Biliary U/S

 Identify the following:

 Gallbladder (longitudinal and tranverse planes)
 Main lobar fissure (MLF) of liver
 Common Bile Duct (CBD)
 Portal vein
 Hepatic Artery
 Measure the anterior gallbladder wall (<3mm)
 Measure the CBD <6 mm (+1 mm for every decade of life after age 60; 10 mm if s/p
cholecystectomy)
Tips:
 Scan through entire GB including the neck
 Use patient’s deep inspiration to image GB
 SIN Sign – Cholelithiasis. Stone in the neck is high risk. Roll patient in the LLD to see if the
stone moves.
 WES Sign – wall echo shadow sign. Ultrasonographic finding within the gallbladder fossa
referring to the appearance of wall-echo-shadow

o WES Sign not specific but cholecystitis

 Phrygian cap (Smurf Cap) – normal finding.
 Attempt visualization of the GB anteriorly subcostal and laterally
 Use color flow doppler to differentiate CBD from hepatic artery
 Measure the anterior GB wall (not posterior)
Gastrointestinal U/S
Body Habitus:
 Linear – small patients. Looking around the esophagus or appendix
 Curvilinear – large patients. Differentiating small and large bowel. Appendix (in large
patient)

Esophageal:
Stomach:
Intestinal:
 Normal intestine
o Layered appearance
o Easily compressible
o Intermittent Peristalsis
o Large intestine has wall thickness < 4mm
o Small intestine has wall thickness < 3mm
o Plica circularis – small bowel. Go all the way around a bowel.
o Haustra – large intestine. Does not go all the way across.
 Technique – mowing the lawn
o Have probe transverse with indicator to patient’s right
o Start in RUQ and identify ascending colon by its constancy of position and
haustra
o Follow ascending colon to RLQ and identify
the cecum’s blind-ended loop
o Cecum should lead you to the terminal
ileum where the appendix is found
o Turn probe with indictor towards patient’s
head
 Overcoming air in the intestines – have patient
right leg cross over their left leg as far as possible
without rolling their hip off the table  keeps everything in an anterior to posterior
plane so bowel doesn’t move laterally
 Disease states of the intestine result in decreased peristalsis, bowel wall thickening,
decreased luminal gas content
Appendicitis:
 Normal appendix – difficult to visualize when not swollen
 Compress so you can sandwich the appendix between abdominal wall musculature and
the psoas muscle
 Normal looking appendix is a compressible loop; doesn’t maintain its round shape; <
6mm; no material in appx; no edema; normal power doppler; no peristalsis
 Acute appendicitis – Noncompressible; > 6 mm; no peristalsis; appendicolith;
surrounding edema; ring of fire with PD
 How to find it by ultrasound:
 o STEP 1: Ask the patient where they have the most tenderness! Have them put
the probe where it feels the worst or sharpest
 If that doesn’t work, look for the iliac artery
 Appendix might be draped over the iliac artery
 Go Longitudinal and look for appendix coming off the cecal pouch
SBO
Appendicitis
Free Air