2004 Emergency Ultrasound

Radiol Clin N Am 42 (2004) xi
Preface
Emergency ultrasound
Vikram Dogra, MD
Guest Editor
Ultrasonography has undergone many technologic tient care. Most of the articles describe sonography
changes resulting in its present state-of-the-art equip- techniques and pertinent sonographic anatomy to help
ment that is capable of high-resolution real-time those who are new to the field of ultrasonography.
gray-scale imaging and tissue harmonics, including This issue on emergency ultrasound provides the
color and power Doppler. These advances in ultra- reader with up-to-date information on what is new,
sound technology have resulted in improved work-up exciting, and relevant in the practice of ultrasonog-
of patients undergoing evaluation in emergency de- raphy as it pertains to acutely ill patients.
partments because it is the first imaging performed on I wish to express my thanks to Joseph Molter for
almost all patients presenting to an emergency facil- preparing the illustrations, to Bonnie Hami, MA, for
ity. This easily available imaging modality remains her editorial assistance, and to Adrienne Jones for her
the primary workhorse in diagnostic radiology not secretarial assistance. In addition, my sincere thanks
only in day-to-day practice but also in emergency go to Barton Dudlick at Elsevier Science for his
situations. There has been a need for the Radiologic administrative and editorial assistance.
Clinics of North America to dedicate an issue solely
to the practice of emergency ultrasound and I am Vikram Dogra, MD
honored to be the guest editor of this issue. Great care Division of Ultrasound
has been given to the selection of topics for this issue, Department of Radiology
and pertinent findings have been summarized in the Case Western Reserve University
form of tables for easy reference in most of the University Hospitals
articles where problem-solving algorithms are also 11100 Euclid Avenue
included. Relevant topics have been included that Cleveland, OH 44106, USA
are helpful to all clinicians involved in emergency pa- E-mail address: Dogra@uhrad.com
0033-8389/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.rcl.2004.01.004
Radiol Clin N Am 42 (2004) 257 – 278
Hepatobiliary imaging and its pitfalls

