Clinical Indications For An Abdominal Sonogram Biology Essay

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A synopsis of abdominal sonography practice is provided in this chapter. A brief summary of the importance of obtaining and recognizing important clinical findings, relevant laboratory results, frequently identified artifacts, and common abdominal masses, should provide the analytical groundwork for a thorough preparation for the abdomen registry provided by the American Registry for Diagnostic Medical Sonography and the abdominal portion of the registry offered by the American Registry of Radiologic Technologist. The outlines for each examination can be found at www.ardms.org and www.arrt.org respectively. The most current outlines are not provided, as they are modified periodically.

<kt1>Key Terms

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ascites - a collection of abdominal fluid within the peritoneal cavity

chromaffin cells - the cells in the adrenal medulla that secrete epinephrine and norepinephrine

endoscopy - a means of looking inside of the human body by utilizing an endoscope

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exudate ascites - a collection of abdominal fluid within the peritoneal cavity may be associated with cancer

hematocrit - the laboratory value that indicates the amount of red blood cells in blood

leukocytosis - an elevated white blood cell count

nuclear medicine - a diagnostic imaging modality that utilizes the administration of radionuclides into the human body for an analysis of the function of organs, or for the treatment of various abnormalities

oncocytes - large cells of glandular origin

paracentesis - a procedure that uses a needle to drain fluid from the abdominal cavity for diagnostic or therapeutic reasons

parietal peritoneum - the portion of the peritoneum that lines the abdominal and pelvic cavity

radiography - a diagnostic imaging modality that uses ionizing radiation for imaging bones, organs, and some soft tissue structures

thoracentesis - a procedure that uses a needle to drain fluid from the thoracic cavity for either diagnostic or therapeutic reasons

transudate ascites - a collection of abdominal fluid within the peritoneal cavity often associated with cirrhosis

visceral peritoneum - the portion of the peritoneum that is closely applied to each organ

<h1>Clinical Indications for an Abdominal Sonogram

Abdominal sonograms may be requested for various reasons. The American Institute of Ultrasound in Medicine (AIUM) publishes the practice guidelines for an abdominal sonogram on their website at www.aium.org (Table 8-1). <tab8-1>

<h1>Patient Preparation for an Abdominal Sonogram and Invasive Procedures

Patients, who are having an abdominal sonogram, and particularly those with intact gallbladders, need to fast for at least 6 hours prior to the examination. This preparation can also eliminate the presence of bowel gas that can inhibit the likelihood of obtaining a detailed diagnostic sonographic study. Most often, renal sonograms require no preparation, although some facilities recommend that the patient be well hydrated. This is true especially if the urinary bladder needs to be assessed for intraluminal masses. Diabetic patients need to be scheduled early in the morning to prevent hypoglycemic incidents. Also, abdominal sonography should be performed before radiographic testing that utilizes barium contrast agents.

Patient preparation for invasive procedures varies among clinical facilities. However, informed consent from the patient and laboratory findings are universally obtained. Sterile field preparation is performed prior to the procedure as well. Some invasive procedures that are commonly performed in the sonography department include thoracentesis, paracentesis, organ biopsies, mass biopsies, and abscess drainages. Biopsies can be performed using a freehand technique or under ultrasound guidance using a needle guide that attaches to the transducer.

<h1>Gathering a Clinical History

A review of prior examinations should be performed by the sonographer before any contact with the patient. This review includes reports from previous sonograms, CT scans, MRI studies, nuclear medicine exams, radiography procedures, endoscopy examinations, and any additional related diagnostic reports available. Moreover, sonographers must be capable of analyzing the clinical history and complaints of their patients. This practice will not only aid in clinical practice, but will also assist in answering complex certification examination questions. By correlating clinical findings with sonographic findings, the sonographer can directly impact the patient's outcome by providing the most targeted exam possible. Furthermore, when faced with a complicated, in-depth registry question, the test taker should be capable of eliminating information that is not applicable, in order to answer the question appropriately.

