Abdomen and Superficial Structures

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DIAGNOSTIC MEDICAL SONOGRAPHY

Abdomen and Superficial

Structures
DIAGNOSTIC MEDICAL SONOGRAPHY

Abdomen and
Superficial Structures
FOURTH EDITION

Diane M. Kawamura, PhD, RT(R), ROMS, FSDMS, FAIUM

Brady Presidential Distinguished Professor
Department of Radiologic Sciences
Weber State University
Ogden, Utah

Tanya D. Nolan, EdD, RT(R), ROMS

Associate Professor
Department of Radiologic Sciences
Weber State University
Ogden, Utah

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Library of Congress Cataloging-in-Publication Data

Names: Kawamura, Diane M., editor. I Nolan, Tanya D., editor.
Title: Diagnostic medical sonography. Abdomen and superficial structures /
[edited by] Diane M. Kawamura, Tanya D. Nolan.
Other titles: Abdomen and superficial structures
Description: Fourth edition. I Philadelphia : Wolters Kluwer Health, 2018. I
Includes bibliographical references and index.
Identifiers: LCCN 2017024239 I ISBN 9781496354921
Subjects: I MESH: Abdomen-diagnostic imaging I Ultrasonography-methods I
Digestive System-diagnostic imaging I Urogenital System-diagnostic imaging
Classification: LCC RC944 I NLM WI 900 I DDC 617.5/507543-dc23 LC record available at https:/flccn.loc.gov/2017024239

This work is provided uas is," and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy,
comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals' examination of each patient and consideration
of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to
the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and
not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.
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 To my late husband. Bryan, who provided me
with confidence and who always supported my
professional endeavors. This edition was hard.er
without my favorite companion and best friend.
To our wonderful children, Stephanie and Nathan,
who continue to inspire me to appredate how
important it is to learn new things and to enjoy
learning. To all my colleagues on campus and
in the profession who provide encouragement,
support, and stimulating new challenges.
-DIANE M. KAWAMURA

To my husband and best friend, 1Tent, whose

unconditional love and encouragement has
sustained me through every challenge and
enriched my life's journey. To my amazing
children, Joseph. Ethan, and Spencer, for
inspiring me to become a better person and for
fi.lling my dreams with hope and joy. To my
many colleagues, for giving me the strength and
motivation to aim high, learn more, and be
determined to the end.
-TANYA D. NOLAN

And to students and professionals who will use

this book:
''.Any piece of knowledge I acquire today has a
value at this moment exactly proportioned to
my skill to deal with it. Tomorrow, when I know
more, I recall that piece of knowledge and use
it better."-Mark Van Doren, Liberal Education
(1960)
-DIANE M. KAWAMURA, TANYA D. NOLAN
CONTRIBUTORS

Monica M. Bacani Barbara Hall-Terracciano, BS, RT(R), RDMS

Retired Status with ARDMS Clinical Sonographer
Retired Pediatric Sonographer Author/Editor
Columbus, Ohio St. George, Utah

Sara M. Baker, MEd, RT(R), RDMS, RVT, RMSKS Charlotte Henningsen, MS, RT(R), RDMS, RVT, FSDMS,
Senior Sonographer FAIUM
University of Wisconsin Hospital and Clinics Associate Vice President
Madison, Wisconsin Faculty Development in Teaching & Learning
Director and Professor
Teresa M. Bieker, MBA, RT, RDMS, RDCS, RVT Center for Advanced Ultrasound Education
Lead Sonographer Adventist University of Health Sciences
Division of Ultrasound and Prenatal Diagnosis Orlando, Florida
University of Colorado Hospital
Aurora, Colorado Terri L. Jurkiewic , RDMS, RVT
Adjunct Fae
Joie Burns, MS, RT(R)(S), RDMS, RVT Departme ces
Sonography Program Director Weber St
Associate Professor Ogden,
Boise State University
Boise, Idaho ura, PhD, RT(R), RDMS, FSDMS,

Catherine Carr-Hoefer, CRA, RT(R), RDMS, RDCS, RVT al Distinguished Professor

Diagnostic Imaging Manager of Radiologic Sciences
Samaritan North Lincoln Hospital e University
Lincoln City, Oregon en, Utah

M. Robert De Jong, RDMS, RDCS, RVT, FSDMS, FAIUM George M. Kennedy-Antillon, AS, RT(R), RDMS, RDCS,
Radiology Technical Manager, Ultrasound RVT
Johns Hopkins Medical Institutions Clinical Instructor
Baltimore, Maryland Department of Ultrasound
University of Colorado Hospital
Kevin D. Evans, PhD, RT(R)(M)( Aurora, Colorado
FSDMS
Professor Darla Matthew, BAS, RT(R)(S), RDMS
School of Health & Rehabilitation Sciences Associate Professor/Program Director
The Ohio State University Diagnostic Medical Sonogrpahy
Columbus Ohio Dona Ana Community College
Las Cruces, New Mexico
Alyssa Frederick, BS, RT(R), RDMS, RVT
Clinical Instructor J. P. Moreland, BS, RT(R)(CT), RDMS, RVS
Ultrasound Technologist Product Manager
Primary Children's Medical Center Radiology /Vascular Ultrasound
Salt Lake City, Utah Samsung Healthcare America
San Francisco, California
Tim S. Gibbs, BSDMS, RT(R), RDMS, RVT, CTNM
Ultrasound Supervisor Tanya D. Nolan, EdD, RT(R), RDMS
West Anaheim Medical Center Associate Professor
Anaheim, California Department of Radiologic Sciences
Weber State University
Sasha P. Gordon, BS, RDMS, RVT Ogden, Utah
Clinical Instructor/Pediatric Ultrasound Educator
Primary Children's Medical Center
Salt Lake City, Utah

vi
 CONTRIBUTORS vii

Rechelle A. Nguyen, RDMS Dana C. Walker, BS, RDMS, RVT

Clinical Sonographer Radiology Manager-Ultrasound
DepartinentofUltrasound University of Wisconsin Hospitals and Clinics
Nationwide Children's Hospital Madison, Wisconsin
Columbus, Ohio
Michelle Wilson, EdD, RDMS, RDCS
Aubrey J. Rybyinski, BS, RDMS, RVT Clinical Sonographer/Educator
Lead Technologist/Technical Director Kaiser Permanente
Navix Diagnostix Napa, California
Thunton, Massachusetts

Kellie A. Schmidt, BS, RDMS, RVT, RDCS

Clinical Instructor
Division of Ultrasound and Prenatal Diagnosis
University of Colorado Hospital
Aurora, Colorado
REVIEWERS

Brent Bereska. ARDMS. RDMS, RDCS
Sonography Canada: CRGS, CRCS
Northern Alberta Institute of Technology
Edmonton, Canada
Martie Grant, ARDMS
General and Cardiac and Breast Sonography Canada:
Generalist and Cardiac
Northern Alberta Institute of Technology
Edmonton, Canada
Kellee Stacks, BS, RTR, RDMS, RVT
Cape Fear Community College
Wilmillgton, North Carolina
Stacey Rider, RDMS (Abdomen, OB/Gyn, Breast), RVT,
RDCS (Adult Echo)
Keiser University
Ft. Lauderdale, Florida

DwJshtGunte~BS.RDMS
Cambridge College of Healthcare and Technology
Atlanta, Georgia

viii

T he fourth edition of Diagnostic Medical, Sonogmphy:
Abdomen and Superficial Structures is updated to reflect
the major developments that have occurred since the last
edition. Educators and colleagues encouraged us to produce
a fourth edition to incorporate new advances used to im-
age, to refresh the foundational content, and to continue to
provide information that recognizes readers have diverse
backgrounds and experiences. The result is a textbook that
can be used as either an introduction to the profession or
a reference for the profession. The content lays the foun-
dation for a better understanding of anatomy, physiology,
and pathophysiology to enhance the caregiving role of the
sonographer practitioner, sonographer, sonologist, or student
when securing the imaging information on a patient.
The first chapter introduces terminology on anatomy,
scanning planes, and patient positions. Adopting universal
terminology permits every sonographer to communicate
consistent information on how he or she positioned the pa-
tient, how he or she scanned the patient, and how anatomy
and pathology are sonographically represented.
The next four sections are divided into specific content
areas. Doing this allowed the contributors to focus their
attention on a specific organ or system. This simulates
PREFACE
application in that while scanning, the sonographer inves-
tigates the organ or system, moves systematically to the
next organ or system, and completes the examination by
synthesizing all the infonnation to obtain the total picture.
We made every attempt to produce an up-to-date and
factual textbook while presenting the material in an interest-
ing and enjoyable format to capture the reader's attention.
To do this, we provided detailed descriptions of anatomy,
physiology, pathology, and the normal and abnormal so-
nographic representation of these anatomic and pathologic
entities with illustrations, summary tables, and images,
many of which include valuable case study information.
Our goal is to present as complete and up-to-date a
text as possible, while recognizing that by tomorrow, the
textbook must be supplemented with new information
reflecting the dynamic sonography profession. With every
technologi.c advance made in equipment, the sonographer's
imagination must stretch to create new applications. With
the comprehensive foundation available in this book, the
sonographer can meet that challenge.
Diane M. Kawamura
'Cm.ya D. Nolan
ix
ACKNOWLEDGMENTS
A special recognition to Bridgette Lunsford, co-editor
of the third edition. As a sonographer, educator, and
author, Bridgette's contributions made it possible to have
made the giant leap that occurred between the second and
the third editions. While preparing the fourth edition, we
appreciated the support, ideas, and collaboration of Anne
Marie Kupinski, Susan Stephenson, and Julia Dmitrieva
as we worked on the three volumes of Diagnostic Medical
Sonogmphy. Their input and ideas were a significant con-
tribution to the project.
Our thanks and gratitude go to all the contributors of
the fourth edition who gave of their expertise, time, and
energy, updating the content with current information to
use in obtaining a more accurate imaging examination for
our patients.
The image contributions became treasured moments.
We thank the many sonographers and physicians for their
assistance. A special thank you and recognition for ongoing
support in image acquisition goes to Taco Geertsma, MD,
Ede, the Netherlands, at Ultrasoundcases.info and Siemens
x
Medical Solutions USA, Inc. Thank you to the contributors
of the third edition: Philips Medical Systems, Bothell, Wash-
ington; GE Healthcare, Wauwatosa, Wisconsin; Joe Anton,
MD, COchin, India; Dr. Nakul Jerath, Falls Church, Vuginia;
and Monica Bacani and Rechelle Nguyen at Nationwide
Children's Hospital in Columbus, Ohio.
Many thanks to all the production team at Wolters
Kluwer, who helped edit, produce, promote, and deliver
this textbook. We especially thank in the development
of this edition Jay Campbell, acquisitions editor; Heidi
Grauel, freelance product manager; Jennifer Clements, art
director; and John Larkin, Editorial Coordinator, for their
patience, follow-through, support, and encouragement.
'lb our colleagues, students, friends, and family, who
provide continued sources of encouragement, enthusiasm,
and inspiration-thank. you.
Diane M. Kawamura
Tanya D. Nolan
 USING THIS SERIES

T he books in the Diagnostic Medi.cal Sonography series will help you develop an under-
standing of specialty sonography topics. Key learning resources and tools throughout the
textbook aim to increase your understanding of the topics provided and better prepare you for
your professional career. This User's Guide will help you
familiarize yourself with these exciting features designed
to enhance your learning experience.

Chapter Objectives
Measurable objectives listed at the beginning of each Introduction
chapter help you understand the intended outcomes for
the chapter, as well as recognize and study important
concepts within each chapter.

Glossary
Key terms are listed at the beginning of each chapter
___ _
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Critical Thinking Questions

Throughout the chapter are critical thinking questions
to test your knowledge and help you develop analytical
skills that you will need in your profession.
CRITICAL THINKING QUESTIONS
l. A Doppler apeclral anafylil of the DOl'lllBl SMA mmla a
cbaracterlst1c pattl!m associated with a hfgbly reliltant
YUCUlar bed. There • a 8harp rite in ftow during fY9fO)e
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Resources thePoinf
You will also find additional resources and exercises on thePoint, including a glossary with
pronunciations, quiz bank, sonographic video clips, and weblinks. Use these interactive
resources to test your knowledge, assess your progress, and review for quizzes and tests.
CONTENTS

Introduction I
DIANE M. KAWAMURA

PART ONE I ABDOMINAL SONOGRAPHY

2 The AbdominaJ Wall and Diaphragm 13
TERRI L. JURKIEWICZ

3 The Peritoneal Cavity 41

JOIE BURNS

4 Vascular Structures 59
AUBREY J. RYBYINSKI

5 The Liver IOI

M. ROBEIU DE JONG

6 The GaJlbladder and Biliary System 171

TERESA. M. BIEKER

7 The Pancreas 213

KEWEA 50-IMIDT

8 The Spleen 229

TANYAD. NOLAN

9 The Gastrointestinal Tract 247

llAABAAA HALL-TERRACCIANO

I0 The Kidneys 271

SARAM. BAKER I DANAC. WALKER

11 The Lower Urinary System 335

DANA C. WALKER. I SARA M. WER

12 The Prostate Gland 357

GEORGE M. KENNEDY->NTILLON

13 The AdrenaJ Glands 377

DARLA MATTHEW

14 The Retroperitoneum -405

JOIE BURNS

PART TWO SUPERFICIAL STRUCTURE SONOGRAPHY

15 The Thyroid Gland, Parathyroid Glands, and Neck 421
DIANE M. KAWAMURA

xii
 CONTENTS xiii

16 The Breast 455

CATHERINE CARR-HOEFER

17 The Scrotum 51 I
MICHELL£ WILSON

18 The Musculoskeletal System 551

KEYlN D. EVANS

PART THREE NEONATAL AND PEDIATRIC SONOGRAPHY

19 The Pediatric Abdomen 611
SASHA P. GORDON

20 The Pediatric Urinary System and Adrenal Glands 655

ALYSSA FREDERICK

21 The Neonatal Brain 687

MONICA M. Bll.CANI

22 The Infant Spine 715

RECHELL£A. NGUYEN

23 The Infant Hip Joint 729

CHARILOTIE HENNINGSEN

PART FOUR SPECIAL STUDY SONOGRAPHY

24 Organ Transplantation 739
KEYlN D. EVANS

25 Point-of-Care Sonography 757

J. P. MORELAND I MICHELLE WILSON

26 Foreign Bodies 779

TIMS. GIBBS

27 Sonography-Guided lnterventional Procedures 795

AUBREY J. RYBYlNSKI

Index 813
 Introduction

DIANE M. KAWAMURA

OBJECTIVES KEY TERMS

-----------------------------------------------------

■ Identify anatomic definitions in regard to directional terms, anatomic position, and anatomic accuracy
planes. anechoic
■ Demonstrate the sonographic examination to include patient position, transducer coronal plane
orientation, and image presentation and labeling.
echogenic
■ Define the terms used to describe image quality.
echopenic
■ Describe the sonographic echo patterns to demonstrate how normal and~ tholagic
heterogeneous
conditions can be defined using image quality definitions.
■ List and recognize the sonographic criteria for cystic, solid, and complex co 01tions.
homogeneous

■ Describe the appropriate patient preparation for a sonographic evalua 10n.

hyperechoic
hypoechoic
■ State what should and what should not be included in a prelimi ~ ry ejJO .
isoechoic
■ Calculate sensitivity, specificity, and accuracy using the four o tco es of true positive, false
positive, true negative, and/or false negative. sagittal plane
sensitivity
GLOSSARY specificity
transverse plane
anechoic describes the portion of an image that appears echo-free
echogenic describes an organ or tissue that is capable of producing echoes by refiecting
the acoustic beam
echopenic describes a structure-that is less echogenic or has few internal echoes
heterogeneous describes tissue or organ structures that have several different echo
characteristics
homogeneous refers to imaged echoes of equal intensity
hyperechoic describes image echoes brighter than surrounding tissues or brighter than
is normal for that tissue or organ
hypoechoic describes portions of an image that are not as bright as surrounding tissues
or are less bright than normal
isoechoic describes structures of equal echo density

T his chapter focuses on the sonography examination of

the abdomen and superficial structures. It was written to
assist sonographers in acquiring, using, and understanding
the sonographic imaging terminology used in the remainder
of this textbook. Accurate and precise terminology allows
communication among professionals.
ANATOMIC DEFINITIONS
The profession adopted standard nomenclature from the
anatomists' terminology to communicate anatomic direction.
Table 1-1 and Figure 1-1 illustrate how these simple terms help
avoid confusion and convey specific information. A person
l PART ONE ABDOMINAL SONOGAAPHY

