Ebook Diagnostic medical sonography - Abdomen and superficial structures (3rd edition): Part 1

Diagnostic Medical Sonography

ABDOMEN AND
SUPERFICIAL
STRUCTURES



Diagnostic Medical Sonography

ABDOMEN AND
SUPERFICIAL
STRUCTURES
Third Edition

Diane M. Kawamura, PhD, RT(R), RDMS
Professor, Radiologic Sciences, Weber State University
Ogden, UT

Bridgette M. Lunsford, MAEd, RVT, RDMS
GE Healthcare - Ultrasound
Arlington, VA


Publisher: Julie K. Stegman
Senior Product Manager: Heather Rybacki
Product Manager: Kristin Royer
Marketing Manager: Shauna Kelley
Design Coordinator: Joan Wendt

Art Director: Jennifer Clements
Manufacturing Coordinator: Margie Orzech
Production Services: Absolute Service, Inc.
Copyright © 2012 by Lippincott Williams & Wilkins, a Wolters Kluwer business
351 West Camden Street
Baltimore, MD 21201

Two Commerce Square
2001 Market Street
Philadelphia, PA 19103

Third Edition
All rights reserved. This book is protected by copyright. No part of it may be reproduced in any form by any
means, including photocopying, or utilized by any information storage and retrieval system without written
permission from the copyright owner, except for brief quotations embodied in critical articles and reviews.
Materials appearing in the book prepared by individuals as part of their official duties as U.S. government
employees are not covered by the above-mentioned copyright.
Printed in China.
Library of Congress Cataloging-in-Publication Data
Diagnostic medical sonography. Abdomen and superficial structures / edited by Diane M. Kawamura,
Bridgette M. Lunsford. -- 3rd ed.
p. ; cm.
Abdomen and superficial structures
Rev. ed. of: Abdomen and superficial structures / edited by Diane M. Kawamura. 2nd ed. c1997.
Includes bibliographical references and index.
ISBN 978-1-60547-995-8 (alk. paper)
I. Kawamura, Diane M. II. Lunsford, Bridgette M. III. Title: Abdomen and superficial structures.
[DNLM: 1. Abdomen--ultrasonography. 2. Digestive System--ultrasonography. 3. Ultrasonography--methods.
4. Urogenital System--ultrasonography. WI 900]
617.5’5075--dc23

2011045980
Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any
consequences from application of the information in this book and make no warranty, express or implied, with
respect to the contents of the publication. Application of the information in a particular situation remains the
professional responsibility of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set
forth in this text are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information
relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for
any change in indications and dosage and for added warnings and precautions. This is particularly important
when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA)
clearance for limited use in restricted research settings. It is the responsibility of the health care providers to
ascertain the FDA status of each drug or device planned for use in their clinical practice.
To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders
to (301) 223-2320. International customers should call (301) 223-2300.
Visit Lippincott Williams & Wilkins on the Internet at LWW.com. Lippincott Williams & Wilkins customer
service representatives are available from 8:30 AM to 6:00 PM, EST.
10

9

8

7

6

5

4

3

2

1


To my husband, Bryan, for providing me with
confidence, for supporting my professional
endeavors, for giving of himself to help me, and
for being my favorite companion and best friend.
To our wonderful children, Stephanie and Nathan,
who continue to inspire me to appreciate
how important it is to learn new things.
To all my colleagues on campus and in the
profession who provide encouragement, support,
and stimulating new challenges.
Diane M. Kawamura
To my husband, James, with love and gratitude
for his constant support, encouragement, patience,
and understanding without which I would not
have had the courage to take on this task.
To my family for instilling a love of learning and
supporting me in all of my endeavors.
To my colleagues at GE from whom I have learned
so much and who continue to inspire me on a
daily basis to expand my knowledge and take on
new challenges.

