Adrenais Eco

Ultrasound of the adrenal glands has been performed for well over twenty years. In general, in adult
patients only pathologically enlarged adrenal glands are seen on ultrasound. The exception may be a
neonatal patient or a young child in whom normal adrenal glands may be seen. Normal adult adrenal
glands are not well visualized with ultrasonography. Imaging technique mirrors that of the renal
examination, and for good reason, since the two glands have a close anatomic relationship.

In this course we will review the anatomy of the right and left adrenal glands. The physiology of the
adrenal glands will be discussed. We will review the sonographic anatomy of the adrenal glands and
the ultrasound imaging techniques used to identify the adrenals.

Adrenal Glands
The adrenal glands are paired endocrine organs. They are located anteromedial to the superior pole
of the kidneys. In adults, they are approximately 1/13th the size of each respective kidney and
measure approximately 3 to 5 centimeters in length, 2 to 3 centimeters in width, and 1 centimeter in
depth. They are relatively flattened organs and are invested along with each respective kidney in
Gerota's fascia, and are surrounded by adipose. Of note, neonatal adrenal glands are 1/3rd the size
of the neonatal kidneys.
This module will discuss the adrenal glands, also known as the suprarenal glands, which are
endocrine glands that sit above the kidneys within the retroperitoneal perirenal fat. The right adrenal
gland is located posterior to the inferior vena cava, medial to the right lobe of the liver, and lateral to
the crus of the right diaphragm, just above the right kidney. The left adrenal lies posterior to the
pancreas and splenic vein, medial and anterior to the upper pole of the left kidney, and lateral to the
crus of the left hemidiaphragm.
This is a magnification of the previous image, centered at the level of the adrenal glands. The adrenal
glands have the shape of an inverted or upside down V or Y, and have medial and lateral limbs, which
are smooth and uniform in thickness and density. The outer adrenal cortex and the inner adrenal
medulla cannot be distinguished using standard CT imaging techniques.

This is a relatively posterior coronal CT image of the same patient, centered at the level of the adrenal
glands. Again, the adrenal glands are both located superior to the kidneys and lateral to the crus of
the diaphragms, and have both medial and lateral limbs. The spine, liver, stomach, and a portion of
the spleen are also identified on this image.
This is a magnification of the previous coronal image, centered at the level of the adrenal glands.
Again, the adrenal glands are both located superior to the kidneys and lateral to the crus of the
diaphragms, and have both medial and lateral limbs. Diseases of the adrenal glands can manifest
anatomically as diffuse thickening or focal nodular masses of the adrenal glands, and may result in
the overproduction or underproduction of various hormones. The adrenal glands can also be a
common site of metastatic disease, such as from lung cancer.

Adrenal Gland Anatomy

The adrenal glands vary in shape, size, and configuration. The right adrenal is triangular in shape and
sits along the medial aspect of the right renal superior pole. The left adrenal is semilunar in overall
shape and is positioned along the superior-medial aspect of the left kidney, stretching from its hilum to
upper pole. The cortex is the outer layer, comprising 90 percent of the adrenal gland, and medulla is
the inner layer, comprising the remaining 10 percent.

The adrenal glands are supplied by the superior, middle, and inferior suprarenal arteries. They arise
from the suprarenal branch of the inferior phrenic artery, the abdominal aorta, and the renal artery,
respectively. This applies to both left and right adrenal glands. Each adrenal gland is drained by one
suprarenal vein. On the right, venous drainage flows directly into the inferior vena cava, while on the
left, drainage flows into the left renal vein.

Correct. The right lobe of the liver sits anterolateral to the right adrenal gland, while the inferior vena
cava sits just anterior to the right adrenal gland. The left adrenal gland is slightly posterolateral to the
aorta.

Histophysiology

The adrenal gland produces a series of regulatory hormones. The adrenal gland is divided into the
outer adrenal cortex and inner adrenal medulla.

The adrenal cortex secretes three steroid classes: mineralocorticoids, glucocorticoids, and sex
hormones. The cortex is divided into three layers, the zona glomerulosa, the zona fasciculata, and the
zona reticularis, each of which produces a distinctive class of steroids. Mineralocorticoids, produced in
the glomerulosa, are responsible for regulation of electrolyte and fluid balance, with aldosterone being
the principle one. Glucocorticoids, produced in the fasciculata, play a key role in carbohydrate
metabolism. Cortisone and hydrocortisone are the main glucocorticoids. Estrogen and anabolic
androgens, are produced in the zona reticularis.

The adrenal medulla comprises the core of the adrenal gland and produces epinephrine and
norepinephrine, collectively known as catecholamines. These two key hormones are termed "fight or
flight" hormones and increase in response to physical and emotional stress. The adrenal medulla is
under autonomic nervous system neural control. Epinephrine primarily elevates heart rate, while
norepinephrine primarily constricts blood vessels.

