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Abdominal circumference Atrial septal defect Biparietal diameter Crown-rump length Computed tomography Diameter of the aorta Diameter of the inferior vena cava Estimated fetal weight Ectopic pregnancy

Endoscopic retrograde cholangiopancreatography Extracorporeal shock wave lithotripsy Frontal horn ventricular index Femoral length Focal nodular hyperplasia Gastrointestinal tract

Gestational sac (= chorionic cavity) diameter Head circumference Human chorionic gonadotropin Intrauterine device In vitro fertilization Midclavicular line Magnetic resonance imaging Nothing by mouth Nuchal translucency Occipitofrontal diameter Occipital horn ventricular index Polycystic ovarian syndrome Pulsed wave Doppler Resistance index Systemic lupus erythematosus Superior mesenteric artery Status post

Transposition of the great arteries Volume of the urinary bladder Ventricular septal defect Yolk sac diameter

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Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation or commercialization outside the narrow limits set by copyright legislation, without the publisher's consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage.

© 1999 Georg Thieme Verlag, Rüdigerstraße 14, D-70469 Stuttgart, Germany Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA

Typesetting by primustype R. Hurler GmbH,

D-73274 Notzingen typeset on Textline/HerculesPro

Printed in Germany by Druckhaus Götz, Ludwigsburg ISBN 3-13-111041-4 (GTV)

Important Note:

Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect of any dosage instructions and forms of application stated in the book. Every user is requested to examine carefully the manufacturer's leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user's own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed.


The increasing role that imaging procedures have assumed in the clinical routine must be considered at an early stage in the education of medical students. The vast use and noninvasive character of sonography make it prudent to familiarize tomorrow's physicians today with this comparatively low-risk technology.

The pilot project on medical didactics that began in Dusseldorf in 1992 consisted of preliminary lessons in sonography for a few medical students particularly interested in sonography and endoscopy. Soon, the hands-on instructions in small groups became more and more accepted and this teaching concept could be enlarged and improved.

Under the guidance of residents and lecturers, student instructors relate the sonographic diagnostic to their junior students. The participants examine each other and systematically learn the anatomic relationship of the abdominal organs as seen in the standard sonographic sections. Step by step, they learn how to use and handle the transducer. These hands-on instructions are accompanied by complementary lectures, which address the subject of differential diagnosis of the pathologic changes by means of videos, slides, and live demonstrations.

The workbook presented here is largely based on the curriculum of this introductory sonography course for beginners. The approach selected here considers in particular the difficulties generally encountered by the novice. By relying on the step-by-step process of the workbook, the novice will soon realize that initial frustration ("I only see a snow storm") will soon give way to increasing enthusiasm for this elegant modality.

It should be pointed out, however, that each sonographic diagnosis can only be as good as the examiner. False diagnoses can only be avoided through profound anatomic and sonomorphologic knowledge, unrelenting thoroughness, and, where appropriate, comparison with other imaging procedures. Intitial successes ("I now recognize all parenchymal organs") should not lead to overconfidence during the learning phase; a truly profound knowledge can only be gained through long exposure in the clinical setting and the resultant practical experience that leads to the familiarization of the diverse anatomic variations and pathologic changes.

This workbook, of course, cannot encompass all aspects of diagnostic sonography and this is not its goal. Instead, it should offer the reader an optimal introduction to sonography. The spectrum of the information presented and the pathologic examples are especially targeted at the beginner. The carefully prepared didactic presentation, which reflects the author's teaching experience over many years, will hopefully motivate or perhaps even excite many students.

Director, Institute of Diagnostic Radiology Heinrich-Heine-University, Düsseldorf Germany

Introduction and Suggestions to the Reader

This workbook is primarily for medical students, technicians, and residents that have had no or little exposure to sonography and wish to learn this technique systematically. The first step is recognizing the normal anatomic structures.

Each section therefore begins with the anatomic orientation of the respective body region (where is the top of the image?) before presenting and commenting on a selection of the most common diseases.

Before reading the individual sections, the material on pages 6 to 10 should be studied to learn the basics before the hands-on practice. Thereafter, it is advisable to make a drawing of the body planes as seen in typical longitudinal (sagittal) as well as in typical cross (transverse) sections, for example on a cone coffee filter. The shape of the cone coffee filter corresponds to the shape of the sonographic image for the examination of the abdomen.

At this stage the reader can already experience the grati-faction of successful learning. The correct answer should not be passively copied from page 78. Instead, the anterior and dorsal structures as well as the superior and inferior structures, as seen on the sagittal section and viewed from the patient s right side, should be deduced. The cone coffee filter should be placed on the abdomen and oriented along the plane of the sonographic beam of a transducer (convex border of the cone coffee filter) placed on the epigastric region along the midline (linea alba, between both rectus muscles) (Fig. 4.1a).

