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1316 PART IV Obstetric and Fetal Sonographyechogenic bowel is unclear, but it has been attributed to thepresence of GI dysfunction and dysmotility. 113 Intestinal stasis,for any reason, can lead to increased absorption of luid fromthe bowel lumen, which can result in thick meconium andtherefore increased echogenicity of the bowel content. 114 Otherchromosomal abnormalities that have been associated withechogenic bowel include trisomies 13 and 18, 45,X0, andtriploidies. 110,111,115Cystic Fibrosis. Echogenic bowel, meconium ileus, andmeconium peritonitis are possible sonographic indings in fetuseswith cystic ibrosis. 116 he echogenic appearance of the bowelin fetuses with cystic ibrosis is the result of the biochemicalalterations in the secretory-digestive-absorptive function of thesmall intestinal mucosa, which can result in the meconium beingmore viscous than normal and therefore more echogenic. 117 heincidence of cystic ibrosis in fetuses with isolated echogenicbowel varies from 1.3% to 5%. 106,118,119Intraamniotic Bleeding. Echogenic bowel has been notedin pregnancies complicated by vaginal bleeding, in those withasymptomatic subchorionic hemorrhage, and following invasiveprocedures such as chorionic villous sampling and amniocentesis.Each of these conditions may result in intraamniotic bleeding,and the blood-containing amniotic luid swallowed by the fetuscan be visible as echogenic debris in the fetal stomach or asincreased echogenicity of the bowel content (Fig. 38.16C). 114,120In a case series of pregnant women undergoing amniocentesis,there was evidence of blood in the amniotic luid on spectrophotometryof 8 in 40 (20%) of those with echogenic bowelcompared to 3 in 64 (5%) of those without. 121 In one series, 19%of fetuses with isolated echogenic bowel had sonographic evidenceof intrauterine bleeding, of which 70% were conirmed to haveintraamniotic bleeding on amniocentesis. 122 History of bleedingduring pregnancy, history of invasive procedure earlier inpregnancy, sonographic evidence of retroplacental or subchorionichemorrhage, or evidence of debris in the fetal stomach providessupport for intraamniotic bleeding as the cause of echogenicbowel.Fetal Infection. Echogenic bowel is one of the manifestationsof fetal infection, including cytomegalovirus (CMV), parvovirusB19, varicella, herpes simplex, and toxoplasmosis (Fig. 38.16B). 123he incidence of infection in fetuses with echogenic bowel is inthe range of 0.5% to 6.3%. 122,124,125 he cause of the echogenicbowel in fetuses with infection is not known but may be relatedto inlammation and edema of the bowel wall as well as theassociated decreased peristalsis of the infected bowel.Bowel Obstruction. As previously noted, bowel of obstructionor stasis for any reason, including GI atresia or Hirschsprungdisease, 89 can result in thickening of the meconium and thereforeincrease in the echogenicity of bowel content.Fetal Growth Restriction and Fetal Demise. he risk ofboth fetal growth restriction and fetal demise increases in thesecond and third trimesters in fetuses with echogenic bowel.he reported incidence is 10% to 20% for fetal growth restriction102,118 and 6% to 15% for fetal demise. 73,118,126 In a recent studyof 188 fetuses with isolated echogenic bowel (i.e., ater the exclusionof chromosomal abnormalities, major malformation, andfetal infection), the rate of fetal growth restriction and fetal demisewere 19.5% and 7.3%, respectively (compared with 12.9% and0.9% in the control group, respectively). Possible explanationfor these indings is the association between subchorionic bleeding(which can result in echogenic bowel) with fetal growth restrictionand fetal demise. 127 In addition, in cases of severe fetal growthrestriction, it is believed that redistribution of cardiac output inthe compromised fetus to vital organs (i.e., brain, heart, andadrenal gland) results in decreased splanchnic blood low, includingperfusion to the bowel, which can result in impaired peristalsis.128 he association of echogenic bowel with fetal anemia,which can also result in bowel hypoxia, provides support to thishypothesis. 129Summary. Given the associations described previously, theinding of echogenic bowel requires careful investigation andappropriate monitoring. he evaluation of pregnancies withechogenic bowel typically includes (1) genetic counseling andconsideration of amniocentesis or cell-free fetal DNA testing;(2) parental screening for cystic ibrosis; (3) maternal serologyfor viral infections, including CMV and parvovirus B19; (4)detailed sonographic assessment for associated structuralanomalies or sot markers, signs of bowel obstruction, assessmentof fetal biometry, placental morphology, and amniotic luid; and(5) follow-up for growth. Information regarding episodes ofvaginal bleeding or invasive testing earlier in pregnancy shouldbe recorded. In cases