Bridgette M. Lunsford
And to students and professionals
who will use this book:
“Any piece of knowledge I acquire today has a
value at this moment exactly proportioned to my
skill to deal with it. Tomorrow, when I know more,
I recall that piece of knowledge and use it better.”
—Mark Van Doren, Liberal Education (1960)
DMK, BML



Contents

1

Introduction ...........................................................................................................1
Diane M. Kawamura

PART 1 • ABDOMINAL SONOGRAPHY
2

The Abdominal Wall and Diaphragm ..................................................................13
Terri L. Jurkiewicz

3

The Peritoneal Cavity ..........................................................................................39
Joie Burns

4

Vascular Structures...............................................................................................57
Kathleen Marie Hannon

5

The Liver ............................................................................................................101
Joyce A. Grube

6

The Gallbladder and Biliary System ..................................................................165
Teresa M. Bieker

7

The Pancreas......................................................................................................207
Julia A. Drose

8

The Spleen .........................................................................................................225
Tanya D. Nolan

9

The Gastrointestinal Tract ..................................................................................243
John F. Trombly

10 The Kidneys .......................................................................................................265
Cathie Scholl

11 The Lower Urinary System .................................................................................341
Bridgette M. Lunsford • Christine Schara

12 The Prostate Gland ............................................................................................367
George M. Kennedy

13 The Adrenal Glands ...........................................................................................389
Kari E. Boyce

14 The Retroperitoneum ........................................................................................419
Joie Burns

PART 2 • SUPERFICIAL STRUCTURE SONOGRAPHY
15 The Thyroid Gland, Parathyroid Glands, and Neck ...........................................435
Diane M. Kawamura • Janice L. McGinnis

16 The Breast ..........................................................................................................471
Catherine Carr-Hoefer

vii


viii

CONTENTS

17 The Scrotum ......................................................................................................529

Wayne C. Leonhardt • Zulfikarali H. Lalani

18 The Musculoskeletal System..............................................................................571
Patrick R. Meyers

PART 3 • NEONATAL AND PEDIATRIC SONOGRAPHY
19 The Pediatric Abdomen.....................................................................................633
Bridgette M. Lunsford • Regina K. Swearengin

20 The Pediatric Urinary System and Adrenal Glands............................................677
Bridgette M. Lunsford • Heidi S. Barrett

21 The Neonatal Brain ............................................................................................707
Monica M. Bacani

22 The Infant Spine.................................................................................................735
Rechelle A. Nguyen

23 The Infant Hip Joint ...........................................................................................749
Charlotte Henningsen

PART 4 • SPECIAL STUDY SONOGRAPHY
24 Organ Transplantation .......................................................................................759
Kevin D. Evans

25 Emergency Sonography ....................................................................................777
J. P. Moreland • Michelle Wilson

26 Foreign Bodies...................................................................................................791
Tim S. Gibbs

27 Sonography-Guided Interventional Procedures ................................................807
Aubrey J. Rybyinski

Index ..................................................................................................................825


Acknowledgments

Throughout the process, we appreciated the support and enthusiasm from Anne Marie
Kupinski and Susan Stephenson as we collaborated on the three volumes of Diagnostic
Medical Sonography. Their input and ideas were a significant contribution to the project.
Our thanks and gratitude goes to all the contributors of the third edition who gave of
their expertise, time, and energy updating the content with current information to utilize
in obtaining a more accurate imaging examination for our patients.
The image contributions became treasured moments. We thank the many sonographers
and physicians for their assistance. A special thank you and recognition for ongoing support
in image acquisition includes Taco Geertsma, MD, Ede, the Netherlands at Ultrasoundcases.
info; Philips Medical Systems, Bothell, WA; GE Healthcare, Wauwatosa, WI; Joe Anton, MD,
Cochin, India; Dr. Nakul Jerath, Falls Church, VA; and from Monica Bacani and Rechelle
Nguyen at Nationwide Children’s Hospital in Columbus, OH.
Many thanks to all of the production team at Lippincott Williams & Wilkins who
helped edit, produce, promote, and deliver this textbook. We especially thank in the
development of this edition Peter Sabatini, acquisitions editor, Kristin Royer, associate
product manager, Jennifer Clements, art director, and Carol Gudanowski, illustrator, for
their patience, follow-through, support, and encouragement.
To our colleagues, students, friends, and family, who provide continued sources of
encouragement, enthusiasm, and inspiration, thank you.
Diane M. Kawamura, PhD, RT(R), RDMS
Bridgette M. Lunsford, MAEd, RVT, RDMS

