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Epicardial Lymph Nodes
Unfolded Aorta Echo
Fig. 75.4a
Epicardial Lymph Nodes

Solutions to the Quiz

Solution to Fig. 16.2 (question 7):

Solution to Fig. 16.2 (question 7):

Sonographic section: sagittal section of the upper abdomen, paramedian over the inferior vena cava (16). Organs: liver (9), heart, and pancreas (33).

Structures: diaphragm (13), hepatic veins (10), portal branch (11), connective tissue (5), caudate lobe between 5 and 16.

Abnormal finding: echo-free space between the myocardium and diaphragm. Diagnosis: pericardial effusion (79). Differential diagnosis: epicardial fat.

Solution to Fig. 22.1 (question 4):

Solution to Fig. 22.1 (question 4):

Lymph Node Levels

Sonographic section: sagittal section of the upper abdomen at the level of the left renal vein crossing the aorta. Vessels and structures: refer to key on the unfolded back cover. Dilatation?: no, only dilated left renal vein due to compression between aorta (15) and SMA (17), still physiologic.

Solution to Fig. 33.1 (question 6):

Lymph Quadrants

Sonographic section: oblique subcostal section of the right upper quadrant of the abdomen.

Diagnosis: Focal fatty infiltration (63) of the liver (9) and multiple hepatic metastases (56) with hypoechoic rim. Note: two episodes of metastatic spreading since new and older metastatic foci are visible! Differential diagnosis: none, the finding is pathognomonic.

Solution to Fig. 33.2 (question 6):

Solution to Fig. 33.2 (question 6):

Hemangioma Aorta

Sonographic section: sagittal section along the right MCL. Diagnosis: subdiaphragmatic hepatic metastasis (56) with hypoechoic rim, pleural effusion (69). Differential diagnosis: hemangioma instead of a metastasis considering the echogenicity of the lesion.

Solution to Fig. 33.3 (question 6):

Solution to Fig. 33.3 (question 6):

Subdiaphragmatic Nodes

Sonographic section: sagittal section of the right upper quadrant of the abdomen along the paramedian plane. Diagnosis: Hyperechoic, partially heterogeneous space-occupying lesion (61). Here: hemangioma with draining vein (10) arising from it. Differentia! diagnosis: tumor, hyperechoic metastasis.

Solution to Fig. 36.3 (question 2):

Solution to Fig. 36.3 (question 2):

Subdiaphragmatic Nodes

Sonographic section: oblique subcostal section of the right upper quadrant of the abdomen, liver (9). Diagnosis: cholecystitis with markedly thickened wall (80). Differential diagnosis: postprandial biliary sludge in the gallbladder, parasitic involvement of the liver or gallbladder.

Solutions to the Quiz

Solution to Fig. 46.1 (question 6):

Solution to Fig. 46.2 (question 6):

Solution to Fig. 50.1 (question 5):

Solution to Fig. 46.2 (question 6):

Lymph Quadrants

Sonographic section: intercostal plane of the right flank in left lateral decubitus position.

Organs: liver (9), renal parenchyma (29) with renal pelvis (31), lung (47), abdominal oblique musculature (4), diaphragm (13), intestinal loop (46). Diagnosis: renal cyst (64) with distal acoustic enhancement (70). Differential diagnosis: adrenal tumor with cystic component.

Sonographic section: intercostal plane of the right flank in left lateral decubitus position.

Organs: liver (9), abdominal oblique vasculature (4), interstinal loop (46) with acoustic shadowing (45), renal parenchyma (29), renal pelvis (31), upper renal pole (27), lower renal pole (28). Diagnosis: renal cell carcinoma (54), hypoechoic tumor with space-occupy-ing effect.

Differential diagnosis: renal lymphoma, metastasis, hyperplastic column of Bertin, hemorrhagic renal cyst.

Sonographic section: high section of the left flank in the right lateral decubitus position.

Organs: spleen (37), lung (47), colon (43), diaphragm (13). Parenchyma: not normally homogeneous, but patchy with several interspersed hyperechoic foci. Diagnosis: multiple splenic hemangiomas.

Differential diagnosis: hyperechoic metastases, vasculitis due to SLE, histiocytosis X.

Solution to Fig. 73.1 (question 2)

Solution to Fig. 73.2:

Solution to Fig. 73.3:

Solution to Fig. 73.1 (question 2)

Cervix Dilation With Clots

Solution to Fig. 73.2:

Sonographic Reverberation Images

Solution to Fig. 73.3:

Cervix Dilation With Clots

Imaging plane: endovaginal visualization of the uterus.

Diagnosis: endometrial hyperplasia (78) > 8 mm in a postmenopausal woman without estrogen replacement therapy (refer to question). Recommendation: fractionated dilatation and curettage to exclude an endometrial carcinoma.

Sonographic Section: suprapubic longitudinal (sagittal) section of the lower abdomen.

