Ebook Diagnostic imaging ultrasound: Part 1

FOREWORD

It is a particular pleasure to be asked to provide a foreword for Anil Ahuja's timely contribution
to the literature. I have
long maintained that ultrasound is one of the most difficult of all imaging techniques, largely because the only person who can
really assess the clinical problem is the operator who performed the study! Because of this it is critical that all those carrying out
ultrasound are trained to an appropriate level. This book will help such training and provide a constant source of reference for
workers faced with an unexpected lesion.
It is also pleasing to see a comprehensive
text on ultrasound being developed at a time when many people wish to be
trained in just one particular clinical subspecialty. While a musculoskeletal radiologist may become extremely competent in
musculoskeletal ultrasound, there is still a pressing need for experts to be able to cover the whole range of ultrasound procedures.
They will be the only people to advise on such developments as probe technology, ultrasound contrast agents, etc. There is no
certainty that a patient presenting with a problem seemingly related to one body system may not have a lesion in another! Hence
the importance of being able to switch from ultrasound of the hip to ultrasound of the iliac fossa. This book will assist such a
comprehensive
ultrasound approach.
With the rapidly increasing technical specifications of ultrasound machines and relative reduction in costs, it is not at
all improbable that every ward of a hospital might soon "own" their own ultrasound machine. Indeed, in time, a personal

ultrasound machine may become even more important than a stethoscope!
These developments mean that ultrasound will have
to be learned by a larger range of personnel and supervised to appropriate standards. This book will help all those participating
in the wider scheme of ultrasound training. It will also be of enormous use to radiologists learning the technique and studying
for postgraduate examinations.
The authors and the publisher have all done a superb job in making this book so attractive. I strongly believe that it will
become the essential ultrasound text book and that Anil Ahuja's name will, as a result, become even more widely recognized
within enlightened ultrasound departments. Congratulations
to all.
Adrian K. Dixon, MD, FRCR, FRCP, FRCS, FMedSci
Professor of Radiology
University of Cambridge
Honorary Consultant
Radiologist
Addenbrooke's
Hospital
Cambridge, United Kingdom

XI



PREFACE

I have been fortunate to know Drs. Ric Harnsberger & Anne Osborn. What started as an academic relationship has over
the years developed into a close friendship. I am privileged to have been asked to undertake this project and it is their vision,
enthusiasm, and support that has helped me accomplish this task.
This book is unique in the Diagnostic Imaging series as it deals with a modality rather then a clinical specialty such as
Head & Neck or Neuroradiology. Its scope is therefore wide, but this book is limited to clinical conditions that general
sonologists, radiologists, clinicians, & residents commonly encounter in routine practice. The discussion of the role of ultrasound

in Obstetric & Pediatric imaging has been restricted as these have been dealt with separately in other books in the Diagnostic
Imaging series.
Although it is a book on ultrasound, you will find information & images from other modalities. In this era of
multimodality
imaging, techniques complement each other in diagnosis & management of patients. It is therefore essential to be
familiar with the role of ultrasound in relation to other modalities. Each diagnosis contains common imaging appearances, basic
pathology, treatment options and prognosis. The section introductions
contain relevant information on anatomy, practical tips,
technical parameters for optimal scanning. The protocol section includes indications where other imaging modalities may be
necessary. The image annotation & key facts box crystallize relevant information and are ideal for those with short attention
spans.
This book would not have been possible without the help of friends (authors and contributors) from various parts of
the world. They have been generous with their images, expertise, time and patience, and I remain forever indebted. In particular I
would like to acknowledge Dr. Chander Lulla & Prof. Ravi Ramakantan for their generosity with images and Prof. William
Zwiebel & Prof. Paula Woodward for their help in preparing the table of contents. The team from Amirsys has been superb.
Despite being in different continents & time zones they have patiently guided me along the entire process and none of this would
have been possible without their help. Lastly, on behalf of all the authors I would like to thank sonographers in our respective
departments for their dedication to this unique imaging modality.
The preparation of this book has brought members of my department closer, helped make new friendships,
consolidate old ones. I have enjoyed the process & hope you find this book useful.