ix





Preface

The third edition of Diagnostic Medical Sonography: Abdomen and Superficial Structures
is a major revision. Educators and colleagues encouraged us to produce a third edition
to incorporate new advances used to image, to refresh the foundational content, and to
continue to provide information that recognizes readers have diverse backgrounds and
experiences. The result is a textbook that can be used as either an introduction to the profession or as a reference for the profession. The content lays the foundation for a better
understanding of anatomy, physiology, and pathophysiology to enhance the caregiving
role of the sonographer practitioner, sonographer, sonologist, or student when securing
the imaging information on a patient.
The first chapter introduces terminology on anatomy, scanning planes, and patient
positions. Adopting universal terminology permits every sonographer to communicate
consistent information on how he or she positioned the patient, how he or she scanned
the patient, and how anatomy and pathology are sonographically represented.
The next four sections are divided into specific content areas. Doing this allowed the
contributors to focus their attention on a specific organ or system. This simulates application in that while scanning, the sonographer investigates the organ or system, moves
systematically to the next organ or system, and completes the examination by synthesizing all of the information to obtain the total picture.
We made every attempt to produce an up-to-date and factual textbook while presenting the material in an interesting and enjoyable format to capture the reader’s attention.
To do this, we provided detailed descriptions of anatomy, physiology, pathology, and the
normal and abnormal sonographic representation of these anatomical and pathologic
entities with illustrations, summary tables, and images, many of which include valuable
case study information.
Our goal is to present as complete and up-to-date a text as possible, while recognizing that by tomorrow, the textbook must be supplemented with new information

reflecting the dynamic sonography profession. With every technologic advance made
in equipment, the sonographer’s imagination must stretch to create new applications.
With the comprehensive foundation available in this text, the sonographer can meet that
challenge.
Diane M. Kawamura, PhD, RT(R), RDMS
Bridgette M. Lunsford, MAEd, RVT, RDMS

xiii



Contributors

Monica M. Bacani, RDMS
Clinical Manager - Ultrasound
Nationwide Children’s Hospital
Columbus, OH
Heidi S. Barrett, RT(R), RDMS, RVT, RDCS
Clinical Specialist – SF Bay Area
SonoSite, Inc.
San Francisco, CA
Teresa M. Bieker, MBA-H, RT(R), RDMS,
RDCS, RVT
Department of Ultrasound
University of Colorado Hospital
Aurora, CO
Kari E. Boyce, PhD, RDMS
College of Allied Health
The University of Oklahoma
Oklahoma City, OK

Joie Burns, MS, RT(R)(S), RDMS, RVT
Sonography Program Director
Boise State University
Boise, ID
Catherine Carr-Hoefer, BS, RT(R),
RDMS, RDCS, RVT
Assistant Manager, Diagnostic Imaging
Good Samaritan Regional Medical Center
Corvallis, OR
Julia A. Drose, BA, RDMS, RDCS
Department of Ultrasound
University of Colorado Hospital
Aurora, CO
Kevin D. Evans, PhD,
RT(R)(M)(BD), RDMS
School of Allied Medical Professions
The Ohio State University
Columbus, OH
Tim S. Gibbs, RT(R), RDMS,
RVT, CTNM
Ultrasound Supervisor
West Anaheim Medical Center
Anaheim, CA

Joyce A. Grube, MS, RDMS
Sonography Education Consultant
Jamestown, OH
Kathleen Marie Hannon, RN, MS,
RVT, RDMS
Vascular Diagnostic Laboratory

Massachusetts General Hospital
Boston, MA
Charlotte Henningsen, MS, RT(R),
RDMS, RVT
Chair and Professor, Sonography
Department
Florida Hospital College
Orlando, FL
Terri L. Jurkiewicz, MS, RT(R)(M),
RDMS, RVT
Assistant Professor, Radiologic Sciences
Weber State University
Ogden, UT
Diane M. Kawamura, PhD,
RT(R), RDMS
Professor, Radiologic Sciences
Weber State University
Ogden, UT
George M. Kennedy, AS, RT(R), RDMS,
RDCS, RVT
Department of Ultrasound
University of Colorado Hospital
Aurora, CO
Zulfikarali H. Lalani, RDMS, RDCS
Senior Staff Sonographer and
Clinical Instructor
Alta Bates Summit Medical Center
Oakland, CA
Wayne C. Leonhardt, BA, RDMS,
RVT, APS

Lead Sonographer, Technical Director, CE
Coordinator
Alta Bates Summit Medical Center
Oakland, CA

xv


xvi

CONTRIBUTORS

Bridgette M. Lunsford, MAEd,
RVT, RDMS
Clinical Applications Specialist
GE Healthcare - Ultrasound
Arlington, VA

Aubrey J. Rybyinski, BS, RDMS, RVT
Ultrasound Section
The Hospital of the University of
Pennsylvania
Philadelphia, PA