Deborah J. Rubens, MD
Departments of Radiology and Surgery, University of Rochester Medical Center, 601 Elmwood Avenue,
Rochester, NY 14642-8648, USA
Diagnosis of acute cholecystitis Sonographic Murphy’s sign
Acute cholecystitis is the result of obstruction of The sonographic Murphy’s sign is defined as
the gallbladder and accompanying inflammation of specific reproducible point tenderness over the gall-
the gallbladder wall with associated infection and bladder as the transducer applies pressure. In a classic
sometimes necrosis. Ninety percent to 95% of cases article by Dr. Phillip Ralls [4], which included only
of acute cholecystitis are caused by obstruction by patients with right upper quadrant pain, fever, and an
gallstones in either the gallbladder neck or the cystic elevated white blood cell count, a sonographic Mur-
duct [1]. Acute cholecystitis occurs in only approxi- phy’s sign was 87% specific for the diagnosis of
mately 20% of patients who have gallstones [2]. This acute cholecystitis. When a positive sonographic
means that many patients with gallstones have no Murphy’s sign is used in conjunction with the pres-
symptoms, and their right upper quadrant pain may ence of gallstones, it has a positive predictive value of
be caused by a different etiology [3]. Of patients who 92% for diagnosing acute cholecystitis. Persons in
present with right upper quadrant pain, only 20% to whom a sonographic Murphy’s sign may be absent
35% have acute cholecystitis [1,2]. As the definition include persons who are medicated; therefore, careful
of ‘‘right upper quadrant pain’’ becomes less specific, attention to a patient’s clinical status is important.
especially lacking an accompanying elevated white Denervated gallbladders in patients who have diabe-
blood cell count and fever, the percentage of patients tes or gangrenous cholecystitis may result in the loss
who actually have acute cholecystitis given the his- of a sonographic Murphy’s sign.
tory of right upper quadrant pain diminishes further.
Specific criteria for the diagnosis of acute cholecys-
titis are important, because many patients have gall-
Gallstone diagnosis and pitfalls
stones but may not have acute cholecystitis. The
primary diagnostic criterion is a positive sonographic
Gallstones are diagnosed by the presence of
Murphy’s sign in the presence of gallstones. Second-
gravity-dependent, mobile intraluminal echoes within
ary signs of acute cholecystitis include gallbladder
the gallbladder, which cast a posterior shadow
wall thickening more than 3 mm, a distended or
(Fig. 1). Although ultrasound (US) has a high accu-
hydropic gallbladder (loss of the normal tapered neck
racy ( > 95%) for the diagnosis of gallstones, some
and development of an elliptical or rounded shape),
stones may be missed [3]. False-negative results
and pericholecystic fluid.
occur because of stones that are too small to cast a
shadow (usually smaller than 1 mm), soft stones that
lack strong echoes [1], and gallstones that are im-
pacted in the gallbladder neck or in the cystic duct
and may not be as readily visible (see Fig. 1) [5]. If
the gallbladder is focally tender but no gallstones are
E-mail address: Deborah_Rubens@urmc.rochester.edu appreciated, the patient should be examined from
doi:10.1016/j.rcl.2003.12.004
258 D.J. Rubens / Radiol Clin N Am 42 (2004) 257–278
Fig. 1. Gallstones. (A, left) Gallstone in the gallbladder neck (arrow) casts no significant shadow and is nearly invisible. Gas in
the duodenum (arrowhead) obscures the fundus and casts a strong sharp shadow (asterisk). (Right) With patient in sitting
position, stone (arrow) moves out of the neck and casts a clear shadow (asterisk). Adjacent duodenum (arrowheads) is separate
from the gallbladder but still casts a strong shadow, equivalent to the gallstone. (B, left) Multiple gallstones (arrowheads), some
of which cast shadows (arrows) and some of which do not. (Right) Normal caliber common duct (6 mm at the porta) with stones
(arrows) in same patient. Choledocholithiasis may be difficult to detect, especially in the distal duct, if the stones do not shadow
or are not outlined by the distal fluid. (C, left) Longitudinal US shows a normal gallbladder. (Right) Harmonic imaging reveals
multiple small stones (arrows).
multiple positions, including prone position or up- Echogenicity of stones may be decreased in soft
right position, to help stretch out the gallbladder pigment stones. These stones are commonly associ-
[3,6]. Decubitus or intercostal scanning also may ated with recurrent pyogenic cholangiohepatitis and
help visualize the neck, which may not be as easily are more often seen in the bile ducts than in the
apparent from a subcostal supine approach. gallbladder. They look more like soft-tissue masses
Resolution of small stones in the gallbladder can than stones and may or may not cast acoustic shad-
be improved with use of harmonic imaging [7,8]. This ows. They may be misinterpreted as sludge or debris
approach uses the higher frequency of the returning and give a false-negative diagnosis for gallstones.
sound beam for better resolution and decreases the False-positive results may arise from side lobe
scattering from superficial structures in the abdominal artifacts, which give rise to echoes that seem to arise
wall and in the adjacent liver. Harmonic imaging within the gallbladder lumen but are actually gener-
improves the echoes cast by stones and strengthens ated from the wall or outside the wall [1]. Similarly,
their posterior shadows. This improved resolution partial volume artifacts from gas in the adjacent bowel
may permit visualization of stones not seen with may mimic stones with strong echoes and posterior
conventional gray scale US (see Fig. 1). shadowing (see Fig. 1A). A calcium bile salt precipi-
Fig. 2. Pseudo gallbladders. (A) Transverse image in the right upper quadrant with structure identified as the gallbladder (arrows)
containing debris (asterisk). Note that the ‘‘gallbladder’’ does not extend anteriorly and that the aorta (A) is immediately adjacent.
(B, left) CT image of the same area as in A shows a fluid-containing structure (arrows) with similar attenuation to blood in the
aorta (A). This was a hematoma.(Right) The true gallbladder (GB) is lateral to the aorta and extends anteriorly. (C, left) Distended
fluid- and debris-containing structure believed to represent an abnormal gallbladder in this patient with right upper quadrant pain.
(Right) The true gallbladder (arrows) is compressed and displaced by the adjacent mass, a pancreatic pseudocyst. (D) CT of the
pancreatic pseudocyst (P) displacing the gallbladder (arrows).
D.J. Rubens / Radiol Clin N Am 42 (2004) 257–278 259
tate may form with the use of Ceftriaxone and mimic associated with complications such as gangrenous
gallstones on sonographic examination. These precip- cholecystitis [9]. A striated wall also is nonspecific,
itates resolve after the patient ends therapy. however, and may be seen in all the other causes of
Other fluid-containing structures may mimic the wall thickening, including hepatitis (Fig. 6) [10].
gallbladder, especially if the gallbladder is out of its Similarly, pericholecystic fluid is a nonspecific
normal position or is small and contracted. These finding; it may occur because of ascites or localized
structures include the duodenum, gastric antrum or inflammation from other causes, such as peptic ulcer
colon, hematomas, pancreatic pseudocysts (Fig. 2), or disease (see Fig. 4) [2]. Teefey et al [10] described
even dilated vascular collaterals. Mistaking these two specific patterns of pericholecystic fluid. Type I,
structures for the gallbladder may result in missed a thin, anechoic, crescent-shaped collection adjacent
pathology in the true gallbladder or a false-positive to the gallbladder wall, is nonspecific (see Fig. 4B).
diagnosis of gallbladder disease (ie, obstructed gall- Type II, a round or irregular shaped collection with
bladder or acalculous cholecystitis). thick walls, septations, or internal debris, is associated
with gallbladder perforation and abscess formation
(Fig. 7) [10]
Gallbladder wall thickening and pericholecystic
fluid
Gallbladder wall thickening is defined as a wall Acute acalculous cholecystitis