Adrenal Gland Sonographic Anatomy

Normal adrenal glands are difficult to visualize in adults with ultrasound. The value of understanding
their location and general sonographic characteristics lies in detection of adrenal gland pathology.
Pathologically enlarged adrenal glands are detectable using sonography. A normal adult adrenal
gland has a hypoechoic appearance (relative to the adjacent liver or spleen and kidney) and is
surrounded by echogenic fat.

In neonates and small children, one may be able to visualize a hypoechoic cortex surrounding a
hyperechoic adrenal medulla. The liver serves as an acoustic window for imaging the right adrenal
gland, and is also a key landmark, as shown in this image. A normal adrenal gland is seen superior to
the upper pole of the kidney, tucked just deep to the liver in the image on the right, obtained from a
pediatric patient.
The left adrenal gland is more difficult to image due to stomach and bowel gas interference. The left
adrenal gland may be seen as a cap to the left kidney, as in this image taken from a pediatric patient.
The spleen is not an effective acoustic window for the left adrenal gland, nor does it serve as a useful
anatomic landmark. Arrows point to the normal adrenal gland, seen superior to a portion of the upper
pole of the left kidney

Curved Array Linear Array

The highest frequency abdominal transducer possible to obtain optimal image resolution and
penetration should be selected. In adults, curved-abdominal transducers (5 to 2 MHz) are commonly
used to scan the adrenal gland. Patients will often need to be placed in different positions in an
attempt to identify an image window that yields a view of the adrenal gland.
Visualization of the normal adrenal glands is typically very difficult, especially in larger patients. The
adrenal gland's small size and medial body position, coupled with surrounding perirenal fat and
frequently noted overlying bowel gas, limits sonographic visualization.

Hence, one should image the region of the adrenal gland, rather than strictly seeking to image the
adrenal gland. The operator will often have to utilize a decubitus or oblique body position and use the
kidney and the aorta or IVC, depending on the side being scanned, as anatomical landmarks.
Scanning the region of the adrenal gland will breed familiarity with surrounding anatomy and will
facilitate detection of pathologically enlarged adrenal glands. Scan the region of the adrenal gland in
two orthogonal planes.

VIDEO SUPRARENAL

The right adrenal gland is best imaged with a high abdominal transverse scan with the patient in left
lateral decubitus position. Place the transducer along the right midclavicular line with the probe
indicator pointing to the anatomic right. Identify the liver and the inferior vena cava. Sweep inferiorly
with the probe, and examine the region of the adrenal gland. This region is bounded posteriorly by the
upper pole of the right kidney and anteriorly by the overlying liver and inferior vena cava.

VIDEO 2

Place the transducer along the midclavicular line, as if performing a high abdominal longitudinal scan.
Ensure the probe indicator is pointing cephalad. Obtain a sagittal plane view of the IVC, and fan back
and forth between the IVC and the right kidney. This is the region of the right adrenal gland. The renal
artery and vein are also helpful landmarks, as the adrenal gland is located just anterior to them.

VIDEO 3
The left adrenal gland is more difficult to scan than the right. Anteriorly, it is covered by the stomach
and bowel, hence, a lateral scanning approach must be used.

Position the patient in a right lateral decubitus position. Position the transducer along the posterior
axillary line, as if performing a longitudinal flank scan, with the probe indicator pointing cephalad.
Identify the spleen and the superior pole of the left kidney. Angle the transducer slightly anteriorly and
scan the region of the adrenal gland.

Upon scanning in a longitudinal plane, rotate the probe 90 degrees counterclockwise and obtain a
transverse flank scan. Identify the region of the adrenal gland along the anterior and medial aspect of
the superior pole of the left kidney. The adrenal gland region will be bounded by the abdominal aorta
medially, and the kidney laterally.

The correct choice is E. The right adrenal gland is best imaged with a high-abdominal transverse
scan, with the patient in a left lateral decubitus position. Place the transducer along the right
midclavicular line with the probe indicator pointing to the anatomic right. Identify the liver and the
inferior vena cava. Sweep inferiorly with the probe, and examine the region of the adrenal gland. This
region is bounded posteriorly by the upper pole of the right kidney, and anteriorly by the overlying liver
and inferior vena cava.

VIDEO 4

Use the highest frequency transducer that provides requisite depth of tissue penetration. Scan
patients using a variety of body positions, such as a lateral decubitus position, coupled with different
scanning approach angles. Having a patient fast or drink water prior to scanning may minimize or
move gas out of the way and improve imaging.

The zoom function is available on most ultrasound machines and can help visualize the adrenal
gland. Adequate resolution is important, or zooming in will simply result in an image that is too grainy
to interpret. This ultrasound clip shows the zoom activated to focus on the inferior portion of the liver,
superior pole of the kidney, and the adrenal gland in between, as indicated by arrow.

The adrenal glands may be seen in some but not all patients, even with ideal body preparation and
expert sonographic technique.