ULTRASOUND

ANA QOMARIYATUN NI’MAH

BY dr. Sandy Istanto

 PENDAHULUAN

• Ultrasound merupakan salah satu modalitas radiologi

untuk mendeteksi / diagnosis penyakit dengan
menggunakan gelombang suara

• Beberapa jenis pemeriksaan ultrasound (3) :

1. USG ABDOMEN  5,5 MHz
2. USG SMALL PART  7,5 MHZ
3. USG OBSGYN
 TOOLS

Transducer  gel. Suara  image

Operating sonographic equipment
Jenis – jenis transducer
sagital transversal
PEDOMAN DASAR SONOGRAFI

Sagital view

• Conventinally viewed as seen from

the patient’s right side
 cranial aspect – left side
 caudal aspect – right side
Transversal viewed

• Conventinally viewed as seen

from the patient’s right side
 left aspect – left side
 right aspect – right side
Anatomic Landmark
TEKNIK SCANNING
Penilaian sonografi hepar :
• Ukuran  < 14 – 15 cm
ekogenisitas parenkim  sama dengan korteks ginjal
• Tepi
• Permukaan
• Duktus biliaris ( intra-ekstrahepatal )  normal tidak
tervisualisasi
• Kelainan pada parenkim  misal nodul
• Ukuran vaskuler
 V. hepatika : Right hepatic vein, Middle hepatic vein, Left
hepatic vein
PENTING dalam penentuan segmen hepar
 V. porta  pengukuran dilakukan pada hilus
HEPATIC MEASUREMENT

MIDCLAVICULA LINE  LONGITUDINAL

Normal : craniocaudal 14-15 cm

Ligamentum teres
 Variant Normal
• Fatty Liver  peningkatan ekogenisitas hepar
 dibandingkan dengan ekogenisitas korteks ginjal
• 3 grade :
Grade I : Pe>> ekogenisitas dengan batas vaskuler
yang masih jelas
Grade II : Pe>> ek. Dengan batas vaskuler yang kabur
Grade III : grade II-III + diafragma (-)
 METASTASIS
• Tumor sekunder
• Polimorfik
 ekogenik : kolorektal Ca
 hipoekoik : Ca mammae / Ca paru
 Bull’s eye : perihipoekoik halo / rim
• Multipel
• Pendesakan struktur di sekitarnya ; vaskuler / duktus
biliaris
 Sirosis dan HCC
• Tahap akhir dari penyakit hepar ; hepatitis,
alkoholisme, toxin substance
 hcc

hcc
 Hipertensi Portal
• Sekunder terhadap sirosis / adanya massa
• Dilatasi v. porta > 13 mm  hipertensi portal
v. porta
Teknik scanning
Penilaian Vesika Felea
• Ukuran
• Dinding  menebal atau tidak
• Batu
• Massa
1. Gallstone
 Kolesterol / kalsium
 echogenic band dg acoustic shadow
 dipastikan dengan perubahan posisi pasien 
dislodge ~ polip
2. Kolesistitis
• Inflamasi di vesika felea, biasanya k/ batu
• Awal  hanya nyeri tekan
late  edema ~ dinding menebal dan multipel
layer
• Dinding V F > 4 mm
• Perikolesistik fluid
Anatomy
• Kidneys are retroperitoneal, T12 - L4
• Right kidney is lower than the left kidney
• Right kidney is posterio-inferior to liver &
gallbladder
• Left kidney is inferior-medial to the spleen
• Adrenal glands are superior, anterior, medial to
each kidney
 Hepatic
Veins

Spleen
Celiac
axis
Liver
SMA Left
Right
Renal artery kidney
kidney
Renal vein
 Approach to Scanning

LIVER STOMACH

I
K K
AORTA
IVC
S
• Right kidney scanning • Left kidney: requires a
approach: anterior, posterior approach, through
lateral, posterior
the spleen
• Liver is the acoustic
window • Air-filled bowel impedes
anterior scanning
 Anatomy
• 9-12 cm long, 4-5 cm wide, 3-4 cm thick
• Gerota’s fascia encloses kidney, capsule, perinephric
fat
• Sinus
▫ Hilum: vessels, nerves, lymphatics, ureter
▫ Pelvis: major and minor calyces
• Parenchyma surrounds the sinus
▫ Cortex: site of urine formation, contains nephrons
▫ Medulla: contains pyramids that pass urine to minor
calyces. Columns of Bertin separate pyramids
Medullary pyramids
Kidney
Minor
Calyx Anatomy

