engl_09.indd 269

25.08.2011 14:12:00

9  Bladder

270

239 Bladder, prostate, rectum

240 Bladder, ureteral orifice, prostate, rectum

Block_engl_09.indd 270

25.08.2011 14:12:00

Bladder in Longitudinal Sections

271

82

80

83

89 94

The full bladder appears in longitudinal section as a triangular structure devoid of internal echoes.

80

82 83

84 89 94

The internal genitalia are seen posterior to the bladder in the midsagittal scan.

Block_engl_09.indd 271

25.08.2011 14:12:00

9  Bladder

272

241 Bladder, rectum

242 Bladder, bowel

Block_engl_09.indd 272

25.08.2011 14:12:01

Bladder in Longitudinal Sections

273

80

77, 89

The anterior wall of the bladder is loosely attached to the anterior abdominal wall by the vesicoumbilical fascia. This keeps gas-containing bowel loops from coming between the abdominal wall and the anterior surface of the full bladder.

80

77 94

Bowel loops containing gas are seen posterior to the bladder in the lateral scan.

Block_engl_09.indd 273

25.08.2011 14:12:01

9  Bladder

274

243 Bladder, ureteral orifices

244 Bladder, inflow of urine

Block_engl_09.indd 274

25.08.2011 14:12:01

Details of the Bladder

275

80

81

81

The ureters appear as fine tubular structures in the posterior bladder wall.

*inflowing urine

80

* 89

Ultrasound can often demonstrate urine flowing into the bladder from a ureteral orifice.

Block_engl_09.indd 275

25.08.2011 14:12:01

Block_engl_10.indd 276

25.08.2011 14:12:14

Prostate in Longitudinal Sections … p. 278 245 246 247 248

Prostate, rectum, bladder Prostate, rectum, bladder Prostate, seminal vesicles Prostate, seminal vesicles

Prostate in Transverse Scans from Below Upward … p. 282 249 250 251 252 253 254

Prostate, urethra, bladder Prostate, urethra, bladder Prostate, urethra, bladder, rectum Seminal vesicles, rectum, bladder, ampulla of vas deferens Seminal vesicles, rectum, bladder, ampulla of vas deferens Seminal vesicles, rectum, bladder, ampulla of vas deferens

Block_engl_10.indd 277

25.08.2011 14:12:14

10  Prostate

278

245 Prostate, rectum, bladder

246 Prostate, rectum, bladder

Block_engl_10.indd 278

25.08.2011 14:12:15

Prostate in Longitudinal Sections

279

80 83 84

89 94

The prostate displays a bulbous shape in longitudinal section.

80 83 84

89 94

The rectum usually appears as an air-filled structure posterior to the prostate.

Block_engl_10.indd 279

25.08.2011 14:12:15

10  Prostate

280

247 Prostate, seminal vesicles

248 Prostate, seminal vesicles

Block_engl_10.indd 280

25.08.2011 14:12:15

Prostate in Longitudinal Sections

80 94

281

81 83

84

89 94

The seminal vesicles are in contact with the bladder over their full length.

94

80

81

84

89 94

The seminal vesicles are located lateral and superior to the prostate.

Block_engl_10.indd 281

25.08.2011 14:12:15

10  Prostate

282

249 Prostate, urethra, bladder

250 Prostate, urethra, bladder

Block_engl_10.indd 282

25.08.2011 14:12:15

Prostate in Transverse Scans from Below Upward

283

80 82 83

The prostate presents an elliptical “chestnut” shape when viewed in transverse section.

80 82 83

The middle lobe of the prostate sometimes bulges a short distance into the bladder lumen.

Block_engl_10.indd 283

25.08.2011 14:12:15

10  Prostate

284

251 Prostate, urethra, bladder, rectum

252 Seminal vesicles, rectum, bladder, *ampulla of vas deferens

Block_engl_10.indd 284

25.08.2011 14:12:16

Prostate in Transverse Scans from Below Upward

285

83

82

83 89

The urethra appears as a round, hypoechoic structure within the prostate.

80

*

*

84 89

The rectum is consistently visualized posterior to the prostate.

Block_engl_10.indd 285

25.08.2011 14:12:16

10  Prostate

286

253 Seminal vesicles, rectum, bladder, *ampulla of vas deferens

254 Seminal vesicles, rectum, bladder, *ampulla of vas deferens

Block_engl_10.indd 286

25.08.2011 14:12:16

Prostate in Transverse Scans from Below Upward

287

80

*

*

84 89

The seminal vesicles are approximately 5 cm long and 1 cm in diameter and are located on the posterior bladder wall.