&

Anil T. Ahuja, MD, FRCR
Professor
Department of Diagnostic Radiology and Organ Imaging
The Chinese University of Hong Kong
Hong Kong, China

XIII

ACKNOWLEDGMENTS
Illustrations
Lane R. Bennion,
MS
Richard Coombs,
MS
Wes Price, MS

Image/Text Editing
Douglas Grant Jackson
Amanda
Hurtado
Roth LaFleur

Medical Text Editing
Paula J. Woodward,
MD
Anne Kennedy, MD
Daniel N. Sommers,
MD
Marta E. Heilbrun,
MD
Akram M. Shaaban,
MBBCh

Case Management
Christopher

Odekirk

Contributors
Jitendra
Astekar
Nitin Chaubal
Avinash
Gutte
Mukund
Joshi
Sudheer Joshi
Arun Kinare
Ann King
William
K.M. Kong
Aniruddha
Kulkarni
Paul S.F. Lee
Tom W.K. Lee
Yolanda YP. Lee
Darshana
Rasalkar
Rhian Rhys
lain Stewart
Ki Wang
Simon C.H. Yu

Associate Editor
Kaerli Main

Production lead
Melissa

A. Hoopes

xv



SECTIONS
liver

rn
rn

Biliary System
Pancreas
Spleen

[l]
@]

[5J
Renal Transplants ffiJ
Urinary Tract

[Z]

Adrenal Gland

Abdominal Wall/Peritoneal
Female Pelvis
Scrotum

1101
[1]

[11]

Musculoskeletal
Vascular

[ill

[2]

