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98 PART II Abdominal and Pelvic Sonographynear the umbilicus (Cruveilhier-Baumgarten syndrome) 86(Fig. 4.31A). Some studies suggest that, if the hepatofugallow in the patent paraumbilical vein exceeds the hepatopetallow in the portal vein, patients may be protected fromdeveloping esophageal varices. 87,88• Splenorenal and gastrorenal: Tortuous veins may be seenin the region of the splenic and let renal hilus (Fig. 4.31Eand F), which represent collaterals between the splenic, coronary,and short gastric veins and the let adrenal or renalveins.• Intestinal: Regions in which the gastrointestinal tract becomesretroperitoneal so that the veins of the ascending and descendingcolon, duodenum, pancreas, and liver may anastomose withthe renal, phrenic, and lumbar veins (systemic tributaries).• Hemorrhoidal: he perianal region where the superiorrectal veins, which extend from the inferior mesentericvein, anastomose with the systemic middle and inferiorrectal veins.Duplex Doppler sonography provides additional informationregarding direction of portal low. False results may occur,however, when sampling is obtained from periportal collateralsin patients with portal vein thrombosis or hepatofugal portallow. 89 Normal portal venous low rates vary in the same individual,increasing postprandially and during inspiration 75,90 anddecreasing ater exercise or in the upright position. 91 An increaseof less than 20% in the diameter of the portal vein with deepinspiration indicates portal hypertension with 81% sensitivityand 100% speciicity. 92he normal portal vein demonstrates an undulating hepatopetal(toward the liver) low. Mean portal venous low velocityis 15 to 18 cm/sec and varies with respiration and cardiac pulsation.As portal hypertension develops, the low in the portal veinloses its undulatory pattern and becomes monophasic. As theseverity of portal hypertension increases, low becomes biphasicand inally hepatofugal (away from the liver). Intrahepaticarterial-portal venous shunting may also be seen.Chronic liver disease is also associated with increased splanchnicblood low. Evidence suggests that portal hypertension ispartly caused by the hyperdynamic low state of cirrhosis. Zwiebelet al. 93 found that blood low was increased in the superiormesenteric arteries and splenic arteries of patients with cirrhosisand splenomegaly, compared with normal controls. Of interest,in patients with cirrhosis and normal-sized livers, splanchnicblood low was not increased. Patients with isolated splenomegalyand normal livers were not included in this study.he limitations of Doppler sonography in the evaluation ofportal hypertension include the inability to determine vascularpressures and low rates accurately. Patients with portal hypertensionare oten ill, with contracted livers, abundant ascites, andloating bowel, all of which create a technical challenge. In acomparison of duplex Doppler sonography with magnetic resonanceangiography, MRI imaging was superior in the assessmentof patency of the portal vein and surgical shunts, as well as indetection of varices. 94 However, when technically adequate, theDoppler study was accurate in the assessment of normal portalanatomy and low direction. Duplex Doppler sonography hasthe added advantages of decreased cost and portability of theequipment and therefore should be used as the initial screeningmethod for portal hypertension.Portal Vein ThrombosisPortal vein thrombosis has been associated with malignancy,including HCC, metastatic liver disease, carcinoma of thepancreas, and primary leiomyosarcoma of the portal vein, 95 aswell as with chronic pancreatitis, hepatitis, septicemia, trauma,splenectomy, portacaval shunts, hypercoagulable states such aspregnancy and in neonates, omphalitis, umbilical vein catheterization,and acute dehydration. 96Sonographic indings of portal vein thrombosis includeechogenic thrombus within the lumen of the vein, portal veincollaterals, expansion of the caliber of the vein, and cavernoustransformation 96 (Figs. 4.32 and 4.33). Cavernous transformationof the portal vein refers to numerous wormlike vessels at theporta hepatis, which represent periportal collateral circulation. 97his pattern is observed in long-standing thrombosis, requiringup to 12 months to occur, and thus is more likely to developwith benign disease. 98 Acute thrombus may appear relativelyanechoic and thus may be overlooked unless Doppler ultrasoundinterrogation is performed. Malignant thrombosis of the portalvein has a high association with HCC and is oten expansive, asis malignant occlusion from other primary or secondary disease(Fig. 4.32A and B and Fig. 4.34).Doppler sonography is useful in distinguishing between benignand malignant portal vein thrombi in patients with cirrhosis.Both bland and malignant thrombi may demonstrate venousblood low. Pulsatile (arterial) low, however, has been found tobe 95% speciic for the diagnosis of malignant portal veinthrombosis (see Fig. 4.32). he sensitivity was only 62% becausemany malignant thrombi are hypovascular. 99Budd-Chiari Syndromehe Budd-Chiari syndrome is a relatively rare disorder characterizedby occlusion of the lumens of the hepatic veins with orwithout occlusion of the IVC lumen. he degree of occlusionand presence of collateral circulation predict the clinical course.Some patients die in the acute phase of liver failure. Causes ofBudd-Chiari syndrome include coagulation abnormalities suchas polycythemia rubra vera, chronic leukemia, and paroxysmalnocturnal hemoglobinuria; trauma; tumor extension fromprimary HCC, renal carcinoma, and adrenocortical carcinoma;pregnancy; congenital abnormalities; and obstructing membranes.he classic patient in North America is a young adultwoman taking oral contraceptives who presents with an acuteonset of ascites, right upper quadrant pain, hepatomegaly, and,to a lesser extent, splenomegaly. In some cases, no causal factoris found. he syndrome is more common in other geographicareas, including India, South Africa, and Asia.Sonographic evaluation of the patient with Budd-Chiarisyndrome includes gray-scale and Doppler features. 100-111 Ascitesis invariably seen. he liver is typically large and bulbous in theacute phase (Fig. 4.35A). Hemorrhagic infarction may producesigniicant altered regional echogenicity. As infarcted areas becomemore ibrotic, echogenicity increases. 109 he caudate lobe is oten