Major
Calyx

Sinus

Medulla

Renal capsule
Cortex
Sonographic Appearance
• Ureters are normally not seen
• Renal pelvis is black when visible
• Renal sinus is echogenic due to fat
• Medullary pyramids are hypoechoic
• Cortex is mid-gray, less echogenic than liver or
spleen.
• Capsule is smooth and echogenic
Right Kidney Long Axis
Anterior

Superior Inferior
Liver
Sinus

Cortex

Diaphragm

Posterior
Right Kidney Short Axis
Anterior

Right Left
GB Liver

IVC

R Kidney
Vertebral
Aorta
Body Renal a.

Posterior
Left Kidney Long Axis
Anterior

Superior Inferior

Rib
Shadow

Kidney
Posterior
Spleen
Left Kidney Short Axis
Anterior

Right Liver Left

Spleen

L Kidney

Posterior
Common Pitfalls in
Renal Scanning
• Failure to scan both kidneys
• Mistaking prominent renal pyramids
for hydronephrosis
• Mistaking prominent pyramids for
cysts
• Confusing normal renal arteries for the
ureter
 Common Pitfalls in
Renal Scanning
• Failure to scan through the bladder to
search for stone at the uretero-vesicular
junction
• Inability to visualize left kidney due to
anterior probe placement
• Failure to scan the aorta in suspected
renal colic
 Normal Variants
• Dromedary humps:
▫ Lateral kidney bulge, same echogenicity as the cortex
• Hypertrophied column of Bertin:
▫ Cortical tissue indents the renal sinus
• Double collecting system:
▫ Sinus divided by a hypertrophied column of Bertin
• Horseshoe kidney:
▫ Kidneys are connected, usually at the lower pole
• Renal ectopia:
▫ One or both kidneys outside the normal renal fossa
Clinical Indications

1. Obstructive Uropathy
Nephrolithiasis

• 12% of the US population

• Incidence of renal colic is 3% with
50% recurrence within 10 years

▫ Manthey DE. Emerg Med Clin North Am.2001; 19(3):

633-54
Radiographic Modalities
Radiography
• 62% Sensitivity, 67% Specificity

▫ Sharma RN, Shah I, Gupta S, et al:

Thermogravimetric analysis of urinary stones. Br
J Urol 64:564-566, 1989
Radiographic Modalities
IVP vs. US
• Prospective study, 85 patients
ULTRASOUND IVP
Sensitivity=85% Sensitivity=90%
Specificity=92% Specificity=94%
▫ Sinclair D, Wilson S, Toi A, et al. Ann Emerg Med
18:556-559, 1989
Radiographic Modalities
ED Ultrasound + KUB vs. IVP
• Prospective study, 108 patients
Sensitivity = 97% PPV = 81%
Specificity = 59% NPV = 92%
Sensitivity = 97%
Specificity = 59%

Henderson, S, et al: Acad Emerg Med.1998;5:666-671.

Radiographic Modalities
Helical CT- Gold Standard
• Accurate, fast, no contrast
• Identifies presence and size of stone
•Location of stone
• Level of obstruction
• Other sources of pain
Location of Stone
• 378 patients
• Rate of spontaneous stone passage
 22% for proximal ureteral stones
 46% for midureteral stones
 71% for distal ureteral stones

▫ Morse R. J Urol. 1991; 145:263-265

Width of Stone
• 520 patients
• Rate of spontaneous stone passage
▫ 100% for stones that were 1 mm or smaller in width
▫ 90% for stones 2 to 3 mm
▫ 80% for stones that were 4 mm
▫ 55% for stones that were 5 mm
▫ 35% for stones that were 6 mm
▫ 25% for stones that were 7 mm
▫ 12% for stones that were 8 mm
 Ueno A. Urology. 1977; 10:544-546
Radiographic Modalities
Ultrasound
• Fast
• Can identify other causes of pain
• Safe in pregnant patients, children
Hydronephrosis