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<h1>Laboratory Findings Relevant to Abdominal Sonography

There is an extensive list of laboratory findings that may be relevant for abdominal sonographic imaging. Applicable laboratory findings are found in each specific organ/system chapter. However, it is important to remember two significant laboratory findings that may be mentioned in clinical history questions. First, leukocytosis, or an elevation in white blood cell count, always indicates the presence of infection. Patients who have some form of "itis" (such as cholecystitis or pancreatitis), or possibly even an abscess, may have an abnormal white blood cell count with existing infection. Secondly, a decrease in hematocrit indicates some type of bleeding. Patients who have suffered recent trauma or have an active hemorrhage will have a decreased hematocrit level. Keep these two laboratory findings in mind as you study.

<h1>Artifacts in Abdominal Imaging

Abdominal sonography involves careful analysis of vital structures. Often, artifacts will be observed during an abdominal sonogram. It is important to know that artifacts exist and why they occur (Table 8-2).<tab8-2>

<h1>Abdominal Cavity

The double lining of the abdominal cavity is the peritoneum. The peritoneum consists of a parietal and visceral layer. The parietal peritoneum forms a closed sac, except for two openings in the female pelvis, which permits passage of the fallopian tubes from the uterus to the ovaries. Furthermore, each organ is covered by a layer of visceral peritoneum, which is essentially each organs serosal layer.

Some abdominal organs are considered intraperitoneal and some are considered retroperitoneal (Table 8-3 & Table 8-4). <tab 8-3 & tab 8-4> The retroperitoneal structures are only covered anteriorly with peritoneum. The abdominal parietal peritoneum can be divided into two sections: the greater sac and the lesser sac. The greater sac extends from the diaphragm to the pelvis, while the lesser sac is located posterior to the stomach.

Potential spaces, which are essentially outpouching in the peritoneum, exist between the organs (Table 8-5). <tab 8-5> These spaces provide an area for fluid to collect in the abdomen and pelvis. Ascites is an abnormal collection of abdominal fluid in these spaces. It can be found in association with several pathologies (Table 8-6). <tab8-6> Ascites can be single fluid, such as serosal fluid, pus, blood, or urine, or it may be a combination of fluids. Exudate ascites can be a malignant form of ascites. It may appear as complex fluid with loculations and produce matting of the bowel. Benign ascites, or transudate ascites, consist of serosal fluid, and typically appears simple and anechoic.

<h1>Summary of Adult Abdominal Solid Masses

A synopsis of the most common benign and malignant adult abdominal solid masses encountered with sonography is provided in Table 8-7 and Table 8-8 respectively (Table 8-7 & Table 8-8). <tab8-7 & tab 8-8> A description of each mass and the most common abdominal location is provided for further understanding. Each of these masses will be further discussed in the following chapters.

<h1>Summary of Solid Pediatric Malignant Abdominal Masses

A synopsis of the most common pediatric malignant abdominal masses encountered with sonography is provided in Table 8-9. <tab8-9> A common theme that one can recognize is the presence of the word part "blast" in these malignant tumors.

<h1>Analyzing an Abdominal Registry Question

Registry examination questions can be intimidating. Here are a couple of steps that you can use to give you a better chance at answering these complex questions. Read the question below.

A 28 year-old male patient presents to the ultrasound department. He has a history of a sudden onset of abdominal pain, and an elevation in amylase and lipase. Sonographic findings include a hypoechoic region in the head of the pancreas and a small fluid collection adjacent to the pancreatic body. What is the most likely diagnosis?

A. Pancreatic adenocarcinoma

B. Pancreatic cystadenocarcinoma

C. Focal acute pancreatitis

D. Chronic pancreatitis

Step #1: Read the question and try to answer it without looking at the answers provided.

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The first step is to see if you know the answer without looking at the answers provided. If you have an idea, and your answer is one of the choices, then you are well on your way to answering the question correctly.

Step #2: If you don't know the answer right away, then break the question down.