CHAPTER 4 The Liver 99ABCDFIG. 4.32 Portal Vein Thrombosis: Benign and Malignant. Malignant thrombus: transverse views of (A) the vein at the porta hepatis and(B) left ascending left portal vein. Both are distended with occlusive thrombus. Benign thrombus: (C) transverse and (D) sagittal images of simple,bland nonocclusive thrombus in the left portal vein at the porta hepatis.ABFIG. 4.33 Cavernous Transformation of Portal Vein. (A) Gray-scale image. (B) Color Doppler image. Numerous periportal collateral vesselsare present.
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viiiContributorsOlga R. Brook, MDAs
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xContributorsChristy K. Holland, Ph
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xiiContributorsRupa Radhakrishnan,
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xxiiContentsVOLUME IIPART IV Obstet
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xxivVideo ContentsVideo 12.8 Angiog
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xxviVideo ContentsVideo 26.20 High-
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xxviiiVideo Contents42 Fetal Measur
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2 PART I Physicsphysics. he amplitu
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4 PART I Physics× ms×FIG. 1.4 Ult
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6 PART I Physicsθ 1 = 20°Tissue A
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8 PART I Physicssignature. Broad-ba
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10 PART I PhysicsFIG. 1.13 B-Mode I
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12 PART I PhysicsIn these transduce
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14 PART I PhysicsFIG. 1.17 Tissue H
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16 PART I PhysicsKey Points of Ultr
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18 PART I PhysicsA - Normal liverv
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20 PART I PhysicsFIG. 1.27 Reverber
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22 PART I Physics-0 dBUncorrected-0
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24 PART I Physicsθ = 0°cos θ = 1
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26 PART I PhysicsABFIG. 1.38 Color
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28 PART I PhysicsChanges in Doppler
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30 PART I PhysicsABFIG. 1.44 Wall F
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32 PART I PhysicsABCDFIG. 1.46 Alia
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CHAPTER2Biologic Effects and Safety
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36 PART I PhysicsPressurePulse repe
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38 PART I PhysicsUltrasound imaging
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40 PART I Physicsacoustic power and
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42 PART I PhysicsFIG. 2.6 Acoustic
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44 PART I PhysicsThe AIUM Statement
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46 PART I Physics1. Current ultraso
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148 PART II Abdominal and Pelvic So
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ABFIG. 5.20 Microabscesses in Two P
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ABFIG. 6.32 Distal Cholangiocarcino
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CHAPTER7The PancreasThomas Winter a
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CHAPTER8The Gastrointestinal TractS
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ABFIG. 8.16 Lymphadenopathy in Two
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A B CD E FG H IFIG. 8.23 Inlammator
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FIG. 8.56 Gastrointestinal Stromal
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CHAPTER9The Kidney and Urinary Trac
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Remnant ofpronephrosMesonephrosBMes
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CHAPTER11The Adrenal GlandsChristin
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CHAPTER12The RetroperitoneumRaymond
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CHAPTER13Dynamic Ultrasound of Hern
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CHAPTER14The PeritoneumAnthony E. H
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CHAPTER15The UterusDouglas Brown an
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CHAPTER16The AdnexaRochelle Filker
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692 PART III Small Parts, Carotid A
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CHAPTER20The Parathyroid GlandsBonn
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*** *FIG. 21.8 Terminal Ductolobula
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CHAPTER22The ScrotumDaniel Sommers
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CHAPTER23Overview of Musculoskeleta
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CHAPTER25Musculoskeletal Interventi
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ABCDFIG. 25.15 Biceps Tendon Sheath
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CHAPTER27Peripheral VesselsMark E.
