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222 PART II Abdominal and Pelvic Sonographyguide management and for those who have a contraindicationto CECT.Endoscopic ultrasound is more sensitive than abdominalultrasound for the detection of common bile duct stones andcan be useful in suspected gallstone pancreatitis. 60 Endoscopicultrasound is also valuable in diagnosing microlithiasis andpancreas divisum. 61Because of its complications (including pancreatitis) andexpense, ERCP, formerly both a diagnostic and a therapeuticmodality, is now usually reserved for therapy. 62 Sometimes coupledwith endoscopic sphincterotomy and stone removal, ERCP is avaluable therapeutic modality in choledocholithiasis with jaundice,dilated common bile duct, acute pancreatitis, or cholangitis. 63Ultrasound FindingsEvaluation of the gallbladder and bile ducts is the focus of mostsonographic examinations performed in patients with acutepancreatitis. Nevertheless, understanding pancreatic and extrapancreaticabnormalities associated with acute pancreatitis isimportant. he combined use of serum amylase and serum lipaseyields sensitivity and speciicity of 90% to 95% in diagnosingacute pancreatitis, 64 but mild cases may be missed. In mild acutepancreatitis the patient may present for diagnosis ater transientelevated amylase and lipase levels have resolved; thus no serologicindicators of pancreatitis may be present. 65 In these patients thediagnosis of mild acute pancreatitis is clinical. On the otherhand, the diagnosis may be missed in patients with severepancreatitis because pain is absent or masked by other, moresevere symptoms. Analyzing fatal pancreatitis between 1980 and1985, Lankisch et al. 66 reported that 30% of cases were notdiagnosed until autopsy.Ater a careful search of the gallbladder and bile duct forstones, the entire pancreas should be scanned. Ater scanningthe pancreas, peripancreatic pathology should be sought in thelesser sac, anterior pararenal spaces, and transverse mesocolon.he reported prevalence of sonographic abnormality in acutepancreatitis varies from 33% to 92%. In a retrospective evaluationof patients with acute pancreatitis, using a deined scanningprotocol to look for pancreatitis-associated indings, Finstadet al. 37 found that sonography revealed abnormalities in 45 of48 patients (92%) (Table 7.2).Pancreatic echogenicity typically decreases in patients whohave acute pancreatitis because of interstitial edema. In somepatients, echogenicity is normal. In rare cases, echogenicity mayincrease, possibly because of hemorrhage, necrosis, or fatsaponiication. Cotton et al. 67 noted that, compared with the liver,the pancreatic echogenicity was increased in 16% of normalindividuals and 32% of patients with acute pancreatitis. Finstadet al. 37 found no acute pancreatitis patients with globally increasedechogenicity, although focal areas of increased echogenicity andinhomogeneity did occur.Enlargement of the pancreas is almost universal in acutepancreatitis. Unfortunately, enlargement may be diicult tojudge, because pancreatic size before the onset of pancreatitisis usually unknown and varies widely. In 1995 Guerra et al. 7found that the thickness of the body of the normal pancreasin 261 adults was 10.1 mm (±3.8 mm; range, 4-23 mm). InTABLE 7.2 Sonographic Abnormalities inPatients With Acute PancreatitisAbnormalityNo. of Patients(48 Total)PrevalencePeripancreatic29 60%inlammationHeterogeneous27 56%parenchymaDecreased gland21 44%echogenicityIndistinct ventral16 33%marginPancreas enlarged a 13 27%Focal intrapancreatic11 23%echo changePeripancreatic luid10 21%collectionsFocal mass 8 b 17%Perivascular5 10%inlammationPancreatic duct dilation 2 4%Venous thrombosis 2 4%a Anteroposterior dimension was ≥23 mm at superior mesentericartery.b Five of eight were hypoechoic.Modiied from Finstad TA, Tchelepi H, Ralls PW. Sonography of acutepancreatitis: prevalence of indings and pictorial essay. Ultrasound Q.2005;21(2):95-104. 372005, Finstad et al. 37 in his series of patients with acute pancreatitisfound that the mean anteroposterior measurement ofthe pancreatic body at the SMA level was 21.1 mm (±6.4 mm;range, 12-45 mm), almost twice the average found in normalindividuals by Guerra et al. It seems reasonable, therefore, touse 22 mm (mean plus 3 standard deviations) as the upper limitof normal pancreatic thickness, understanding that this is likelyto be an insensitive parameter for diagnosing acute pancreatitis(Fig. 7.22).he classic inding of decreased gland echogenicity is presentin only 44% of patients. In addition, when there is fatty iniltrationof the liver, the normal pancreas may appear hypoechoic, a patterncalled “pseudopancreatitis” (Fig. 7.23). Pancreatic heterogeneityis a subjective but common inding, present in more than 50%of patients (Fig. 7.24). Focal hypoechoic regions are noted insome patients (Fig. 7.25).he least subjective, most common, and thus most usefulinding is pancreatitis-associated inlammation (Fig. 7.26; seealso Figs. 7.22 and 7.24). Extrapancreatic inlammatory changesmay be detected even when the pancreatic contour is normaland the pancreas is not obviously enlarged. Pancreatic inlammationis typically hypoechoic or anechoic (Fig. 7.27) andconforms to a known retroperitoneal or peritoneal space (Video7.2). It may be diicult or impossible to distinguish inlammationfrom luid (Fig. 7.28). In contrast to inlammation, luid collections
CHAPTER 7 The Pancreas 22326 mmPCSMAFIG. 7.22 Enlarged Pancreas, Acute Pancreatitis With Inlammation.Transverse image of the pancreas shows 26-mm anteroposteriordimension (calipers) at the level of the superior mesenteric artery (SMA).Note the acute inlammation ventral to the pancreas (yellow arrow) andventral to (blue arrow) the splenic vein–superior mesenteric vein conluence(C).FIG. 7.23 Pseudopancreatitis. Longitudinal image of pancreas (P)and liver shows that the fatty liver is more echogenic than the normalpancreas, simulating a hypoechoic pancreas.ABCFIG. 7.24 Heterogeneous Pancreas, Acute Pancreatitis. (A)Transverse image shows that heterogeneity can be a subtle, subjectiveinding. Arrow indicates the perivascular inlammation and splenicvein–superior mesenteric vein clot. (B) Transverse sonogram in a differentpatient shows heterogeneous pancreatic echotexture with trace areasof peripancreatic luid about the gland and interspersed between parenchymallobules (arrows). (C) Transverse contrast-enhanced computedtomography (CT) image of the same patient in (B) shows correspondingCT appearance of heterogeneous gland with peripancreatic luid.
