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 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
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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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Cephalic/Superior Cephalic/Superior Anterior Anterior

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
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F. SHRINER.

Noblesville, Ind., June 21, 1884.

Crane & Allen:
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S. D. COTTINGHAM & CO.

Ovid, Mich., Sept. 18, 1886.

Crane & Allen:
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C. W. DANFORTH.

Leipsic, Ohio, Nov. 26, 1883.

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S. WATTERS.

Clinton, Wis., July 4, 1884.

Crane & Allen:
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M. P. TREAT & CO.

Danielsonville, Conn., Jan. 14, 1884.

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E. DEXTER.

Newark, N. J., Jan. 16, 1883.

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C. W. COMPTON.

Charles City, Iowa, April 21, 1887.

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STEVENS, HERING & CO.

York, Pa., Feb. 1, 1888.

Crane & Allen:
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C. A. STRACK.
 Muir, Mich., Oct. 4, 1884.
Crane & Allen:
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GEO. N. SHAW.

Bath, N. Y., July 16, 1887.

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JNO. STOCUM & SON.

Weeping Water, Neb., March 25, 1886.

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CHASE & CHURCHILL.

Westfield, Ind., April 8, 1887.

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Ashland, Ky., June 22, 1886.

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S. CASEBOLT.

Succasunna, N. J., Nov. 25, 1886.

Crane & Allen:
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JARDINE & HANCE.

Nokomis, Ills., Dec. 21, 1886.

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GEO. CULP.

Carthage, Aug. 5, 1885.

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W. S. JOHNSON.

Berlin, Wis., June 9, 1884.

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HOEFT & TUCKER.

Mt. Pleasant, Pa., April 18, 1887.

Crane & Allen:
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S. P. ZIMMERMAN.

Dover, N. J., Sept. 21, 1883.

Crane & Allen:
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J. L. Van LIEW.

Detroit, Sept. 5, 1884.

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LATIMER & HAMILTON.

Necedah, Wis., Nov. 11, 1886.

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H. F. YOUNG.
And again, Ashland, Aug. 30, 1887:
Crane & Allen:
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H. F. YOUNG.

Kent, Ohio, Jan. 13, 1882.

Crane & Allen:
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HERRIFF & REED.
 Rock Island, Ill., March 26, 1887.
Crane & Allen:
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C. B. KNOX.

Philadelphia, July 26, 1886.

Crane & Allen:
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have yet seen.

H. C. SHURTLEFF,
3722 Market St.

New York City, May 24, 1882.

Crane & Allen:
I am a great deal better satisfied when using your Preservative
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including some of the cemetery officials, who can vouch for the facts
as I have stated them. I also embalmed a body with the Preservative
and shipped it to Troy, N. Y., which was buried three weeks after, in a
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JOHN W. LYON,
74 and 76 E. 125th St.
 Pendleton, Ind., Oct. 8, 1886.
Crane & Allen:
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C. B. KEESLING.

Oswego, N. Y., May 4, 1885.

Crane & Allen:
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JOHN F. DAIN.

Racine, Wis., Oct. 24, 1884.

Crane & Allen:
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S. G. AUGUSTINE & SON.

Rushsylvania, Ohio, Sept. 10, 1885.

Crane & Allen:
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WRIGHT BROS.
And again, Aug. 7, 1886:
Crane & Allen:
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& Allen’s Preservative was our reliance in all.
WRIGHT BROS.

New Carlisle, Ind., March 13, 1884.

Crane & Allen:
 I have this much to say in regard to your Preservative, that I do not
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S. L. ARGABRITE.

Saratoga Springs, N. Y., July 20, 1885.

Crane & Allen:
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HOLMES & CO.

North Bend, Neb., March 11, 1887.

Crane & Allen:
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A. CRAWFORD.

Tiffin, Ohio, April 21, 1883.

Crane & Allen:
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C. W. HORN.

Peru, Ills., Nov. 23, 1885.

Crane & Allen:
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HAAS & WASSOM.
 Parker City, Pa., Feb. 23, 1885.
Crane & Allen:
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S. J. ERVIN.

Fort Dodge, Iowa, April 8, 1886.

Crane & Allen:
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EIKER & KING.

Morrisonville, Ill., March 21, 1884.

Crane & Allen:
The Preservative is perfect, and I have been very successful with it.
I have kept bodies ten days with it, with only partial embalming.
W. H. DRAKE.

Geneseo, Ills., Oct. 13, 1883.

Crane & Allen:
I am well pleased with your Preservative, and shall order more in
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D. F. ZIMMERMAN.

Castile, N. Y., May 31, 1887.

Crane & Allen:
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J. H. Van ARSDALE.
 Milan, Tenn., April 30, 1883.
Crane & Allen:
I take pleasure in saying in regard to your Excelsior Preservative
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J. W. YOUNGER.

Marion, Ind., April 14, 1883.

Crane & Allen:
We have sold our business, which accounts for our not ordering
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WHISLER & COX.

Dodgeville, Wis., Aug. 11, 1886.

Crane & Allen:
I have some of the Preservative yet, but I will not let it run too low
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F. C. BARTLE.

Woodbury, N. J., April 9, 1884.

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E. CATLETT.

Beaver, O., Aug. 25, 1887.

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condition and from all appearances it would have kept for weeks
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B. F. WEST.

Bradford, Ohio, Nov. 6, 1884.

Crane & Allen:
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death.
WILLIAMSON & SON.
And again, June 6, 1887:
Crane & Allen:
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WILLIAMSON & SON.

Martinsburg, West Va., June 1, 1883.

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WILLIAM WILEN & SONS.

Portland, Ind., July 28, 1884.

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JOHN CRING.

Bement, Ill., April 19, 1886.

Crane & Allen:
 I consider that I have had a good test of the merits of your
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J. H. CAMP.

Darlington, Wis., May 30, 1887.

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F. CORNELIUS.

Van Wert, Ohio, Oct. 19, 1883.

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J. H. CONOVER.

Pittsfield, Ills., Sept. 24, 1883.

Crane & Allen:
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WINANS & PLATNER.

Lake Village, N. H., Oct. 13, 1884.

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E. D. WARD.
 Knoxville, Sept. 11, 1883.
Crane & Allen:
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E. D. YOUNG.

Mt. Pleasant, Mich., Oct. 24, 1884.

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J. E. WILCOX.

Bluffton, O., Sept. 12, 1885.

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WM. WILSON.

Decatur, Ills., March 10, 1885.

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J. B. BULLARD.

Rockland, Maine, Nov. 3, 1885.