Janice L. McGinnis, RDMS
Ultrasound Department
Bay Area Hospital
Coos Bay, OR

Christine Schara, BS, RT(R)(N), RDMS

Program Chair, Diagnostic Medical
Sonography
Athens Technical College
Athens, GA

Patrick R. Meyers, BS, RT(R), RDMS
Owner
Musculoskeletal Ultrasound of SE WI LLC
Mequon, WI

Cathie Scholl, BS, RDMS, RVT
Ohio Health Westerville Medical Campus
Westerville, OH

J.P. Moreland, RT(R)(CT), RDMS, RVS
Director, Customer Education
GE Healthcare - Ultrasound
San Francisco, CA

Regina K. Swearengin, AAS, BS, RDMS
Department Chair, Sonography
Austin Community College
Austin, TX

Rechelle A. Nguyen, RDMS
Department of Ultrasound
Nationwide Children’s Hospital
Columbus, OH

John F. Trombly, MS, RT(R), RDMS, RVT

Director, Medical Imaging Education
Red Rocks Community College
Arvada, CO

Tanya D. Nolan, MAEd,
RT(R), RDMS
Assistant Professor, Radiologic Sciences
Weber State University
Ogden, UT

Michelle Wilson, MS, RDMS, RDCS
Instructional Designer
Sonography Sessions, L.L.C
Distance Education Specialists
Napa, CA


1

Introduction
Diane M. Kawamura
OBJECTIVES
Identify anatomic definitions in regard to directional terms, anatomic position, and
anatomic planes.
Demonstrate the sonographic examination to include patient position, transducer
orientation, and image presentation and labeling.
Define the terms used to describe image quality.
Describe the sonographic echo patterns to demonstrate how normal and pathologic
conditions can be defined using image quality definitions.
List and recognize the sonographic criteria for cystic, solid, and complex conditions.

Describe the appropriate patient preparation for a sonographic evaluation.
State what should and what should not be included in a preliminary report.
Calculate sensitivity, specificity, and accuracy using the four outcomes of true-positive,
false-positive, true-negative, and/or false-negative.

KEY TERMS
accuracy | anechoic | coronal plane | echogenic | echopenic | heterogeneous |
homogeneous | hyperechoic | hypoechoic | isoechoic | sagittal plane | sensitivity |
specificity | transverse plane

GLOSSARY
anechoic describes the portion of an image that
appears echo-free
echogenic describes an organ or tissue that is capable
of producing echoes by reflecting the acoustic beam
echopenic describes a structure that is less echogenic
or has few internal echoes
heterogeneous describes tissue or organ structures
that have several different echo characteristics

This chapter focuses on the sonography examination of
the abdomen and superficial structures. It was written
to assist sonographers in acquiring, using, and understanding the sonographic imaging terminology used in
the remainder of this textbook. Accurate and precise terminology allows communication among professionals.
ANATOMIC DEFINITIONS
The profession adopted standard nomenclature from
the anatomists’ terminology to communicate anatomic direction. Table 1-1 and Figure 1-1 illustrate how
these simple terms help avoid confusion and convey

homogeneous refers to imaged echoes of equal intensity

hyperechoic describes image echoes brighter than
surrounding tissues or brighter than is normal for that
tissue or organ
hypoechoic describes portions of an image that are not
as bright as surrounding tissues or are less bright than
normal
isoechoic describes structures of equal echo density

specific information. A person in the conventional
anatomic position is standing erect, feet together,
with the arms by the sides and the palms and face
directed forward, facing the observer. When sonographers use directional terms or describe regions or
anatomic planes, it is assumed that the body is in the
anatomic position.
There are three standard anatomic planes (sections)
that are imaginary flat surfaces passing through a body
in the standard anatomic position. The sagittal plane
and coronal plane follow the long axis of the body and
the transverse plane follows the short axis of the body1
(Fig. 1-2).
1


TABLE

1-1

Directional Terms
Term

Definition

Superior
(cranial)
Inferior
(caudal)
Anterior
(ventral)
Posterior
(dorsal)
Medial
Lateral
Ipsilateral
Contralateral
Proximal
Distal
Superficial
Deep