80

84

*

*

84

89

The vasa deferentia are located between the seminal vesicles and bladder.

Block_engl_10.indd 287

25.08.2011 14:12:16

Block_engl_11.indd 288

25.08.2011 14:12:28

Uterus in Longitudinal Sections from Left to Right … p. 290 255 256 257 258

Uterus, vagina, bladder, rectum Uterus, vagina, bladder, rectum Uterus, vagina, bladder, rectum Ovary

Uterus in Transverse Sections from Below Upward … p. 294 259 260 261 262 263 264

Vagina, bladder, rectum Vagina, bladder Vagina, bladder, rectum Uterus, bladder Uterus, bladder, ovaries Uterus, bladder, ovaries

Block_engl_11.indd 289

25.08.2011 14:12:28

11  Uterus

290

255 Uterus, vagina, bladder, rectum

256 Uterus, vagina, bladder, rectum

Block_engl_11.indd 290

25.08.2011 14:12:28

Uterus in Longitudinal Sections from Left to Right

291

80

86

85 89

The vagina appears behind the bladder as an elongated, hypoechoic structure with a central band of higher-level echoes.

80

86 85 89

The uterus consists of the fundus, corpus, and cervix.

Block_engl_11.indd 291

25.08.2011 14:12:29

11  Uterus

292

257 Uterus, vagina, bladder, rectum

258 Ovary

Block_engl_11.indd 292

25.08.2011 14:12:29

Uterus in Longitudinal Sections from Left to Right

293

80

77

86 85 89

The uterine cavity is visible sonographically only during menstruation and pregnancy.

80

88 86

The ovaries flank the superior border of the full urinary bladder.

Block_engl_11.indd 293

25.08.2011 14:12:29

11  Uterus

294

259 Vagina, bladder, rectum

260 Vagina, bladder

Block_engl_11.indd 294

25.08.2011 14:12:29

Uterus in Transverse Sections from Below Upward

295

80

86 89

The vaginal lumen has a streaklike appearance in transverse section.

80

86

The uterus impresses on the posterior bladder wall.

Block_engl_11.indd 295

25.08.2011 14:12:29

11  Uterus

296

261 Vagina, bladder, rectum

262 Uterus, bladder

Block_engl_11.indd 296

25.08.2011 14:12:30

Uterus in Transverse Sections from Below Upward

297

80

86 89

Transverse scan of the female pelvis displays, from anterior to posterior, the urinary bladder, vesicouterine pouch, uterus, and rectum.

80

85

With the bladder distended, the uterus can be clearly visualized from the anterior side.

Block_engl_11.indd 297

25.08.2011 14:12:30

11  Uterus

298

263 Uterus, bladder, ovaries

264 Uterus, bladder, ovaries

Block_engl_11.indd 298

25.08.2011 14:12:30

Uterus in Transverse Sections from Below Upward

299

80 88 87 85

The ovaries are usually located lateral to the uterus at the level of the uterine corpus.

80 87

88

85

The ovaries appear as rounded structures approximately 3 cm long and are extremely variable in their location.

Block_engl_11.indd 299

25.08.2011 14:12:30

Block_engl_12_u-letzte-S.indd 300

25.08.2011 14:14:38

Left Thyroid Lobe in Longitudinal Scans from Right to Left … p. 302 265 266 267 268 269 270 271 272

Isthmus of thyroid gland Isthmus of thyroid gland Left lobe of thyroid gland, sternohyoid muscle, sternothyroid muscle Left lobe of thyroid gland, sternohyoid muscle, sternothyroid muscle Left lobe of thyroid gland, sternohyoid muscle, sternothyroid muscle Left lobe of thyroid gland, common carotid artery Internal jugular vein, sternocleidomastoid muscle Internal jugular vein, sternocleidomastoid muscle

Left Thyroid Lobe in Transverse Scans from Below Upward … p. 310 273 274 275 276 277 278

Left lobe of thyroid gland, common carotid artery, internal jugular vein Left lobe of thyroid gland, common carotid artery, internal jugular vein Left lobe of thyroid gland, common carotid artery, internal jugular vein Left lobe of thyroid gland, common carotid artery, internal jugular vein Left lobe of thyroid gland Left lobe of thyroid gland

Block_engl_12_u-letzte-S.indd 301

25.08.2011 14:14:38

12  Thyroid Gland

302

265 Isthmus of thyroid gland

266 Isthmus of thyroid gland

Block_engl_12_u-letzte-S.indd 302

25.08.2011 14:14:39

Left Thyroid Lobe in Longitudinal Scans from Right to Left

303

100

107

107

The trachea is located directly behind the isthmus of the thyroid gland.