where the investigation is negative, theinding of “isolated” echogenic bowel may represent a normalvariant or a false-positive inding, and fetal outcome may benormal.Liverhe fetal liver is clearly visualized in the upper abdomen in thesecond half of gestation, although earlier in gestation it has anechogenicity similar to renal echoes.HepatomegalyGiven the asymmetrical shape of the liver, accurate determinationof its size is diicult and is associated with high interobservervariability. herefore in many cases the diagnosis of hepatomegalyis made subjectively. Hepatomegaly is associated with a varietyof conditions including fetal hemolytic anemia which resultsin a compensatory increase in hematopoiesis within the liver, 130metabolic and storage diseases, fetal infections 131 (Fig. 38.17),liver masses, hepatic congestion secondary to cardiac failure,and overgrowth syndromes such as Beckwith-Wiedemannsyndrome. 132,133 Hepatomegaly has also been associated withtrisomy 21, possibly because of the abnormal myelopoiesis inthese fetuses. 134Hepatic CalciicationsHepatic calciications can be single or multiple (Fig. 38.18). Inone series, hepatic calciications were identiied in 14 of 24,600consecutive pregnancies scanned between 15 and 26 weeks,representing an incidence of 1 in 1750 pregnancies. 135 hepathophysiology of hepatic calciications in otherwise normalfetuses is unknown, and in the majority of cases, such calciicationsrepresent an isolated inding and have no clinical consequence.136 However, hepatic calciications are associated with
CHAPTER 38 The Fetal Gastrointestinal Tract and Abdominal Wall 1317ABFIG. 38.17 Hepatosplenomegaly. (A) Transverse and (B) reconstructed coronal images at 33 weeks show marked hepatosplenomegaly in afetus with congenital cytomegalovirus infection. LK, Left kidney; RK, right kidney; Sp, spleen; St, stomach.ABCFIG. 38.18 Hepatic Calciications. (A) Sagittal and (B)transverse views of hepatic calciication (arrows) with shadowingposteriorly. In this fetus, karyotype and infectious workup werenormal; the calciications were conirmed postnatally, with anormal newborn physical examination. (C) Multiple hepaticcalciications in otherwise normal-appearing fetus. (With permissionfrom McNamara A, Levine D. Intraabdominal fetal echogenicmasses: a practical guide to diagnosis and management.Radiographics. 2005;25[3]:633-645. 32 )
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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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48 PART I PhysicsEPIDEMIOLOGYWith a
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50 PART I Physicscontrols whether t
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52 PART I Physics70. Hwang JH, Tu J
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54 PART I PhysicsA B 5 μmFIG. 3.1
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56 PART I Physicsstudies with Levov
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58 PART I Physicsabdominal organs.
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60 PART I PhysicsHarmonic B-Mode Im
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62 PART I PhysicsFIG. 3.9 Contrast-
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64 PART I Physicsdramatic manifesta
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66 PART I Physics5 µmFIG. 3.15 Fra
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68 PART I Physicsplatelet lysis), n
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70 PART I PhysicsEnhancement1 2 3 4
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72 PART I Physics46. Hamilton MF, B
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PART TWO: Abdominal and Pelvic Sono
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76 PART II Abdominal and Pelvic Son
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100 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
Page 1437 and 1438: CHAPTER 36 The Fetal Chest 12659. B
Page 1439 and 1440: CHAPTER 36 The Fetal Chest 1267107.
Page 1441 and 1442: CHAPTER 36 The Fetal Chest 1269204.
Page 1443 and 1444: CHAPTER 37 The Fetal Heart 1271TABL
Page 1445 and 1446: CHAPTER 37 The Fetal Heart 1273TABL
Page 1447 and 1448: CHAPTER 37 The Fetal Heart 1275Plac
Page 1449 and 1450: CHAPTER 37 The Fetal Heart 1277ADop
Page 1451 and 1452: CHAPTER 37 The Fetal Heart 1279LVRV
Page 1453 and 1454: CHAPTER 37 The Fetal Heart 1281RARV
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Page 1457 and 1458: CHAPTER 37 The Fetal Heart 1285Norm
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Page 1461 and 1462: CHAPTER 37 The Fetal Heart 1289RVTA
Page 1463 and 1464: CHAPTER 37 The Fetal Heart 1291LVRA
Page 1465 and 1466: CHAPTER 37 The Fetal Heart 1293Aspl
Page 1467 and 1468: CHAPTER 37 The Fetal Heart 1295PLVL
Page 1469 and 1470: CHAPTER 37 The Fetal Heart 1297HR-L
Page 1471 and 1472: CHAPTER 37 The Fetal Heart 129951.
