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PATHOLOGY OF THE GALLBLADDER AND BILIARY TREE 43 Figure 3.3 Floating stones just below the anterior gallbladder wall. a b c d Shadow No shadow Figure 3.4 (a) A shadow will be displayed from the stone, which occupies the width of the beam. (b) The stone is smaller than the beam. (c) The stone is large, but just out of the beam. (d) The stone is large, but outside the focal zone, where the beam is wider. fills the width of the beam (Fig. 3.4). This will happen easily with large stones, but a small stone may occupy less space than the beam, allowing sound to continue behind it, so a shadow is not seen. Small stones must therefore be within the focal zone (narrowest point) of the beam and in the centre of the beam to shadow (Fig. 3.5). Higher-frequency transducers have better resolution and are therefore more likely to display fine shadows than lower frequencies.
44 ABDOMINAL ULTRASOUND A Figure 3.6 The shadow behind the gallstone (left image) is obscured if the time gain compensation is set too high behind the gallbladder (right image). demonstrate (Fig. 3.7B). This is a particular problem with stones in the common bile duct (CBD). Try turning the patient to move the gallbladder away from the bowel. The shadow cast by gas in the duodenum, which contains reverberation, should usually be distinguishable from that cast by a gallstone, which is sharp and clean. B Figure 3.5 (A) The stones are outside the focal zone, and do not appear to shadow well. (B) The focal zone has been moved to the level of the stones, allowing the shadow to be displayed. ● ● The machine settings must be compatible with demonstrating narrow bands of shadowing. The fluid-filled gallbladder often displays posterior enhancement, or increased throughtransmission. If the echoes posterior to the gallbladder are ‘saturated’ this will mask fine shadows. Turn the overall gain down to display this better (Fig. 3.6). Some image-processing options may reduce the contrast between the shadow and the surrounding tissue, so make sure a suitable dynamic range and image programme are used. Bowel posterior to the gallbladder may cast its own shadows from gas and other contents, which makes the gallstone shadow difficult to Reflectivity The reflective nature of the stone is enhanced by its being surrounded by echo-free bile. In a contracted gallbladder the reflectivity of the stone is often not appreciated because the hyperechoic gallbladder wall is collapsed over it. Some stones are only poorly reflective, but should still cause a distal acoustic shadow. Mobility Most stones are gravity-dependent and this may be demonstrated by scanning the patient in an erect position (Fig. 3.7), when a mobile calculus will drop from the neck or body of the gallbladder to lie in the fundus. Some stones will float, however, forming a reflective layer just beneath the anterior gallbladder wall with shadowing that obscures the rest of the lumen (Fig. 3.3). When the gallbladder lumen is contracted, either due to physiological or pathological reasons,
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Abdominal Ultrasound
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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 58 and 59: PATHOLOGY OF THE GALLBLADDER AND BI
Page 92 and 93: Chapter 4 79 Pathology of the liver
Page 94 and 95: PATHOLOGY OF THE LIVER AND PORTAL V
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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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