TABLE 1-1 Dlrectlonal Terms

'llrm Daftnldan Eample
Superior (cranial) Toward the head, doser to the head, the upper portion of the body, the The left adrenal gland is superior to the left
upper part d a structure, or a structure higher than another structure kidney
Inferior (caudal) Toward the feet, away from the head, the lower portion of the body. The lo>.Ver pole d each kidney is inferior to the
toward the lower part of a structure, or a structure lower than another upper pole
structure
Anterior (ventral) Toward the front or irt the front of the body or a strud.\Jre in front of The main portal vein is anterior to 1he inferior
another strud.\Jre venacava
Posterior (dorsal) Toward the back or the bade d 1he body or a structure behind anotiier The main portal vein is posterior to the
structure common hepatic artery
Medial Toward the middle or mid line of the body or the middle of a structure The middle vein is medial tD the ri.!trt hepatic vein
Lateral Away from the middle or the midline of the body or perlaining to the side The ri.!trt lciciiey is lateral tD the inferior vena caw.
Ipsilateral Located on the same side of1he body or afecting the same side of the body The gallbladder and right kidney are ipsilateral
Contralateral Located on the opposite side of1he body or affecting the opposite sided The pancreatic: tail and pancreatic head are
the body contralateral
Proximal Ooser to the attachment of an extremity to the trunk or 1he ori_i;n of a The abdominal aorta is proximal to the
body part bifurcation of the iliac arteries

Distal Farther from the attachment of an extremity to 1he trunk or the origin of a The iliac arteries are distal to the abdominal
body part aorta

Superficial Toward or on the body surface or external The thyroid and breast are consiclered
superficial strud.\Jres
Deep Away from the body surface or internal The peritoneal organs and great vessels are
deep strudures

Cranial
Cephalic
Superior

II
+- ~ ~
-~
Anterior
Ventral 001881
Lateral

Distal

J Caudal
Inferior

FIGURE 1-1 Directional tenns. The drawir« depicts a body in the anatomic position (standing erect. arms by 1he side, face and palms directed forward) with the
directional terms. The directional terms COl'Telate with 1he terms in Table 1-1.
 I INTRODUCTION l

in the conventional an.atomic position is standing erect, feet
together, with the arms by the sides and the palms and face
directed forward, facing the observer. When sonographers
use directional terms or descnbe regions or anatomic planes,
it is assumed that the body is in the anatomic position.
There are three standard anatomic planes (sections) that
are imaginary flat surfaces passing through a body in the
standard anatomic position. The sagittal plane and coronal
plane follow the long axis of the body and the transverse
plane follows the short axis of the body1 (Fig. 1-2).
Superior
The word sagittol. literally means "flight of an arrow"'
and refers to the plane that runs vertically through the body
and separates it into right and left portions. The plane that
divides the body into equal right and left halves is referred
to as the median sagittal or midsagittal plane. Any vertical
plane on either side of the midsagittal plane is a parasagit-
tal. plane (para means "alongside of"). In most sonography
cases, the term sagittal usually implies a parasagittal plane
unless the term is specified as median sagittal or midsag-
ittal. The coronal plane runs vertically through the body
from right to left or left to right, and divides the body into
anterior and posterior portions. The transverse plane passes
through the body from anterior to posterior and divides the
body into superior and inferior portions and runs parallel
to the surface of the ground.

SCANNING DEFINITIONS
Patient Position
Positional terms refer to the patient's position relative to
the surrounding space. For sonographic examinations, the
patient position is described relative to the scanning table
or bed (Table 1-2; Fig. 1-3). In clinical practice, patients are
scanned in a recumbent, semierect (reverse 'Jl'endelenburg
or Fowler), or sitting position. On occasion. patients may be
placed in other positions, such as the lrendelenburg (head
lowered) or standing position, to obtain unobscured images
of the area of interest. Sonographers frequently convey
information on patient position and transducer placement
simultaneously. This terminology most likely was adopted
from radiography, where it describes the path of the X-ray
beam through the patient's body (projection). which results

TABLE 1-2 Patient Positions

'R9rm DelCl'lptlon
Decubltu1 or The act d lying dOIMl. The adjective
Recumbent before 1he word desaibes the most
dependent body surface
Supine or dorsal Lying on 1he bac:k
Prone or ventral Lying face cbNn

RLD Lying on 1he right side

LLD Lying on 1he left side

Oblique Named for the body side dosest to

the scanning table
RPO Lying on 1he right posterior surface,
the left posterior surface is elevated
LPO Lying on 1he left posterior surface,
1he right posterior surface is elevated
RAO Lying on 1he right anterior surface,
the left anterior surface is elevated

Inferior LAO Lying on the left anterior surface, the

FIGURE 1-1 Anatomic: planes. The standard anatomic: position is use<J to
depict 1he three imafjnary anaromic: flat surface planes. Both the~ and
coronal planes !>i1S$1tirough ttie long axis and the 1ransvel'$C plane passes
through the short axis.
right anterior S\Jrface is elevated
LAO, left anterior oblique; LLD, left lateral de<:ubitus; LPO, left posterior
oblique; RAO. right anterior oblique: RlD. right lareral de<:ubitus; RPO. right
posterior oblique.
 PART ONE ABDOMINAL SONOGRAPHY
Supine
Lateral
~
RAO
LPO
FIGURE I·3 Patient positioos. The various patient positions depicted in the illustration correlate with the descriptions in Table 1-2. lAO, left anterior oblique; I.PO,
left posterior oblique: RAO, right anterior oblique: RPO. right posterior oblique.
in a radiographic image {view). There is no evidence in the
literature that this nomenclature has been adopted as a
professional standard for sonographic imaging. Describing
sonograms using the terms projection or view should be
avoided. It is more accurate to describe the sonographic image
stating the anatomic plane visualized, which is due to the
transducer's orientation (i.e., transverse). A more specific
description of the image would include both the anatomic
plane and the patient position (i.e., transverse, oblique).
Transducer Orientation
The transducer's orientation is the path of the insonating
sound and the path returning echoes is viewed on the
monitor. 'Itansducers are manufactured with an indicator
(notch, groove, light) that is displayed on the monitor as
a dot, arrow, letter of the manufacturer's insignia, and so
forth. Scanning plane is the term used to describe the trans-
ducer's orientation to the anatomic plane or to the specific
organ or structure. The sorwgraphi.c image is a representa-
tion of sectional anatomy. The term plane combined with
the adjectives sagittal, parasagittal, coronal, and transverse
describes the section of anatomy represented on the image
(e.g., transverse plane).
Because many organs and structures lie oblique to the
imaginary body surface planes, sonographers must identify
sectional anatomy accurately to utilize a specific organ and
structure orientation for scanning surfaces. The sonography
imaging equipment provides great flexibility to rock, slide,
and angle the transducer to obtain sectional images of organs
oriented obliquely in the body. For example, to obtain the
~
Prone
Oblique
LAO
RPO
long axis of an organ, such as the kidney, the transducer is
oblique and is angled off of the standard anatomic positions:
sagittal, parasagittal, coronal, or transverse plane. Sonog-
raphers frequently use the terms sagittal. or parasagittal to
mean longitudinal in depicting the anatomy in a long-axis
section. Although some images in this text are labeled sagittal
or parasagittal, they are, in fact, longitudinal planes because
the image is organ specific. For organ imaging, transverse
planes are perpendicular to the long axis of the organ, and
longitudinal and coronal planes are referenced to a surface.
All three planes are based on the patient position and the
scanning surface (Fig. 1-4A-C).
Image Presentation
When describing image presentation on the display monitor,
the body, organ, or structure plane terminology, coupled with
transducer placement. provides a very descriptive portrayal of
the sectional anatomy being depicted. CUrrent flexible, free-
hand scanning techniques may lack automatic labeling of the
scanning plane. With the free-hand sc.anning technique, quan-
titative labeling may be limited, which means reduced image
reprodUCJ.'bility from one sonographer to another sonographer.
Sonographers usually can select from a wide array of protocols
for image annotation or em.ploy postprocessing annotation.
This is extremely important when the image of an isolated
area does not provide other anatomic structures for a reference
location. 1b ensure consistent practice, sonographers must
correctly label all sonograms. With today's equipment, stan-
dard presentation and labeling is easily achieved along with
additional labeling of specific structures and added comment.
 I INTRODUCTION s

Longitudinal section Sonogram

Anterior

Posterior

Coronal plane Coronal section Sonogram

Right

Tulnswrae plane Tulnswrae section Sonogram

Anterior

Posterior

FIGURE 1-4 Transduair orientation. A:. A parasagittal plane provides a longitudinal section of the kidney on the sonogram. B: The coronal plane provides a coro-
nal section on the sonogram. C: The trar\Sllerse plane provides a tranwerse section on the sonogram. The sonogram is the image the sonographer observes on
1he monitor.

The anterior, posterior, right, or left body surface is
usually scanned in the sagittal (parasagittal), coronal, and
transverse scanning planes. For organ or structure imag-
ing, these same body surfaces are scanned with different
angulations and obliqueness of the transducer to obtain
longitudinal, coronal. or transverse scanning planes. With
few exceptions. the transducer at the scanning surface is
presented at the top of the image. 1.2 Images obtained using
an endovaginal probe are usually flipped so that they are
presented in the more traditional transabdominal transducer
orientation, whereas images obtained using an endorectal
probe are presented in the transducer-organ orientation.
With the neonatal head (neurosonography, neurosonology),
the superior scanning surface is presented at the top of the
image when the transducer is placed on the neonate's head.
These six scanning surfaces, anterior or posterior, right
or left. endocavitary (vaginal or rectal), and the cranial
fontanelle coupled with three anatomic planes (sagittal,
coronal, and transverse) produce a combination of 14 dif·
ferent image presentations.
Longitudinal: Sqittal Planes
When scanning in the longitudinal, sagittal plane, the trans-
ducer orientation sends and receives the sound from either
an anterior or posterior scanning surface. For a longitudinal
plane, the transducer indicator is in the 12 o'clock position
to the organ or to the area of interest. This always places the
superior (cephalic} location on the image. From either the
anterior or posterior body surface, the patient can be scanned
in either erect, supine, prone, or an oblique position. The
6 PART ONE ABDOMINAL SONOGAAPHY

image presentation includes either the anterior or posterior,
the superior (cephalic), and the inferior (caudal) anatomic
area being ex:amined.1•2 (Fig. 1-SA). Because the longitudinal,
sagittal image presentation does not demonstrate the right
and left lateral areas, adjacent areas can be evaluated and
documented with transducer manipulation, changing the
transducer orientation, or changing the patient position.2
Lonsitudinal: Coronal Planes
When scanning in the longitudinal, coronal plane, the
transducer orientation sends and receives the sound from
either the right or left scanning surface. Because the trans-
ducer indicator is in the 12 o'clock position to the organ or
to the area of interest, the superior (cephalic) location is
always imaged. From either the right or left body surface,
the patient can be scanned in either an erect, decubitus, or
an oblique position and the image presentation includes
either the left or right, the superior (cephalic), and the in-
ferior (caudal) anatomic area being examined1.2 (Fig. 1-SB}.
Because the longitudinal, coronal image presentation does
not demonstrate the anterior or posterior areas, adjacent
areas can be evaluated and documented with transducer

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FIGURE 1-5 Image presentl.tions. k Longitudinal, sagittll plane. With 1he patient being scanned from either 1he anterior or 1he posterior surface with or without
obliquity. the image seen on the monitor demonstrates the scanning wrface (anterior or posterior) and the wperior (cephalic) and inferior (caudal) area being ex-
amined. 8: Lon,P!clinal, ooronal plane. Wrth the patient bei~ scanned from either the right or left surface with or without obliquity, the image seen on the monitor
demonstrates the sanni~ surface (right or left) and the superior (cephalic) ind inferior (caudal) areas being examined. C: Transverse plane, anterior or posterior
S\Jrfaae. Wth the patient being scanned from either the anterior or posterior surface with or without obliquity. the image seen on the monitor demonstrates the
scanning surface (anterior or posterior) and the right and left areas being examined. 0: Transverse plane, right or left wrface. Wilh 1he patient being scanned from
either the right or the left surface wi1h orwittlout obliquity. the image seen on the monitor demonstrates the scanning surfate (right or left) and the anterior and
posterior areas being examined.
 I INTRODUCTION 7

manipulation, changing the transducer orientation, or
changing the patient position.1
Transverse Plane: Anterior or Posterior Surface
Using the anterior or posterior surface, the transducer orien-
tation for a transverse plane places the transducer indicator
in the 9 o'clock position on either the anterior or posterior
surface to the organ or to the area of interest. The right and
left location is always imaged. From either the anterior or
posterior surfaces, the patient can be scanned in either an
erect, decubitus, or an oblique position. The image pre-
sentation includes either the anterior or posterior and the
right and left anatomic area being examined1..2 (Fig. 1-SC).
Transverse Plane: Right or Left Surface
Using the right or left surface, the transducer orientation
for a transverse plane places the transducer indicator in
the 9 o'clock position on either the right or left surface to
the organ or to the area of interest. From either the right or
left surfaces, the patient can be scanned in either an erect,
decubitus, or an oblique position. The image presentation
includes either the right or left and the anterior and posterior
anatomic area being examined1..2 (Fig. 1-SD).
Endovaginal Planes
The patient is in the supine position for endovaginal imag-
ing. The image presentation does not change if the system

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Sagittal Coronel Saglttal Coronel orTranswrse

Ceudalllnferlor Caudal/Inferior
FIGURE 1-5 {CDntinued) E: Endovaginal planes. The image preserrtrtion on
1t1e left illustrates a sat')ttal plane and 1t1e one on the right is the coronal plane.
On either presentation, the apex of the image seen on the monitor cor-
responds t.o the il'\ilt.omy dose st to the faced the transducer: F: Endomc:IAI ...
.9
planes. The image presentdioo on the left illustral:es a sagill2l plane and the
one on 1t1e right is 1t1e transverse or coronal plane. On either presentation,
1t1e apex of the image seen on the bottom c:J1t1e monitor corresponds to the
anatomy closest to the face of the transducer. G: Cranial fontanelle planes.
I
With the patient being scanned from either the anterior or the posterior sur- Cephalic/Superior Cephallc/Superlor
face wi1t1 or without obliquity. the image seen on the monitor demonstrates
1t1e scanning surface (anterior or posterio1' and the superior (cephalic) and
inferior (caudal) areas being examined. Sagittal: Anterior Fontanelle Coronal: Anterior Fontanelle
8 PART ONE ABDOMINAL SONOGRAPHY
employs either an end-firing or an angle-firing endovagi-
nal transducer. For the sagittal Oongitudinal) plane, the
transducer is placed at the caudal end of the body with the
indicator in the 12 o'clock position. Orientations of both
the endovaginal sagittal and the translabial transducer produce
the same image presentation. The inferior (caudal) anatomy
is presented at the top of the monitor with visualization of
the anterior and posterior anatomic areas.
The coronal plane is obtained with the transducer at the
caudal end of the body and the indicator in the 9 o'clock
position. The top (apex) of the image is the inferior (caudal)
area and the right and left anatomic areas can be visualized
on the display monitor. The coronal plane is sometimes
described using an older description reference to the trans-
verse plane1 (Fig. 1-SE).
Endorectal Planes
The patient is most often in a left lateral decubitus position for
placement of either the end-firing or the bi-plane endorectal
transducer. When used for biopsy, both the end-firing and
the bi-plane endorectal transducers place the biopsy guide
anterior toward the prostate. For either the sagittal plane or
the transverse or coronal planes, the anterior rectal wall is
the scanning surface and is assigned to the bottom of the
display monitor (Fig. 1-SF).
Cranial Fontanelle Planes
For neonatal brain examinations, the sagittal and coronal
planes are most commonly accessed using the anterior
fontanelle. For the sagittal plane, the transducer indicator
is in the 6 o'clock position and indicates the anterior side
of the brain. For the coronal plane, the transducer indicator
is in the 9 o'clock position and indicates the right side of
the brain (Fig. 1-SG).
IMAGE QUALITY DEFINITIONS
Evaluation of sonographic image quality is learned and
communicated using specific definitions. Normal tissue and
organ structures have a characteristic echographic appearance
relative to surrounding structures. An understanding of the
normal appearance provides the baseline against which to
recognize variations and abnormalities. These definitions
describe and characterize the sonographic image.
An eclw is the recorded acoustic signal. It is the reflection
of the pulse of sound emitted by the transducer. Prefixes
or suffixes modify the quality of the echo and are used to
describe characteristics and patterns on the image.
Echogenic describes an organ or tissue that is capable
of producing echoes by reflecting the acoustic beam. This
term does not describe the quality of the image; it is often
used to describe relative tissue texture (e.g., more or less
echogenic than another tissue) (Fig. 1-6A,B). An aberration
from normal echogenicity patterns may signify a pathologic
condition or poor examination technique such as incorrect
gain settings.
Aneclwic describes the portion of an image that appears
echo-free. A urine-filled bladder, a bile-filled gallbladder,
and a clear cyst all appear anechoic (Fig. l -6C). Sonolu-
cent is the property of a medium allowing easy passage of
sound (i.e., low attenuation). Sonolucent or transonic are
misnomers that are often substituted for anechoic. 3 When
the sonographic appearance is anechoic, sonographers fre-
quently use the term cystic. When describing the appearance
of the echo, the term anechoic is correct. When describing
the histopathologic nature of an anechoic structure, cystic
or cyst-like is correct (see "Interpretation of Sonographic
CharacteristicsH section).
If the scattering amplitude changes from one tissue to
another, it results in brightness changes on an image. These
brightness changes require terminology to describe normal
and abnormal sonographic appearances. Hyperechoic describes
image echoes brighter than surrounding tissues or brighter
than normal for a specific tissue or organ. Hyperechoic
regions result from an increased amount of sound scatter
relative to the surrounding tissue. Hypoechoic describes
portions of an image that are not as bright as surrounding
tissues or less bright than normal. The hypoechoic regions
result from reduced sound scatter relative to the surrounding
tissue. Eclwpenic describes a structure that is less echogenic
than others or has few internal echoes. Isoeclwic describes
structures of equal echo density. These terms can be used
to compare echo textures (Fig. 1-60).
Homogeneous refers to imaged echoes of equal intensity.
A homogeneous portion of the image may be anechoic,
hypoechoic, hyperechoic, or echopenic. Heterogeneous de-
scribes tissue or organ structures that have several different
echo characteristics. A normal liver, spleen, or testicle has
a homogeneous echo texture, whereas a normal kidney is
heterogeneous, with several different echo textures.
Acoustic enhancement is the increased acoustic signal
amplitude that returns from regions lying beyond an ob-
ject that causes little or no attenuation of the sound beam
such as fluid-filled structures. The opposite of acoustic
enhancement is acoustic shadowing and both are types of
sonographic artifacts. Acoustic shadowing describes reduced
echo amplitude from regions lying beyond an attenuating
object. An example is seen with echogenic calculi (choleli-
thiasis, urolithiasis) which does not allow ultrasound to pass
through (it is attenuated) resulting in a sharp, distinctive
shadow (Fig. l-6E). Air bubbles (bowel gas) do not allow
transmission of the sound beam and most of the sound is
reflected.4 Often, sonographers refer to the shadowing caused
by low reflectivity as soft or dirty shadowing.
INTERPRETATION OF SONOGRAPHIC
CHARACTERISTICS
Three other definitions are frequently used to describe
internal echo patterns: cystic, solid, and complex.
The diagnosis of a cyst is made on many asymptomatic
patients based on specific sonographic characteristic ap-
pearances and only in certain situations, with a correlation
with the patient's history. The sonographic criteria for cystic
structures or masses are as follows: (1) Cysts retain an an-
echoic center, which indicates the lack of internal echoes
even at high instrument gain settings. (2) The mass is well
defined, with a sharply defined posterior wall indicative of
a strong interface between cyst fluid and tissue or paren-
chyma. (3) There is an increased echo amplitude in the tissue
beginning at the far wall and proceeding distally compared
to surrounding tissue. This increased amplitude is better
known as through-transmission or the acoustic enhancement
 I INTRODUCTION 9