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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. 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.
Page 1415 and 1416:
CHAPTER36The Fetal ChestDorothy Bul
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CHAPTER 36 The Fetal Chest 1245seco
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CHAPTER 36 The Fetal Chest 1247TABL
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CHAPTER 36 The Fetal Chest 1249Left
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CHAPTER 36 The Fetal Chest 12511ABC
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CHAPTER 36 The Fetal Chest 1253ABCF
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CHAPTER 36 The Fetal Chest 1255cent
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CHAPTER 36 The Fetal Chest 1257Left
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CHAPTER 36 The Fetal Chest 1259ABCD
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CHAPTER 36 The Fetal Chest 1261RTLT
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CHAPTER 36 The Fetal Chest 1263ARig
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CHAPTER 36 The Fetal Chest 12659. B
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CHAPTER 36 The Fetal Chest 1267107.
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CHAPTER 36 The Fetal Chest 1269204.
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CHAPTER 37 The Fetal Heart 1271TABL
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CHAPTER 37 The Fetal Heart 1273TABL
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CHAPTER 37 The Fetal Heart 1275Plac
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CHAPTER 37 The Fetal Heart 1277ADop
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CHAPTER 37 The Fetal Heart 1279LVRV
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CHAPTER 37 The Fetal Heart 1281RARV
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CHAPTER 37 The Fetal Heart 1283RARV
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CHAPTER 37 The Fetal Heart 1285Norm
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CHAPTER 37 The Fetal Heart 1287RVLV
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CHAPTER 37 The Fetal Heart 1289RVTA
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CHAPTER 37 The Fetal Heart 1291LVRA
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CHAPTER 37 The Fetal Heart 1293Aspl
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CHAPTER 37 The Fetal Heart 1295PLVL
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CHAPTER 37 The Fetal Heart 1297HR-L
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CHAPTER 37 The Fetal Heart 129951.
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CHAPTER 38 The Fetal Gastrointestin
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UrogenitalsinusMesonephrosMesonephr
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CHAPTER 39 The Fetal Urogenital Tra
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CHAPTER 40 The Fetal Musculoskeleta
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CHAPTER 41 Fetal Hydrops 1413ABFIG.
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ABCDFIG. 41.2 Ascites. (A) Fluid ou
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CHAPTER 41 Fetal Hydrops 1417A B CD
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CHAPTER 41 Fetal Hydrops 1423later
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CHAPTER 41 Fetal Hydrops 1427CHABCH
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CHAPTER 41 Fetal Hydrops 1429Monoch
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CHAPTER 41 Fetal Hydrops 1431feedin
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CHAPTER 41 Fetal Hydrops 1433TABLE
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CHAPTER 41 Fetal Hydrops 1435sampli
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CHAPTER 41 Fetal Hydrops 1437Predel
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CHAPTER 41 Fetal Hydrops 143973. Ma
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CHAPTER 41 Fetal Hydrops 1441169. I
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CHAPTER42Fetal Measurements: Normal
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CHAPTER 42 Fetal Measurements 1445F
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CHAPTER 42 Fetal Measurements 1447T
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CHAPTER 42 Fetal Measurements 1451p
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CHAPTER 42 Fetal Measurements 1453d
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CHAPTER 42 Fetal Measurements 1455A
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CHAPTER 42 Fetal Measurements 1459A
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CHAPTER 42 Fetal Measurements 14618
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CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
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CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
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CHAPTER 44 Cervical Ultrasound and
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PART FIVE: Pediatric SonographyCHAP
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CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
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CHAPTER 46 Duplex Sonography of the
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CHAPTER47Doppler Sonography of the
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CHAPTER 47 Doppler Sonography of th
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CHAPTER 48 The Pediatric Head and N
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CHAPTER 49 The Pediatric Spinal Can
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RA B CDEFGFIG. 49.27 Neuroblastoma
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CHAPTER50The Pediatric ChestChetan
Page 1875 and 1876:
CHAPTER 50 The Pediatric Chest 1703
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CHAPTER 51 The Pediatric Liver and
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Page 1939 and 1940:
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Page 1943 and 1944:
ABCFIG. 51.39 Hepatosplenomegaly. W
Page 1945 and 1946:
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
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Page 1991 and 1992:
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Page 1997 and 1998:
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Page 2003 and 2004:
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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 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:
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Page 2123 and 2124:
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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 2137 and 2138:
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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