Let's assume that you have no idea what the answer is. Then you move on to step #2, which is breaking the question down. This step is complicated, but it will help.

The first part of the question provides the age of the patient, which is 28 years old. Look at the answers provided. Is there one that you can eliminate solely on the patient's age? There are two; 28-year-old men rarely have carcinoma of the pancreas. Mark them off the list! You now have a 50% chance of answering the question correctly. We now move on to the patient's clinical history. It appears that he had a "sudden onset" of abdominal pain. This most likely means that the condition is acute, or new. Look at the answers and see if there are any that you can select that are linked with "acute" abnormalities. Yes, acute pancreatitis fits! But do the sonographic findings match? There is one definite choice and one possible choice. You must know your clinical and sonographic findings to correctly answer these questions. Sonographic findings for chronic pancreatitis include a small, echogenic pancreas and calcification of the gland. Focal acute pancreatitis can resemble a hypoechoic mass, and it can also be associated with peripancreatic fluid collections. So there is your answer!

<rq1>Review Questions

<rq>

1. Transitional cell carcinoma is commonly found in all of the following locations except:

Liver

Renal pelvis

Urinary bladder

Ureter

2. The neuroblastoma is a malignant pediatric mass commonly found where?

A. Kidney

B. Liver

C. Testicle

D. Adrenal gland

3. The pheochromocytoma is a benign mass commonly located where?

A. Testicle

B. Thyroid gland

C. Adrenal gland

D. Liver

4. Which of the following is not considered an intraperitoneal organ?

A. Liver

B. Pancreas

C. Gallbladder

D. Spleen

5. Which of the following is not considered retroperitoneal organs?

A. Abdominal lymph nodes

B. Kidneys

C. Adrenal glands

D. Ovaries

6. The hypernephroma may also be referred to as:

A. Nephroblastoma

B. Neuroblastoma

C. Hepatocellular carcinoma

D. Renal cell carcinoma

A type of reverberation artifact caused by a number of small, highly reflective interfaces, such as gas bubbles, describes:

Mirror image artifact

Posterior shadowing

Comet tail artifact

Ring down artifact

The term cholangiocarcinoma denotes:

Bile duct carcinoma

Hepatic carcinoma

Pancreatic carcinoma

Splenic carcinoma

The hepatoma is a:

Benign tumor of the spleen

Benign tumor of the liver

Malignant tumor of the pancreas

Malignant tumor of the liver

The hepatoblastoma is a:

Benign tumor of the pediatric liver

Malignant tumor of the adult liver

Malignant tumor of the pediatric liver

Malignant tumor of the pediatric adrenal gland

A Wilms' tumor may also be referred to as a:

Neuroblastoma

Nephroblastoma

Hepatoblastoma

Hepatoma

Among the list below, angiosarcoma would most likely be discovered in the:

Rectum

Liver

Spleen

Pancreas

Among the list below, a gastrinoma would most likely be discovered in the:

Pancreas

Adrenal gland

Stomach

Spleen

The space located behind the liver and stomach, and posterior to the pancreas is the:

Hepatosplenic space

Lesser sac

Greater sac

Supraduodenal space

Of the list below, which is considered to be an intraperitoneal organ?

Left kidney

Aorta

IVC

Liver

Of the list below, which is considered to be a malignant testicular neoplasm?

Neuroblastoma

Hepatoma

Yolk sac tumor

Hamartoma

The oncocytoma is a mass noted more commonly in the:

Liver

Adrenal glands

Pancreas

Kidneys

These potential spaces extend alongside the ascending and descending colon on both sides of the abdomen.

Paracolic gutters

Periumbilical gutters

Greater gutters

Suprapubic gutters

This common tumor of the kidney consists of blood vessels, muscle, and fat.

Hemangioma

Angiomyolipoma

Oncocytoma

Pheochromocytoma

Which of the following is not a pediatric malignant mass?