diameter more than 3 mm and is present in 50% of
patients with acute cholecystitis (Fig. 3) [1]. The This is an acute inflammation of the gallbladder
gallbladder wall may be thickened because of hepatic that occurs in up to 14% of patients with acute
congestion or edema from liver disease, right heart cholecystitis [11]. It is most frequently seen in post-
failure, or generalized edema from hypoproteinemia, trauma and postsurgical patients and other hospital-
which is often associated with renal disease or hepatic ized patients and occurs because of conditions that
dysfunction [3]. A thickened gallbladder wall also lead to ischemia, hypotension, or sepsis [12]. These
can occur in association with adjacent inflammatory critically ill patients are often medicated with nar-
conditions, including hepatitis, peptic ulcer disease cotics, are on ventilators, and receive hyperalimenta-
(Fig. 4), pancreatitis, perihepatitis (Fitz-Hugh-Curtis tion, which contributes to biliary stasis and functional
syndrome), and pyelonephritis (Fig. 5). cystic duct obstruction [2,12]. Gallbladder gangrene
A thickened, striated gallbladder wall consists of is associated in 40% to 60% of cases, with increased
alternating hyper- and hypoechoic layers. When seen risk of perforation [2]. Mortality ranges from 6% to
in the setting of acute cholecystitis, it is strongly 44% but can be reduced by early diagnosis and
therapy [12]. In the series by Cornwall et al [12],
only 50% had a sonographic Murphy’s sign. This is
a difficult clinical and ultrasonic diagnosis, because
gallstones are absent and the sonographic Murphy’s
sign may be limited because of other illnesses
and medication. The diagnosis is made by gallblad-
der tenderness (if present) and is associated with
gallbladder distension, intraluminal debris, and gall-
bladder wall thickening that is not caused by other
etiologies, such as hypoalbuminemia, congestive
heart failure, or hepatic congestion (Fig. 8). Because
gallbladder wall thickening is nonspecific, CT can be
used to visualize pericholecystic inflammation to
improve diagnostic specificity [2,13].
Fig. 3. Acute cholecystitis. This patient presented with right Complicated cholecystitis
upper quadrant pain and a positive sonographic Murphy’s
sign. Longitudinal US shows stones (arrows) and diffuse Complications of acute cholecystitis include gan-
gallbladder wall thickening (cursors) that measures 5 mm. grenous cholecystitis, emphysematous cholecystitis,
Fig. 4. Peptic ulcer perforation and thick gallbladder wall. (A) Patient with right upper quadrant pain, fever, and elevated white
blood cell count. US shows focal gallbladder wall thickening (7-mm cursors) and gallstones (asterisks) and could be interpreted
as cholecystitis. The free air with reverberation shadows (arrows) that leads to the correct diagnosis could be overlooked easily.
(B) Transverse US shows wall thickening (cursors) and simple pericholecystic fluid (arrow). (C) CT image shows peri-
cholecystic fluid (arrows), free air (arrowheads), and extraluminal accumulated air (paired arrowheads) in perforated duo-
denal ulcer.
and gallbladder perforation. These complications oc- Gangrenous cholecystitis