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ABFIG. 27.29 Chronic Deep Venous Th
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1000 PART III Small Parts, Carotid
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e2APPENDIXUltrasound Artifacts: A V
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FIG. A.18 Comet-Tail Artifact. On c
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e12APPENDIXUltrasound Artifacts: A
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I-2 IndexAcetabulumdescription of,
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I-4 IndexAnemiafetal, hydrops from,
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I-6 IndexAttenuationcoeicient, 36of
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I-8 IndexBlood low. See also Cerebr
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I-10 IndexBreast(s) (Continued)thic
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I-12 IndexCat-scratch disease, pedi
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I-14 IndexChorion laeve, 1465-1466C
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I-16 IndexContrast agents (Continue
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I-18 IndexCyst(s) (Continued) Cyst(
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I-20 IndexDoppler ultrasound (Conti
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I-22 IndexEndocardial cushion(s), 1
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I-24 IndexFibroma(s) (Continued)par
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I-26 IndexGerminal epithelium, 565G
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I-28 IndexHematoma(s) (Continued)pe
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I-30 IndexHoloprosencephaly (HPE) (
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I-32 IndexImplants, breast (Continu
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I-34 IndexJaundice (Continued)bile
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I-36 IndexLipomyelocele, closed spi
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I-38 IndexMammary ductsnormal sonog
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I-40 IndexMolar pregnancy. See Hyda
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I-42 IndexNonrhizomelic chondrodysp
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I-44 IndexPancreas (Continued)percu
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I-46 IndexPeritoneum (Continued)tum
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I-48 IndexPosterior fossa (Continue
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I-50 IndexPyloric musclehypertrophy
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I-52 IndexSample volume size, Doppl
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I-54 IndexSpectral broadening, in D
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I-56 IndexSuperoanteromedial ridge,
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I-58 Indexhrombosis (Continued)of s
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I-60 IndexTrisomy 18 (Edwards syndr
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I-62 IndexUrinary tract, pediatric
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I-64 IndexWalker-Warburg syndromeco
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DIAGNOSTICULTRASOUND
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DIAGNOSTICULTRASOUND5TH EDITIONCARO
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ABOUT THE EDITORSCarol M. Rumack, M
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ContributorsviiCONTRIBUTORSJacques
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ContributorsixPeter M. Doubilet, MD
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ContributorsxiAna P. Lourenco, MDAs
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ContributorsxiiiWendy hurston, MDAs
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In memory of my parents, Drs. Ruth
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PrefacexviiPREFACEhe ith edition of
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AcknowledgmentsxixACKNOWLEDGMENTSWe
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ContentsxxiCONTENTSVOLUME IPART I P
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Video ContentsxxiiiVIDEO CONTENTS4
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Video Contentsxxv19 The Thyroid Gla
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Video Contentsxxvii33 The Fetal Fac
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Video Contentsxxix52 The Pediatric
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DIAGNOSTICULTRASOUND
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PART FOUR: Obstetric and Fetal Sono
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CHAPTER 28 Overview of Obstetric Im
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ABCDFIG. 28.9 Second-Trimester Biom
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CHAPTER 29 Bioeffects and Safety of
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CHAPTER 30 The First Trimester 1049
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CHAPTER 31 Chromosomal Abnormalitie
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ABCDFIG. 31.12 Sonographic Findings
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CHAPTER32Multifetal PregnancyMary C
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CHAPTER 32 Multifetal Pregnancy 111
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ABFIG. 32.5 Sonographic Findings Se
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CHAPTER33The Fetal Face and NeckAna
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CHAPTER 33 The Fetal Face and Neck
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ABCDFIG. 33.13 Hypertelorism With E
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ABCDFIG. 33.16 Dacryocystocele. (A)
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ABCDEFFIG. 33.24 Unilateral Complet
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CHAPTER 34 The Fetal Brain 1167impo
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CHAPTER 34 The Fetal Brain 1169cmAB
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CingulatePOCalcarineAB21 wkCD25 wkI
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CHAPTER 34 The Fetal Brain 1173FIG.