A B

c D

FIGURE 1-6 Tissue texture5. A:. On this longitudinal section in the supine
position, 1he diaphl"llglll (v.hite solid <Jm1N) is described as more ediogenic
1han 1he normal texture of1he right liver lobe (RU.), which is more echogenic.
1han 1he renal parendiyma (...Alite am:1N) (FV, portal vein; l'llite solid <XIT1N, dia-
phragm). B: In 1his patient. the transver.;e section demonstr.rtes 1hat tne liver
and panen!aS 11!!X:t!Jres have a similar ediogenicity (ISOl!d'loic) (Ao. aorta; NC,
inferiorvena cava; PH, pancrealic head; PT, pancre.alic. tail; RRA, right renal
artery; SMV, ruperior mesenteric. vein). C: On 1his longitudinal section made
in tne supine position, 1he bile-filled gallbladder (GB) appear$ anecnoic.. 0: On
a longitlldinal section of the right kidney, the renal c.ipsule is normally a specu-
lar reflector and is hyperechoic compared to surrounding tissues. Tne renal
cortex is homogeneously echogenic: and 1he pyramids (P) seel'1 in 1he medulla
become more prominent and can diange from hypoechoic. to anechoic with
increased diuresis. Tne area labeled shadowing is caused by bowel gas and is
due 10 low reflectivity (referred to as soft or dirty shadow). E: The transverse
gallbladder is from a patient with diolecy,;ti1is (1hiclcened wal~ and a diolelithia-
sis aealing an acoustic. shadow due to atteN.lation. Compare f\gure I-OE with
Figure I-OD with the appearance of a shadow due to low reflec!Mo/. (Images
courtesy of Philips Medical System, Bothell, WA) E
10 PART ONE ABDOMINAL SONOGRAPHY
artifact. It occurs because tissue located on either side of
the cystic structure attenuates more sound than does the
cystic structure. (4) Reverberation artifacts can be identified
at the near wall if the cyst is located close to the transducer.
(S} Edge shadowing artifacts may appear, depending on the
incident angle {refraction) and the thickness of the cystic
wall at the periphery of the structure. The tadpole tail sign
occurs with a combination of an edge shadow next to the
echo enhancement (Fig. l-7A).
A solid structure may have a hyperechoic, hypoechoic,
echopenic, or anechoic homogeneous echo texture, or it
may be heterogeneous because it contains many different
types of interfaces. Usually, solid structure exhibit the fol-
lowing characteristics: (1) internal echoes that increase with
an increase in instrument gain settings; (2) irregular, often
poorly defined walls and margins; and (3) low-amplitude
A B
c System, Bothell, WA)
echoes or shadowing posterior to the mass due to increased
acoustic attenuation by soft tissue or calculi (Fig. 1-78).
A complex structure usually exhibits both anechoic and
echogenic areas on the image, originating from both fluid
and soft tissue components within the mass. The relative
echogenicity of a soft tissue mass is related to a variety
of constiwents, including collagen content, interstitial
components, vascularity, and the degree and type of tissue
degeneration (Fig. l-7C).
The amplitude of echoes distal to a mass, structure, or
organ can be used to evaluate the attenuation properties of
that mass. Thlnsonic or sonolucent refers to masses, organs,
or tissues that attenuate little of the acoustic beam and result
in images with distal high-intensity echoes. An example is a
cystic structure with the associated acoustic enhancement
artifact. Masses that attenuate large amounts of sound
FIGURE 1-7 lnterpretition. A:. Cystic. A longitlJdinal seaion d the right
kidney demonstrates a renal cyst. The following sonographic criteria for a cyst
are present (I) anechoic: center; (2) cle.ilr definition witn a sharply defined
posterior wall, (3) acoustic enhancement, (4) reverberation artifac:ts (~
art'CN>head), and (S) edge shadowing artifact. 8: Solid. A transverse section
1hrough 1he right lobe of the liver demonstrates a hemanjjoma. The benign
solid mass presents wi1h 1he following sonographic aiteria for a solid mass:
(I) internal ed:loes that increase witn increased gain settings and (2) low-
amplitude echoes (arrow) or shadowing posterior to the mass. l~larwalls
may be present when the solid mass is a calculus or a malignant tumor. C:
Complex. The encapsulated mass is a complex struc:llJre exhibiting septa.
between echogenic and aned10ic areas. (Images courtesy cl Philips Medical

show a marked decrease in the amplitude of distal echoes.
An example is calculi, with the associated shadow artifact.
PREPARATION
Before the patient is scanned, it is important for the so-
nographer to obtain as much information as possible. The
sonographer should be aware of the indications for the
study and of any additional clinical information such as
laboratory values, results of previous examinations, and
related imaging examinations. The sonographic examination
should be tailored to answer the clinical questions posed
by the overall clinical assessment.
Patient apprehension is reduced when the examination
is explained. Apprehension may be lessened further by pro-
viding a clean, neat examination room, extending common
courtesies and a smile, and letting the patient know that
the sonographer enjoys providing this diagnostic service.
It is important that patients know that they are the focus
of the sonographer's attention.
The region of interest is visualized by planning the
sonographic examination to image in multiple planes, two
of which are perpendicular. Any abnormalities are imaged
with differing degrees of transducer and patient obliquity
to collect more information. The patient is released only
after sufficient information is documented, because being
called back for a repeat examination increases apprehension.
EXAMINATION DOCUMENTATION
AND THE SONOGRAPHER'S
PRELIMINARY REPORT
The minimum documentation on sonographic images includes
(I) the patient's name and other identifying information,
(2) the facility's identifying information, (3) date of the
examination, and (4) the image orientation if appropriate.5
In many departments, sonographers provide a preliminary
report. Legally, physicians can provide a diagnosis or an
interpretive report, whereas sonographers cannot. Sonog-
raphers function as a delegated agent of the physician and
do not practice independently. 6 The preliminary report is
more commonly referred to as the technical impressions or
the examination worksheet. The minimum documentation
on a technical impression worksheet should include (I)
the patient's name and other identifying information, (2)
date of the examination, (3) relevant clinical information
which may include classification of disease code, (4) specific
examination requested, and (S) the name of the patient's
health-care provider and contact information. 5 The techni-
cal impressions worksheet should give key sonographic
findings. Ideally, the sonographer has an opportunity to
discuss these findings with the sonologist. As a team, the
sonographer and sonologist determine when the documenta-
tion is sufficient to complete the sonography examination.
When immediate action is indicated by the sonographic
findings and the sonologist is unavailable to provide the
final interpretive report, the sonographer should provide the
referring physician with as much information as possible
immediately following the examination.
The sonographer's report should describe the sono-
graphic findings only on what is documented, without
I INTRODUCTION 11
offering a conclusion regarding pathology. The terminology
presented previously is very helpful. Include the scanning
plane, normal tissue echogenicity, abnormal tissue texture
(anechoic, hyperechoic, hypoechoic, isoechoic, cystic, solid
or complex, focal or diffused, and shadowing or acoustic
enhancement), measurements (vessels, ducts, organs, wall
thickness, masses), location of measurements, and abnormal
amounts of fluid collections. For example, describing an
echogenic mass attached to the gallbladder wall that does
not move as the patient changes position discusses the
sonographic findings, whereas stating that the patient has
a polyp located in the gallbladder is a diagnosis.
The department should have a policy regarding the docu-
mentation to include on the image and interpretive report
worksheet as well as the final report from the interpreting
physician. Sonographers should be competent, through
education and experience, to provide images of adequate
quality and written documentation of the sonographic find-
ings without legal obligation. 6 Sonographers should not
provide any verbal or written sonographic findings to the
patient or the patient's family.
While demonstrating their sonographic evaluation ex-
pertise, sonographers should always adhere to the codes of
medical ethics and/or professional conduct available from
professional associations. 6 These codes and clinical prac-
tice standards should also be included in the sonographer
employment Gob) description.
SENSITIVITY, SPECIFICITY,
AND ACCURACY
Sonographers should be aware of a few statistical parameters
developed to judge the efficacy of sonographic examinations.
These statistics are frequently reported in the literature.
Knowing these statistics allows the sonographer to provide
a sound rationale for why a diagnostic procedure should or
should not be performed.
There are four possible results for each sonographic
examination correlated with an independent determination
of disease, such as a biopsy or a surgical procedure. (1) A
true-positive result means that the sonographic findings were
positive and the patient does have the disease or pathology.
(2) A true-negative result means that the sonographic findings
were negative and the patient does not have the disease or
pathology. (3) A false-positive result means that the sono-
graphic findings were positive but the patient does not have
the disease or pathology. (4) A false-negative result means that
the sonographic findings were negative but the patient does
have the disease or pathology. Sonographers should strive
to increase both the true-positive and true-negative results.
The examination's sensitivity describes how well the
sonographic examination documents whatever disease or
pathology is present. Mathematically, it is determined by
the equation [true positive + (true positive + false nega-
tive) x 100]. If the number of false-negative examinations
decreases, the sensitivity of the examination increases.
The examination's specificity describes how well the sono-
graphic examination documents normal findings or excludes
patients without disease or pathology. Mathematically, it is
determined by the equation [true negative + (true negative
+ false positive) x 100]. If the number of false-positive
12 PART ONE ABDOMINAL SONOGRAPHY
examinations decreases, the specificity of the examination
increases.
The accuracy of the sonographic examination is its abil-
ity to find disease or pathology if present and to not find
disease or pathology if not present. Mathematically, it is
determined by the equation [true positive + true negative+
(all patients receiving the sonographic examination) x 100].
There are two other statistics that sonographers should
be aware of. The positive predictive value indicates the
likelihood of disease or pathology if the test is posi-
tive. Mathematically, it is detennined by the equation
SUMMARY
• Learning and understanding accurate and precise ter-
minology allows commUIJication among professionals.
• Developing standard protocols based on understanding
patient positions, transducer orientations, and image
presentations increases the accuracy of the sonography
examinations.
• Sonographers describe sonographic findings with ter-
minology that defines echo amplitude, echo texture,
structural borders, characteristics of organs and anatomic
relationships, sound transmission, and acoustic artifacts
and identifies cystic, solid, and complex masses.
• The sonography examination relies on the skill, knowl-
edge. and accuracy of the sonographer who must pay
attention to the texture, outline, size. and shape of both
normal and abnormal structures.
• The patient will benefit most when the sonographic
appearance is correlated with patient history, clinical
presentation. laboratory function tests, and other imag-
ing modalities to compose a clinically helpful picture.
REFERENCES
1. American Institute of Ultrasound in Medicine. AlUM Tuchnical
Stan.d/l1'ds Comm.itttt: Stmu1.a:rd Presentation and Labeling of
Ultmsound Images. Stb ed. Laurel, MD: American lns!itute of
Ultraaound in Medicine; 2013.
2. Tempkin BB. Scanning planes and scanning methods. In: Tumpkin
BB, ed. Sonography Scanning: Principles and 1'1:otDaJU. 4th ed. St.
Louis, MO: msmer; 2013:15-28.
3. American lnalitute of Ultrasound in Medicine. .AruM Recommended
Ultmsound 'n!rminology. 3rd ed. Laurel, MD: American Institute
af Ultrasound in Medicine; 2008.
[true positives+ (true positives+ false positives) x 100].
The negative predictive value indicates the likelihood
of the patient being free of disease or pathology if the
test is negative. Mathematically. it is determined by
the equation [true negatives + (true negatives + false
negatives) x 100].
The mathematical formulas presented provide a percent-
age. If sensitivity, specificity, accuracy, and positive and
negative predictive values are expressed by fractions between
0 and 1 rather than by a percentage, the parameters were
not multiplied by 100.
CRITICAL THINKING QUESTIONS
1. If the patient is lying on his or her right side and the
transducer indicator is at the 12 o'clock position on the
left Jateral abdominal wall, what is the scanning plane
and how is the image presented on the display monitor1
2. What anatomic areas are not visualized on a longitu-
dinal, sagittal image presentation and how does the
sonographer evaluate these areas?
3. Explain the mechanism and differentiate between acous-
tic shadowing and low refiectivity due to air bubbles.
MEDIA MENU
Student Resources available on thePoint• include:
• Audio glossary
• Interactive question bank
• Internet resources
4. Lunsford BM. Basic principles. In: Sanders RC, Hall-Turracciano
B, eds. Clinical Sonogruphy: A Practical Gaide. Stb ed. Baltimore,
MD: WOltm Kluwer; 2016:106-118.
S. American Institute of Ultrasound in Medicine. AlUM Practice
Pammeter for Docu.numtaJ:iDn of an Ultnzsound Emmination.
Laurel, MD: .American Institute of Ultrasound in Medicine; 2014.
6. Society of Diagnostic Medical Sonography. Scope of Practice and
Clinical Standards for the Diagnostic Mediml Sonographer. Plano,
TX: Society of Diagnostic Medical Sonography; 2013-2015.
 ABDOMINAL SONOGRAPHY

The Abdominal Wall and

Diaphragm
TERRIL. JURKIEWICZ

OBJECTIVES KEY TERMS

■ Locate the nine regions of the abdomen and the four quadrants of the abdominopelvic abdominal hernia
cavity. abdominopelvic cavity
■ Discuss the extent, the muscles , and the subcutaneous layers of the abdominal wall a'.E abscess
diaphragm.
aponeurosis
■ Describe the role of sonography, the sonographic technique, and the normal onographic
desmoid tumor
appearance of the abdominal wall and diaphragm.
diaphragm
■ Identify the etiology and sonographic appearance of acute and t,;,to~ic al5~inal wall
infiammatory process to include resolution, organization, and absces's::fom;iation. diaphragmatic hernia
■ Describe the common etiologies and sonographic appearanQ -abeiominal wall diaphragmatic inversion
hematomas and trauma. diaphragmatic paralysis
■ Identify the different types of abdominal hernias and hieir s01\1ographic appearance. endometrioma
■ List the neoplasms that affect the abdominal ~I an<:l tlesc[i oe their sonographic appearance. eventration
■ Identify diaphragmatic pathologies that can be e~a~ d with sonography. fascia
■ Identify technically satisfactory and unsatisfacto sonographic examinations of the hematoma
abdominal wall and diaphragm.
inguinal canal
inguinal hernia
GLOSSARY
lipoma
abscess a cavity containing dead tissue and pus that forms due to an infectious process neuroma
ascites an accumulation of serous fiuid in the peritoneal cavity pleural effusion
ecchymosis skin discoloration caused by the leakage of blood into the subcutaneous tis-
rectus abdominis
sues, which is often referred to as a bruise
rhabdomyolysis
erythema redness of the skin due to infiammation
linea alba fibrous structure that runs down the mid line of the abdomen from the xiphoid sarcoma
process to the symphysis pubis separating the right and left rectus abdominis muscles seroma
omphalocele a congenital defect in the midline abdominal wall that allows abdominal
organs, such as the bowel and liver, to protrude through the wall into the base of the
umbilical cord
peristalsis rhythmic wavelike contraction of the gastrointestinal tract that forces food
through it
pneumothorax collapsed lung that occurs when air leaks into the space between the
chest wall and lung

