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/ Scan Plane Label Key Landmarks Identified

Order
• Pancreas head
PANCREAS • Portal splenic confluence
• CBD
o If CBD is enlarged, measure internal AP diameter
Transverse
• Pancreas body
Pancreas plane on
PANCREAS • Aorta
the body
• Measurement
o If pancreatic duct is seen measure internal AP diameter
PANCREAS • Pancreas tail
• Splenic vein
• Proximal aorta
AO SAG PROX • Celiac axis
• SMA
Aorta Sagittal
• Mid aorta
AO SAG MID
• SMA
AO SAG DIST • Distal aorta as it tapers before bifurcation
• IVC
IVC Sagittal IVC • Right atrium
• Left lobe

Organ/ Scan Plane Label Key Landmarks Identified

Order
LIVER Sagittal LIVER SAG • Left lobe with inferior tip
Sagittal The transducer is
placed sagittal in the LIVER SAG • Left lobe

mid portion of the • Caudate lobe
patient’s body • IVC

LIVER SAG • Right lobe

• Diaphragm

Sagittal LIVER SAG SUP • Right lobe superior
LIVER The transducer is • Right hemidiaphragm
Sagittal placed sagittal and • Right pleural space
lateral on the LIVER SAG MID • Right lobe mid
patient’s body • Main portal vein
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 LIVER SAG INF • Right lobe inferior
o Demonstrating largest superior to inferior area
o Measure liver length from superior to inferior
• Right kidney
• Left lobe
LIVER TX
Transverse • Caudate lobe


• IVC
The transducer is
placed transverse in
• Right lobe
LIVER
the mid portion of • Left lobe
Transverse LIVER TX HV
the patient’s body • Right hepatic vein

• Left hepatic vein
Angulation of the
probe is used for • Middle hepatic vein
right lobe images LIVER TX • Right lobe - most anterior portion
• Diaphragm
• Right lobe superior
LIVER TX SUP
• Right hemidiaphragm

• Right pleural space
LIVER TX MPV • Right lobe mid
Transverse • Main portal vein
LIVER TX MPV • Right lobe mid
LIVER The transducer is
• Main portal vein with color Doppler
Transverse placed transverse
and lateral on the • Right lobe mid
patient’s body LIVER TX MPV • Main portal vein with color & spectral Doppler
o Normal waveform will demonstrate slight phasic flow
toward the liver
LIVER TX INF • Right lobe - inferior
• Right kidney

Organ/ Scan Plane Label Key Landmarks Identified

Order
• Gallbladder body
Sagittal GB SUPINE SAG
• Gallbladder fundus
plane of the
Gallbladder • Gallbladder body
GB GB SUPINE SAG
• Gallbladder neck
Patient in Transverse GB SUPINE TX • Gallbladder mid body with clear delineation of anterior wall
Supine position plane of the • Gallbladder mid body with clear delineation of anterior wall
GB GB SUPINE TX • Measurement
o measure anterior wall thickness
GB LLD SAG • Gallbladder body
Gallbladder Sagittal
• Gallbladder fundus
plane of the
GB LLD SAG • Gallbladder body
Patient in Left GB
• Gallbladder neck
lateral
decubitus Transverse • Gallbladder mid body
position plane of the GB LLD TX
GB
Gallbladder • Gallbladder body
Sagittal GB RLD SAG
• Gallbladder fundus
plane of the
Patient in Right • Gallbladder body
lateral
GB GB RLD SAG
• Gallbladder neck

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 decubitus Transverse • Gallbladder mid body
position plane of the GB RLD TX
GB
Transverse • Portal vein
plane of the CBD TX • CBD
CBD • Hepatic artery
• Portal vein
CBD SAG
Common • CBD
Bile Duct • Enlarged image
CBD SAG • Portal vein
Sagittal
level of the • CBD
porta hepatis plane of the
CBD • Enlarged image
• Portal vein
CBD SAG • CBD
• Measurement
o Internal AP diameter

Organ/ Scan Plane Label Key Landmarks Identified

Order
RT KID SAG LAT
• Renal parenchyma and capsule
• Renal parenchyma and capsule
RT KID SAG MID
• Renal sinus
Sagittal • Renal parenchyma and capsule
plane of • Renal sinus
RT KID SAG MID
the kidney • Measurement
o Length measurement from superior to inferior pole
RT Kidney
• Renal parenchyma and capsule
RT KID SAG MED
• Renal sinus at hilum