Head and Neck
Breast

Cavity

1131

1141

XVII



TABLE OF CONTENTS

Focal Solid Masses

SECTION 1
Liver

Hepatic Adenoma

1-64

Gregory E. Antonio, MO, FRANZCR

Focal Nodular Hyperplasia

Introduction and Overview
Hepatic Sonography

1-2

Gregory E. Antonio, MD, FRANZCR

Hepatocellular

Acute Hepatitis

Hepatic Cavernous Hemangioma
Gregory E. Alltonio,

1-6

Gregory E. Antonio, MO, FRANZCR

Cirrhosis, Hepatic

Gregory E. Alltonio,

1-10

Hepatic

Steatosis, Hepatic

Vascular Conditions
1-88

1-20

Porto-Systemic ColJaterals
William J. Zwiebel, MD

1-92

1-24

TIPS Shunts
William J. Zwiebel,

1-96

Gregory E. Antonio, MO, FRANZCR

Diffuse Microabscesses,

Hepatic

Hepatic

Portal Vein Occlusion
William J. Zwiebel, MD

1-100

1-28

Budd-Chiari Syndrome

1-104

GregolY E. Antonio, MD, FRANZCR

Cyst and Cyst-like
Hepatic Cyst

William

j. Zwiebel, MO

Portal Vein Gas
William J. Zwiebel,

lesions

1-32

GregolY E. Antonio, MD, FRANZCR

Caroli Disease

Post-Transplant
William

1-108
MO

Liver

1-110

j. Zwiebel, MD

1-36

Gregory E. Antonio, MO, FRANZCR

Biloma

SECTION 2
Biliary System

1-40

Gregory E. Antonio, MO, FRANZCR

Pyogenic Hepatic Abscess

1-42

Gregory E. Antonio, MO, FRANZCR

Pyogenic Peri-Hepatic Abscess

1-48

Gregory E. Antonio, MO, FRANZCR

Amebic Hepatic Abscess

Introduction and Overview
Biliary Sonography

Cyst

1-50

Gallstones and Mimics
1-54

Gregory E. Antonio, MO, FRANZCR

Hepatic Trauma
Gregory E. Antonio, MD, FRANZCR

2-2

K.T Wong, MBChB, FRCR

Gregory E. Antonio, MO, FRANZCR

Hepatic Echinococcus

MD

1-26

GregolY E. Antonio, MO, FRANZCR

Lymphoma,

1-82

MO, FRANZCR

Portal Hypertension
William J. Zwiebel, MD

GregolY E. Antonio, MO, FRANZCR

Hepatic

1-78

1-16

Gregory E. Antonio, MO, FRANZCR

Calcification,

1-72

MD, FRANZCR

Hepatic Metastases

Gregory E. Antonio, MO, FRANZCR

Parenchymal

Carcinoma

Gregory E. Antonio, MD, FRANZCR

Diffuse Parenchymal Disease

Schistosomiasis,

1-68

GregOlY E. Antonio, MD, FRANZCR

Cholelithiasis

2-6

K.T Wong, MBChB, FRCR

1-60

Echogenic Bile, Blood Clots, Parasites

2-12

K.T Wong, MBChB, FRCR

XIX


Gallbladder Cholesterol
K. TWang,

Polyp

K.T Wong, MBChB, FRCR

Solid-Appearing Pancreatic
Neoplasms

Gallbladder Wall Pathology
Thickened Gallbladder Wall
K. TWang,

MBChB, FRCR

Ductal Pancreatic Carcinoma

2-22

Acute Calculous Cholecystitis

. KT

K.T Wong, MBChB, FRCR

Acute Acalculous Cholecystitis

K TWang,

3-28

MBChB, FRCR

Solid and Papillary Neoplasm

2-28

Chronic Cholecystitis

KT

3-24

Wong, MBChB, FRCR

Islet Cell Tumors

2-26

K.T Wong, MBChB, FRCR
K. TWang,

3-20

Serous Cystadenoma

2-16

MBChB, FRCR

3-32

Wong, MBChB, FRCR

MBChB, FRCR

2-30

Porcelain Gallbladder

SECTION 4
Spleen

K.T Wong, MBChB, FRCR

2-32

Hyperplastic Cholecystosis
K.T Wong, MBChB, FRCR

2-36

Gallbladder Carcinoma

Introduction and Overview

K.T Wong, MBChB, FRCR

4-2

Splenic Sonography
Shlok j. Lolge, MD

Ductal Pathology
2-40

Biliary Ductal Dilatation

Spleen

K.T Wong, MBChB, FRCR

Choledochal
K. TWang,

Cyst

Accessory Spleen
Shlok f. Lolge, MD

4-6

2-46

Splenomegaly

4-8

2-50

Cysts & Cyst-Like Splenic Lesions

2-52

Splenic Tumors
Shlok f. Lolge, MD

4-16

2-56

Splenic Trauma
Shlok f. Lolge, MD

4-22

2-60

Splenic Calcifications

4-26

2-64

Splenic Vascular Disorders

MBChB, FRCR

Choledocholithiasis
K. TWang,

2-42

Shlok j. Lolge, MD

MBChB, FRCR

Biliary Ductal Gas
K.T Wong, MBChB, FRCR

Cholangiocarcinoma
K.T Wong, MBChB, mCR

Ascending Cholangitis
K. TWang,

MBChB, FRCR

Recurrent Pyogenic Cholangitis

Shlok j. Lolge, MD

K.T Wong, MBChB, FRCR

AIDS-Related Cholangiopathy
K. TWang,

S_E_C_T_IO_N_3
Pancreas
Introduction

1

3-2

K.T Wong, MBChB, FRCR

Acute Pancreatitis

3-6

MBChB, FRCR

.