13
14 PART ONE ABDOMINAL SONOGRAPHY

T he human body contains two major cavities: the ven-

tral (anterior) cavity and the dorsal (posterior) cavity.
The dorsal cavity is divided into the cranial cavity and the
spinal cavity. In the ventral cavity, the diaphragm muscle
separates the thoracic cavity from the abdominopelvic
cavity. The abdominopelvic cavity has an upper portion
(the abdomen). a lower portion (the pelvis). and it is sur-
rounded by the abdominal wall This chapter focuses on
the abdominal wall and diaphragm.
REGIONS AND QUADRANTS
For clinical reasons used to descnoe the location of organs,
pain, or pathology, the abdomen is divided into nine region&
and the abdominopelvic cavity is divided into four quad-
rants. The nine regions are delineated by two horizontal
(transverse) planes and two vertical (longitudinal) planes
and the four quadrants are delineated by one horizontal
(transverse) plane and one vertical {longitudinal, midsagit-
tal, or sagittal} plane. 1.2 The nine regions are the (1) right
hypochondrium. (2) epigastrium, (3) left hypochondrlum,
(4) right lumbar. (5) umbilical, (6) left lumbar, (7) right iliac
fossa, (8) hypogastrium, and (9) left iliac fossa. 1.2 The four
quadrants are the (1) right upper quadrant (RUQ}, (2) left
upper quadrant (LUQ). (3) right lower quadrant {RLQ), (4)
and left lower quadrant (LLQ)M (Fig. 2-lA,B).
ANATOMY
The abdominal wall is continuous but, for descriptive
reasons, it is divided into the anterior wall, right and left
lateral walls, and posterior wall. Because the anterior and
lateral wall boundaries are indefinite, they will be combined
in the presentation as they are combined in other refer-
ences1.2 (Fig. 2·2).
Anterolateral Abdominal Wall
The anterolateral wall extends from the thoracic cage to the
pelvis. Superiorly, it is bounded by the cartilages of the 7th
to 10th ribs and the xiphoid process. Inferiorly, it is bounded
by the inguinal ligament and iliac crests, pubic crests, and
pubic symphysis of the pelvic bones.4
Layers
To better understand abdominal wall anatomy, it is important
to distinguish between fascia and aponeurosis. A fasci.a. is
a fibrous tissue network located between the skin and the
underlying structures. It is richly supplied with both blood
vessels and nerves. The fascia is composed of two layers: a
superficial layer and a deep layer. The superficial fascia is
attached to the skin and is composed of connective tissue
containing varying quantities of fat. The deep fascia underlies
the superficial layers to which it is loosely joined by fibrous
strands. It serves to cover the muscles and to partition them
into groups. Although the deep fascia is thin, it is more
densely packed and is stronger than the superficial fascia;
however, neither the superficial fascia nor the deep fascia
possesses any notable internal strength since they are a
condensation of connective tissue organized into definable
homogeneous layers within the body.s

Median plane

- - - ----Transumblllcal
Transtubercular plane
plan&-l"'f""·~...-

Midinguinal
r-!->-=t=:-~--!--Publc
point
symphysis

Antartor view• A Nine abdominal region• B Four abdominal quadranta

- Right hypochondriac (RH) 1=i Left lateral (lumbar) (LL) 1=i Right upper quadrant (RUQ)
1=i Eplgastrtc (E) c::::::::J Right Inguinal (groin) (RI) c:::::::::i Left upper quadrant (LUQ)
c:::::::::i Left hypochondriac (LH) c:::::::::i Pubic (hypogastric) (P) c:::::::::i Right lower quadrant (RLQ)
c:::::::::i Right lateral (lumbar) (RL) - Lsft inguinal (groin) (LI) c:::::::::i Left lower quadrant (LLQ)
c:::::::::i Umbilical (U)

FIGURE 2-1 AbdominopeMc cavity subdivisions. k The regions are formed by two sagittal ('lelt.icaf) and two tranMrse {horiz.onrt.11) planes. B: The quadrams are
funned by the midsagittal plane and atranMlrse plane passing through the umbiliws at the iliac creit or the disk level between the 13--4 vertebrae. (Reprinted with
pennissionfrom Moore KL.~rAM. Essential C/inica/Anaumy. 3rd ed. Baltimo~. MD: Lippincott Wiiiams& Willcins: 2007:119.)

Linea
alba
Lumbar vertebra
Inferior vi..,,,
FIGURE 2-2 Abdominal wall subdivisions. The 1ransverse section illuWates
the structural relationships of the abdominal wall. (Reprinted with permission
from Moore K. Dalley A >€ur A OinicaJ/y Orientlld Anattxrtf. 6th ed. Philadel-
phia, PA: Lippinaitt Williams & Wilkins; 20 I0: 186.)
The aponeurose.s are layers of fl.at tendinous fibrous sheets
fused with strong connective tissue that serve as tendons to
attach muscles to fixed points. An aponeurosis is minimally
served by blood vessels and nerves. The aponeuroses are
primarily located in the ventral abdominal regions with
a primary function to join muscles to the body parts that
the muscles act upon. An aponeurosis possesses excellent
strength.3
The multilayered abdominal wall appean as a laminated
structure when viewed from the superficial, outermost
layer to the deep layer.4 It consists of skin, subcutaneous
tissue (superficial fascia), muscles and their aponemo-
ses, a deep fascia, extraperitoneal fat, and the parietal
peritoneum.l,M The skin attaches loosely to most of the
subcutaneous tissue except that it normally adheres firmly
at the umbilicus.u
The subcutaneous tissue anterior to the muscle layers
makes up the superficial fascia. Superior to the umbilicus,
Superficial tatty layer of
subcutaneoustlBSue(Camperfascla)--;- . 1 : ~:
·-·:.:..•
Deep membranous layer of ~ ;-. · · · • · · • · · ~External oblique muse!&
subcutaneous ti$11ue (Scarpa fascia)/~ lnt al bl.
• • ~ ""!"" s ~ ern o 1quemusce
lnv&Sting (deep) fascia: ~ :;; -::s ;;z..,,,lhlnswrse abdominal muscle
superficial, intermediate, deep ~ :::<'.
~ Extraperttoneal fat
Endoabdominal (transversalis)~ • • ·· ~~ ' '
fascia
FIGURE 2-3 Anterolateral abdominal wall. The section of1he anterolateral abdominal wall inferior to 1he umbilicus illustrates the multilayered, laminar-appeari~
tissue and musdes located anterior to 1he peritoneal cavity.
2 THEABDOMINAL WALLAND DIAPHRAGM IS
it is consistent with that found in most regions. Inferior to
the umbilicus, the deepest part of the subcutaneous tissue
is reinforced with elastic and collagen fibers and is divided
into two layers. The first is a superficial fatty layer (Camper
fascia) containing small vessels and nerves. camper fascia
gives the body wall its rounded appearance. The second layer
is a deep membranous layer {Scarpa fascia) and it consists
of a combination of fat and fibrous tissue that blends with
the deep fascia. 1.2 The membranous layer continues into
the perineal region as the superficial perinea! fascia (Coll.es
fascia) 1 {Fig. 2-3).
The three anterolateral abdominal muscle layers and
their aponeuroses (flat extended tendons) are covered by
the superficial, intennediate, and deep layers of extremely
thin investing fascia. 1 The investing layer of fascia is lo-
cated on the external aspects of the three muscle layers
and is not easily separated from the external muscle layer.
Varying thicknesses of membranous and areolar sheets
of endoabdominal fascia line the internal aspects of the
wall. Although the endoabdominal fascia is continuous,
different names account for the muscle or aponeurosis it
is lining. For ex.ample, the portion liniDg the deep surface
of the transversus abdominis muscle and its aponeurosis
is the transversalis fascia. Internal to the transversalis
fascia is the parietal peritoneum. The distance separating
the parietal peritoneum from the transversalis fascia is
determined by the variable amounts of extraperitoneal
fat in the fascia. 1 The parietal peritoneum is a glistening
lining of the abdominopelvic cavity formed by a single
layer of epithelial cells and supporting connective tissue1•2
(see Fig. 2·3).
Muscles
There are five bilaterally paired muscles in the anterolat-
eral abdominal wall and one unpaired. muscle (Tu.ble 2-1).
Located bilaterally on the anterior abdominal wall are
the rectus abdorninis muscles (see Fig. 2-2). The rectus
abdominis is a long, broad, vertical, strap-like muscle that
is mostly enclosed in the rectus sheath. Also located on the
anterior abdominal wall in the rectus sheath is the pyrami-
dal.is muscle. The pyramidali.s, a small triangular muscle,
is considered insignificant and is absent in approximately
20% of people1•2 {Fig. 2-4A).
There are three flat, bilaterally paired muscles of the
anterolateral group: (I} the external oblique (most su-
perficial), (2} the internal oblique (middle layer), and
(3) the transversus abdominis (also known as transverse
Skin SUperftclal
" . : ';. :.~
!
1
.7"' Parietal peritoneum Deep
16 PART ONE ABDOMINAL SONOGRAPHY

TABLE 2-1 Muscles of the Abdominolateral Wall 1.2

Rectus abdominis Bilaterally paired, vertical muscle
(Rgs. 2-2 and 2-4A) Origin: Arises from the front of the pubic bone and pubic symphysis
Insertion: Inserts into the frfth, sixth, and seventh costal cartilages and the xiphoid process
Action: Acts to flex the trunk, compress abdominal viscera, and stabilize and control pelvic tilt

Pyramidal is Small, insignificant triangular musde

(Rg. 2-4A) Origin: Arises from the anterior surface of the pubis
Insertion: Inserts into the linea alba; lies anterior to the lower part of the rectus abdominis
Action: Acts to draw the linea alba inferiorly

External oblique Bilaterally paired, flat muscle

(Rgs. 2-2 and 2-4B,q Origin: Arises from the external surface ofthe lower eight ribs
Insertion: Inserts in linea alba via an aponeurosis and into the iliac crest and pubis via the inguinal ligament
Action: Acts to compress and support abdominal viscera, flexes and rotate trunk

Internal oblique Bilaterally paired, flat muscle

(Rgs. 2-2 and 2-4B,q Origin: Arises from the thoracolumbar fascia and the anterior two-thirds of the iliac crest
Insertion: Inserts into the inferior borders of 'ttle lower three ribs, linea alba, and pubis via a conjoint tendon
Action: Acts as a postural function of all albdominal muscles

Transversus abdominis Bilaterally paired, fla:t muscle

(transverse albdominal; Origin: Arises from the internal surfaces of the lower eight cost.al cartilages,7- 12 the thoracolumbar fascia, the anterior
Figs. 2-2 and 2-4B,q two-thirds of the iliac crest, and the lateral 'ttlird of the inguinal ligament
Insertion: Inserts into the xiphoid process, linea alba with aponeurosis of internal oblique, pubic crest, and pectin pubis
via a conjoint tendon
Action: Same as external oblique; acts to compress and support albdominal viscera

abdominal) 1- 3 (see Fig. 2-2 and Table 2-1). Coupled with
the vertical orientation of the fibers of the rectus abdominis,
the fibers in the three flat muscles are arranged to provide
maximum strength by forming a supportive muscle gird.le
that covers and supports the abdominopelvic cavity. In the
external oblique, the muscle fibers have a diagonal inferior
and medial orientation. The fibers of the internal oblique,
the middle muscle layer, have a perpendicular orientation
at right angles to those of the external oblique. The fibers
of the innermost muscle layer, the transversus abdominis,
are oriented transversely or horizontally. 1- 3
Structures
The other structures within the anterolateral abdominal
wall include the rectus sheath, linea alba, umbilical ring,
and the inguinal canal.
The rectus sheath is the strong, fibrous compartment for
the rectus abdominis and pyramidalis muscles as well as
for some arteries, veins, lymphatic vessels, and nerves. The
anterior and posterior layers of the rectus sheath compart-
ment are formed by the intercrossing and interweaving of
the aponeuroses of the flat abdominal muscles. The lateral
aspect of the rectus abdominis, the aponeuroses, fuses to
form the linea semilunaris.3 The arcuate line is located half
way from the umbilicus to the pubis symphysis and refers
to the transition terminating the posterior rectus sheath
covering the proximal, superior three-quarters of the rectus
abdominis muscle.3 The distal, inferior quarter is covered
by the transversalis fascia, which lies below the rectus
muscles and is all that separates the rectus muscles from
the peritoneum3 (Fig. 2-SA,B).
Throughout its length, the linea alba is formed as fibers
of the anterior and posterior layers of the sheath interlace
in the anterior median line. 1- 3 The linea alba is oriented
vertically and courses the length of the anterior abdominal
wall. It separates the bilateral rectus sheaths. Superiorly, the
Iinea alba is wider and it narrows inferior to the umbilicus to
the width of the pubic symphysis. The linea alba transmits
small vessels and nerves to the skin (Figs. 2-2, 2-4A, and
2-SA,B). In thin, muscular people, a groove is visible in the
skin overlying the linea alba.
The umbilicus is the area where all layers of the antero-
lateral abdominal wall fuse.1 The umbilical ring is a defect
in the linea alba and is located underlying the umbilicus. 1•2
This is the area through which the fetal umbilical vessels
passed to and from the umbilical cord and placenta. After
birth, fat accumulation in the subcutaneous tissue raises
the umbilical ring and depresses the umbilicus.
The inferior border of the external oblique extends be-
tween the anterior superior iliac spine and the pubic tubercle
forming the inguinal ligament.3 Located in the inguinal
region superior and medial to the inguinal ligament is the
inguinal canal, which is formed during fetal development.
It is an important canal where structures exit and enter
the abdominal cavity, and the exit and entry pathways are
potential sites of herniation. 1- 3 In adults, the inguinal canal
is an oblique passage approximately 4 cm long. It has an
inferior-to-medial orientation through the inferior part of the
anterolateral abdominal wall and lies parallel and superior
to the median half of the inguinal ligament.2 Functionally
and developmentally distinct structures located within the
canal are the spermatic cord in males and the round uterine
ligament in females. Other structures included in the canal
in both sexes are blood and lymphatic vessels and the ilio-
inguinal nerves. The inguinal canal has two openings. The
deep (internal) inguinal ring serves as an entrance and the
superficial (external) inguinal ring serves as the exit for
the spermatic cord or the round ligament in females. Normally,
the inguinal canal is collapsed anteroposteriorly against the
 2 THEABDOMINAL WALLAND DIAPHRAGM 17

A Antwtor view

External Extemal
oblique obllque
(cut) (cut)
Internal
Internal Rectus oblique--.'Hf
oblique-~"' sheath (cut)
(anterior
layer)

-"'---Inguinal
ligament

B c D
Lateralvltwa
FIGURE 2-4 Abdominolateral wall muscles. A; The bilaterally pai~. vertially oriented redl.Js abdcminis muscles and the small triangular pyramidalis muscle are
located on 1he anterior wall. ~: The 1hree flat, bilaterally paired muscles comprising the anterolateral group include the external oblique, 1he intemal oblique,
and 1he transverse abdcminal. The strength of1he muscles can be contributed to 1he collaborative relationship of1he orientation of1he fiber d eacn muscle. (Re-
printed with permission from Moore KL, ~r AM. Essential Oinkal /\nat.txrrt. 3rd ed. Baltimore, MD: Lippincott Williams & Wikins; 2007: 122.)

sperm.atic cord or round ligament. Between the two open-
ings (rings), the inguinal canal has two walls (anterior and
posterior), a roof, and a fl.oor1· 2 (Table 2-2; Fig. 2-6A,B).
Posterior Abdominal Wall
The posterior abdominal wall is composed of the lumbar
vertebra, posterior abdominal wall muscles, diaphragm,
fascia, lumbar plexus, fat, nerves, blood vessels, and lym-
phatic vessels.
Layers
The posterior abdominal wall is covered with a continu-
ous layer of endoabdominal fascia, which is continuous
with the transversalis fascia. 1.2 The posterior wall fascia is
located between the parietal peritoneum and the muscles.
The psoas fascia (sheath) is attached medially to the lumbar
vertebrae and pelvic brim. Superiorly, the psoas fascia is
thickened and forms the medial arcuate ligament. Laterally,
the psoas fascia fuses with both the quadratus lumborum
fascia and the thoracolumbar fascia. Inferior to the iliac
crest, the psoas fascia is continuous with that part of the
iliac fascia that covers the iliacus1 (Fig. 2-7).
On the posterior abdominal wall, the thoracolumbar
fascia is an extensive complex. Medially, it attaches to the
vertebral column. In the lumbar region, the thoracolumbar
fascia has posterior, middle, and anterior layers with enclosed
muscles between them. The fascia is thin and transparent in
18 PART ONE ABDOMINAL SONOGRAPHY

Anterior layer of
rectus shealh
APoneurosis of extemal oblique
Rectus
abdomlnls Aponeurosis of intemal oblique
(Anterior and posterior laminae)