Hepatoblastoma

Neuroblastoma

Pheochromocytoma

Nephroblastoma

A tumor that consists of tissue from all three germ cell layers is the:

Pheochromocytoma

Oncocytoma

Choriocarcinoma

Teratoma

A benign tumor that consists primarily of blood vessels best describes:

Adenocarcinoma

Oncocytoma

Hemangioma

Lymphoma

The insulinoma is a:

Malignant pediatric adrenal tumor

Benign pancreatic tumor

Malignant pancreatic tumor

Benign liver tumor

A tumor that consists of a group of inflammatory cells best describes the:

Hematoma

Hemangioma

Lymphoma

Granuloma

A tumor that consists of a focal collection of blood best describes the:

Hematoma

Hemangioma

Hamartoma

Hepatoma

The malignant testicular tumor that consist of trophoblastic cells is the:

Cholangiocarcinoma

Teratoma

Yolk sac tumor

Choriocarcinoma

Which of the following laboratory values would be most helpful in evaluating a patient with recent trauma?

White blood cell count

Alpha-fetoprotein

Blood urea nitrogen

Hematocrit

Which of the following laboratory values would be most helpful in evaluating a patient with an infection?

White blood cell count

Alpha-fetoprotein

Blood urea nitrogen

Hematocrit

The artifact most commonly encountered posterior to a gallstone is:

Acoustic enhancement

Shadowing

Ring down

Reverberation

A collection of abdominal fluid within the peritoneal cavity often associated with cancer is termed:

Transudate ascites

Peritoneal ascites

Exhudate ascites

Chromaffin ascites

<rq1>Answers for Chapter 1 Review Questions:

A

D

C

B

D

D

C

A

D

C

B

C

A

B

D

C

D

A

B

C

D

C

B

D

A

D

D

A

B

C

Table 8-1. The AIUM practice guidelines for a sonogram of the abdomen and/or retroperitoneum.

Abdominal, flank, and/or back pain

Signs or symptoms that may be referred from the abdominal and/or retroperitoneal regions, such as jaundice or hematuria

Palpable abnormalities, such as an abdominal mass or organomegaly

Abnormal laboratory values or abnormal findings on other imaging examinations suggestive of abdominal and/or retroperitoneal pathology

Follow-up of known or suspected abnormalities in the abdomen and/or retroperitoneum

Search for metastatic disease or an occult primary neoplasm

Evaluation of suspected congenital abnormalities

Abdominal trauma

Pre- and post-transplantation evaluation

Planning and guidance for an invasive procedure

Search for the presence of free or loculated peritoneal and/or retroperitoneal fluid

Table 8-2. Several artifacts commonly observed during an abdominal sonogram.

Artifact

Description

Comet tail artifact

A type of reverberation artifact, caused by a number of small, highly reflective interfaces, such as gas bubbles

Seen with adenomyomatosis of the gallbladder

Mirror image

Produced by a strong reflector and results in a copy of the anatomy being placed deeper than the correct location

Seen posterior to the liver and diaphragm

Posterior (acoustic) enhancement

Produced when the sound beam is barely attenuated through a fluid or a fluid-containing structure

Seen posterior to cystic structures such as the gallbladder and renal cysts, and with ascites

Reverberation artifact

Caused by a large acoustic interface and subsequent production false echoes

Seen as an echogenic region in the anterior aspect of the gallbladder or other cystic structures

Ring down artifact

A type of reverberation artifact that appears as a solid streak or a chain of parallel bands radiating away from a structure

Seen emanating from gas within the abdomen.

Shadowing

Caused by attenuation of the sound beam

Seen posterior to calculi and dense structures

Table 8-3. The list of intraperitoneal organs.

Gallbladder

Liver (except for bare area)

Ovaries

Spleen (except for the splenic hilum)

Stomach

Table 8-4. The list of retroperitoneal organs.

Abdominal lymph nodes

Adrenal glands

Aorta

Ascending and descending colon

Duodenum

Inferior vena cava

Kidneys

Pancreas

Prostate gland

Ureters

Urinary bladder

Uterus

Table 8-5. The location and significance of the peritoneal cavity spaces.

