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OPTIMIZING THE DIAGNOSTIC INFORMATION 9 Equipment manufacturers now follow the DICOM standard. Digital Imaging and Communications in Medicine is the industry standard for transferring medical images and related information between computers. This facilitates compatibility between different pieces of equipment from different manufacturers and potentially enables them to be linked up. RECORDING OF IMAGES There are no hard and fast rules about the recording of ultrasound scans and departmental practices vary. It is good practice for departments to have guidelines for taking and retaining images within individual schemes of work, outlining the minimum expected. 3 The advantages of recording images are: ● ● ● ● They provide a record of the quality of the scan and how it has been conducted: the organs examined, the extent of the scan, the type and standard of equipment, the settings used and other scanning factors. This can be an invaluable tool in providing a medicolegal defence. They provide an invaluable teaching aid. They help to ensure quality control within departments: promoting the use of good technique, they can be used to ensure protocols are followed and provide an excellent audit tool. They can be used to obtain a second opinion on difficult or equivocal cases and provide a basis for discussion with clinical colleagues. The disadvantages are: ● ● ● ● ● The cost of buying, running and maintaining the recording device or system. The quality of images in some cases may not accurately reflect that of the image on the ultrasound monitor. The scanning time must be slightly increased to accommodate the taking of images. Storage and retrieval of images may be timeand space-consuming. Hard copy may be mislaid or lost. ● If the examination has been badly performed, the hard copy may demonstrate that too! Generally speaking the recording of images is encouraged. It reduces the operator’s vulnerability to litigation and supports the ultrasound diagnosis. 4 It is only possible to record the entire examination by using videotape, which is rarely practical in larger departments. The operator must take the responsibility for ensuring the scan has been performed to the required standard; any images produced for subsequent discussion are only representative of the examination and have been chosen by the operator as an appropriate selection. If you have missed a small metastasis in the liver while scanning, or a gallstone in the gallbladder, you are unlikely to have included it on an image. Choice of image-recording device depends on many factors. Considerations include: ● ● ● ● ● ● ● ● ● image quality—resolution, grey-scale, storage life capital cost of the system—including the installation together with the installation of any other necessary equipment, such as a processor cost of film processing costs if applicable—this includes the cost of chemicals, the cost of buying and maintaining a processor and possibly a chemical mixer maintenance costs reliability of the system storage of images in terms of available space and cost location and size of the imaging system other considerations —ease of use —mobility —colour capability —ability to produce slides/teaching aids —shelf life of unused film and stored images. Numerous methods of recording images are available to suit all situations. Small printers, attached to ultrasound scanners, are easy to use, cheap to buy and run and convenient if the machine is used on wards or distant satellite units. However, systems which produce hard copy, however good, are inevitably of inferior image quality to electronic image capture.
10 ABDOMINAL ULTRASOUND Multi-system departments are tending towards networked systems which produce high-quality images, and can be linked to multiple machines and modalities. These are, of course, more expensive to purchase and install, but are generally reliable and produce consistent, high-quality image. Ultimately, the goal of the filmless department is being realized in PACS (photographic archiving and communications systems). Digital imaging networks are convenient, quick and relatively easy to use. The image quality is excellent, suffering little or no degradation in capture and subsequent retrieval, and the system can potentially be linked to a conventional imager should hard copy be required. The number of workstations in the system can be virtually unlimited, depending on the system, affording the operator the flexibility of transmitting images immediately to remote locations, for example clinical meetings, outpatient clinics, etc. It is also possible to download images from scans done with mobile equipment, remote from the main department, on to the PACS. Digital storage and retrieval avoid loss of films and afford considerable savings in time, labour and space. Increasingly it is also possible to store moving clips—useful for dynamic studies such as those involving contrast agents and for teaching purposes. Many systems also incorporate a patient registration and reporting package, further streamlining the ultrasound examination. Not all systems store images in colour and there are considerable differences between the facilities available on different systems. The potential purchaser is advised to plan carefully for the needs of the ultrasound service. The capital costs for PACS are high, but these can, to a certain extent, be offset by subsequently low running costs and potential savings in film, processing materials, equipment maintenance, and manual storage and retrieval. SAFETY OF DIAGNOSTIC ULTRASOUND Within the field of clinical diagnostic ultrasound, it is currently accepted that there is insufficient evidence for any deleterious effects at diagnostic levels and that the benefits to patients outweigh the risks. As new techniques and technological developments come on to the market, new biophysical conditions may be introduced which require evaluation with regard to safety 5 and we cannot afford to become complacent about the possible effects. The situation remains under constant review. Several international bodies continue to consider the safety of ultrasound in clinical use. The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) has confirmed the safety of diagnostic ultrasound and endorsed its ‘informed’ use. 6 Whilst the use of pulsed Doppler is considered inadvisable for the developing embryo during the first trimester, no such exceptions are highlighted for abdominal ultrasound. The European Committee for Ultrasound Radiation Safety (ECURS) confirms that no deleterious effects have yet been proven in clinical medicine. It recommends, however, that equipment is used only when designed to national or international safety standards and that it is used only by competent and trained personnel. The World Federation for Ultrasound in Medicine and Biology (WFUMB) confirms that the use of B-mode imaging is not contraindicated, 7 concluding that exposure levels and duration should be reduced to the minimum necessary to obtain the required diagnostic information. Ultrasound intensities used in diagnostic ultrasound vary according to the mode of operation. Pulsed Doppler usually has a higher level than B-mode scanning, which operates at lower intensities, although there may be overlap with colour or power Doppler. The American Institute for Ultrasound in Medicine (AIUM) has suggested that ultrasound is safe below 100 W/cm. 8 This figure refers to the spatial peak temporal average intensity (I SPTA ). The use of intensity, however, as an indicator of safety is limited, particularly where Doppler is concerned, as Doppler intensities can be considerably greater than those in B-mode imaging. The Food and Drug Administration (FDA) sets maximum intensity levels allowed for machine output, which differ according to the application. 9 Biological effects of ultrasound Harmful effects from ultrasound have been documented in laboratory conditions. These include thermal effects and mechanical effects.
