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1764 PART V Pediatric SonographyAter any obstruction of the hepatic veins, the liver becomesenlarged and congested. Because the caudate lobe has its ownhepatic vein that drains into the IVC below the others, it is otenspared and serves as the only initial venous drainage route forthe entire liver. he caudate lobe enlarges quickly and otencompresses the IVC. his is followed by ascites, oten pleuralefusions, splenomegaly, and the formation of portosystemiccollaterals. Doppler sonography shows absence or reversal oflow in the hepatic veins. Areas of high-velocity low near stenosesof hepatic veins are easily detected with color-guided, pulsedDoppler sonography. In the absence of hepatic venous drainage,arterial blood may be shunted into the portal vein throughmicroscopic shunts at the portal triad or through larger intrahepaticshunts. Portal venous low may reverse. Alternately, theportal vein may thrombose when liver congestion is severe. Wedgehepatic venography, which shows a spider web network ofintrahepatic veins instead of the usual hepatic venous lumens,is now rarely performed, because the hepatic vasculature is wellassessed with Doppler sonography.he patient with acute Budd-Chiari syndrome rarely has timeto form portosystemic collateral routes. If present, shunt routesare similar to those seen in cirrhosis. Periportal and pericholecysticveins do not usually serve as shunt routes because they draininto the segmental branches of the right portal vein, which arehighly congested in response to hepatic vein obstruction. Extensiveintrahepatic shunts may form.he treatment of hepatic vein occlusion is anticoagulanttherapy, deibrotide, ablation of obstructive webs, or emergencyportocaval shunting. he recanalization of hepatic veins, theregression of portal hypertension (decreased caliber and lowvelocity in portosystemic shunts, smaller spleen, absorption ofascites), and the patency of therapeutic shunts can be assessedwith Doppler sonography.Surgical Portosystemic ShuntsPreviously, deinitive treatment of children with bleedingesophageal varices was surgical portosystemic shunts. heseshunts are now created only when sclerotherapy of varices hasfailed or liver transplantation is not feasible. Children with healthylivers and prehepatic portal hypertension are still candidates forshunt procedures. Transjugular intrahepatic portosystemicshunt (TIPS) procedures are being performed as an alternate toclassic surgical shunts in adults, with increasing use in children.he patency of transjugular shunts is monitored with Dopplersonography, which shows blood lowing from the “donor” rightportal vein through the intrahepatic stent and into the right (oranother) hepatic vein. Shunt stenoses, thrombosis, and lowaround the stent are readily visible with Doppler sonography.Surgical portosystemic shunts can be total or partial. Totalshunts direct the entire venous blood low from the congestedsplanchnic system into a systemic vein, as in the end-to-sideportocaval shunt, in which the main portal vein is redirected.he hepatic end is ligated and the splanchnic end is connectedto the IVC. In this situation, portal venous perfusion of the liveris minimal. Partial shunts divert only some of the splanchnicblood into a systemic vein, thereby yielding better liver perfusionand reducing the incidence of hepatic encephalopathy. he distalsplenorenal (Warren) shunt connects the splenic vein to the letrenal vein. he side-to-side, H-type, portocaval shunt connectsthe portal vein to the IVC at the porta hepatis. he REX shuntconnects the let portal vein to the IVC using a donor vein. Manyvariants of these surgical procedures exist.Doppler study of the intrahepatic portal veins is invaluablein the assessment of portocaval shunt patency. In the majorityof patent shunts, low in the intrahepatic portal veins is hepatofugal.84 It is easy to understand why this should be so inside-to-side portocaval shunts, in which high-pressure intrahepaticvenous blood lows through the shunt into the low-pressurevena cava. It is more diicult to explain hepatofugal low in theintrahepatic portal veins in patients with an end-to-side portocavalshunt, in which the hepatic end of the portal vein has beenligated and cut. Blood may leave the liver through a system ofcollateral veins between intrahepatic branches of the portal veinand low-pressure systemic veins. his phenomenon has beendemonstrated on angiography. 85Signs of shunt obstruction include the following:• he shunt site is diicult or impossible to detect, and noDoppler signals can be obtained.• Blood in the splanchnic vein feeding the shunt no longerlows toward the shunt.