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CHAPTER 34 The Fetal Brain 1175LTAR
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CHAPTER 34 The Fetal Brain 1177CC12
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CHAPTER 34 The Fetal Brain 1179SPEC
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CHAPTER 34 The Fetal Brain 1181ABCD
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CHAPTER 34 The Fetal Brain 1183asym
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CHAPTER 34 The Fetal Brain 1185FIG.
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CHAPTER 34 The Fetal Brain 1187Cere
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CHAPTER 34 The Fetal Brain 1189loba
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CHAPTER 34 The Fetal Brain 1191ABCF
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CHAPTER 34 The Fetal Brain 1193ABCF
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CHAPTER 34 The Fetal Brain 1195spor
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ABCCCDEFFIG. 34.24 Type 2 Lissencep
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CHAPTER 34 The Fetal Brain 1199ABFI
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CHAPTER 34 The Fetal Brain 120120 w
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CHAPTER 34 The Fetal Brain 1203Ultr
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CHAPTER 34 The Fetal Brain 1205ABCD
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VSSABHHPHCDEFFIG. 34.35 Intracrania
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CHAPTER 34 The Fetal Brain 1209VABC
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CHAPTER 34 The Fetal Brain 1211Huma
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CHAPTER 34 The Fetal Brain 1213121.
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CHAPTER 34 The Fetal Brain 1215221.
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CHAPTER 35 The Fetal Spine 1217ABCF
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CHAPTER 35 The Fetal Spine 1219L1S3
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CHAPTER 35 The Fetal Spine 1221FTFT
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CHAPTER 35 The Fetal Spine 1223FIG.
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CHAPTER 35 The Fetal Spine 1225TABL
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CHAPTER 35 The Fetal Spine 1227Feta
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CHAPTER 35 The Fetal Spine 1229MMAB
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ABCDEFFIG. 35.15 Skin-Covered Myelo
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CHAPTER 35 The Fetal Spine 1233diic
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CHAPTER 35 The Fetal Spine 1235CCSC
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CHAPTER 35 The Fetal Spine 1237chon
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CHAPTER 35 The Fetal Spine 1239BSCT
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CHAPTER 35 The Fetal Spine 124162.
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CHAPTER36The Fetal ChestDorothy Bul
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CHAPTER 36 The Fetal Chest 1245seco
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CHAPTER 36 The Fetal Chest 1247TABL
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CHAPTER 36 The Fetal Chest 1249Left
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CHAPTER 36 The Fetal Chest 12511ABC
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CHAPTER 36 The Fetal Chest 1253ABCF
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CHAPTER 36 The Fetal Chest 1255cent
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CHAPTER 36 The Fetal Chest 1257Left
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CHAPTER 36 The Fetal Chest 1259ABCD
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CHAPTER 36 The Fetal Chest 1261RTLT
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CHAPTER 36 The Fetal Chest 1263ARig
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CHAPTER 36 The Fetal Chest 12659. B
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CHAPTER 36 The Fetal Chest 1267107.
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CHAPTER 36 The Fetal Chest 1269204.
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CHAPTER 37 The Fetal Heart 1271TABL
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CHAPTER 37 The Fetal Heart 1273TABL
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CHAPTER 37 The Fetal Heart 1275Plac
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CHAPTER 37 The Fetal Heart 1277ADop
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CHAPTER 37 The Fetal Heart 1279LVRV
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CHAPTER 37 The Fetal Heart 1281RARV
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CHAPTER 37 The Fetal Heart 1283RARV
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CHAPTER 37 The Fetal Heart 1285Norm
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CHAPTER 37 The Fetal Heart 1287RVLV
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CHAPTER 37 The Fetal Heart 1289RVTA
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CHAPTER 37 The Fetal Heart 1291LVRA
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CHAPTER 37 The Fetal Heart 1293Aspl
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CHAPTER 37 The Fetal Heart 1295PLVL
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CHAPTER 37 The Fetal Heart 1297HR-L
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CHAPTER 37 The Fetal Heart 129951.