Page 2 and 3: Abdominal Ultrasound
Page 4 and 5: Abdominal Ultrasound How, Why and W
Page 6 and 7: v Contents Contributors Preface ix
Page 8 and 9: vii Contributors Rosemary Arthur FR
Page 10 and 11: ix Preface Ultrasound continues to
Page 12 and 13: ABBREVIATIONS xi MHA MHV MI MPV MRA
Page 14 and 15: Chapter 1 1 Optimizing the diagnost
Page 16 and 17: OPTIMIZING THE DIAGNOSTIC INFORMATI
Page 30 and 31: Chapter 2 17 The normal hepatobilia
Page 32 and 33: THE NORMAL HEPATOBILIARY SYSTEM 19
Page 54 and 55: Chapter 3 41 Pathology of the gallb
Page 56 and 57: PATHOLOGY OF THE GALLBLADDER AND BI
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PATHOLOGY OF THE GALLBLADDER AND BI
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Chapter 4 79 Pathology of the liver
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PATHOLOGY OF THE LIVER AND PORTAL V
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Chapter 5 121 The pancreas CHAPTER
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THE PANCREAS 123 the patient’s le
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THE PANCREAS 125 Acute pancreatitis
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THE PANCREAS 127 E F G Figure 5.3 c
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A C DISTANCE = 3.43 CM 5%. 13 Over
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THE PANCREAS 131 G H I Figure 5.5 c
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THE PANCREAS 133 head of pancreas.
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THE PANCREAS 135 pancreatic juice i
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Chapter 6 137 The spleen and lympha
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THE SPLEEN AND LYMPHATIC SYSTEM 139
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Chapter 7 153 The renal tract CHAPT
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THE RENAL TRACT 155 As with any oth
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THE RENAL TRACT 157 A B q 0 LRA AO
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THE RENAL TRACT 159 junctions of or
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THE RENAL TRACT 161 A B Figure 7.5
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THE RENAL TRACT 163 carcinomas, the
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THE RENAL TRACT 165 the vesicourete
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THE RENAL TRACT 167 Table 7.1 Sourc
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THE RENAL TRACT 169 A B Figure 7.13
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THE RENAL TRACT 171 Table 7.2 Diffe
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THE RENAL TRACT 173 Ultrasound stil
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THE RENAL TRACT 175 CT is useful fo
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THE RENAL TRACT 177 Xanthogranuloma
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THE RENAL TRACT 179 As with acute t
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THE RENAL TRACT 181 der with increa
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THE RENAL TRACT 183 ● ● Morphol
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THE RENAL TRACT 185 ● ● hydrone
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THE RENAL TRACT 187 A Figure 7.27 A
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THE RENAL TRACT 189 vascular reject
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THE RENAL TRACT 191 B A C Figure 7.
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THE RENAL TRACT 193 computerised ul
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Chapter 8 195 The retroperitoneum a
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THE RETROPERITONEUM AND GASTROINTES
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Chapter 9 215 The paediatric abdome
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THE PAEDIATRIC ABDOMEN 217 A B SPLE
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THE PAEDIATRIC ABDOMEN 219 B A B Fi
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THE PAEDIATRIC ABDOMEN 221 probe de
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THE PAEDIATRIC ABDOMEN 223 When the
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THE PAEDIATRIC ABDOMEN 225 + 78 A 2
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THE PAEDIATRIC ABDOMEN 227 A B C D
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THE PAEDIATRIC ABDOMEN 229 Table 9.
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THE PAEDIATRIC ABDOMEN 231 A LT B C
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THE PAEDIATRIC ABDOMEN 237 mesenter
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THE PAEDIATRIC ABDOMEN 239 E F G Fi
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THE PAEDIATRIC ABDOMEN 241 system i
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Chapter 10 The acute abdomen 243 CH
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THE ACUTE ABDOMEN 245 scan of the p
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THE ACUTE ABDOMEN 247 LIVER LS GB S
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THE ACUTE ABDOMEN 249 D A RT B C E
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THE ACUTE ABDOMEN 251 17. Patlas M,
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Chapter 11 253 Interventional and o
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INTERVENTIONAL AND OTHER TECHNIQUES
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275 Bibliography and further readin
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277 Index A Abdomen, acute gastroin
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INDEX 279 Continuous ambulatory per
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INDEX 281 Intravenous urography (IV
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INDEX 283 Phrygian cap, 29 Pneumobi
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