Example

Toward the head, closer to the head, the upper
portion of the body, the upper part of a structure,
or a structure higher than another structure
Toward the feet, away from the head, the lower
portion of the body, toward the lower part of a
structure, or a structure lower than another structure
Toward the front or at the front of the body or a
structure in front of another structure
Toward the back or the back of the body or a

structure behind another structure
Toward the middle or midline of the body or the
middle of a structure
Away from the middle or the midline of the body
or pertaining to the side
Located on the same side of the body or affecting
the same side of the body
Located on the opposite side of the body or
affecting the opposite side of the body
Closer to the attachment of an extremity to the
trunk or the origin of a body part
Farther from the attachment of an extremity to the
trunk or the origin of a body part
Toward or on the body surface or external
Away from the body surface or internal

The left adrenal gland is superior to the left kidney

The lower pole of each kidney is inferior to the upper pole

The main portal vein is anterior to the inferior vena cava
The main portal vein is posterior to the common hepatic
artery
The middle vein is medial to the right hepatic vein
The right kidney is lateral to the inferior vena cava
The gallbladder and right kidney are ipsilateral
The pancreatic tail and pancreatic head are contralateral
The abdominal aorta is proximal to the bifurcation of the
iliac arteries
The iliac arteries are distal to the abdominal aorta

The thyroid and breast are considered superficial structures
The peritoneal organs and great vessels are deep structures

Cranial
Cephalic
Superior

Proximal

Anterior
Ventral

Medial

Posterior
Dorsal

Lateral

Distal

Caudal
Inferior

Figure 1-1 Directional terms. The drawing depicts a body in the anatomic position (standing erect, arms by the side, face and palms directed
forward) with the directional terms. The directional terms correlate with the terms in Table 1-1.

2

1 — Introduction

The word sagittal literally means “flight of an arrow” and refers to the plane that runs vertically through
the body and separates it into right and left portions.
The plane that divides the body into equal right and
left halves is referred to as the median sagittal or midsagittal plane. Any vertical plane on either side of the
midsagittal plane is a parasagittal plane (para means
“alongside of”). In most sonography cases, the term

3

sagittal usually implies a parasagittal plane unless the
term is specified as median sagittal or midsagittal. The
coronal plane runs vertically through the body from
right to left or left to right, and divides the body into
anterior and posterior portions. The transverse plane
passes through the body from anterior to posterior and
divides the body into superior and inferior portions and
runs parallel to the surface of the ground.

SCANNING DEFINITIONS
PATIENT POSITION

Superior

Positional terms refer to the patient’s position relative to
the surrounding space. For sonographic examinations,
the patient position is described relative to the scanning
table or bed (Table 1-2, Fig. 1-3). In clinical practice,
patients are scanned in a recumbent, semierect (reverse

Trendelenburg or Fowler), or sitting position. On occasion, patients may be placed in other positions, such as
the Trendelenburg (head lowered) or standing position,
to obtain unobscured images of the area of interest. Sonographers frequently convey information on patient
position and transducer placement simultaneously.
This terminology most likely was adopted from radiography, where it describes the path of the X-ray beam
through the patient’s body (projection), which results
in a radiographic image (view). There is no evidence in
the literature that this nomenclature has been adopted
as a professional standard for sonographic imaging.

Sagitta

l

Fronta

l

Posterior

Medial
Transverse

Anterior

Lateral
TABLE

1-2

Patient Positions
Term

Description

Decubitus or
Recumbent

The act of lying down. The adjective
before the word describes the
most dependent body surface.
Lying on the back
Lying face down
Lying on the right side

Supine or dorsal
Prone or ventral
Right lateral
decubitus (RLD)
Left lateral
decubitus (LLD)
Oblique
Right posterior
oblique (RPO)
Left posterior
oblique (LPO)
Inferior
Figure 1-2 Anatomic planes. The standard anatomic position is
used to depict the three imaginary anatomic flat surface planes. Both
the sagittal and coronal planes pass through the long axis and the

transverse plane passes through the short axis.

Right anterior
oblique (RAO)
Left anterior
oblique (LAO)

Lying on the left side
Named for the body side closest to
the scanning table.
Lying on the right posterior surface,
the left posterior surface is
elevated
Lying on the left posterior surface,
the right posterior surface is
elevated
Lying on the right anterior surface,
the left anterior surface is elevated
Lying on the left anterior surface, the
right anterior surface is elevated


4

PART 1 — ABDOMINAL SONOGRAPHY

Supine

Prone

Lateral

Oblique

Right anterior oblique (RAO)

Left anterior oblique (LAO)

Left posterior oblique (LPO)

Right posterior oblique (RPO)

Figure 1-3 Patient positions. The various patient positions depicted in the illustration correlate with the descriptions in Table 1-2.

