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Abdomen Protocol

This protocol includes images of several organs and structures. It has been divided into
sections to assist in determining diagnostic images that should be stored for the physician
o Midline structures (Pancreas, Aorta, and IVC)
o Liver
o Gallbladder and Common Bile Duct
o Kidneys and Spleen
Physicians may request a full examination of all abdominal organs or only specific
abdominal organs
o Students will be provided separate protocols for organs in addition to this full
examination protocol
You must always evaluate the entire organ first before you store an image
You should understand completely why you stored the image and identify everything in
the image
Multiple breathing techniques and patient positions will be required

Organ/
Order

Scan
Plane

Label

PANCREAS

Pancrea
s

Transvers
e plane
on the
body

PANCREAS

PANCREAS
AO SAG
PROX
Aorta

Sagittal

AO SAG MID
AO SAG
DISTAL

IVC

Organ/
Order
LIVER
Sagittal

Sagittal

IVC

Key Landmarks Identified

Pancreas head
Portal splenic confluence
CBD
o If CBD is enlarged, measure internal AP diameter
Pancreas body
Aorta
Measurement
o If pancreatic duct is seen measure internal AP
diameter
Pancreas tail
Splenic vein
Proximal aorta
Celiac axis
SMA
Mid aorta
SMA
Distal aorta as it tapers before bifurcation

IVC
Right atrium
Left lobe

Scan Plane

Label

Sagittal

LIVER SAG

Left lobe with inferior tip

LIVER SAG

Left lobe
Caudate lobe
IVC
Right lobe

The transducer
is placed sagittal
in the mid
portion of the
patients body

LIVER SAG

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Key Landmarks Identified

Diaphragm

LIVER TX
MPV

Right lobe superior


Right hemidiaphragm
Right pleural space
Right lobe mid
Main portal vein
Right lobe inferior
o Demonstrating largest superior to inferior
area
o Measure liver length from superior to inferior
Right kidney
Left lobe
Caudate lobe
IVC
Right lobe
Left lobe
Right hepatic vein
Left hepatic vein
Middle hepatic vein
Right lobe - most anterior portion
Diaphragm
Right lobe superior
Right hemidiaphragm
Right pleural space
Right lobe mid
Main portal vein

LIVER TX
MPV

Right lobe mid


Main portal vein with color & spectral Doppler

Right lobe mid


Main portal vein with color & spectral Doppler
o Normal waveform will demonstrate slight
phasic flow toward the liver
Right lobe - inferior
Right kidney

LIVER SAG
SUP
LIVER
Sagittal

Sagittal
The transducer
is placed
sagittal and
lateral on the
patients body

Transverse

LIVER
Transver
se

LIVER SAG
MPV
LIVER SAG
INF

LIVER TX

The transducer
is placed
transverse in the
mid portion of
the patients
body
Angulation of the
probe is used for
right lobe images

LIVER TX
HV

LIVER TX
LIVER TX
SUP

Transverse
LIVER
Transver
se

The transducer
is placed
transverse and
lateral on the
patients body

LIVER TX
MPV

LIVER TX
INF

Organ/
Order
Gallblad
der
Patient in
Supine
position

Scan
Plane
Sagittal
plane of
the GB
Transvers
e plane of

Label
GB SUPINE
SAG
GB SUPINE
SAG
GB SUPINE
TX

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Key Landmarks Identified

Gallbladder body
Gallbladder fundus
Gallbladder body
Gallbladder neck
Gallbladder mid body with clear delineation of
anterior wall

the GB
GB SUPINE
TX
Sagittal
plane of
the GB

Patient in
Left lateral
decubitus
position

Transvers
e
plane of
the GB

GB LLD TX

Gallblad
der

Sagittal
plane of
the GB

GB RLD
SAG
GB RLD
SAG

Patient in
Right lateral
decubitus
position

Transvers
e plane of
the GB
Transvers
e plane of
the CBD

level of the
porta
hepatis

GB LLD SAG

Sagittal
plane of
the CBD

Scan
Plane

Sagittal
plane of
the
kidney

Transver
se plane
of the

Gallbladder
Gallbladder
Gallbladder
Gallbladder
Gallbladder

CBD TX

CBD SAG

CBD SAG

Organ/
Order
RT
Kidney

body
fundus
body
neck
mid body

GB RLD TX

CBD SAG

Common
Bile Duct

GB LLD SAG

Gallblad
der

Gallbladder mid body with clear delineation of


anterior wall
Measurement
o measure anterior wall thickness
Gallbladder body
Gallbladder fundus
Gallbladder body
Gallbladder neck
Gallbladder mid body