Subcutaneous
tissue
Extemal oblique
Posterior layer of Internal oblique
rectus sheath
Transversus
A abdominis
TransversalI&
Anterior layer of rectus sheath fascia
Uneaalba

Anterior layer of
rectus sheath
(consisting of all thme
aponeurotlc layers) FIGURE 2-5 Abdominal wall structures.
Trar6Verse sections of the anterior abdom-
Layers lft A A B inal wall (A) superior to 1he umbilicus with
the posterior layer of the redu!; sheath. B:
i=i External oblique
Inferior 101he UT1bilicus, the rectus shea!h
- lntemal oblique is separated from 1he parietal peritoneum
i = i Transversus abdominis
i = i Transversalis fascia
only by 1he transversalis fascia. (Reprinted
i = i Parletal perttoneum
witk permission from Moore KL, Af}Jr AM.
Essential Oinica! Anatomy. 3rd ed. Ba~
- Membranous layer of more, MD: Lippincott Wiiiams & Wikins;
subcutaneous tissue
2007:123.)

the thoracic region it covers, whereas it is thick and strong
in the lumbar region it covers. The posterior and middle lay-
ers of the thoracolumbar fascia, which enclose the bilateral
erector spinae muscles or the vertical deep back muscles,
are comparable to the enclosure of the rectus abdominis
by the rectus sheath on the anterior wall.1 When compar-
ing the posterior sheath to the rectus sheath, the posterior
sheath is stronger because it is thicker and has a central
attachment to the lumbar vertebrae. The rectus sheath has
no bony attachment and fuses with the linea alba. Ll.ke
the rectus sheath, the lumbar part of the posterior sheath
extending between the 12th rib and the iliac crest attaches
laterally to the internal oblique and transversus abdominis
muscles. The rectus sheath attaches to the external oblique
muscle, but the thoracolumbar fascia attaches to the latis-
simus dorsi1 (see Fig. 2-7).
The anterior layer of the thoracolumbar fascia is the qua-
dra.tus lwnborum fasda and it covers the anterior surface
of the quadratus lumborum muscle. 1•2 Compared to the
middle and posterior layers of the thoracolumbar fascia, it
is a thinner and more transparent layer. The anterior layer
attaches to the anterior surfaces of the lumbar transverse
processes, to the iliac crest, and to the 12th rib. Laterally, the
anterior layer is continuous with the aponeurotic origin of

TABLE 2-2 Boundaries of the Inguinal Canal"

Boundary Deep RI.,..._... Third
Posterior wall Transversalis fascia
Anterior wall Internal oblique plus lateral CNS of
aponeurosis of external oblique
Transversalis fascia
Mlclclle Third
Transversalis fascia
Aponeurosis of external oblique
(lateral crus and intercrural fibers)
Musculoaponeurotic arches of
internal oblique and 1ransverse
abdominal
....._.. Thlrd/Superftclal Rlns
Inguinal falx (conjoint tendon) plus reflected inguinal
ligament
Aponeurosis of external oblique (inten:Nral fibers),
with fascia of external oblique continuing onto cord as
external spermatic fascia
Medial CNS of aponairosis of external oblique

Floor lliopubic 1ract Inguinal ligament l..acunar ligament

°See figure 2-6.
Reprinted with permission from Moore K. Dalley A. Af}Jr A Oinicalfy Orientlld Anatomy. 6tk ed. Philadelphia. PA: Lippincott Williams & Wilkins; 2010:204.
 2 THEABDOMINAL WALLAND DIAPHRAGM 19

ll'ansverse abdomlnal muscle

Skin-----
Fatty layer--:...:....
Retroinguinal space
(of Bogros)
Membranous Peritoneum
layer of sub· Inguinal falx (conjoint
ct.ttaneous tendon) forming
tissue posterior wall of canal
Anterior wall lllopublc tract
of lngulnal canal Inguinal ligament
(lntercrural forming •gutter" (floor
ftbers)
of inguinal canal)
Superior ramus
of pubis
~----Fascia lata
of thigh

B Schematic aglttal section of lngulnal canal

Superficial inguinal ring

Extemal spermatlc fascia
Reflected inguinal ligament

=al spermatlc,

Spermaticcord~~
~

External spermatlc fascia

Testis ~
?
• Musculoaponeurotic arcades of
Internal oblique & transverse abdominal

A Anf.911or vltw
FIGURE W Inguinal canal. The anrerior and posterior wall, the roof. and tne floor cl ttie inguinal canal are illustr.ired. A: Tne abdominal wall layers and the c<N-
erings d the spermaiic cord and testis an! seen in the anterior view. In females, the canal serves as the passageway for the f't)Und ligament. 8: At the plane shewn
in (A), the sagittal seaion illustrates the composition of the canal. (Reprinted wi1h permission from Moore K, Dalley A. A(}Jr A Oinicaity Oriertte<J Anatomy. 6th ed.
Philadelphia, PA: Lippincott Vvllliams & Vvllkins; 20 I 0:20<!.)

the transversus abdominis muscle. Superiorly, it thickens to Diaphragm

form the lateral arcuate ligament and inferiorly, it is adher-
ent to the ili.olumbar ligaments1 {see Fig. 2-7).
Muscles
The muscles of the posterior abdomen are categorized as
the superficial and intermediate extrinsic back muscles and
the superficial layer, intermediate layer, and deep layer of
intrinsic back muscles1•2 (Table 2-3). The three main, bilat-
erally paired muscles comprising the posterior abdominal
wall are the psoas major, iliacus, and quadratua lumborum
(Fig. 2-8).
The diaphragm is a doubl~med, musculotendinous partition
separating the thoracic cavity from the abdominal cavity.1•6•7
The convex superior surface faces and forms the floor of the
thoracic cavity and the concave inferior surface faces and
forms the roof of the abdominal cavity. The concave surfaces
form the right and left domes with the right dome slightly
higher because of the presence of the liver and the central
part slightly depressed by the pericardium. 1 Its periphery is
the fixed muscle origin. which attaches to the inferior margin
of the thoracic cage and the superior lumbar vertebrae.2•6 .As
10 PART ONE ABDOMINAL SONOGRAPHY

Anterior
layer (quadratus
lumborum fascia}
Middle Thoracolumbar
layer fas<:ia

I
Intrinsic (deep} back muscles
FIGURE 2-7 Posterior abdominal wall fascia. The relationship of the psoas fuscia, the 1hree layers of1he thoracolumbar fascia, and quadratus lumborum fascia
with the musde5 and vertebrae are illustrated on this 1ransvel'$C section of the posterior abdominal wall. (Reprinted with permi$ion from Moore KL. At/}Jr AM.
Essemia/ Oinical Anatomy. 3rd ed. Baltimore, MD: Lippincott 'Mlliams & Wilkir'6; 2007:300.)

TABLE 2-3 Muscles of the Posterior Abdomen Wan•.z

Psoas major (Rgs. 2-6 and 2-7)
llia.cus (lig. 2-7)
Bilaterally paired, long, thick, fusiform mus:cle
Origin: Arises from the bodies and transverse proce!.'Se:S of lumbar vertebrae
Insertion: Inserts into the lesser trochant:er of femur with iliacus via iliopsoa.s tendon
Action: Ads to flex the thigh; flexes and laterally bends the lumbar vertebral column
Bilaterally paired, triangular musde
Origin: Arises from the iliac fossa and iliac aest and ala of the samJm
Insertion: Inserts into the lesser trochant:er of1he femur
Action: Ads to flex the thigh; if thigh is fixed, it flexes the pelvis on the thigh

Quadratus Jumborum Bilaterally paired, thick muscular sheet

(ligs. 2-6 and 2-7)
Psoas minor(lig. 2-7)
Origin: Arises from the iliolumbar ligament and iliac aest
Insertion: Inserts into the 12th rib and tran~ process of first four lumbar vertebrae
Action: Ads to flex vertebral column laterally and depress the last rib
Bilaterally paired, Jong, slender muscle anterior to psoas major
Origin: Arises from the bodies of the 12th thoracic and first lumbar vertebrae
Insertion: Inserts into the iliopubic eminence at the line of junction of the ilium and the superior pubic ramus
Action: Ads to flex and laterally bends the lumbar vertebral column

lliopsoa.s Formed by the psoas and iliacus muscles

Latissimus dorsi (Fig. 2-6)
Origin: Arises from the iliac fossa, bodie5 and transverse processes of lumbar vertebrae
Insertion: Inserts into the lesser trochanter of the femur
Action: Ads to flex the thigh, flexes and laterally bends the lumbar vertebral column
Bilaterally paired, broadest back. muscle
Origin: Arises from the lower six thoracic vertebrae, lumbar vertebrae, iliac CteSt via thoracolumbar fascia,
sac.rum, lower three or four ribs, and inferior angle of scapula
Insertion: Jr.sens into the interll.Jbercular (bicipital) f!OCNe on the medial side of the humerus
Action: Ads to abduct, medially rotate, and extend arm a:t shoulder

Erector spinae (Rg. 2-6) Location: A group of three columns d muscle loc:ated on each side of the vertebral column
Action: Ads as the chief extensor d the vertebral column

TranSllef'SOSpinaJ (Fig. 2-6) Location: An oblique group d three muscles dee? to the erector spinae
Action: In the abdominal area, they a.ct to stabilize vertebrae and assist with e><tension and rotation movements
 2 THEABDOMINAL WALLAND DIAPHRAGM 21

Right lung
'-·· r..- - Diaphragm
1'... _.>lill<"ft.A
l.JJmboc:ostal
ligament
P808.8 major-------....,. ~~s;:;:..;1+---Alght
P8088 minor-----Hm!K-~~ kldnsy
lilac fo&sa---=-- 12th rib
lllac Cf88t---!- A
~~---Quadratus
lllacus--~ lumborum
Right ureter
lllacCf86t
lliopectinea1-~-...1
arch .~~~.:::::,~- lllopectlnaal lllolumbar
L8911er eminence ligament
trochanter·-...:,;;...---;r
of femur

FIGURE 2..a Fbsterior abdominal wall muscles. The amerior and posterior sections illusb"ate the mUSOJloskeletal relationship of the major posterior abdominal wall
muscles. (Reprinted wi1t1 penn~on from Moore K. Dalley A. ~r A Oinicolo/ Oriented lwJtr>rrrt. 61t1 ed. Philadelphia, PA: Lippincott Wiiiams & Wilkins; 20 I 0:311 .)

the major muscle of inspiration, the central part descends
during inspiration, ascends during expiration (to the fifth nb
on the right and fifth intercostal space on the left), varies in
postural position {supine or standing), and varies in height
based on the size and degree of abdominal visceral distention. 1
The muscular part of the diaphragm. is located peripher-
ally with fibers that converge radially on the ttifoliate central
aponeurotic part, the central tendon. The central tendon
has no bony attachments and appears incompletely divided
into what resembles the three leaves of a wide cloverleaf.
Although. it lies near the center of the diaphragm, the central
tendon is closer to the anterior part of the thorax1.2 (Fig. 2-9).
The area around the caval opening is surrounded by a
muscular part that fonn.s a continuous sheet. For descriptive