100

The thyroid gland is imaged with a high-resolution transducer.

Block_engl_12_u-letzte-S.indd 303

25.08.2011 14:14:39

12  Thyroid Gland

304

267 Left lobe of thyroid gland, sternohyoid muscle, sternothyroid muscle

268 Left lobe of thyroid gland, sternohyoid muscle, sternothyroid muscle

Block_engl_12_u-letzte-S.indd 304

25.08.2011 14:14:39

Left Thyroid Lobe in Longitudinal Scans from Right to Left

305

101, 102 100

Scant vascularity is seen in the normal thyroid parenchyma.

101, 102

100

The sternohyoid and sternothyroid muscles are anterior to the thyroid gland.

Block_engl_12_u-letzte-S.indd 305

25.08.2011 14:14:39

12  Thyroid Gland

306

269 Left lobe of thyroid gland, sternohyoid muscle, sternothyroid muscle

270 Left lobe of thyroid gland, common carotid artery

Block_engl_12_u-letzte-S.indd 306

25.08.2011 14:14:40

Left Thyroid Lobe in Longitudinal Scans from Right to Left

307

100, 102

100

Normal thyroid parenchyma has a homogeneous echo pattern.

101, 102 100 106

The thyroid gland narrows markedly in the lateral direction.

Block_engl_12_u-letzte-S.indd 307

25.08.2011 14:14:40

12  Thyroid Gland

308

271 Internal jugular vein, sternocleidomastoid muscle

272 Internal jugular vein, sternocleidomastoid muscle

Block_engl_12_u-letzte-S.indd 308

25.08.2011 14:14:40

Left Thyroid Lobe in Longitudinal Scans from Right to Left

309

103 106

The common carotid artery is in contact with the lateral aspect of the thyroid gland.

103

103

105

The large jugular vein appears lateral to the common carotid artery.

Block_engl_12_u-letzte-S.indd 309

25.08.2011 14:14:40

12  Thyroid Gland

310

273 Left lobe of thyroid gland, common carotid artery, internal jugular vein

274 Left lobe of thyroid gland, common carotid artery, internal jugular vein

Block_engl_12_u-letzte-S.indd 310

25.08.2011 14:14:40

Left Thyroid Lobe in Transverse Scans from Below Upward

311

103 101, 102 100 106

105

The large vessels in the neck run just lateral to the thyroid gland.

103

101, 102

100

106

105

The common carotid artery appears just lateral to the thyroid gland in a transverse scan.

Block_engl_12_u-letzte-S.indd 311

25.08.2011 14:14:41

12  Thyroid Gland

312

275 Left lobe of thyroid gland, common carotid artery, internal jugular vein

276 Left lobe of thyroid gland, common carotid artery, internal jugular vein

Block_engl_12_u-letzte-S.indd 312

25.08.2011 14:14:41

Left Thyroid Lobe in Transverse Scans from Below Upward

101, 102

313

103

100 106

105

The jugular vein appears as a hypoechoic structure, not completely circular, located adjacent to the common carotid artery.

101, 102

103

100 106

105

The sternocleidomastoid is a powerful muscle located anterior and lateral to the thyroid gland.

Block_engl_12_u-letzte-S.indd 313

25.08.2011 14:14:41

12  Thyroid Gland

314

277 Left lobe of thyroid gland

278 Left lobe of thyroid gland

Block_engl_12_u-letzte-S.indd 314

25.08.2011 14:14:41

Left Thyroid Lobe in Transverse Scans from Below Upward

315

100

The thyroid gland is a butterfly-shaped organ with smooth borders and high-level internal echoes.

100

The parathyroid glands are located posterior to the lateral and superior poles of the thyroid gland. They may not be visible at ultrasound unless they are enlarged.

Block_engl_12_u-letzte-S.indd 315

25.08.2011 14:14:41

Block_engl_12_u-letzte-S.indd 316

25.08.2011 14:14:41

Block_engl_12_u-letzte-S.indd 317

25.08.2011 14:14:41

Normal Sonographic Dimensions of the Pancreas, Spleen, and Kidneys

Head < 30 mm

Pancreas

Body < 25 mm