• he direction of intrahepatic portal venous low returns tonormal.• Spontaneous portosystemic shunts and other signs of portalhypertension reappear.Hepatic Shear Wave ElastographyReal-time shear wave elastography (SWE) is a rapidly expandingmethod to assess liver stifness or ibrosis in cirrhosis, inlammatoryconditions, and tumors. An earlier technique formechanical compression without imaging (Fibroscan), transientelastography (TE), was rapidly adopted by gastroenterologistsand hepatologists but has been shown to be less reliable andreproducible than shear wave elastography (SWE) (Fig. 51.34).A third type of elastography, acoustic radiation force imaging(ARFI) (Fig. 51.35), uses a B-mode ultrasound image to positiona ixed region of interest (ROI) box, which is measured in realtime during a button push (which sends the shear wave pulse).ARFI is similar to TE with the added beneit of seeing the segmentof liver being interrogated. Ultrasound elastography is readilyperformed in children without sedation, and measurements canbe timed during respiratory pauses. Ultrasound elastographyhas shown good correlation with magnetic resonance elastography(MRE) and liver biopsy. Both techniques have potential to decreasethe need for liver biopsy in children. 86-89DOPPLER SONOGRAPHY IN CHILDRENRECEIVING LIVER TRANSPLANTPretransplantation EvaluationBefore liver transplantation can be considered, the caliber andpatency of the main portal vein and IVC must be assessed. hisis usually done with Doppler sonography and supplementedwith MRI. 90-92 If the portal vein diameter is less than 4 mm (as
CHAPTER 51 The Pediatric Liver and Spleen 1765ABFIG. 51.34 Chronic Liver Disease Due to Hepatitis B. (A) Shear wave elastography color map and circular region of interest placed overa relatively homogenous area of liver, yielding a shear wave velocity of 2 m/sec. (B) Propagation wave display shows vertical blue bands of theshear wave front passing through the liver. Regular wave contours and intervals favor a homogenous site for measurements.ABCDFIG. 51.35 Acoustic Radiation Force Imaging (ARFI). (A) Shear wave region of interest is selected perpendicular to the liver capsule andmore than 1 cm deep to the liver margin. (B) Color display of elastography to aid in selecting an appropriate site. (C) Larger box in which multipleshear wave measurements have been made. (D) Table of results to look for erroneous data and spurious results, average values, standard deviation,and interquartile range (IQR).
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1600 John F. Kennedy Blvd.Ste 1800P
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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
Page 1289 and 1290:
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 1313 and 1314:
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
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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
Page 1357 and 1358:
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.
Page 1397 and 1398:
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
Page 1413 and 1414:
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
Page 1423 and 1424:
CHAPTER 36 The Fetal Chest 12511ABC
Page 1425 and 1426:
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
Page 1607 and 1608:
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
Page 1619 and 1620:
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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CHAPTER47Doppler Sonography of the
Page 1765 and 1766:
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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Page 1865 and 1866:
RA B CDEFGFIG. 49.27 Neuroblastoma
Page 1867 and 1868:
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Page 1871 and 1872:
Page 1873 and 1874:
CHAPTER50The Pediatric ChestChetan
Page 1875 and 1876:
CHAPTER 50 The Pediatric Chest 1703
Page 1877 and 1878:
Page 1879 and 1880:
Page 1881 and 1882:
Page 1883 and 1884:
Page 1885 and 1886: CHAPTER 50 The Pediatric Chest 1713
Page 1903 and 1904: CHAPTER 51 The Pediatric Liver and
Page 1935: 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 1987 and 1988:
CHAPTER 52 The Pediatric Urinary Tr
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 2017 and 2018:
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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 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:
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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 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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