/Cos1al cartilage
~~~
- Leftc:oebd part
Esophageal
hiatus

CfUS

........._ -1...umbocostal
.........._ triangle
""' 12thrib
Quadratus Jumborum
An1erlor longltudlnal
ligament
lrrfarlor view
FIGURE 1-9 Diaphragm. The vieNI of the concave inner surface forming 1he roof of1he abdominopeMc. cavity illustrates 1he fleshy sternal, costal, and lumbar
parts of the diaphragm (001lined with bro/lerl lines). Identify 1he relationship of hem each part attaches centrally to the tre!Oil-shaped central tendon, the aponeurotic:
insertion of tne diaphragmatic. musde fibers. (Reprinted with permis;ion ii'om Moore K. Dalley A. ~ur A Qinioolo/ Oriented Anatomy. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2010:306.)
22 PART ONE ABDOMINAL SONOGRAPHY
TABLE 2-4 Diaphragmatic Peripheral
Attachments I .2
Sternal part Two muscular slips ;rttac;h the diaphragm to the
posterior aspect of xiphoid process. This part is not
always present.
Costal part Wide muscular slips bilaterally attach the diaphragm
to the internal surfaces of the inferior six costal
cartilages and their adjoining ribs. The costal parts
fonm the right and left domes.
Lumbar part The medial and lateral arcuate ligaments (two
aponeurotic arches) and the three superior lumbar
vertebrae fonm the right and left muscular crura that
ascend and insert into the central tendon.
purposes, the continuous sheet is divided into three parts
based on its area of attachment: the sternal part, the costal
part, and the lumbar part1..2 (Table 2-4) .
The diaphragmatic crura are musculotendinous bands
that arise from the anterior surfaces of the bodies of the
superior three lumbar vertebrae, the anterior longitudinal
ligament, and the intervertebral discs. The right crus is
larger and longer than the left crus and appears as a tri-
angular mass anterior to the aorta. 1 It arises from the first
three lumbar vertebrae and appears posterior to the caudate
lobe of the liver.1 •6 The left crus arises from the first two
lumbar vertebrae. 1•6
Diaphragmatic Apertures
The diaphragmatic apertures {openings, hiatus) permit several
structures (esophagus, blood vessels, nerves, and lymphatic
vessels) to pass between the thorax and the abdomen. 1•2
The three larger apertures are the caval, esophageal, and
aortic, and there are a number of small openings. 1•7 The
caval hiatus is primarily for the inferior vena cava (IVC)
as it ascends into the thoracic cavity. 1•7 The IVC shares the
caval opening with the terminal branches of the right phrenic
nerve and a few lymphatic vessels passing from the liver to
the middle phrenic and mediastinal lymph nodes. 1•7 Located
to the right of the median plane, at the junction of the right
and middle leaves of the central tendon, and at the level of
the TS-9 intervertebral disk space, the ca.val opening is the
most superior of the three large diaphragmatic apertures.
Because the IVC is adherent into the margin of the caval
opening, diaphragmatic contraction during inspiration wid-
ens the opening, which allows the IVC to dilate and helps
facilitate blood flow through this large vein to the heart. 1•2
The esophageal hiatus is an oval opening located in the
muscle of the right crus at the TIO level. 1..2 The esophageal
hiatus is superior to the left of the aortic hiatus and, in 70 %
of individuals, both margins of the hiatus are formed by
muscular bundles of the right crus. In 30 % of individuals, a
superficial muscular bundle from the left crus contributes to
the formation of the right margin of the hiatus. The hiatus
allows the esophagus to course from the thorax into the
abdominal cavity and also serves as the opening for trans-
mitting the anterior and posterior vagal esophageal branches
of the left gastric vessels and a few lymphatic vessels. 1•7
The aortic hiatus passes between the crura posterior
the median arcuate ligaments at the inferior border of the
Tl2 vertebra. 1•2 The hiatus is the opening posterior in the
diaphragm for the aorta to course between the thoracic
cavity to the abdominal cavity. The thoracic duct and
sometimes the azygos and hemiazygos veins are also
transmitted through the aortic hiatus. The aorta does not
pierce the diaphragm or adhere to the hiatus, which means
diaphragmatic movements during respiration do not affect
aortic blood flow. 1•2 The stemocostal triangle (foramen) is a
small opening between the sternal and costal attachments
of the diaphragm. This triangle transmits lymphatic vessels
from the hepatic diaphragmatic surface and the superior
epigastric vessels. The sympathetic trunk passes deep to
the medial arcuate ligament and is accompanied by the
least splanchnic nerves. In each crus, there are two small
apertures: one transmits the greater splanchnic nerve and
the other the lesser splanchnic nerve. l..2
Variants
Anatomic variants are composed of individual variations
in fat and muscle content. In more muscular individuals,
each lateral muscle layer tends to be identifiable, whereas
in less well-developed individuals, muscle groups tend to
be indistinct. It is important to note that in obese patients,
the fatty layer variation can be significant.
SONOGRAPHIC APPEARANCES AND
TECHNIQUES
Abdominal Wall
Sonography should be first in imaging abdominal wall struc-
tures because it is fast, available, and provides a valuable,
inexpensive, and noninvasive method of imaging.4 •8 Imaging
the normal abdominal wall and detecting pathologic pro-
cesses such as inflammatory lesions, hemorrhage, hernia, or
masses makes sonography of the abdominal wall an excellent
modality for diagnosing pathology. Many clinical questions
can be answered with the use of sonography in evaluating
posttrauma or postsurgical patients. It is extremely important
to understand the normal sonographic appearance of the
abdominal wall and the appropriate instrumentation and
scanning techniques necessary to achieve that appearance.
The superficial nature of the abdominal wall and its
lesions demands excellent near-field imaging. Newer,
high-frequency, short focal zone transducers (7.5 MHz or
higher linear array transducers) are the optimum tools for
scanning this area. 4•9 Focal zone placement at the area of
interest is especially important. Sonography enables the
viewer to see the superficial layers of the abdomen. 4
In some instances, a standoff device or other scanning
technique may be indicated when scanning the superficial
cutaneous layers to avoid a "main-bang" transducer artifact.
Excellent standoff devices exist in the form of flotation pads
constructed of liquid-filled rnicrocell sponges, synthetic
polymer blocks, and silicone elastomer blocks. Each of
these substances is dense enough to stand alone and offers
uniform consistency to minimize artifacts. When it is neces-
sary to scan over a surgical wound, any protective dressings
are removed and a commercially available adhesive plastic
membrane can be applied directly to the wound to provide
a smooth, safe scanning surface. The use of sterile gel and
 2 THEABDOMINAL WALLAND DIAPHRAGM 2l

FIGURE 1-10 Arrterior abdominal wall.

On transverse sections d tt1e anterior
abdominal wall, the subcutaneous tissue
line.a alba and rech.ts abdominis muscle
can be visualized. On the sonogram
(A) superior to the umbilicus, both the
antefior and posterior rectus sheaths are
seen. but (B) inferior to the umbilicus.
the red!Js sheath is separa1ecl from the
parietal peritoneum only by the trans-
versalis fascia. Compare the sonogr.iphic
anatomy with the illustrated matcmy in
Figure 2-SA,B. {Images courtesy of Kacey
R. Crandall, Tremonton, UT.) B

a sterile probe cover aids in protecting the patient from any
bacterial. contamination.10 The sonographer should use light
transducer pressure while scanning to eliminate distortion
of the superficial. layers.
Demonstration of various layers of the normal abdominal
wall and a contiguous diaphragm should not be limited to
patients with superficial lesions. It should be an integral
part of every high-quality sonographic abdominal study
(Fig. 2-IOA,B).
to the upper abdominal aorta and appear as thin. hypoechoic
bands that thicken during deep inspiration. The crus of the
right hemidiaphragm contain medium-density echoes. In
some patients, diaphragmatic slips appear as round, focal,
echogenic masses when seen in transverse section. They
should not be mistaken for focal liver or peritoneal masses.
They can be clarified by rotating the transducer from its
transverse orientation and scanning along their long axis,
noting their now elongated appearance.

Diaphragm
The sonographic appearance of the diaphragm is of a thin.
curvilinear, hyperechoic band on adults and hypoechoic
structure on fetuses. The abdominal. side of the diaphragm
produces a thin, curved. line representing the diaphragm-liver
interface. An additional. thin, echogenic line, an artifactual.
mirror image of the diaphragm-liver interface, may some-
times be seen on the thoracic side (Fig. 2-11). Another thick,
echogenic line can be seen on the diaphragm-lung interface.
Occasionally, reverberation artifacts from air in the lung
originate from this area. The diaphragmatic crura lie anterior
ABDOMINAL WALL PATHOLOGY
A thorough understanding of the anatomy and sonographic
appearance of the superficial. layers of the abdominal. wall,
and the tissues and organs directly beneath it, is essential.
before pathologic changes can be fully appreciated. Three
major categories of disease affect the abdominal. wall, the
peritoneum, and the abdominal spaces. Both the tissues of
the abdominal wall and the membranes lining its spaces
are affected by inflammatory, traumatic, and neoplastic
changes.
24 PART ONE ABDOMINAL SONOGRAPHY
FIGURE 2· 11 Diaphragm. A longitudinal section through the right liver lobe
shows the nonnal sonographic appearance of the thin, curvilinear, hyperechoic:
diaphragm (Cl.'nlWS). On the chest side of1he diaphragm, 1he mirror image
artif.id of 1he liver an be identified in the plrural cavity.
lnOammatory Response: Abscess
It is vitally important that sonographers understand the
medical aspects of inflammation. as well as its sono-
graphic appearance. Inflammation can be acute or chronic.
Acute inflammation frequently results from cuts. scrapes,
crushing injuries, or surgical trauma that produces tissue
damage such as mesh for hernia repair.4 Deep abdominal
organs can also be the source of infection spreading to
the abdominal wall.4 •11•12 Consequently, an inflammatory
response can occur whenever bacterial infection damages
the skin and underlying tissues. The four main indica-
tions of inflammatory response are heat, redness, pain,
and swelling.13•14
In most patients with acute inflammations, the body will
return to normal. This process of resolution can be hastened
by the use of antiinflammatory drugs. Such drugs block the
body's natural inflammatory reactions, allowing removal of
debris and fluid exudates associated with the inflammation
via the circulatory and lymphatic systems.
If resolution occurs slowly, other consequences may
result. Fibrous tissue growth invades areas of long-standing
cellular and fluid exudates to form scar tissue. This process,
called organization, is responsible for the development of
adhesions following surgery. If sufficient necrosis of the
involved tissues occurs, resolution does not take place and
a cavity containing dead tissue and pus forms. The liquid
pus in such a cavity consists ofliving and dead microorgan-
isms, necrotic tissue, exudate, and granulocytes. The cavity
itself is called an abscess. 13• 14
Abscesses are space-occupying lesions whose fluid content
allows them to assume varied shapes (usually spherical or
elliptical) (Fig. 2·12A,B). Because of their internal pressure,
however, they can exert a mass effect on surrounding struc-
tures, causing compression, displacement, or both. Abdominal
wall abscesses frequently occur as a result of postsurgi.cal
incision.al infections or exist as extensions of a superficial
intraperitoneal abscess. Less frequently, tuberculous para-
spinal abscesses may also track along the musculofascial
plane into the lateral and posterior abdominal walls.
Wherever abscesses occur, the usual treatment involves
antibiotic therapy and sometimes drainage to facilitate
resolution. Failure of an abscess to resolve can lead to
thickening of its contents as a result of the reabsorption of
water (inspissation). and eventually, calcifications develop.
If the cause of the acute inflammation is not eliminated, the
processes of tissue injury and repair will continue simulta-
neously. producing chronic inflammation. 13•14
One variation is called chronic suppurative inflammation
or pyogeni.c in.flam:nuU:ion, in which an abscess is created
as a result of persistent infection. Suppurative inflamma-
tion describes a condition in which a purulent exudate is
accompanied by significant liquefactive necrosis; it is the
equivalent pus. The term suppurative refers to this forma-
tion of pus. Body defenses may be poor because the blood
supply to the area is limited. If so, chronic suppurative
inflammation can easily occur, requiring surgical drainage
and the use of specific antibiotics to affect a cure.13•14
Superficial abdominal wall abscesses can be caused by
swgical or external trauma, and occasionally from deep o~an
rupture. neoplasms, tuberculous or bacterial abscesses.4• In
evaluating superficial abscesses, precise scanning is required
to display the superficial layers of the skin, subcutaneous
fat, muscle planes, and the peritoneum. The most clini-
cally important aspect of treating abscesses is to determine
whether the abscess is intraperitoneal or extraperitoneal.
This is done by demonstrating the peritoneal line.
Superficial wound abscesses commonly result from
intraoperative contamination. In such cases, sonography
may have limited diagnostic value because the diagnosis
can usually be made easily on physical examination. Most
incisional abscesses are superficially located and display clini-
cal signs of erythema, tenderness, purulence, and induration
of the wound.14 There have been several reported cases of
abdominal. wall abscesses forming around laparoscopic cho-
lecystectomy gallstones that have fallen out of the gallbladder
during perforation or removal. During imaging there may be
calcific shadowing if the patient has had a cholecystectomy
via laparoscopy. 15•16 However, if the abscess develops below
the fascial plane, detection by physical examination alone can
be difficult. There have been many cases where abscesses
form from cancer which has perforated bowel or other struc-
tures. The sonographer should look for fluid collections in
pre-hepatic space and thickening of bowel wall.11 Aspiration
of a soft tissue abscess under sonography guidance may be
indicated so that the specimen can be sent to the laboratory
for culture and sensitivity testing. 14
The differential diagnosis of superficial abscesses in-
cludes rectus sheath hematomas and hernias, in addition
to noninfected collections.4,17
Sonographically, most abscesses appear as hypoechoic
fluid masses, with iITegular borders and may have internal
patterns ranging from unifonnly echo-free to mildly or even
highly echogenic.4•11 The presence of particulate debris or
micro bubbles floating within an abscess cavity is generally
the cause of its increased echogenicity. If the particulate
matter is uniformly distributed throughout the abscess, it
may be difficult to recognize and differentiate the abscess
from surrounding structures. Despite their variable internal
textures, however, the majority of abscesses demonstrate
posterior enhancement, revealing their fluid nature4.u.t4
(Fig. 2·12C-E).
 2 THEABDOMINAL WALLAND DIAPHRAGM 25

A B

c D

FIGURE 1-12 A periumbilical abscess (A) presents with a mixed echo ap-
pearance wi1t1 good acoustic transmis!iion. B: Compute<! tomography exami-
nation demonstrates the size, shape, and periumbilical location (arrows). (A
and B courtesy of Dr: Nakul Jerath. Falls Olun:h. VA.) C: Air-filled abscess in
1he abdominal wall after laparoscopic colon operation. Air within the absce;s
is distinguished by a blight echogenic border and dirt¥ shadow (arrow.s). 0:
lntraabdominal abscess of mixed echogenicity {clased am1H) extending into the
pelvic region adjacent to ttie fluid-filled bladder (open amrw). Good acoustic
transmission is demonstrated posterior to the abscess collection. (C and D
courtesy of Dr. Taco Geero;ma, Hospital Gelderse Vallei, Ede, The Nether-
lands.) E: ~itudinal image of a left psoas muscle abscess (om1NS) located
ne.ar the left kidney and extending superiorly. The mixed echo appearance
demonstrates good acoustic transmission. (Image courtesy of Philips Medical
E Systems, Bothell, WA)
26 PART ONE ABDOMINAL SONOGRAPHY

Abscesses vary in contour from flat to oval or bonnet-shaped.
Occasionally, large abscesses may compress adjacent structures
and cause confusion in the differentiation of extraperitoneal
versus intraperitoneal locations.4
Table 2-5 describes the common types of tissue changes
associated with abscesses and their corresponding sonographic
patterns. Because sonographic diagnosis is very technique-
and operator-dependent, it is critical to understand how
instrumentation and scan technique can alter the echo image
from within an abscess. Occasionally, septations may be
seen within abscesses. 11 Such findings require documenta-
tion because their presence contraindicates percutaneous
drainage. Fortunately, septated abscesses occur infrequently
within the peritoneal cavity.
To permit contact scanning, postoperative patients' surgi-
cal dressings must be removed. The face of the transducer
should be cleansed with a sterilizing solution to avoid
contamination. Caution must be used to avoid damaging
the transducer's electrical connections when such a steril-
izing process is used. 10
The search for an abscess must be conducted in a sys-
tematic fashion, with special attention and care given to
areas of swelling or tenderness. If there is any open wound,
incision, drain site, or enterostomy, it is important to use
sterile gel and a sterile transducer cover as a precaution
against infectious contamination. 10 Scan around such sites
by angling the transducer to view the area beneath.
As the survey of such areas is made, special techniques
may be necessary to enhance the appearance of any sus-
picious lesions. Because the gain setting may affect the
overall appearance of lesions, it is important to vary the
gain. When gain settings are excessively high, small fluid
collections may be overlooked because of the "fill in." In
contrast, when extremely low gain settings are used, there
is a risk of making a homogeneously solid mass appear
cystic. Moderate gain settings are useful in demonstrating
the far wall of an abscess, but low gain may also be required
to avoid the strong reverberation artifacts frequently seen
at, or obscuring, the near walls. By creating several images
using different settings and scanning planes, it is possible
to obtain maximum information about an abscess.
The shape of an abscess and its relationship to surround-
ing structures are valuable information if the clinician is
planning percutaneous needle aspiration. Sonography aids
in planning a safe aspiration route and monitoring the
procedure, and it also provides a means of evaluating the
effectiveness of therapy on follow-up examinations.14
Trauma/Tear
Abdominal muscles may be injured by penetrating wounds,
by blows to the abdomen, or by hyperextension strain. Sub-
cutaneous edema or muscle contusions are commonly seen
with blunt trauma. Traumatic hernias, which go unnoticed
because of more apparent injury, may be missed. 18 •19 A con-
tused muscle will appear thicker and more anechoic if edema
is present. In cases of extravasated blood and inflammatory
reactions, a disorganized, coarse echo pattern is common.
A similar appearance may be seen with rhabdomyolysis
(the breakdown of muscle caused by injury).
With violent hyperextension strain, it is possible for the rec-
tus muscle to rupture, causing tearing of the inferior epigastric
artery. Such patients present with a tender mass, sonographi-
cally resembling the appearance of a superficial hematoma.4•11
Hematomas
Hematomas are generally associated with muscular trauma
that results in hemorrhage. They can also result from infec-
tion, debilitating disease, collagen disorders, pregnancy, and
childbirth. Straining, coughing, anticoagulant therapy, and
surgery can also be precipitating factors. 4.u,18•20•21
Among the most common superficial abdominal wall
hematomas are those occurring within the rectus sheath.

TABLE 2-5 Sonographic Appearances

Location
Abscess Near surgical site or painful area,
subphrenic, subhepatic, paracolic
gutters, and left perihepatic,
perisplenic, and pelvis
Acoustic 'hnsmlsslon
Shape: Lentirular or shape of space Usually good
Anechoic, with irregular or smooth borders; may have
internal echoes, septations, fluid-fluid level; abscesses
that contain gas are ediogenic and may shadow

Hematoma Near wound or surgical site Shape: Lentirular or shape of space Coincides with stage; good to
Change with stage of resolution; fresh blood is slow or decreased; may increase
hypoechoic, as is clotted blood; fragmentation of clot due to fluid portion
creates internal echoes and anechoic areas with some
scattered echoes; fluid-fluid level may be caused by
cholesterol in breakdown of red blood cells; long-
standing hematoma may have thick contours

Ascites Most dependent areas of body, Anechoic if benign, ascites if exudative, internal echoes Increased
cul-de-sac, Morrison pouch, if malignant; bowel and implants in anechoic ascitic
paracolic gutter, pararenal areas, fluid
perihepatic, midabdominal

Urinoma Adjacent to kidneys Usually anechoic unless infected Increased

Lymphocele Adjacent to renal transplant Usually anechoic but may have septations Increased

Courtesy of Mimi Berman, PhD, RDMS.