Page 1477 and 1478: CHAPTER 38 The Fetal Gastrointestin
Page 1487: CHAPTER 38 The Fetal Gastrointestin
Page 1509 and 1510: UrogenitalsinusMesonephrosMesonephr
Page 1511 and 1512: CHAPTER 39 The Fetal Urogenital Tra
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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
Page 1875 and 1876:
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
Page 1945 and 1946:
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CHAPTER52The Pediatric Urinary Trac
Page 1949 and 1950:
CHAPTER 52 The Pediatric Urinary Tr
Page 1951 and 1952:
TABLE 52.4 Mean Total Renal Volumes
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CHAPTER53The Pediatric Gastrointest
Page 2007 and 2008:
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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Page 2099 and 2100:
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Page 2103 and 2104:
Page 2105 and 2106:
Page 2107 and 2108:
Page 2109 and 2110:
ABCDFIG. 55.13 Normal and Dislocate
Page 2111 and 2112:
Page 2113 and 2114:
Page 2115 and 2116:
CHAPTER 56 Pediatric Interventional
Page 2117 and 2118:
Page 2119 and 2120:
Page 2121 and 2122:
Page 2123 and 2124:
Page 2125 and 2126:
Page 2127 and 2128:
Page 2129 and 2130:
Page 2131 and 2132:
ABCFIG. 56.15 Access for Drainage o
Page 2133 and 2134:
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Page 2139 and 2140:
Page 2141 and 2142:
APPENDIXUltrasound Artifacts: A Vir
Page 2143 and 2144:
APPENDIX Ultrasound Artifacts: A Vi
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Page 2177 and 2178:
Page 2179 and 2180:
IndexAAA anastomoses. See Arterial/
Page 2181 and 2182:
Index I-3Adnexa (Continued)transvag
Page 2183 and 2184:
Index I-5Arrays, transducer, 11-12A
Page 2185 and 2186:
Index I-7Bioefects (Continued) Biop
Page 2187 and 2188:
Index I-9Brain, neonatal/infant (Co
Page 2189 and 2190:
Index I-11Carcinoma(s) (Continued)
Page 2191 and 2192:
Index I-13Cervix (Continued)for sym
Page 2193 and 2194:
Index I-15Color Doppler ultrasound
Page 2195 and 2196:
Index I-17Cystic artery, 194promine
Page 2197 and 2198:
Index I-19Diabetes mellituschronic
Page 2199 and 2200:
Index I-21Echinococcal disease (Con
Page 2201 and 2202:
Index I-23Exudate ascites, 506-507E
Page 2203 and 2204:
Index I-25Gallbladder (Continued)ad
Page 2205 and 2206:
Index I-27Gyriabnormalities of, in
Page 2207 and 2208:
Index I-29Hernia(s). See also Diaph
Page 2209 and 2210:
Index I-31Hyperechoic tissue, in br
Page 2211 and 2212:
Index I-33Internal jugular vein (IJ
Page 2213 and 2214:
Index I-35Kidneys, pediatric (Conti
Page 2215 and 2216:
Index I-37Liver transplantation (Co
Page 2217 and 2218:
Index I-39Mesentery, small bowel, 5
Page 2219 and 2220:
Index I-41Nasal bone, fetal (Contin
Page 2221 and 2222:
Index I-43Orbits, fetal (Continued)
Page 2223 and 2224:
Index I-45Patau syndrome. See Triso
Page 2225 and 2226:
Index I-47Pleural efusionsfetal, 12
Page 2227 and 2228:
Index I-49Prostate (Continued)thera
Page 2229 and 2230:
Index I-51Renal transplantation (Co
Page 2231 and 2232:
Index I-53Shunt(s) (Continued) Skel
Page 2233 and 2234:
Index I-55Splenic vein (Continued)t
Page 2235 and 2236:
Index I-57Testis(es) (Continued)cys
Page 2237 and 2238:
Index I-59Transcranial Doppler (TCD
Page 2239 and 2240:
Index I-61Umbilical cord, 1481-1487
Page 2241 and 2242:
Index I-63Vein of Galen (Continued)
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Page 2249:
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