Describing sonograms using the terms projection or
view should be avoided. It is more accurate to describe
the sonographic image stating the anatomic plane visualized, which is due to the transducer’s orientation (i.e.,
transverse). A more specific description of the image
would include both the anatomic plane and the patient
position (i.e., transverse, oblique).

TRANSDUCER ORIENTATION
The transducer’s orientation is the path of the insonating sound and the path returning echoes are viewed
on the monitor. Transducers are manufactured with
an indicator (notch, groove, light) that is displayed on
the monitor as a dot, arrow, letter of the manufacturer’s insignia, and so forth. Scanning plane is the term
used to describe the transducer’s orientation to the
anatomic plane or to the specific organ or structure.
The sonographic image is a representation of sectional
anatomy. The term plane combined with the adjectives

sagittal, parasagittal, coronal, and transverse describes
the section of anatomy represented on the image (e.g.,
transverse plane).
Because many organs and structures lie oblique to
the imaginary body surface planes, sonographers must
identify sectional anatomy accurately to utilize a specific organ and structure orientation for scanning surfaces. The sonography imaging equipment provides
great flexibility to rock, slide, and angle the transducer

to obtain sectional images of organs oriented obliquely
in the body. For example, to obtain the long axis of an
organ, such as the kidney, the transducer is oblique and
is angled off of the standard anatomic positions: sagittal, parasagittal, coronal, or transverse plane. Sonographers frequently use the terms sagittal or parasagittal
to mean longitudinal in depicting the anatomy in a
long-axis section. Although some images in this text are
labeled sagittal or parasagittal, they are, in fact, longitudinal planes because the image is organ specific. For
organ imaging, transverse planes are perpendicular to
the long axis of the organ, and longitudinal and coronal
planes are referenced to a surface. All three planes are
based on the patient position and the scanning surface
(Fig. 1-4A–C).

IMAGE PRESENTATION
When describing image presentation on the display
monitor, the body, organ, or structure plane terminology, coupled with transducer placement, provides
a very descriptive portrayal of the sectional anatomy
being depicted. Current flexible, free-hand scanning
techniques may lack automatic labeling of the scanning plane. With free-hand scanning technique, quantitative labeling may be limited, which means reduced
image reproducibility from one sonographer to another
sonographer. Sonographers usually can select from a
wide array of protocols for image annotation or employ

1 — Introduction

Longitudinal plane

5

Sonogram

Longitudinal section

A

Caudal/Inferior

Cephalic/Superior

Anterior

Posterior

Coronal plane

Coronal section

Sonogram

B

Caudal/Inferior

Cephalic/Superior

Left

Right

Transverse plane

Transverse section

Sonogram

C

Left

Right

Anterior

Posterior

Figure 1-4 Transducer orientation. A. A parasagittal plane provides a longitudinal section of the kidney on the sonogram. B. The coronal
plane provides a coronal section on the sonogram. C. The transverse plane provides a transverse section on the sonogram. The sonogram is
the image the sonographer observes on the monitor.

postprocessing annotation. This is extremely important
when the image of an isolated area does not provide

other anatomic structures for a reference location. To
ensure consistent practice, sonographers must correctly
label all sonograms. With today’s equipment, standard
presentation and labeling is easily achieved along with
additional labeling of specific structures and added
comment.
The anterior, posterior, right, or left body surface is
usually scanned in the sagittal (parasagittal), coronal,
and transverse scanning planes. For organ or structure
imaging, these same body surfaces are scanned with
different angulations and obliqueness of the transducer

to obtain longitudinal, coronal, or transverse scanning
planes. With few exceptions, the transducer at the
scanning surface is presented at the top of the image.1,2
Images obtained using an endovaginal probe are usually flipped so that they are presented in the more traditional transabdominal transducer orientation, whereas
images obtained using an endorectal probe are presented in the transducer-organ orientation. With neurosonography (neurosonology), the superior scanning
surface is presented at the top of the image when the
transducer is placed on the head.
These six scanning surfaces, anterior or posterior,
right or left, endocavitary (vaginal or rectal), and the


