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Abdomen Complete 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

Pancreas

Scan Plane

Transverse
plane on
the body

Label

PANCREAS

PANCREAS

PANCREAS

AO SAG PROX
Aorta

Sagittal
AO SAG MID
AO SAG DIST

IVC

Organ/
Order
LIVER
Sagittal

Key Landmarks Identified

Sagittal

IVC

Scan Plane

Label

Sagittal

LIVER SAG

Left lobe with inferior tip

LIVER SAG

Left lobe
Caudate lobe
IVC
Right lobe
Diaphragm

Right lobe superior


Right hemidiaphragm
Right pleural space
Right lobe mid
Main portal vein

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

LIVER SAG

LIVER
Sagittal

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

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

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LIVER SAG SUP

LIVER SAG
MPV

Key Landmarks Identified

LIVER SAG INF

LIVER TX

Transverse
LIVER
Transverse

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

LIVER TX HV

Angulation of the
probe is used for
right lobe images

LIVER TX
LIVER TX SUP
LIVER TX MPV

Transverse
LIVER
Transverse

LIVER TX MPV

The transducer is
placed transverse
and lateral on the
patients body

LIVER TX MPV

Gallbladder
Patient in
Supine position

Gallbladder
Patient in Left
lateral
decubitus
position

Gallbladder
Patient in Right
lateral

Scan Plane

Label

Sagittal
plane of the
GB

GB SUPINE SAG

Transverse
plane of the
GB

GB SUPINE TX

GB SUPINE SAG

GB SUPINE TX
GB LLD SAG

Sagittal
plane of the
GB

GB LLD SAG

Transverse
plane of the
GB
Sagittal
plane of the
GB

LIVER TX INF

Organ/
Order

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
Right lobe mid
Main portal vein with color 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

Key Landmarks Identified

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

Gallbladder body
Gallbladder fundus
Gallbladder body
Gallbladder neck

GB LLD TX
GB RLD SAG
GB RLD SAG

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decubitus
position

Transverse
plane of the
GB
Transverse
plane of the
CBD

CBD TX
CBD SAG
CBD SAG

Sagittal
plane of the
CBD

CBD SAG

Organ/
Order

Scan Plane

Label
RT KID SAG LAT
RT KID SAG MID

Sagittal
plane of
the kidney

RT KID SAG MID

RT Kidney
RT KID SAG MED
RT KID TX SUP
Transverse
plane of
the kidney

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

LT Kidney

Sagittal
plane of
the kidney

Gallbladder mid body

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

GB RLD TX

Common
Bile Duct
level of the
porta hepatis

LT KID SAG MID

LT KID SAG MED

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

LT KID TX SUP
Transverse
plane of
the kidney

LT KID TX MID
LT KID TX INF
SPLEEN SAG

Sagittal
plane of
the spleen
Spleen

SPLEEN SAG

Transverse
plane of
the spleen

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

Measurement
3 cm or less

Pancreas

Head

Pancreatic Duct

Body of the
pancreas

Common Bile
Duct

Level of Porta
Hepatis

Transverse
plane on
the body
Transverse
plane on
the body

Head 2-3.5 cm

2 mm or less

Long Axis

<7-8 mm

Gallbladder wall

Anterior Wall

Transverse

<3 mm

Liver

RT Lobe Inferior

Sagittal

15-17 cm

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Comments
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
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

Main Portal Vein

Porta Hepatis

Transverse
plane on
the body/
long axis
on the
vessel

Normal AP
measurement is
<13mm

Kidneys

Mid

Sagittal

Normal flow
velocity is 20-40
cm/s
10-12 cm

Spleen

Mid

Sagittal

8-13 cm

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

Bilirubin

Blood urea nitrogen (BUN)


Creatinine

White blood cell count

(WBC)
AST (SGOT)
ALT (SGPT)
Alkaline phosphatase

Tips

Organ
Pancreas
Pancreas
Aorta (or
any vessel)
Liver
Liver
Liver
Gallbladder
Liver
Gallbladder
Kidneys
Kidneys
All organs

Level
Increased
Increased
Decreased

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

Increased
Increased
Increased

Hepatitis, fatty liver, cirrhosis other liver disease


Jaundice or hepatitis
Biliary obstruction or metastases

Increased

Jaundice, liver damage or obstruction

Increased
Increased
Increased

Renal failure or renal disease


Renal failure or renal disease
Indicates infection

Patient should be NPO for this study to reduce the amount of gas present and to prevent contraction of the GB
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

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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

o
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
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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