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1752 PART V Pediatric SonographyABFIG. 51.21 Superb Microvascular Imaging (SMI). (A) Color Doppler images show lack of color low in the main extrahepatic portal vein in apatient with chronic liver disease (B) SMI images show illing of the portal vein with blue color, relecting the very-low-velocity low in this still-patentportal vein. See also Video 51.8 and Video 51.9.minimize its movement. he frequency for the examination mayvary from 3.0 to 7.5 MHz, depending on the child’s size andtransducer availability. Because a small or upset child tends tobreathe rapidly, the examiner must be familiar with the Dopplerequipment to manipulate it quickly. All technical settings shouldbe preadjusted or preprogrammed to minimize examinationtime. he vessel to be examined is identiied with real-timesonography. Color Doppler ultrasound can be used to guide theplacement of the sample volume. A spectral display of the Dopplershit is then usually readily obtained, even though it may disappearduring part of the respiratory cycle.Child With Liver Disease: DopplerExamination for Portal Hypertensionhe aim of the Doppler examination is to assess the presenceand direction of low in splanchnic veins, the main portal veinand its segmental intrahepatic branches, the hepatic veins, andthe IVC 63-66 (Fig. 51.23). In addition, the presence of low in themain hepatic artery and its intrahepatic branches should bedetermined. When the clinical or basic Doppler examinationraises suspicion for portal hypertension, a systematic searchfor portosystemic collateral veins follows. Fig. 51.24 outlines theusual sites for spontaneous portosystemic shunts. 65,67 he lesseromentum 68 (from splenomesenteric junction to esophagus) andthe renal, splenic, and hepatic hila as well as the pelvis are screenedfor the presence of dilated, tortuous veins. If hepatofugal (reversed)low is found in a splanchnic vein, this vein is traced to therecipient systemic vessel. In cases of portal hypertension, thelet gastric vein drains blood into the inferior esophageal vein;the splenic vein drains into the renal (or pararenal) veins; thesuperior and inferior mesenteric veins drain into gonadal,retroperitoneal, or hemorrhoidal veins; and the paraumbilicalveins follow the round and falciform ligaments to drain into theanterior abdominal and iliac veins to form the classic caputmedusae or into veins of the anterior chest wall and the internalmammary vein.Direction of low in one or several veins of the portal venoussystem may change in portal hypertension, and it is essential torecord the low direction accurately. he Doppler sample volumeshould be placed in the center of the vessel lumen. If the directionof low within a vessel is diicult to ascertain, a nearby vesselwith known low direction can be used as a reference (e.g., splenicor hepatic artery or adjacent vein).he main portal vein and its right hepatic branches are beststudied through a right intercostal approach. Sometimes thesuperior mesenteric vein is also clearly seen from this position.he let portal vein and three of its four branches (portal branchto caudate lobe is rarely seen) and the hepatic veins are bestseen through an oblique subcostal approach. he splenic veinis explored through a transverse approach over the spleen. hesuperior mesenteric vein and main portal vein are best visualizedthrough a sagittal right paramedian approach. he let gastricvein usually ends near the splenoportal junction and, whenenlarged, is easily observed through a sagittal let paramedianview. he inferior mesenteric vein, when normal, can rarely bevisualized sonographically. When enlarged, it may be tracedthrough a let lateral approach to its junction with the splenicor superior mesenteric vein.he various possible origins of the hepatic artery may bediicult to recognize. We irst look for the artery at its usualorigin from the celiac axis and also as it passes between theportal vein and the CBD. When the let hepatic artery arisesfrom the superior mesenteric artery, it passes through the ligamentumvenosum. he intrahepatic arterial branches accompanybranches of the portal vein and can be detected with a slightlyenlarged Doppler sample volume placed over a portal venousbranch, even when the arterial branch cannot be seen with
CHAPTER 51 The Pediatric Liver and Spleen 1753ABCDEFFIG. 51.22 Typical Duplex Doppler Images of Splanchnic Vessels. (A) Normal portal vein examined through a transverse, paramedian,subcostal approach. Flow luctuates slightly with cardiac systole. Note aliasing artifact from low pulse repetition frequency. (B) Normal right branchof portal vein seen from an oblique right subcostal approach. Note that a few arterial pulsations are seen as a result of respiratory motion. (C)Normal main hepatic artery at the porta hepatis, with typical forward low throughout systole and diastole. (D) Normal left hepatic artery branchwith preservation of the dicrotic notch during systole. (E) Normal hepatic vein, transverse subcostal view, with triphasic low, away from transducerexcept during right atrial systole when low is toward the transducer. (F) Enlarged splenic vein at hilum with monophasic low away from thespleen and numerous adjacent varices medially.
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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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Page 1315 and 1316:
Page 1317 and 1318:
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
Page 1345 and 1346:
CHAPTER 34 The Fetal Brain 1173FIG.
Page 1347 and 1348:
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.
Page 1415 and 1416:
CHAPTER36The Fetal ChestDorothy Bul
Page 1417 and 1418:
CHAPTER 36 The Fetal Chest 1245seco
Page 1419 and 1420:
CHAPTER 36 The Fetal Chest 1247TABL
Page 1421 and 1422:
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
Page 1471 and 1472:
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
Page 1615 and 1616:
CHAPTER42Fetal Measurements: Normal
Page 1617 and 1618:
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
Page 1747 and 1748:
CHAPTER 46 Duplex Sonography of the
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Page 1761 and 1762:
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CHAPTER47Doppler Sonography of the
Page 1765 and 1766:
CHAPTER 47 Doppler Sonography of th
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Page 1799 and 1800:
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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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Page 1865 and 1866:
RA B CDEFGFIG. 49.27 Neuroblastoma
Page 1867 and 1868:
Page 1869 and 1870:
Page 1871 and 1872:
Page 1873 and 1874: CHAPTER50The Pediatric ChestChetan
Page 1875 and 1876: CHAPTER 50 The Pediatric Chest 1703
Page 1903 and 1904: CHAPTER 51 The Pediatric Liver and
Page 1923: CHAPTER 51 The Pediatric Liver and
Page 1943 and 1944: ABCFIG. 51.39 Hepatosplenomegaly. W
Page 1947 and 1948: 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
Page 1975 and 1976:
CHAPTER 52 The Pediatric Urinary Tr
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Page 1979 and 1980:
Page 1981 and 1982:
Page 1983 and 1984:
Page 1985 and 1986:
Page 1987 and 1988:
Page 1989 and 1990:
Page 1991 and 1992:
Page 1993 and 1994:
Page 1995 and 1996:
Page 1997 and 1998:
Page 1999 and 2000:
Page 2001 and 2002:
Page 2003 and 2004:
Page 2005 and 2006:
CHAPTER53The Pediatric Gastrointest
Page 2007 and 2008:
CHAPTER 53 The Pediatric Gastrointe
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Page 2013 and 2014:
Page 2015 and 2016:
Page 2017 and 2018:
Page 2019 and 2020:
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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 2107 and 2108:
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ABCDFIG. 55.13 Normal and Dislocate
Page 2111 and 2112:
Page 2113 and 2114:
Page 2115 and 2116:
CHAPTER 56 Pediatric Interventional
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Page 2129 and 2130:
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ABCFIG. 56.15 Access for Drainage o
Page 2133 and 2134:
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Page 2141 and 2142:
APPENDIXUltrasound Artifacts: A Vir
Page 2143 and 2144:
APPENDIX Ultrasound Artifacts: A Vi
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Page 2175 and 2176:
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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