PART 1 — ABDOMINAL SONOGRAPHY

Longitudinal: Sagittal Planes
When scanning in the longitudinal, sagittal plane, the
transducer orientation sends and receives the sound
from either an anterior or posterior scanning surface.
For a longitudinal plane, the transducer indicator is in

the 12 o’clock position to the organ or to the area of

Anterior

C
Right

Caudal/Inferior

Cephalic/Superior

Anterior

Posterior

Posterior

Posterior
Caudal/Inferior

Anterior

Anterior

Posterior

Left

D
Anterior

Caudal/Inferior

Cephalic/Superior

Left

Right

Right

Right
Anterior

Caudal/Inferior
Left

Posterior

Right

Cephalic/Superior

B

Right

Posterior

Cephalic/Superior

A

interest. This always places the superior (cephalic) location on the image. From either the anterior or posterior
body surface, the patient can be scanned in either erect,
supine, prone, or an oblique position. The image presentation includes either the anterior or posterior, the
superior (cephalic), and the inferior (caudal) anatomic
area being examined1,2 (Fig. 1-5A). Because the longitudinal, sagittal image presentation does not demonstrate the right and left lateral areas, the adjacent areas
can be evaluated and documented with transducer

Left

cranial fontanelle coupled with three anatomic planes
(sagittal, coronal, and transverse) produce a combination of 14 different image presentations.

Left

6

Left

Figure 1-5 Image presentations. A. Longitudinal, sagittal plane. With the patient being scanned from either the anterior or posterior surface
with or without obliquity, the image seen on the monitor demonstrates the scanning surface (anterior or posterior) and the superior (cephalic)
and inferior (caudal) area being examined. B. Longitudinal, coronal plane. With the patient being scanned from either the right or left surface
with or without obliquity, the image seen on the monitor demonstrates the scanning surface (right or left) and the superior (cephalic) and inferior (caudal) area being examined. C. Transverse plane, anterior or posterior surface. With the patient being scanned from either the anterior
or posterior surface with or without obliquity, the image seen on the monitor demonstrates the scanning surface (anterior or posterior) and
the right and left area being examined. D. Transverse plane, right or left surface. With the patient being scanned from either the right or left
surface with or without obliquity, the image seen on the monitor demonstrates the scanning surface (right or left) and the anterior and posterior
area being examined. (Continued)

7

1 — Introduction

F

Sagittal

Cephalic/Superior

Posterior (Rectum)

Right

Caudal/Inferior

Cephalic/Superior

Posterior (Rectum)

Left

Anterior
Cephalic/Superior

Right

Caudal/Inferior
Posterior

Caudal/Inferior

Anterior

Coronal

Left

E

Anterior

Sagittal

Coronal or Transverse

G

manipulation, changing the transducer orientation, or
changing the patient position.2

Longitudinal: Coronal Planes
When scanning in the longitudinal, coronal plane, the
transducer orientation sends and receives the sound
from either the right or left scanning surface. Because
the transducer indicator is in the 12 o’clock position
to the organ or to the area of interest, the superior
(cephalic) location is always imaged. From either the
right or left body surface, the patient can be scanned in

either an erect, decubitus, or an oblique position and
the image presentation includes either the left or right,

Left

Right

Caudal/Inferior

Posterior

Caudal/Inferior

Anterior

Figure 1-5 (Continued) E. Endovaginal planes. The image
presentation on the left illustrates a sagittal plane and the one on
the right is the coronal plane. On either presentation, the apex of
the image seen on the monitor corresponds to the anatomy closest
to the face of the transducer. F. Endorectal planes. The image presentation on the left illustrates a sagittal plane and the one on the
right is the transverse or coronal plane. On either presentation, the
apex of the image seen on the bottom of the monitor corresponds
to the anatomy closest to the face of the transducer. G. Cranial
fontanelle planes. With the patient being scanned from either the
anterior or posterior surface with or without obliquity, the image
seen on the monitor demonstrates the scanning surface (anterior
or posterior) and the superior (cephalic) and inferior (caudal) area
being examined.

Cephalic/Superior

Cephalic/Superior

Sagittal: Anterior Fontanelle

Coronal: Anterior Fontanelle

the superior (cephalic), and the inferior (caudal) anatomic area being examined1,2 (Fig. 1-5B). Because the
longitudinal, coronal image presentation does not demonstrate the anterior or posterior areas, the adjacent
areas can be evaluated and documented with transducer manipulation, changing the transducer orientation,
or changing the patient position.2

Transverse Plane: Anterior or Posterior Surface
Using the anterior or posterior surface, the transducer
orientation for a transverse plane places the transducer
indicator in the 9 o’clock position on either the anterior
or posterior surface to the organ or to the area of interest.