• Renal parenchyma and capsule
RT KID TX SUP • Renal sinus
Transverse • Liver
plane of • Renal parenchyma and capsule
RT KID TX MID
the kidney • Renal sinus at hilum to include renal vessels
• Renal parenchyma and capsule
RT KID TX INF
• Renal sinus
LT KID SAG LAT • Renal parenchyma and capsule
• Renal parenchyma and capsule
LT KID SAG MID
• Renal Sinus
LT Kidney Sagittal • Renal parenchyma and capsule
plane of • Renal Sinus
LT KID SAG MID
the kidney • Measurement
o Length measurement from superior to inferior pole
• Renal parenchyma and capsule
LT KID SAG MED
• Renal sinus at hilum

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 • Renal parenchyma and capsule
LT KID TX SUP
• Renal sinus
Transverse
• Renal parenchyma and capsule
plane of LT KID TX MID
• Renal sinus at hilum to include renal vessels
the kidney
• Renal parenchyma and capsule
LT KID TX INF
• Renal sinus
• Spleen mid
SPLEEN SAG • Left hemidiaphragm
• Left pleural space
Sagittal
• Left kidney (if not seen, may require extra image)
plane of
• Spleen mid with splenic hilum
the spleen
Spleen • Left hemidiaphragm
SPLEEN SAG
• Left pleural space

• Measurement
o Length measurement from superior to inferior
Transverse • Spleen mid
plane of SPLEEN TX
the spleen

Normal Measurement Ranges

Structure Area of Interest Plane Measurement Comments
Aorta Superior, Mid Sagittal 3 cm or less • Only performed if abnormalities are
and Inferior 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
Pancreas Head Transverse Head 2-3.5 cm • Only performed if abnormalities are
plane on suspected
the body
Pancreatic Duct Body of the Transverse 2 mm or less • Only performed if abnormalities are
pancreas plane on suspected
the body • If duct is enlarged measure internal duct
diameter anterior to posterior
Common Bile Level of Porta Long Axis <7-8 mm • Measure inner wall to inner wall
Duct Hepatis • 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)
Gallbladder wall Anterior Wall Transverse <3 mm • Calipers are placed outside to inside of the
anterior wall
Liver RT Lobe Inferior Sagittal 15-17 cm • Measure superior to inferior through the
liver
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Main Portal Vein Porta Hepatis Transverse Normal AP • Internal AP diameter where MPV crosses
plane on measurement is the IVC
the body/ <13mm o Only performed if abnormalities are
long axis suspected
on the Normal flow • Flow should be phasic and toward the liver
vessel velocity is 20-40
cm/s
Kidneys Mid Sagittal 10-12 cm • Measure from superior pole to inferior
pole through the kidney
Spleen Mid Sagittal 8-13 cm • Measure superior to inferior through the
spleen
• Hilum should be demonstrated

Common Laboratory Values to be Reviewed prior to Examination

Lab Value Organ Level Indication or Association
Amylase • Pancreas Increased • Pancreatitis or other pancreatic disease
Lipase • Pancreas Increased • Pancreatitis or other pancreatic disease
Hematocrit • Aorta (or Decreased • Vascular rupture, bleeding, hemorrhage, etc.
any vessel)
AST (SGOT) • Liver Increased • Hepatitis, fatty liver, cirrhosis other liver disease
ALT (SGPT) • Liver Increased • Jaundice or hepatitis
Alkaline phosphatase • Liver Increased • Biliary obstruction or metastases
• Gallbladder
Bilirubin • Liver Increased • Jaundice, liver damage or obstruction
• Gallbladder
Blood urea nitrogen (BUN) • Kidneys Increased • Renal failure or renal disease
Creatinine • Kidneys Increased • Renal failure or renal disease
White blood cell count • All organs Increased • Indicates infection
(WBC)



Tips
• 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 weren’t 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 Gray scale sagittal and transverse images

o Gray scale sagittal and transverse images with 3 measurements (length, width, and height)
o Color Doppler image to document the presence of blood flow
o Spectral Doppler image to document type and velocity of blood flow
o 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
o 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
o If the GB wall measures greater than 3 mm, color Doppler can be used to confirm increased flow in the wall
due to cholecystitis.
o If the patient has gallstones and/or gallbladder wall thickening, they should be evaluated for a positive
Murphy’s 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.
o Must attempt to demonstrate movement of any pathology seen in the GB – sludge and stones will move –
masses will not!!
o 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
o For hydronephrosis, demonstrate connection of the dilated pyramids to the renal pelvis and include ureter
images if the ureter is dilated.
o For renal calculi, move the focal zone to the level of the calculus to aid in demonstrating posterior
shadowing

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