Organs: urinary bladder (38), uterus (39, intestinal loop (43). Diagnosis: blood clot (52) layered along the posterior wall of the urinary bladder.

Differential Diagnosis: Arch artifacts (51) and reverberation echoes (51) in the anterior aspect of the urinary bladder; layered concrements, thickness artifacts-> shaking!

Sonographic Section: oblique section of the left lower quadrant of the abdomen.

Organs: abdomial oblique muscles (4), colon (43).

Diagnosis: multilayered wall-thickening caused by colitis. Differential Diagnosis: ischemia of the intestinal wall caused by thrombosis of the mesenteric vein or occlusion of the mesenteric artery.

Tips and Tricks for the Beginner

anterior cranial caudal posterior planes propagate from the transducer through the body.

All sagittal sections are conventionally viewed as seen from the patient's right side (Fig. 78.1h). Consequently, the cranial aspect of the patient is displayed on the left and the caudal aspect on the right (Fig. 78.1 d).

After turning the transducer 90 (Fig. 78.1 d), the sonographic cross sections, like axial CT sections, are viewed from the patient's feet, resulting in an inverted display of the visualized structures (Fig. 78.1 c). What both sections have in common is that the image displays the anterior abdominal wall, including transducer, on the top and the posterior structures on the bottom. This orientation conforms to the customary display of conventional radiographs, CT, and MRI. Standing in front of the patient, the liver, for instance, is seen on the left though in actual fact it is on the patient's right side.

If, despite every maneuver, the porta hepatis could not be visualized because of meteorism or a postprandial state, an attempt should be made to visualize the porta hepatis intercostally through the liver (Fig. 78.2). Should this also fail, the patient is asked to turn onto the left side and to continue turning beyond the lateral decubitus position (Fig. 78.3). The liver is pushed by its own weight against the anterior abdominal wall and displaces the air-containing intestinal loops laterally. This frequently opens up the view for the portal vein and lesser omentum.

The next difficulty consists of visualizing structures amidst acoustic shadows cast by intestinal air. The solution is not the addition of more coupling gel, as the novice often believes, but a graded increase in the pressure applied to the transducer together with proper breathing instructions for the patient, explained further and illustrated on the next page.

In preparation for the practical sections, the student should become familiar with the spatial orientation in a three-dimensional space. As an introduction, only two planes that are perpendicular to each other should be considered: the vertical (sagittal) plane and the horizontal (transverse) plane. As suggested on page 4, a cone coffee filter should be used to envisage how the sound waves in these two

Fig. 78.1a

Fig. 78.1b

Transversal views:

Tips and Tricks for the Beginner

Optimal adaption of the pressure on the transducer

To avoid any patient discomfort, the beginner is often reluctant to press the transducer firmly on to the abdomen. If this is the case (III), physiologic air remains in the intestinal lumen (46), causing acoustic shadowing (45) that can, for instance, interfere with visualizing the posteriorly located pancreas (33) (Fig. 79.1a). Even the bile duct (66) or the portal vein (11) is frequently obscured by duodenal air or an air-distended stomach.

The solution lies in increasing the pressure applied to the transducer (44 4), but the increase should be gradual rather than sudden to avoid any defense reflex or antagonistic reaction by the patient. By carefully displacing the intestinal air, this maneuver displaces the interfering air shadows (45), and the pancreas (33) and common bile duct (66) come into view (Fig. 79.1 b). The same principle can be applied to the mid and lower abdomen, for instance, for improving the visualization of retroperitoneal lymph nodes.

Lymph Nodes

Fig. 79.1b

Fig. 79.1a

Fig. 79.1b

Competent breathing instructions

Initially, there is some reluctance to tell the patient how to breathe during the examination, though the quality of the sonographic examination of the abdomen strongly depends on the depth of the inspiratory effort necessary, for example, to displace the liver caudally adequate for its visualization. In a neutral respiratory position (Fig. 79.3a), not only are the liver and spleen obscured by the overlying lung bases, but also the pancreas by an air-containing stomach (26). The low position of the liver (9) in maximum inspiration (Fig. 79.3b) displaces air-containing intestinal loops and stomach (26) in-feriorly and opens the pancreatic region (33) for sonographic viewing. ITie same principle can be applied to facilitate the evaluation of the kidneys. Respiratory maneuvers rarely play a role in the lower abdomen.

Should this approach fail, the stomach can be filled with degassed water (tea), following administration of Buscopan (to eliminate any peristaltic activity). This results in good sound transmission through the stomach. The water should be taken through a straw to avoid inadvertent swallowing of air.

Finally, the examiner can sustain the patient's cooperation better by not only giving instructions to inhale, such as "take a deep breath through your mouth and hold your breath," but also by telling the patient to exhale before overdoing the holding of his or her breath (or after the desired image has been captured by freezing the display). This advice is not as trivial as it seems because the inexperienced examiner often fails to achieve good respiratory cooperation, thereby discouraging the patient and further straining the patient's respiratory condition.

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