Dilatation of the urinary tract at any

level secondary to intrinsic and or
extrinsic obstruction to urine flow
Hydronephrosis in Renal Colic

Sensitivity = 90% PPV = 92%

Specificity = 93% NPV = 90%

Smith. AJR Am J Roentgenol. 1996; 167:1109-1113

Sensitivity = 87% PPV = 90%

Specificity = 90% NPV = 89%

Dalrymple. J Urol. 1997; 159:735-740

Obstructive Uropathy
Grading System - Subjective
• Mild
▫ Minimal separation of calyces
• Moderate
▫ Dilation of major and minor calyceal system

•Severe
▫ Marked dilation of the renal pelvis and thinning of
the renal parenchyma
 Range of Hydronephrosis

Normal Mild Moderate Severe

Mild Hydronephrosis

GB

Kidney Liver
Moderate - Severe
Hydronephrosis

GB

Kidney
Liver Dilated pelvis
Renal Pathology

1. Renal Cysts
 Renal Cysts
• Arise in the renal cortex, commonly single rather
than multiple
• Cysts do not communicate; hydronephrosis does
• Shape is round or oval
• Echo free
• Sharp interface between the mass and renal tissue
• Large renal cysts may be mistaken for aortic
aneurysms
Renal Cysts
Penilaian Pankreas

• Ukuran
• Ekogenisitas parenkim
• Kalsifikasi
• massa
• Ekogenisitas parenkim >> dg bertambahnya usia

• Ukuran normal
 kaput : < 3 mm
 korpus : < 2,5 mm
 kauda : < 2,5 mm
PANKREATITIS
• Penyebab
 billiary pankreatitis ; batu di CBD
 alkoholisme
• Pankreatitis akut
 ukuran membesar ( thickness )
 hipoekogenisitas parenkim
• Pankreatitis kronis
 heterogenous fibrosis
 kalsifikasi
 tepi yang irreguler
• Posisi RLD dengan pasien melakukan inspirasi dalam
• Posisi transduser sejajar dengan ICS
• Tervisualisasi dome diafragma dan hilus lien
• Normal ukuran lien < 11 cm
1. Diffuse Splenomegali
• Hipertensi portal, infeksi, proses p>> sintesis
eritrosit ( anemia hemolitik, polisitemia )
• Sistemik hematologi diseases  leukemia
• Splenomegali dimulai dengan rounding dr
bentuk crescentnya  giant spleen  kissing
phenomenon
2. Focal Change
 b
a

Vol = A x B x C x 0,52
c
Penilaian Vesika Urinaria
• Dinding
• Permukaan
• Batu
• massa
• Dinding dan lumen V U hanya dapat dievaluasi bila V U
dalam keadaan penuh
 Pada pasien dengan kateter Foley maka diklem ter
lebih dahulu
• V U yang penuh  window uterus / prostat
• Dinding V U tidak boleh melebihi 4 mm  jika lebih dari
4 mm didiagnosa dg sistitis
• Vesikolitiasis
• Massa  TCC
PENILAIAN PROSTAT

• Ukuran  Normal volume < 25 cc

• Kalsifikasi
• Nodul?
• Kapsul
• Transabdominal  harus dalam keadaan V U penuh
~ menyingkirkan udara usus ke kranial dan lateral
~ acoustic window
• Prostat terletak pada dasar V U anterior terhadap
rektum
• Suprapubic transversal dan longitudinal scanning
 Hipertrofi Prostat
• Mengelevasi lantai V U, dinding masih reguler, belum
tampak penebalan
• Hipertrofi lanjut  stenosis urethra  dinding V U
tebal
 Ca Prostat
• Muncul dari perifer
• Infiltrasi dinding V U
• Massa lobulated dalam lumen V U
FAST ( Focused Assesment with Sonography for Trauma )
untuk mendeteksi cairan bebas intraperitoneal maupun
intratoraks
• Indikasi :
 trauma tumpul / penetrating
 trauma in pregnancy
 pediatric trauma
• FAST pada pasien dengan trauma tumpul abdomen :
1. pasien dengan hemodinamik tidak stabil
2. PF yang meragukan
3. unexplained hypotension
FREE PLEURAL FLUID / EFUSI PLEURA
HEMOPERITONEUM