I

Urinary Tract Sonography

Column of Bertin, Kidney

3-14

Renal Ectopia

Line

K. TWang,

MBChB, FRCR

3-18

5-10

Winnie C. W Chu, MBChB, FRCl~

5-14

Winnie C. W Chu, MBChB, FRCl~

Ureteral Duplication

5-18

Winnie C. W Chu, MBChB, F/~CJ~

Ureteral Ectopia
Winnie C. W Chu, MBChB, FRCR

xx

5-8

Winnie C. W Chu, MBChB, FRCl~

Horseshoe Kidney

Simple Cysts and Cystic Neoplasms

5-6

Winnie C. W Chu, MBChB, FRCl~

Renal Junction

K.T Wong, MBChB, FRCR

Mucinous Cystic Pancreatic Tumor

5-2

Winnie C. W Chu, MBChB, FRCR

3-10

K.T Wong, MBChB, FRCR

Chronic Pancreatitis

SECTION 5
Urinary Tract

Normal Variants and Pseudolesions

Pancreatitis

Pancreatic Pseudocysts

4-28

j. Zwiebel, MD

Introduction and Overview

and Overview

Pancreatic Sonography

K. TWang,

William

MBChB, FRCR

_____

4-12

Shlok f. Lolge, MD

5-22


Ureteropelvic Junction

Obstruction

5-26

Vascular Conditions

Wil/I/ie C. W Chu, MBChB, FRCR

Calculi and Calcinosis
Urolithiasis

5-30

Renal Artery Stenosis
William f. Zwiebel, MO

5-108

Renal Vein Thrombosis

William f. Zwiebel, MO

5-112

Wil/I/ie C. W C/1II, MEChE, FRCR

Nephrocalcinosis

5-36

Prostate

Winnie C. W C11II,MBChB, FRCR

Hydronephrosis

5-40

Winnie C. W Chu, MEChE, FRCR

5-116

Prostatic Hypertrophy
Stella S.Y. /-10, PhO, I?OMS

Prostatic Carcinoma

Cysts and Cystic Disorders
Simple Renal Cyst

5-44

Bladder

Stella S.Y /-10, PhO, IWMS

Complex Renal Cyst

5-48

Diffuse Bladder Wall Thickening

5-54

Bladder Carcinoma

5-58

Ureterocele

Stella 5. Y /-10, PhO, ROMS

Cystic Disease of Dialysis
Stella 5. Y. /-10, P110, ROMS

Multilocular

Cystic Nephroma

5-60

Renal Trauma
0111,

Perinephric

5-128

Winnie C. W CIIII, MBChB, FRCR

5-132

Bladder Diverticulum

5-138

Winnie C. W Chu, MBChB, FRCR

Stella 5. Y. /-10, PhO, ROMS
Winnie C. W

5-124

Winnie C. W Chu, MBChB, FRCR

Winnie C. W Chu, MBChB, mCR

Winl/ie C. W Chu, MEChE, FRCR

Renal Papillary Necrosis

5-120

Stella S.Y. /-10, PhO, ROMS

5-62

Fluid Collections

Bladder Calculi
Winnie C. W

MEChE, FRCR

5-66

Stella S.Y. /-10, PhO, ROMS

Schistosomiasis,

M/3ChB, FRC/?