Patients usually complain of pain and demonstrate a palpable
abdominal mass that persists in both sitting and supine
positions. Ecchymosis (discoloration) of the abdominal wall
and a laboratory variance of a falling hematocrit value are
often seen.20.21
Rectus sheath hematomas may be unilateral or bilateral,
small or large, and may extend along the entire length of
the muscles or sheath. Although enclosed in the sheath, a
hematoma may lie posterior to the muscles, surrounding
them and conforming to the shape of the enclosed space.
A hematoma usually enlarges caudally across the midline
and over the lower abdomen. A rectus sheath hematoma is
usually caused by damage to the epigastric arteries.4 •11 •18•20 A
large bleed may accumulate anterior to the bladder within
the space of Retzius. 22 Such hematomas may produce asym-
metry of the abdominal wall. There is a higher incidence
of complaints of pain and ecchymosis in patients whose
bleeding is not confined to enclosed spaces.
Postsurgical hematomas are usually intimately related to
an incisional site, frequently lying external to the anterior
rectus fascia and presenting as a smooth-bordered, local-
ized mass.
In all hematomas or thrombi, echogenicity will vary
depending on the age and distribution of the hematoma
and its cellular contents. During the acute phase, fluid-fluid
levels may be seen within the hematoma, with clotted
blood layering in the dependent part and unclotted blood
or plasma floating on top. During active bleeding, it may
even be possible to detect turbulent blood flow. If active
arterial bleeding is identified or a hematoma is complicated
by infection, surgery is indicated.4 •11
The sonographic appearance is similar to an abscess but
history as well as blood work will help determine if the col-
lection is abscess or hematoma. 4 The hematoma appearance
will normally be heterogenous with an interruption of the
normal linear appearance of the muscle.23 Above the arcuate
line, the linea alba prevents the spread of hematoma across
the midline and below the arcuate line, blood can spread
to the pelvis or cross the midline. A hematoma above the
arcuate line will appear ovoid transversely and biconcave
in long axis; a hematoma below the arcuate line can form
a large mass that indents on the dome of the urinary blad-
der (Fig. 2-13A,B).
Sonography is valuable during the conservative management
of even large hematomas because of its ability to monitor
their size and resolution as they resorb (hypoechoic phase)
and liquefy (anechoic phase). An important reality is that
hematomas are not limited to the anterior abdominal wall
but can also involve the lateral or retroperitoneal muscles.4
Sonographic patterns closely follow the pathologic evo-
lution of the hematoma. Recent blood collections tend to
appear echo-free, becoming more echogenic as they orga-
nize, although the reverse may also occur (see Table 2-5).
Hematomas and thrombi behave differently, depending on
their size and location. Generally, wound hematomas that
occur within the body resolve. The borders of such masses
differ in echo reflection from their centers. In contrast, ab-
dominal wall hematomas or those surrounded by a capsule
gradually change to an anechoic state.4•11
A seroma is a collection of serum in the tissue resulting from
a surgical incision or from the liquefaction of a hematoma.
The normal small seroma formation during the incisional
l THE ABDOMINAL WALLAND DIAPHRAGM 27
healing process usually resolves. Without resolution, the
seroma may require aspiration drainage to alleviate pain
and/or visible swelling. The sonographic appearance of a
seroma ranges from anechoic to hypoechoic4 (Fig. 2-13C,D).
When bleeding is secondary to anticoagulant therapy, a
wide range of sonographic appearances is possible (Fig. 2- BE).
Although it is uncommon to scan such patients during ac-
tive bleeding, the relative lack of coagulation would likely
produce an echo-free or an unusual layered appearance. The
latter is due to the settling of moderately echogenic red blood
cells to the bottom of the lesion. The fibrin content of the
clot yields decreased echogenicity. Movement of blood can
sometimes be produced in such patients by changing their
positions. If turbulent blood flow is seen in a patient lying
supinely in a fixed position, it indicates active bleeding.24
The sequential use of modem high-resolution sonographic
procedures, which clearly delineate the muscular layers of
the abdominal wall, is a valuable way to study the response
of such lesions to treatment.
Hernias
There are two main categories of abdominal wall hernias:
(1) ventral (anterior or anterolateral abdominal wall) and
(2) groin (indirect inguinal, direct inguinal, and femoral). 25,26
Diaphragmatic hernias occur with less frequency and are
presented later in this chapter. If the abdominal wall muscles
are excessively weak through an acquired or congenital
wall defect (omphalocele), the viscera lying beneath may
protrude, resulting in a hernia. It has been found that three
major factors aid in a weak abdominal wall. These are
abnormal collagen metabolism, pressure overload such as
obesity, heavy lifting, coughing, smoking, familial tendency
or straining that may contribute to either hernia formation
or increased growth of an existing hernia, and insufficient
protein intake.27•28 Natural weak areas include where ves-
sels penetrate the abdominal wall; where fetal migration
of testis, spermatic cord, or round ligament has occurred;
and through aponeuroses. 29
Primary ventral hernias account for 75 % of the repaired
ventral hernias in the United States, and are one of the
most common surgical treatments worldwide.26•30 More
hernia repairs are being done laparoscopically whenever
possible. There is less tissue damage and faster recovery
time for the patient. 30 Abdominal wall hernias consist of
three parts: the sac, the contents of the sac, and the cov-
ering of the sac (Fig. 2-14). Hernia contents vary. Of the
hernias diagnosed by sonography, most contain only fat,
which may be intraperitoneal (mesenteric or omental) or
peritoneal in origin. 11•29 If a hernia does contain intraperi-
toneal fat, it may contain bowel later in its course. When
bowel is included in hernia contents, it increases the risk
compared to those containing only intraperitoneal fat due
to strangulation, which may result in ischemia caused by a
compromised blood supply. 11•29 Some hernias contain free
fluid of intraperitoneal origin.29
Ventral Hemias
Ventral hernias are a category for all hernias occurring in the
abdominal wall excluding groin/inguinal and diaphragmatic
areas. These include umbilical, paraumbilical, epigastric, and
hypogastric hernias. Other hernias and conditions to present
28 PART ONE ABDOMINAL SONOGRAPHY

A B

c D

E
FIGURE 2-13 Recuis shealh hematoma. A heterogeneous, lentia.ilar-shaped hematoma (amiws) can be identified dist.al to the arcuate line on battl (/It.) 1he
lonpx:linal and (8} ttle 1ransverse scnograms. (Images courtesy of Philips Medical Systems. Bothell, WA) C: A rOOl.ts sheath hematoma with a seroma Qiquefled
herrat.oma). D: ~e vastus medialis rupture with sercma.. E: The mixl!d echogeniciJr of tile rectus sheath hematoma is from a 76-year-old woman. The patient
preiented with a dinical findi~ of a palpable mass, low hemoglobin, and uses anticoagulant therapy. Qmages courtesy of Dr. Taco Geertsma, Gelderse Val lei, The
Nedlerlands.)

Hernial coverings
Hemialsac
FIGURE 2-14 Components of a hernia. .Abdominal wall hemias consist
of three parts: the sac:, the contents cl the sac:, and the ~ring cl the sac:.
(Reprinted with permission from Snell RS. Oinic;al Anotomy. 7th ed. Baltimore,
MD: Lippincott Williams & Wilkins; 2003 .)
with ventral hernia types, which also occur in the anterior
and lateral abdominal walls, include lumbar, spigelian,
strangulation, incarcerated, incisional, and parastomal.31
Umbilical hernias are the most common type of ventral
hernia. They are either congenital or acquired and are usu-
ally small. The umbilical hernia is particularly common in
women. Infants and small children often acquire hernias in
this area due to the weakness in the scar of the umbilicus
in the linea alba (Fig. 2-lSA). In most cases in children,
these hernias decrease in size and disappear without event
or treatment as the abdominal cavity enlarges. In adults,
acquired hernias are more commonly termed paraumbili-
cal hernias and are a large abdominal defect through the
linea alba in the region of the umbilicus and are usually
related to diastasis recti, with an increase in the width of
the linea alba between the left and right sides of the rectus
abdominis muscle. 32 Adult paraumbilical hernias increase
gradually in size and are the hernias that most often contain
large intestine as well as omentum. Paraumbilical hernias
occur with a higher incidence in premature infants and in
pregnant women {Fig. 2-1 SB).
Epigastric and hypogastric hernias occur in the linea
alba above and below the umbilicus. Epigastric hernias
occur through the widest part of the linea alba anywhere
from 3 cm below the xiphoid process and 3 cm above the
umbilicus. Usually, such hernias begin as a small defect
of protruding extraperitoneal fat. Over a period of months
or years, that fat is forced through the linea alba, pulling
behind it a small peritoneal sac that often contains a small
piece of the omentum or bowel.33.34
Although the clinical presentation of a spigelian hernia
is rare, sonographically detected spigelian hernias are more
common. 29.35 A spigelian hernia can occur anywhere along
the course of the spigelian fascia, which is the complex
aponeurotic tendon located between the flat anterolateral
2 THE ABDOMINAL WAl.l. AND DIAPHRAGM 29
muscles.29.35 Almost all spigelian hernias are located at the
inferior end of the semicircular line, which is inferior to the
arcuate line where the posterior rectos sheath is absent. 29.35
The spigelian hernia may be listed as an inguinal hernia since
its location is within 2 cm of the internal inguinal rings and
its symptoms are similar to indirect inguinal hernias. 29 Of
note, if the hernia is on a pediatric patient, nearly one half
are associated with an undescended teste. When imaging
a pediatric patient for cryptorchism the sonographer may
want to check for a hernia as well35 (Fig. 2-lSC).
Two complications that may occm in midline hernias
are strangulation (compromised blood supply causing isch-
emia) and incarceration or nonreducible (an irreducible sac
where contents cannot be pushed back into the abdomen
or through torn muscles). 34 Surgery is generally indicated
because these two conditions are vulnerable to serious
complications. With an incarcerated or strangulated hernia,
complicating factors may include edema of the protruding
structure and constriction of the opening through which
intraabdominal contents have emerged or an interruption
its blood flow, which progresses to necrosis and will require
surgery36 (Fig 2-lSD,E).
An incision.al. hernia is a delayed complication caused
by abdominal surgery, which leaves a weak abdominal
wall. The hernias are more commonly encountered with
vertical rather than with transverse incisions. Incisional
hernias usually develop during the first few months after
surgery. Incisional hernias may be as high as 28 % after
abdominal surgery.37 A subtype of an incisional hernia is
a para.stomal hernia. A parastom.al hernia is a common
complication occurring adjacent to a stoma and in about
half of the patients who have an enterostomy.38•39 Elderly,
obese, or malnourished patients are more prone to develop
incisional hernias. Infection, which impairs wound healing,
is also a predisposing factor.
Groin Hernias
Groin hernias are fairly common with approximately 2 %
in the adult population, and are comprised of three compo-
nents, the neck, sac and contents. Groin hernias increase in
frequency as people age, from 0.25% at age 18 to 4.2% at
age 75, and are eight times more likely with a family his-
tory. 25.3t- There is a 20 % to 27 % chance a male will develop
an inguinal hernia in his lifetime, and between 3 % and 6 %
for women.25.41 These occur in the ilioinguinal crease at the
junction of the abdomen and the thigh and the adjacent
areas immediately above and below.29 This definition limits
it to inguinal hernias, but femoral hernias and, at times,
spigelian hernias are also included in this category.25.29.40
Inguinal hernias, which make up 75% of all hernias,
can be either direct or indirect, and can be either inguinal
or femoral.25.40 Both direct and indirect inguinal hernias
are above the inguinal ligament, and are more common on
the right side. Indirect inguinal hernias are one of the most
common forms of hernia and are 10 times more common
in males than in females, and twice as common as direct
hernias.25 Indirect hernias pass through the deep inguinal
ring and extend superficially and interomedially down the
inguinal canal (Fig. 2-16A-D). Indirect hernias protrude
through a defect in the inguinal ring through enlargement
of the vaginalis.34,41 They can extend down into the scrotum
30 PART ONE ABDOMINAL SONOGRAPHY

A B

D E
FIGURE 2· 15 Ventral and spigelian hernias. A: The longiWdinal plane st'IO'M an umbilical hernia (UH) containing fat and bowel 1hat passed throogti a dilared um-
bilic31 ring (UR). (Courtesy of Philips Medical Systems, Bothell, WA) 8: On a different patient, the 1ransverse plane shows a paraumbilical hemia (arrows) containing
fat. (Courtesy ci Taryn Nichols, ProYidence UT.) C: The contiguous muscle can be seen on 1he normal abdominal wall on the left. On the right, the sonogram elem-
~ a small spigelian hernia (datted ollt/ine) as it hemiated through botti the tom transverse abdominis (TA) and the internal oblique (10) musclei. The external
oblique (EO) muscle is intact. On this obese patient. there is a large amOU'1t of fat seen between the internal oblique muscle and 1he extemal oblique musde. A
mushroom-shaped or anvil-shaped hemia ccrrelaw.i with nonreducibility and the increased risk of strangulation. (Courtesy of Philips Medical Systems, Bothell,
WA.) 0: lncarcera12<1 abdominal wall hernia with dilated nonreducible small bowel loops and efti.ision in the hernia. This transverse sedion cithe right upper quad-
rant abdominal wall demonstrates the bo.vel protruding through an abdominal wall defect (amiws). E: Enlarged nonreducible small bowel loops and effiJsion wittlin
the hernia. (D and E courtesy ci Dr: Taco Geertsma, Hospital Gelderse Vallei, Ede. The Netheriands.)
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BLACKWOOD'S EDINBURGH MAGAZINE, VOL. 75, NO. 462,
APRIL 1854 ***
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 BLACKWOOD’S

EDINBURGH MAGAZINE.

No. CCCCLXII. APRIL, 1854. Vol.

LXXV.

CONTENTS.

The Commercial Results of a War with Russia, 381

The Puppets of all Nations, 392
The Quiet Heart.—Part V., 414
Chronological Curiosities: What shall we Collect? 426
The Reform Bills of 1852 and 1854, 441
The Blue Books and the Eastern Question, 461
Life in the Sahara, 479
The Cost of the Coalition Ministry, 492
 EDINBURGH:
WILLIAM BLACKWOOD & SONS, 45 GEORGE STREET, AND 37
PATERNOSTER ROW, LONDON;

To whom all communications (post paid) must be addressed.

SOLD BY ALL THE BOOKSELLERS IN THE UNITED KINGDOM.

PRINTED BY WILLIAM BLACKWOOD AND SONS, EDINBURGH.

 BLACKWOOD’S
EDINBURGH MAGAZINE.

No. CCCCLXII. APRIL, 1854. Vol. LXXV.

THE COMMERCIAL RESULTS OF A WAR

WITH RUSSIA.

After the enjoyment of nearly forty years of peace, during which

two generations of men, whose fate it was to live in more troublous
times, have passed to their account, we are entering upon a war
which will inevitably tax all the energies of the country to conduct it
to a successful and honourable conclusion. The enemy against whom
our arms are directed is not one whose prowess and power can with
safety be slighted. A colossal empire possessed of vast resources,
wielded by a sovereign of indomitable character and vast ambition,
who has for years been collecting strength for a gigantic effort to
sweep away every barrier by which the realisation of that ambition
has been impeded, is our opponent. The issue to him is most
momentous. It is to decide whether he is hereafter to be a controlling
power in Europe and Asia, to rule absolutely in the Baltic, to hold the
keys of the Euxine and the Mediterranean, and to push his conquests
eastwards, until he clutches Hindostan,—or to be driven back and
confined within the limits of the original empire which Peter the
Great bequeathed to his successors. Such a struggle will not be
conducted by Russia, without calling forth all the vigour of her arm.
An issue so far beyond her contemplation as defeat and extinction as
a first-rate power in the world, will not be yielded until she has
drained her last resources, and exhausted every available means of
defence and procrastination. Russia possesses too in this, the climax
of her fate and testing-point in her aggressive career, a mighty source
of strength in the enthusiasm of her people, whom she has taught to
regard the question at issue between herself and Europe as a
religious one, and the war into which she has entered as a crusade
against “the infidel” and his abettors. The result may be seen in the
personal popularity which the Emperor enjoys, and the ready
devotion with which his efforts are aided by the Christian portion of
the population of his empire.
On the other hand, Great Britain enters into the struggle with
every recognised prestige of success in her favour. She has, as her
active ally, the greatest military nation in the world, whose soldiers
and sailors are about, for the first time for many centuries, to fight
side by side against a common enemy. Little as we are disposed to
decry the strength of that navy which Russia, by her wonderful
energy, has succeeded in creating during the past few years, it would
be absurd to compare it with the magnificent fleets which England
and France combined have at present floating in the waters of the
Black Sea, and about to sail for the Baltic. A comparison of our
monetary resources with those of our opponent would be still more
absurd. Another feature in our position as a maritime country at
present, is the vast facilities which we possess, by means of our
mercantile ocean steamers, of transporting any required number of
troops to the locality where their services are required, with a
rapidity and comfort never dreamt of during the last European war.
A veteran of our Peninsular Campaigns, witnessing the splendid
accommodation provided in such noble vessels as the Oriental
Company’s steamer Himalaya at Southampton, the Cunard
Company’s steamer Cambria at Kingston Harbour, Dublin, and the
same Company’s steamer Niagara at Liverpool, and acquainted with
the fact that each of these vessels was capable of disembarking their
freight of armed men within five or six days of their departure hence
in any port of the Mediterranean, must have been struck by the
marked difference between such conveyances and the old troop ships
employed in former days. Moreover, there is scarcely a limit to the
extent of this new element of our power as a military nation. We
enter, too, upon the approaching struggle with Russia backed by the
enthusiastic support of all classes of our population. It is not
regarded with us as a religious war, or one into the incentives to
which religion enters at all. It is scarcely regarded by the mass as a
war of interest. With that sordid motive we cannot as a nation be
reproached. It is felt only that an unjust aggression has been
committed by a powerful state upon a weak one; that the tyranny of
the act has been aggravated by the gross breaches of faith, the glaring
hypocrisy, amounting to blasphemy, and the unparalleled atrocity,
by which it has been followed up; and that we should prove ourselves
recreant, and devoid of all manhood, were we to stand tamely by and
see a gallant people, differing though they do from us in religion,
overwhelmed by brute force, and exterminated from the face of
Europe by such butcheries as Russia has shown us, in the memorable
example of Sinope, that she is not ashamed to perpetrate in the face
of the civilised world, and in the name of Christianity.
There is one consideration, however, connected with the present
warlike temper of our population, which cannot with safety be
permitted to escape remark. We have already stated that two
generations of men have passed away since this country was in actual
war with an enemy in Europe. The bulk of the present race of
Englishmen have never experienced the inconveniences, and
occasional privations, which attend upon war even in countries, like
ours, which are happily free from the affliction of having an armed
enemy to combat upon its own soil. We believe most firmly that we
are not a degenerate people. We see evidence of this in the ready zeal
with which large numbers of our hardy and enterprising youth are
everywhere flocking to be enrolled under the flag of their country,
both for land and sea service. We trust that this feeling will endure,
and that we shall be found willing to bear up cheerfully under any
temporary sacrifices which we shall be called upon to make; but we
cannot blind ourselves to the fact that a great change has taken place
in our social condition, in our traditionary instincts, in our pursuits,
and in our institutions, during the forty years of peace which we have
enjoyed. We have become more essentially a manufacturing and
commercial people. A larger number of our population than formerly
are dependent for their daily bread upon the profitable employment
of capital in our foreign trade. The more extensive adaptation of
machinery to manufacturing processes of every kind has led to the
aggregation of large masses of our population in particular districts;
and such masses, ignorant as we have unfortunately allowed them to