Peritoneal Cavity Spaces

Location and Significant Points

Subphrenic space

Inferior to the diaphragm

Divided into right and left

Subhepatic space

Inferior to the liver

Divided into anterior and posterior

Posterior subhepatic space is also referred to as Morrison's pouch

Lesser sac

Behind the liver and stomach and posterior to the pancreas

Paracolic gutters

Extend alongside the ascending and descending colon on both sides of the abdomen

Posterior cul-de-sac

Male - between the urinary bladder and rectum; also referred to as the rectovesicle pouch

Female - between the uterus and rectum; also referred to as pouch of Douglas and rectouterine pouch

Anterior cul-de-sac

Between the urinary bladder and uterus

Table 8-6. The pathologies associated with ascites.

Acute cholecystitis

Cirrhosis

Congestive heart failure

Ectopic pregnancy

Malignancy

Portal hypertension

Ruptured abdominal aortic aneurysm

Table 8-7. An abbreviated list and description of benign abdominal masses and their locations.

Benign Abdominal Mass

Description

Common (abdominal) Location

Adenoma

Tumor of glandular origin

Most organs

Angiomyolipoma

Tumor of blood vessels, muscle, and fat

Kidney

Focal nodular hyperplasia

Abnormal accumulation of cells within a focal region of an organ

Liver

Granuloma

Tumor consisting of a group of inflammatory cells

Liver and Spleen

Gastrinoma

Tumor that secretes gastrin

Pancreas

Hamartoma

Tumor consisting of an overgrowth of normal cell of an organ

Kidney

Hemangioma

Tumor consisting of blood vessels

Liver, Spleen, and Kidney

Hematoma

Localized collection of blood

Anywhere organ/tissue affected by trauma

Insulinoma

Tumor that secretes insulin

Pancreas

Lipoma

Tumor that consists of fat

Liver, Spleen, and Kidney

Oncocytoma

Tumor consisting of oncocytes

Kidney

Pheochromocytoma

Tumor that consists of chromaffin cells of the adrenal gland

Adrenal gland

Teratoma

Tumor that consists of tissue from all three germ cell layers

Testicle/Ovary

Urinoma

Localized collection of urine

Next to a kidney transplant

Table 8-8. An abbreviated list and description of malignant abdominal/small part masses and their locations.

Malignant Abdominal Mass

Description

Common (abdominal) Location

Adenocarcinoma

Cancer of glandular origin

Pancreas and GI tract

Angiosarcoma

Cancer in the lining of vessels (lymphatic or vascular)

Spleen

Choriocarcinoma

Cancer that consist of trophoblastic cells

Testicle

Cholangiocarcinoma

Cancer of the bile ducts

Biliary tree

Cystadenocarcinoma

Cancer that is fundamentally adenocarcinoma with cystic components

Pancreas

Embryonal cell carcinoma

Cancer that is of germ cell origin

Testicle

Follicular carcinoma

Cancer of aggressive abnormal epithelial cells

Thyroid

Hepatocellular carcinoma

(hepatoma)

Cancer that originates in the hepatocytes

Liver

Hypernephroma

(renal cell carcinoma)

Cancer that originates in the tubules of the kidney

Kidney

Lymphoma

Cancer of the lymphatic system

Spleen and Kidney

Papillary carcinoma

Cancer that has formation of many irregular, fingerlike projections

Thyroid

Seminoma

Cancer that originates in the seminiferous tubules

Testicle

Transitional cell carcinoma

Cancer that originates in the transitional epithelium of an organ or structure

Bladder, Ureter, Kidney

Yolk sac tumor

Cancer that is of germ cell origin

Testicle

Table 8-9. An abbreviated list and description of malignant pediatric abdominal masses and their locations.

Solid Pediatric Malignant Abdominal Mass

Common Location

Neuroblastoma

Adrenal gland

Hepatoblastoma

Liver

Nephroblastoma (Wilms' tumor)

Kidney