Bladder

5-144

Winnie C. W CIIII, MBChB, mCR

Urinary Tract Infection
Acute Pyelonephritis

5-142

0111,

5-70

SECTION 6
Renal Transplants

5-72

Introduction and Overview

Stella S.Y. /-10, PhO, ROMS

Focal Bacterial Nephritis
Stella S.Y. /-10, PhO, ROMS

Emphysematous

Pyelonephritis

5-74

Winnie C. W C/1II, MBChE, FRCR

Pyonephrosis

Sonographic

Features of Renal Allografts

5-76

Renal Transplants

Winnie C. W Chu, MEChE, FRCR

Renal Abscess

5-78

Stella 5. Y. /-10, PhO, ROMS

Xanthogranulomatous

Allograft Hydroneph rosis

Pyelonephritis

Urinary Tract Tuberculosis

5-80
5-82

5-86

Stella S.Y. /-10, PhO, ROMS

Renal Metastases

Allograft Rejection

6-18

Renal Transplant

6-22

William

5-92

SECTION 7
Adrenal Gland

5-94
5-98

Stella 5. Y. /-10, PhO, ROMS
Stella S.Y /-10, PhO, ROMS

Fistula/Pseudoaneurysm

/. Zwiebel, MO

Stella S.Y. /-10, PhO, ROMS

Cell Carcinoma

6-14

Renal Transplant Vascular Disorders
Willim/"l f. Zwiebel, MO

Stella S.Y /-10, PhO, ROMS

Renal Angiomyolipoma

6-10

Stella S.Y. /-10, PhO, ROMS

Solid Renal Neoplasms
Renal Cell Carcinoma

Perigraft Fluid Collections
Stella 5. Y /-10, PhO, ROMS

Stella S.Y. /-10, PhO, ROMS

Renal Lymphoma

6-6

Stella S.Y /-10, PhO, ROMS

Stella 5. Y. /-10, PhO, ROMS

Transitional

6-2

Stella 5. Y. }-}O, PhO, ROMS

Adrenal Hemorrhage

7-2

Shlok f. Lolge, MO

5-104

Myelolipoma

7-6

Sl1lok /. Lolge, MO

Adrenal Cysts

7-10

Shlok /. Lolge, MO

XXI


Pheochromocytoma

Shlok J. Lolge, MD

7-12

Adrenal Carcinoma
Shlok J. Lolge, MD

7-16

SECTION 8
Abdominal Wall/Peritoneal

Cavity

Abdominal Wall Hernia
Shlok f. Lolge, MD

8-2

Groin Hernias
Shlok J. Lolge, MD

8-6

Ascites
Shlok J. Lolge, MD

8-10

Peritoneal Carcinomatosis

Shlok J. Lolge, MD

8-14

Peritoneal Space Abscess

8-18

Shlok f. Lolge, MD

Appendicitis
Shlok J. Lolge, MD

8-22

Intussusception
Shlok f. Lolge, MD

8-26

SECTION 9
Female Pelvis

Pregnancy- Related Disorders
9-48

Ectopic Pregnancy
Roya Sohaey, MD

Interstitial Ectopic Pregnancy

Paula f. Woodward, MD

9-52

Failed First Trimester Pregnancy

9-56

Anne Kennedy, MD

Retained Products of Conception
Paula f. Woodward, MD

9-60

Gestational Trophoblastic Neoplasm

9-62

Roya Sohaey, MD

Ovarian Cysts and Cystic Neoplasms
Functional Ovarian Cyst

9-66

Anne Kennedy, MD

Hemorrhagic Cyst

9-70

Anne Kennedy, MD

Ovarian Hyperstimulation

9-76

Karen Y. Oh, MD

Serous Ovarian Cystadenoma/Carcinoma
Paula f. Woodward, MD

9-80

Mucinous Ovarian Cystadenoma/Carcinoma
Paula f. Woodward, MD

9-84

Ovarian Teratoma

9-88

Anne Kennedy, MD

Polycystic Ovarian Syndrome

9-94

Anne Kennedy, MD

Introduction and Overview
9-2

Pelvic Anatomy & Imaging Issues
Paula J. Woodward, MD

Non-Ovarian

Cystic Masses

Hydrosalpinx

Cervical and Myometrial

Pathology

Nabothian Cyst

Tubovarian Abscess
9-6

Roya Sohaey, MD

Cervical Carcinoma

9-98

Roya Sohaey, MD

Parovarian Cysts
9-10

9-100

Roya Sohaey, MD

9-104

Roya Sohaey, MD

Anne Kennedy, MD

Uterine Adenomyosis

9-14

Roya Sohaey, MD & Steven A. Larsen, MD

Uterine Leiomyoma

9-18

Roya Sohaey, MD & Steven A. Larsen, MD

Vaginal and Vulvar Cysts
Bartholin Cyst
Gartner Duct Cyst

9-22

Anne Kennedy, MD

Endometrial Polyp

Sex Cord-Stromal Tumor

9-32

Ovarian Fibrothecoma
Paula J. Woodward, MD & Kaerli Main

9-116

9-34