Next, anterior and dorsal structures as well as right and left structures should be marked on the reverse of the cone coffee filter as seen on the cross-sectional (transverse) sonographic image viewed from below (!) (Fig. 4.1 b). Only after mastering the spatial orientation is the reader prepared for studying the normal findings as seen in the standard planes and, thereafter, the diffuse and focal abnormalities of the individual organs.

An explanatory diagram, intentionally annotated with numbers only, is placed adjacent to each sonographic image, facilitating the interpretation of the sonographic image with the help of numbers incorporated in the accompanying text. To confirm the interpretation after the text has been studied, the back cover can be opened to use the key found on the unfolded cover page. By blocking the labels, it is easy to check whether all structures have been correctly identified. The numbers of the labels apply to all the diagrams in this workbook.

If the thirst for knowledge has not yet been quenched, the quiz found at the end of each section can be tackled. The images in the quiz should be identified as to sectional orientation and visualized structures, and, if possible, a differential diagnosis provided. Only afterwards should the answers on pages 76 and 77 be consulted since the suspense is prematurely lost otherwise. The quiz may possibly arouse diagnostic inquisitiveness and lead to a first feeling of achievement through an imaging procedure. Whenever these practical applications do not readily lend a mental concept of the imaging plane in question or the reader is confronted with other discouraging events, help may be found on pages 78 and 79.


Image Formation and Echogenicity

Operating Sonographic Equipment 7

Sonographic Equipment and Selection of the

Appropriate Transducer 8

Artifacts 9

Upper Retroperitoneum 11

Lower Retroperitoneum in Oblique Sections: Normal

Findings 12

Aortic Ectasia and Aneurysms 13

Retroperitoneum: Lymph Nodes 14

Retroperitoneum: Other Clinical Cases 15

Upper Abdomen: Basic Anatomy 17

Upper Abdomen: Normal Findings 18

Upper Abdomen: Pancreatitis 19

Pancreas: Additional Cases 20

Upper Abdomen: Lymph Nodes 21

Quiz for Self-Assessment 22

Porta Hepatis: Normal Findings 23

Portal Hypertension: Lymph Nodes 24

Hepatic Vein Confluence and Hepatic Congestion 25

Hepatic Size, Gallbladder, Normal Findings 26

Normal Variants, Fatty Liver 27

Focal Fatty Infiltration 28

Other Focal Changes 29

Infections, Parasite 30

Cirrhosis and Hepatocellular Carcinoma 31

Hepatic Metastases 32

Quiz for Self-Assessment 33

Cholestasis 34

Gallstones and Polys 35

Cholecystitis and Quiz for Self-Assessment 36

Normal Findings 37

Normal Variants and Cysts 38

Atrophy and Inflammation 39

Urinary Obstruction 40

Differential Diagnosis of Urinary Obstruction 41

Renal Stones and Infarcts 42

Renal Tumors ' 43

Renal Transplant: Normal Findings 44

Renal Transplant 45

Quiz for Self-Assessment 46

6 Spleen

Normal Findings 47

Diffuse Splenomegaly 48

Focal Splenic Changes 49

Quiz for Self-Assessment 50

Stomach 51

Colon 52

Small Bowel 53

Normal Findings, Volume Measurements 54

Indwelling Catheter, Cystitis, Sediment 55

Prostate Gland, Testicles and Scrotum 56

Undescended Testicle, Orchitis/Epididymitis 57

Normal Findings 58

Uterus 59

Tumors of the Uterus 60

Ovaries 61

Diagnosis of Early Pregnancy 63

Biometry In the First Trimester 64

Biometry In the Second and Third Trimester 65

Placental Location and Fetal Gender 66

Diagnosis of Fetal Malformations 67

Quiz for Self-Assessment 73

Normal Findings 74

Diffuse and Focal Changes 75

Solutions to the Quiz 76

Tips and Tricks for the Beginner 78

Acknowledgement 80

On the fold-out covers:

Front: Standard Sonographic Sections Rear: Index

Key to Diagrams Normal Measurements

Image Formation and Echogenicity

The sonographic image begins with mechanical oscillations of a crystal that has been excited by electrical pulses (piezoelectric effect). These oscillations are emitted as sound waves from the crystals (dark blue arrows) just as sound waves are emitted from a loudspeaker membrane (Fig. 6.1), though the frequencies used in sonography are not audible to the human ear. Depending on the desired application, the sonographic frequencies range from 2.0 to approximately 15.0 MHz. Several crystals are assembled to form a transducer from which sound waves propagate through the tissues, to be reflected and returned as echoes (light blue ar-

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