Label
RT KID SAG
LAT
RT KID SAG
MID
RT KID SAG
MID
RT KID SAG
MED
RT KID TX
SUP

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Portal vein
CBD
Hepatic artery
Portal vein
CBD
Enlarged image
Portal vein
CBD
Enlarged image
Portal vein
CBD
Measurement
o Internal AP diameter
Key Landmarks Identified

Renal parenchyma and capsule

Renal parenchyma and capsule


Renal sinus
Renal parenchyma and capsule
Renal sinus
Measurement
o Length measurement from superior to inferior pole
Renal parenchyma and capsule
Renal sinus at hilum
Renal parenchyma and capsule
Renal sinus
Liver

kidney

LT
Sagittal
Kidney plane of
the
kidney

Renal
Renal
Renal
Renal
Renal

LT KID SAG
MID

LT KID SAG
MED

Renal parenchyma and capsule


Renal Sinus
Renal parenchyma and capsule
Renal Sinus
Measurement
o Length measurement from superior to inferior pole
Renal parenchyma and capsule
Renal sinus at hilum

RT KID TX
MID
RT KID TX
INF
LT KID SAG
LAT
LT KID SAG
MID

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parenchyma and capsule


sinus at hilum to include renal vessels
parenchyma and capsule
sinus
parenchyma and capsule

Transver
se plane
of the
kidney

LT KID TX
SUP
LT KID TX
MID
LT KID TX
INF
SPLEEN SAG

Sagittal
plane of
the
spleen
Spleen

Transver
se plane
of the
spleen

SPLEEN SAG

Renal parenchyma and capsule


Renal sinus
Renal parenchyma and capsule
Renal sinus at hilum to include renal vessels
Renal parenchyma and capsule
Renal sinus
Spleen mid
Left hemidiaphragm
Left pleural space
Left kidney (if not seen, may require extra image)
Spleen mid with splenic hilum
Left hemidiaphragm
Left pleural space
Measurement
o Length measurement from superior to inferior
Spleen mid

SPLEEN TX

Normal Measurement Ranges


Structure
Aorta

Area of
Interest
Superior, Mid
and Inferior

Plane
Sagittal

Measureme
nt
3 cm or less

Comments

Pancreas

Head

Pancreatic
Duct

Body of the
pancreas

Common Bile
Duct

Level of Porta
Hepatis

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Transver
se plane
on the
body
Transver
se plane
on the
body
Long
Axis

Head 2-3.5
cm

2 mm or less

<7-8 mm

Only performed if abnormalities


are suspected or if required by site
Measured in AP dimension
Measurements taken
perpendicular to the axis of the
lumen
Calipers placed on outer edges of
walls so that walls are included in
the measurement
Aorta should taper as you move
distally
Only performed if abnormalities
are suspected

Only performed if abnormalities


are suspected
If duct is enlarged measure
internal duct diameter anterior to
posterior
Measure inner wall to inner wall
If duct is enlarged:
o Look for and document any
intrahepatic ductal dilatation


Gallbladder
wall
Liver
Main Portal
Vein

Anterior Wall
RT Lobe
Inferior
Porta Hepatis

Transver
se
Sagittal

Kidneys

Mid

Transver
se plane
on the
body/
long axis
on the
vessel
Sagittal

Spleen

Mid

Sagittal

<3 mm

15-17 cm

Normal AP
measurement
is <13mm

Normal flow
velocity is 2040 cm/s
10-12 cm

8-13 cm

o Follow CBD to pancreatic head


If GB removed, CBD may be
enlarged (up to 11 mm)
Calipers are placed outside to
inside of the anterior wall
Measure superior to inferior
through the liver
Internal AP diameter where MPV
crosses the IVC
o Only performed if abnormalities
are suspected
Flow should be phasic and toward
the liver
Measure from superior pole to
inferior pole through the kidney
Measure superior to inferior
through the spleen
Hilum should be demonstrated