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CHAPTER 38 The Fetal Gastrointestin
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UrogenitalsinusMesonephrosMesonephr
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CHAPTER 39 The Fetal Urogenital Tra
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CHAPTER 40 The Fetal Musculoskeleta
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CHAPTER 41 Fetal Hydrops 1413ABFIG.
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ABCDFIG. 41.2 Ascites. (A) Fluid ou
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CHAPTER 41 Fetal Hydrops 1417A B CD
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CHAPTER 41 Fetal Hydrops 1423later
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CHAPTER 41 Fetal Hydrops 1427CHABCH
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CHAPTER 41 Fetal Hydrops 1429Monoch
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CHAPTER 41 Fetal Hydrops 1431feedin
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CHAPTER 41 Fetal Hydrops 1433TABLE
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CHAPTER 41 Fetal Hydrops 1435sampli
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CHAPTER 41 Fetal Hydrops 1437Predel
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CHAPTER 41 Fetal Hydrops 143973. Ma
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CHAPTER 41 Fetal Hydrops 1441169. I
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CHAPTER42Fetal Measurements: Normal
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CHAPTER 42 Fetal Measurements 1445F
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CHAPTER 42 Fetal Measurements 1447T
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CHAPTER 42 Fetal Measurements 1451p
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CHAPTER 42 Fetal Measurements 1453d
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CHAPTER 42 Fetal Measurements 1455A
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CHAPTER 42 Fetal Measurements 1459A
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CHAPTER 42 Fetal Measurements 14618
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CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
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CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
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CHAPTER 44 Cervical Ultrasound and
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PART FIVE: Pediatric SonographyCHAP
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CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
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CHAPTER 46 Duplex Sonography of the
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CHAPTER47Doppler Sonography of the
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CHAPTER 47 Doppler Sonography of th
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CHAPTER 48 The Pediatric Head and N
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CHAPTER 49 The Pediatric Spinal Can
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RA B CDEFGFIG. 49.27 Neuroblastoma
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CHAPTER50The Pediatric ChestChetan
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CHAPTER 50 The Pediatric Chest 1703
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CHAPTER 51 The Pediatric Liver and
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ABCFIG. 51.39 Hepatosplenomegaly. W
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CHAPTER52The Pediatric Urinary Trac
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CHAPTER 52 The Pediatric Urinary Tr
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TABLE 52.4 Mean Total Renal Volumes
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CHAPTER53The Pediatric Gastrointest
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CHAPTER 53 The Pediatric Gastrointe
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CHAPTER 54 Pediatric Pelvic Sonogra
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CHAPTER 55 The Pediatric Hip and Ot
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ABCDFIG. 55.13 Normal and Dislocate
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CHAPTER 56 Pediatric Interventional
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ABCFIG. 56.15 Access for Drainage o
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APPENDIXUltrasound Artifacts: A Vir
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APPENDIX Ultrasound Artifacts: A Vi
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IndexAAA anastomoses. See Arterial/
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Index I-3Adnexa (Continued)transvag
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Index I-5Arrays, transducer, 11-12A
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Index I-7Bioefects (Continued) Biop
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Index I-9Brain, neonatal/infant (Co
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Index I-11Carcinoma(s) (Continued)
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Index I-13Cervix (Continued)for sym
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Index I-15Color Doppler ultrasound
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Index I-17Cystic artery, 194promine
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Index I-19Diabetes mellituschronic
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Index I-21Echinococcal disease (Con
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Index I-23Exudate ascites, 506-507E
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Index I-25Gallbladder (Continued)ad
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Index I-27Gyriabnormalities of, in
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Index I-29Hernia(s). See also Diaph
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Index I-31Hyperechoic tissue, in br
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Index I-33Internal jugular vein (IJ
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Index I-35Kidneys, pediatric (Conti
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Index I-37Liver transplantation (Co
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Index I-39Mesentery, small bowel, 5
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Index I-41Nasal bone, fetal (Contin
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Index I-43Orbits, fetal (Continued)
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Index I-45Patau syndrome. See Triso
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Index I-47Pleural efusionsfetal, 12
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Index I-49Prostate (Continued)thera
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Index I-51Renal transplantation (Co
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Index I-53Shunt(s) (Continued) Skel
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Index I-55Splenic vein (Continued)t
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Index I-57Testis(es) (Continued)cys
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Index I-59Transcranial Doppler (TCD
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Index I-61Umbilical cord, 1481-1487
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Index I-63Vein of Galen (Continued)
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