grow up, are notoriously subject to the incendiary persuasions of
unprincipled and bad men, and have been sedulously taught that
cheapness of all the necessaries of life can only be secured by
unrestricted communication with foreign countries. Moreover, we
have had a large infusion of the democratic element into our
constitution. Our House of Commons no longer represents the
yeomanry and the property classes of the country; but, instead, must
obey the dictates of the shopkeeping and artisan classes of our large
towns. It is no longer the same body of educated English gentlemen,
whose enduring patriotism, during the last war, stood firm against
the clamours of the mobs of London, Manchester, and other large
centres of population, and turned a deaf ear to the persuasions of
faction within its own walls; but a mixed assemblage of a totally
opposite, or, at all events, a materially changed character, so far as
regards a considerable number of its members. We have in it now a
larger proportion of the capitalist class—men suspected of being
rather more sensitively alive to a rise or fall in the prices of funds,
stock, railway shares, &c., than to any gain or loss of national
honour; more wealthy manufacturers, who would be disposed to
regard the loss of a fleet as a minor calamity, compared with the loss
of a profitable market for their cottons, woollens, or hardwares; and,
lastly, more Irish representatives of the Maynooth priesthood, ready
to sell their country, or themselves, for a concession to Rome, or a
Government appointment. The honourable member for the West
Riding—Mr Cobden—showed a thorough appreciation of the
character and position of a portion of the House, and of his own
constituents, when he wound up his speech on the adjourned debate
upon the question of our relations with Russia and Turkey, on the
20th ult., with these words, which deserve to be remembered:—“He
would take upon himself all the unpopularity of opposing this war;
and, more than that, he would not give six months’ purchase for the
popularity of those who advocated it on its present basis.”
Under such circumstances it is material to examine what is the
amount of interruption to the commerce of the country, which may
be assumed as likely to occur, as the result of a state of war with
Russia. What, in other words, is the amount and the nature of the
pressure, to which the masses of our population may be called upon
to submit, to prepare them for the purposes of those persons—
happily few in number at present—whose voice is for peace at any
sacrifice of the national honour, and any sacrifice of the sacred duties
of humanity? We shall perhaps be excused if we examine first the
nature of the pressure which is relied upon by such persons; and we
cannot exemplify this better than by a quotation from the speech
already referred to by the same Mr Cobden—their first volunteer
champion in the expected agitation. The honourable gentleman
remarked:—

“He could not ignore the arguments by which they were called upon by
honourable and right honourable gentlemen to enter into a war with Russia. The
first argument was one which had been a dozen times repeated, relative to the
comparative value of the trade of the two countries. We were to go to war to
prevent Russia from possessing countries from which she would exclude our
commerce, as she did from her own territory. That argument was repeated by a
noble lord, who told the House how insignificant our trade with Russia was,
compared with that with Turkey. Now, that opinion was erroneous as well as
dangerous, for we had no pecuniary interest in going to war. Our interests were all
on the other side, as he was prepared to show. The official returns did not give him
the means of measuring the extent of our exports to Russia, but he had applied to
some of the most eminent merchants in the City, and he confessed he had been
astonished by the extent of our trade with Russia. He used to be told that our
exports to Russia amounted to less than £2,000,000. Now, Russia was still under
the Protectionist delusion, which had also prevailed in this country in his
recollection. (A laugh.) Russia still kept up her protective duties upon her
manufactures, but he would tell the House what we imported from Russia, and
they might depend on it that whatever we imported we paid for. (Hear, hear.) He
had estimated the imports from Russia as of much greater value than most people
thought, and he was under the impression that they might amount to from
£5,000,000 to £6,000,000 per annum. Now, here was a calculation of our imports
from Russia which he had obtained from sources that might be relied upon,—
 Estimated Value of Imports from Russia into the United Kingdom.
Tallow, £1,800,000
Linseed, 1,300,000
Flax and hemp, 3,200,000
Wheat, 4,000,000
Wool, 300,000
Oats, 500,000
Other grain, 500,000
Bristles, 450,000
Timber, deals, &c., 500,000
Iron, 70,000
Copper, 140,000
Hides, 60,000
Miscellaneous, 200,000

£13,020,000

Now, last year our imports from Russia were larger than usual, and another
house, taking an average year, had made them £11,000,000. In that calculation,
the imports of wheat were taken at £2,000,000 instead of £4,000,000, and that
made the difference. He was also credibly informed that Russian produce to the
value of about £1,000,000 came down the Vistula to the Prussian ports of the
Baltic, and was shipped thence to this country; so that our imports from Russia
averaged about £12,000,000 sterling per annum, and included among them
articles of primary importance to our manufactures. How was machinery to work,
and how were locomotives to travel, without tallow to grease their wheels? (A
laugh.) Look, too, at the imports of linseed to the value of £1,300,000. No persons
were more interested than honourable gentlemen opposite in the reduction of the
price of the food of cattle. Then take the articles of flax and hemp. There were
districts in the West Riding which would suffer very serious injury and great
distress if we should go to war and cut off our intercourse with Russia. (Hear.)
Even with regard to the article of Russian iron, which entered into consumption at
Sheffield, he was told it would be hardly possible to manufacture some of the finer
descriptions of cutlery if the supply of Russian iron were interfered with.”

We shall not here take the trouble of criticising Mr Cobden’s

figures, but take them as they stand, although they are exaggerated
enough. His argument is obviously, that we must submit to any
amount of aggression which Russia may choose to make upon
neutral countries, and even upon our own Indian possessions,
because that country supplies us yearly with thirteen millions’ worth
of raw materials and food! The same was the humiliating position
which the men of Tyre and Sidon, as recorded in Scripture, occupied
towards Herod, when “they came of one accord to him, and having
made Blastus, the king’s chamberlain, their friend, desired peace,
because their country was nourished by the king’s country.” How,
asks Mr Cobden, is machinery to work without tallow to grease the
wheels? We are to have an anti-war cry from the farmers for the lack
of Russian linseed; the West Riding of Yorkshire is to be stirred up
into insurrection by the want of flax and hemp; and the fine cutlers
of Sheffield cannot get on without the £70,000 worth of iron which
they import from Russia! The main reliance of the peace-at-any-price
party, we have no doubt, rests upon the probability of high prices of
food, and their hope of producing in the minds of the masses the
impression that the cause of those high prices is mainly the
interruption of our usual imports of grain from the Russian ports of
the Baltic and the Black Sea.
It is rather singular that it should not have struck so astute a man
as Mr Cobden, that Russia is very likely to feel the loss of so excellent
a customer as England appears to have been to her, quite as much as
we are likely to feel the want of her tallow, her flax and hemp, her
linseed, or even her wheat. The vendor of an article is generally the
party who feels most aggrieved when his stock is permitted to
accumulate upon his shelves. The Russian landowners cannot very
conveniently dispense with the annual thirteen millions sterling
which they draw from this country. Mr Cobden may depend upon it
that, if we want it, a portion of their growth of staple articles will find
its way to this country, through intermediate channels, although
Russian ships no longer gain the advantages derived from its
transport. The fact, however, of our absolute dependence upon
Russia for these articles is too palpably a bugbear, either of Mr
Cobden’s own creation, or palmed upon him by his friends, the
“eminent merchants of the City,” to be worthy of serious notice, did it
not betray the direction in which we are to look for the agitation, by
which that gentleman and his friends hope to paralyse the hands of
Government during the coming crisis of the country.
 In the effort to form a correct estimate of the extent of interruption
to our commerce to be anticipated from the existence of a state of
war between this country and Russia, we must have, in the first
place, reliable facts to depend upon, instead of the loose statements
of Russian merchants, who are, as a class, so peculiarly connected
with her as almost to be liable to the imputation of having Russian
rather than British interests nearest to their hearts. We have a right
also to look at the fact that, so far at least as present appearances go,
Russia is likely to be isolated on every side during the approaching
struggle, her principal seaports, both in the Baltic and the Black Sea,
to be commanded by the united British and French fleets; whilst that
produce, by the withholding of which she could doubtless for a time,
and to a certain extent, inconvenience our manufacturers and
consumers, may find its way to us either direct from Russian ports in
neutral vessels, or through those neighbouring countries which are
likely to occupy a neutral position in the quarrel. We have also to
bear in mind that, with respect to many of the articles which we have
lately been taking so largely from Russia, other sources of supply are
open to us. It is remarkable to observe the effect produced by even
temporarily enhanced prices in this country in extending the area on
every side from which foreign produce reaches us. A few shillings per
quarter on wheat, for example, will attract it from the far west States
of America, from which otherwise it would never have come, owing
to the inability of the grower to afford the extra cost of transport. All
these considerations have to be borne in mind; and although it will
perhaps have to be conceded that somewhat enhanced prices may
have to be paid for some of the articles with which Russia at present
supplies us, we think we shall be enabled to show that the
enhancement is not at all likely to be such as to amount to a calamity,
or cause serious pressure upon our people.
Before proceeding further, it may be desirable to explain the mode
in which our trade with Russia, both import and export, is carried
on. Russia is, commercially, a poor country. The description of her
given by M‘Culloch, in an early edition of his Dictionary of
Commerce, published two-and-twenty years ago, is as appropriate
and correct as if it had been written yesterday, notwithstanding the
vast territorial aggrandisement which has taken place in the interim.
Her nobles and great landowners hold their property burdened by
the pressure of many mortgages; and they are utterly unable to bring
their produce to market, or to raise their crops at all, without the
advances of European capitalists. These consist chiefly of a few
English Houses, who have branch establishments at St Petersburg,
Riga, and Memel on the Baltic, and Odessa on the Black Sea. The
mode of operation is the following. About the month of October the
cultivators and factors from the interior visit those ports, and receive
advances on the produce and crops to be delivered by them ready for
shipment at the opening of the navigation; and it is stated that the
engagements made between these parties and British capitalists have
rarely been broken. This process of drawing advances goes on until
May, by which month there are large stocks ready for shipment at all
the ports, the winter in many districts being the most favourable for
their transport. The import trade is carried on in a similar manner by
foreign capital; long credits, in many instances extending to twelve
months, being given to the factors in the interior. A well-known
statistical writer, the editor of the Economist, Mr John Wilson, in his
publication of the 25th ult., says, upon the subject of the amount of
British capital thus embarked in Russia at the period when her
battalions crossed the Pruth: “The most accurate calculations which
we have been able to make, with the assistance of persons largely
engaged in the trade, shows that at that moment the British capital
in Russia, and advanced to Russian subjects, was at least
£7,000,000, including the sums for which Houses in this country
were under acceptance to Russia.” We can perfectly believe this to
have been the fact, under such a system of trading as that which we
have described. We can believe, too, that a considerable number of
British ships and sailors were at the same time in Russian ports, and
would, in case we had treated the occupation of Moldavia and
Wallachia by Russian troops as a casus belli, very probably have been
laid under embargo. We could sympathise with those “persons
largely engaged in the trade,” in rejoicing that, as one effect of a
temporising policy, the whole of this capital, these ships, and these
sailors, had been released from all danger of loss or detention. But
we cannot bring ourselves to consider it decent in a gentleman
holding an important office in the Government, whilst admitting, as
he does, that we have been bamboozled by Russian diplomacy, to
point triumphantly to this saving of “certain monies”—the property
of private individuals, who made their ventures at their own risk and
for their own profit—as in any sort balancing the loss of the national
honour, which has been incurred by our tardiness in bringing
decisive succour to an oppressed ally. Ill-natured people might
suggest a suspicion that Mincing Lane and Mark Lane had been
exercising too great an influence in Downing Street. And the public
may hereafter ask of politicians, who thus ground their defence
against the charges of infirmness of purpose and blind credulity, or
“connivance,” as Mr Disraeli has, perhaps too correctly, termed it,
upon this alleged saving of a few millions of the money of private
adventurers—Will it balance the expenditure of the tens of millions
of the public money which the prosecution of this war will probably
cost, and which might have been saved by the adoption of a more
prompt and vigorous policy in the first instance? Will it balance the
loss of life—will it support the widows and orphans—will it lighten by
one feather the burden upon posterity, which may be the result of
this struggle? It would be a miserable thing should it have to be said
of England, that there was a period in her history when she hesitated
to strike a blow in a just cause until she had taken care that the
offender had paid her shopkeepers or her merchants their debts! We
pass over this part of the subject, however, as scarcely belonging to
the question which we have proposed to ourselves to discuss.
Our imports from Russia, upon the importance of which so much
stress has been laid, were in 1852 as given below, from official
documents. We have ourselves appended the value of the various
items upon a very liberal scale; and we may explain that we select
that year instead of 1853, for reasons which we shall hereafter
explain.
 Quantities of Russian Produce imported into Great Britain during
the year 1852.
Corn, wheat, and flour, qrs. 733,571 value £1,540,499
Oats, „ 305,738 366,855
Other grain, „ 262,348 327,935
Tallow, cwts. 609,197 1,187,700
Linseed, and flax seed, &c. qrs. 518,657 1,125,000
Bristles, lbs. 1,459,303 292,000
Flax, cwts. 948,523 1,897,046
Hemp, „ 543,965 861,277
Wool (undressed), lbs. 5,353,772 200,390
Iron (unwrought), tons 1,792 17,920
Copper (do.), „ 226 20,000
Do. (part wrought), „ 1,042 120,000
Timber (hewn), loads 28,299 94,800
Do. (sawn), „ 189,799 759,196

£8,810,618

We have taken for the above estimate the prices which prevailed in
the first six months of 1852, after which they were raised above an
average by peculiar circumstances. The year selected, moreover, was
one of larger imports than usual of many articles. For example, our
imports of Russian grain in 1852 amounted, in round numbers, to
£2,235,300 sterling, against only £952,924 in 1850. Yet we have less
than nine millions as the amount of this vaunted import trade from
Russia, the interruption of which is to be fraught with such serious
consequences to our internal peace, and to the “popularity” of the
liberal representatives of our large towns.
But fortunately for the country, and rather mal apropos for those
who would fain convert any diminution of our supplies of produce
from Russia into the ground of an anti-war agitation, we have
succeeded in procuring from that country during the past year
supplies unprecedented in quantity. The following have been our
imports from Russia in 1853, as compared with the previous year:—
 Corn, wheat, and flour, qrs. 1,070,909 against 733,571 in 1852.
Oats, „ 379,059 305,738
Other grain, „ 263,653 262,238
Tallow, cwts. 847,267 609,197
Seeds, qrs. 785,015 518,657
Bristles, lbs. 2,477,789 1,459,303
Flax, cwts. 1,287,988 948,523
Hemp, „ 836,373 543,965
Wool, lbs. 9,054,443 5,353,772
Iron, tons 5,079 1,792
Copper (unwrought), „ 974 226
Copper (part wrought), „ 656 1,042
Timber (hewn), loads 45,421 28,299
Timber (sawn), „ 245,532 189,799

If mercantile opinions are at all to be relied upon, these extra

supplies ought to have a tendency to bring down prices, which the
prospect of war has enhanced beyond what existing circumstances
seem to warrant, even presuming that we had no other dependence
than upon Russia for the articles with which she has heretofore
supplied us. For example, we have paid during the past year, if we
take present prices, for our imports of wheat alone from Russia,
about £6,470,000 sterling, whereas, at the prices of the early part of
1852, we should have paid for the same quantity of wheat just half
the money. And at the present moment, and since war has been
regarded as inevitable, we have had a downward tendency in all our
principal markets. It has been discovered that we hold more home-
grown wheat than was anticipated; and, with a favourable seed-time
and a propitious spring, hopes are entertained that we shall not in
the present year be so dependent upon the foreigner as we have been
during that which has passed. Tallow also is an article for which we
have been lately paying the extravagant prices of 62s. to 63s. per cwt.
In the early part of 1852, the article was worth about 37s. 6d. for the
St Petersburg quality. No English grazier, however, ever knew
butcher’s meat or fat at their present prices; and a propitious year for
the agriculturist will most probably bring matters to a more
favourable state for the consumer.
 It is not, however, true that a state of war with Russia can shut us
out from our supply of the produce of that country. It will come to us
from her ports, unless we avail ourselves of our right to blockade
them strictly, in the ships of neutral countries. A portion of it—and
no inconsiderable portion—will reach us overland, Russia herself
being the greatest sufferer, from the extra cost of transit. There can
be no doubt of every effort being made by her great landowners to
make market of their produce, and convert it at any sacrifice into
money; for it must be borne in mind that they are at the present
moment minus some seven or eight millions sterling of British and
other money, usually advanced upon the forthcoming crops. We
need scarcely point at the difficulty in which this want must place
Russia in such a struggle as that in which she is at present engaged.
The paper issues of her government may for a time be forced upon
her slavish population as money. But that population requires large
imports of tea, coffee, sugar, spices, fruits, wines, and other foreign
products; and it is not difficult to predict that there will be found few
capitalists in Europe or Asia, willing to accommodate her with a loan
wherewith to pay even for these necessaries, much less to feed her
grasping ambition by an advance of money for the purchase of
additional arms and military stores. Moreover, we are not by any
means so absolutely dependent upon Russia for many of the
principal articles with which she has heretofore supplied us, as
certain parties would wish us to believe. We could have an almost
unlimited supply of flax and hemp from our own colonies, if we
chose to encourage the cultivation of them there. In the mean time,
Egypt furnishes us with the former article; and Manilla supplies us
with a very superior quality of both. Belgium and Prussia are also
producers, and with a little encouragement would no doubt extend
their cultivation. Our own colonies, however, are our surest
dependence for a supply of these and similar articles. An advance of
seeds and money to the extent of less than one quarter of the sums
which we have been in the habit of advancing to the Russian
cultivator, would bring forward to this country a supply of the raw
materials of flax and hemp, which would be quite in time, with our
present stock, to relieve us from any danger of deficiency for at least
a season to come. With respect to tallow, we have a right to depend
upon America, both North and South, for a supply. Australia can
send us an aid, at all events, to such supply; and we may probably