Common Laboratory Values to be Reviewed prior to Examination


Lab Value
Amylase
Lipase
Hematocrit

AST (SGOT)

ALT (SGPT)

Alkaline phosphatase

Organ
Pancreas
Pancreas
Aorta (or
any
vessel)
Liver

Level
Increased
Increased
Decreased

Increased

Increased
Increased

Hepatitis, fatty liver, cirrhosis other liver


disease
Jaundice or hepatitis
Biliary obstruction or metastases

Increased

Jaundice, liver damage or obstruction

Increased

Renal failure or renal disease

Increased
Increased

Renal failure or renal disease


Indicates infection

Bilirubin

Blood urea nitrogen


(BUN)
Creatinine
White blood cell
count (WBC)

Liver
Liver
Gallbladd
er
Liver
Gallbladd
er
Kidneys

Kidneys
All organs

Indication or Association
Pancreatitis or other pancreatic disease
Pancreatitis or other pancreatic disease
Vascular rupture, bleeding, hemorrhage,
etc.

Tips
Patient should be NPO for this study to reduce the amount of gas present and to prevent
contraction of the GB
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Have patient poke out their abdomen or take in a deep breath if having trouble seeing the
pancreas
Pancreatic tail may be evaluated using the spleen as a window
Sit the patient erect for scanning if suspicious for stones stuck in the neck that werent
confirmed in LLD or RLD
Watch your gain settings:
o Making the GB lumen too dark with TGC can mask pathology
o Using too much gain can give the appearance of pathology
If the GB appears to have artifacts, change to a higher frequency, use harmonics, use a
different window, or have the patient poke out their abdomen
If the GB is enlarged make sure to evaluate the ducts for signs of stones. These can
obstruct the ducts
To find the CBD:
o Scan from the GB in transverse and follow it to the neck and cystic duct, you will
see CBD
o Follow the portal vein from the portal confluence. The CBD will be anterior to the
vein
If the GB has been surgically removed (postcholecystectomy), document a GB FOSSA
image (main lobar fissure near porta hepatis) instead of the gallbladder images
Roll the patient up LLD and RLD, if necessary, to see kidneys better
o Use the liver on the right as a window
o Use the spleen on the left as a window
If urinary obstruction is a concern, use color Doppler to look for bladder jets to verify open
ureter

Coronal Scanning
o

Sometimes, especially on the left, the kidney can be seen best scanning coronally.
Anterior and posterior images can be obtained from the coronal scan plane.
The medial and lateral images cannot be obtained from this plane.
Therefore, anterior, mid, and posterior images in coronal should documented.
The renal parenchyma, sinus, and capsule will be seen in each image
Label Coronal - Anterior, Mid, or Posterior

Pathology Seen
o
o
o
o
o

Gray scale sagittal and transverse images


Gray scale sagittal and transverse images with 3 measurements (length, width, and
height)
Color Doppler image to document the presence of blood flow
Spectral Doppler image to document type and velocity of blood flow
If aortic aneurysm suspected
Measure transverse aorta from outer wall to outer wall (this measurement is
perpendicular to your AP measurement)
Document location in relation to renal and iliac arteries
Use color Doppler to assess thrombus formation
Use spectral Doppler to show patency
If aortic dissection suspected
Demonstrate beginning and end of intimal flap (may not be able to follow it
all the way superiorly if it originated in thoracic aorta)
Demonstrate any branch vessel involvement

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o
o

o
o
o
o

Use color and spectral Doppler to document true and false lumens
If the GB wall measures greater than 3 mm, color Doppler can be used to confirm
increased flow in the wall due to cholecystitis.
If the patient has gallstones and/or gallbladder wall thickening, they should be
evaluated for a positive Murphys sign (extreme tenderness upon transducer or manual
pressure in the RUQ). This needs to be reported to the interpreting physician as it
indicates acute cholecystitis.
Must attempt to demonstrate movement of any pathology seen in the GB sludge and
stones will move masses will not!!
If the CBD is enlarged at the porta hepatis, it should be followed to the pancreatic head
to evaluate for stones or an obstructive lesion
For hydronephrosis, demonstrate connection of the dilated pyramids to the renal pelvis
and include ureter images if the ureter is dilated.
For renal calculi, move the focal zone to the level of the calculus to aid in
demonstrating posterior shadowing

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