Peritoneal Inclusion Cyst

9-120

9-38

Endometriomas

Anne Kennedy, MD

Endometrial Carcinoma
Anne Kennedy, MD

Endometritis
Paula J. Woodward, MD
Myometrial & Endometrial Calcification

9-42

Roya Sohaey, MD

Synechiae
Paula f. Woodward, MD

XXll

Miscellaneous Ovarian Masses

9-26

Anne Kennedy, MD

Endometrial Hyperplasia

9-108

Anne Kennedy, MD

Endometrial Disorders
Hematometrocolpos

9-106

Anne Kennedy, MD

9-44

9-112

Paula f. Woodward, MD

Roya Sohaey, MD & Steven A. Larsen, MD
Roya Sohaey, MD

9-124


Multinodular Goiter

SECTION 10
Scrotum

11-28

Ani! T. Ahuja, MO, FRCR

11-32

Graves Disease
Ani! T. Ahuja, MO, FRCR

Parathyroid Adenoma, Visceral Space

Introduction and Overview

11-36

Ani! T. Ahuja, MO, FRCR

10-2

Scrotal Sonography
Bhawan K. Paunipagar, MO, ONB

Adenopathy

Scrotum
Testicular Atrophy

Reactive Adenopathy
10-6

Bhawan K. Paunipagat; MO, ONB

Undescended Testis

10-8
10-10

Tuberculous Adenopathy
Non-Hodgkin Lymphoma Nodes

10-12

Systemic Metastases, Neck Nodes

Sialadenitis
10-22

Bhawan K. Paunipagat; MO, ONB
Bhawan K. Paunipagat; MO, ONB

Scrotal Trauma

11-64

Ani! T. Ahuja, MO, FRCR

Sjogren Syndrome, Parotid
10-32

11-62

Ani! T. Ahuja, MO, FRCR

Kimura Disease
10-28

11-58

Ani! T. Ahuja, MO, FRCR

Submandibular Gland Carcinoma

10-26

Testicular Torsion/Infarction

11-54

Ani! T. Ahuja, MO, FRCR

Benign Mixed Tumor, Submandibular Gland
10-24

Bhawan K. Paunipagar, MO, ONB

Tubular Ectasia

Salivary Glands

10-18

Bhawan K. Paunipagar, MO, ONB

Testicular Microlithiasis

11-52

10-16

Bhawan K. Paunipagar, MO, ONB

Gonadal Stromal Tumor

11-48

Ani! T. Ahuja, MO, FRCR

Bhawan K. Paunipagar, MO, ONB

Testicular Carcinoma

11-46

Ani! T. Ahuja, MO, FRCR

Bhawan K. Paunipagar, MO, ONB

Epidermoid Cyst

11-42

Ani! T. Ahuja, MO, FRCR

Bhawan K. Paunipagar, MO, ONB

Testicular & Epididymal Cysts

Squamous Cell Carcinoma Nodes
Ani! T. Ahuja, MO, FRCR

Bhawan K. Paunipagar, MO, ONB

Hydrocele

11-40

Ani! T. Ahuja, MO, FRCR

11-68

Ani! T. Ahuja, MO, FRCR

Bhawan K. Paunipagar, MO, ONB

Epididymal Masses
Epidid ymi tis/ 0rchi tis

10-38

Bhawan K. Paunipagar, MO, ONB

Varicocele

Parotid Space

10-34

Bhawan K. Paunipagar, MO, ONB

10-44

Bhawan K. Paunipagar, MO, ONB

Benign Mixed Tumor, Parotid

11-72

Ani! T. Ahuja, MO, FRCR

Warthin Tumor

11-76

Ani! T. Ahuja, MO, FRCR

Mucoepidermoid Carcinoma, Parotid

11-80

Ani! T. Ahuja, MO, FRCR

SECTION 11
Head and Neck

Adenoid Cystic Carcinoma, Parotid

Miscellaneous lumps

Introduction and Overview
Head & Neck Sonography

11-2

Ani! T. Ahuja, MO, FRCR

Benign Masseter Muscle Hypertrophy

Lymphangioma
11-6

Ani! T. Ahuja, MO, FRCR

Ani! T. Ahuja, MO, FRCR

Thyroid Non-Hodgkin Lymphoma
Ani! T. Ahuja, MO, FRCR

Hashimoto Thyroiditis

11-106

Ani! T. Ahuja, MO, FRCR

Lipoma
11-24

11-102

Ani! T. Ahuja, MO, FRCR

Thyroglossal Duct Cyst
11-20

11-98

Ani! T. Ahuja, MO, FRCR

Carotid Body Paraganglioma
11-16

11-92

Ani! T. Ahuja, MO, FRCR

2nd Branchial Cleft Cyst
11-12

Ani! T. Ahuja, MO, FRCR

Anaplastic Thyroid Carcinoma

11-88

Ani! T. Ahuja, MO, FRCR

Thyroid and Parathyroid

Medullary Thyroid Carcinoma

11-86

Ani! T. Ahuja, MO, FRCR

Ranula

Differentiated Thyroid Carcinoma

11-84

Ani! T. Ahuja, MO, FRCR

11-110

Ani! T. Ahuja, MO, FRCR

Ani! T. Ahuja, MO, FRCR

XXlll