cur in up to 20% of patients [3]. Complications of
acute cholecystitis are important to detect because they Gangrenous cholecystitis is defined histologically
are associated with increased morbidity (10%) and as coagulative necrosis of the mucosa or the entire
mortality (15%) [14] and require emergency surgery wall associated with acute or chronic inflammation
[2]. There is also approximately a 30% conversion [10]. It occurs in up to 20% of patients with acute
for laparoscopic cholecystectomy to an open proce- cholecystitis and has an increased risk of perforation
dure in the setting of complicated cholecystitis [14]. [3]. Unfortunately, US is relatively nonspecific for the
Fig. 5. Pyelonephritis with gallbladder wall thickening. (A) Gallbladder wall shows marked 1.3 cm thickening (cursors) and
hypoechoic fluid within the wall. (B) Transverse US of the lower pole of the right kidney shows a 3-cm echogenic mass
(arrows). (C) CT through the right lower pole shows the characteristic round, heterogeneous decreased attenuation area of
pyelonephritis (arrows).
diagnosis of gangrenous cholecystitis because a sono- ciation with gangrenous cholecystitis [3]. The fundus
graphic Murphy’s sign is absent in two thirds of is the most common site for perforation because it has
patients [15]. A relatively specific finding is intra- the least blood supply. Acute perforation with free
luminal membranes caused by a fibrous exudate or intraperitoneal bile results in peritonitis and is rare.
necrosis and sloughing of the gallbladder mucosa More commonly, subacute perforation occurs, which
(Fig. 9). This finding is present, however, in only results in pericholecystic abscess formation [2].
5% of patients [10]. These abscesses may occur in or adjacent to the
gallbladder wall in the gallbladder fossa, within the
liver, or along the free margin of the gallbladder
within the peritoneal cavity [10]. They are character-
Gallbladder perforation ized by complex fluid collections with inflammatory
changes in the adjacent fat on US or CT [2]. Patients
Gallbladder perforation occurs in 5% to 10% of with peritoneal or liver abscesses require immediate
patients with acute cholecystitis, most often in asso- surgery and drainage, respectively, whereas abscesses
in the gallbladder wall and fossa may respond to

conservative management [16].
Pericholecystic fluid adjacent to the gallbladder
wall may mimic perforation. Upon careful inspection,
however, the wall is intact and the fluid anechoic (see
Fig. 4B). Fluid that appears within the walls been
noted to precede perforation in one case [17]; how-
ever, no specific US features predict which gallblad-
ders will perforate.
Emphysematous cholecystitis
This is a rare complication of acute cholecystitis

(less than 1% of all complicated cases) and is
associated with gas-forming bacteria in the gallblad-
der lumen or in the gallbladder wall. As many as 40%
Fig. 6. Hepatitis, with striated gallbladder wall thickening.
of patients with emphysematous cholecystitis have
Longitudinal US of contracted gallbladder with a thickened
striated wall (arrows) with alternating echogenic and hypo- diabetes [2]. The clinical course is rapidly progres-
echoic layers. This patient had right upper quadrant pain, sive, with 75% incidence of gallbladder gangrene and
fever, abnormal liver function tests, and a negative sono- 20% incidence of perforation [18]. Emphysematous
graphic Murphy’s sign. She tested positive for hepatitis B and cholecystitis can be recognized by the antidependent
clinically had acute alcoholic hepatitis. The striated wall is gas echoes within the lumen (Fig. 10). Intramural gas
not specific for gallbladder disease. may be more difficult to identify because it may
mimic the calcified wall of a porcelain gallbladder.
The type of shadowing (‘‘clean’’ versus ‘‘dirty’’) does
not differentiate between calcium and air. The loca-
tion of the echoes does. If the presence of gas is
Fig. 7. Complicated cholecystitis with gallbladder perforation. (A) Longitudinal US of the gallbladder (GB) with adjacent
irregularly marginated pericholecystic intrahepatic fluid (arrows). This patient presented with sepsis 2 weeks after prostate
surgery and was found to have acute cholecystitis with an adjacent liver abscess. (B) Longitudinal US of gallbladder with stones
shows a pericholecystic collection (arrow) that contains debris. The collection abuts the free wall of the gallbladder and is not
contained within the gallbladder wall (double arrow). (C) CT shows an enhancing rim around the fluid (arrows) and
inflammatory edema in the adjacent fat (arrowheads).
Fig. 9. Gallbladder gangrene/mucosal sloughing. Longitu-

dinal US of patient with acute cholecystitis secondary to
stone (arrow) impacted in the gallbladder neck. Note the
intraluminal membranes (arrowheads), which are associ-
ated with gallbladder gangrene.
extrinsic masses with biliary duct compression and

obstruction. The diagnosis is made by evaluation of
Fig. 7 (continued).
intra- and extrahepatic ducts, because one or both
may be dilated, depending on the level of obstruction.
uncertain, either CT or plain film radiography can be

used to differentiate between gas and calcification. Ultrasound diagnosis of duct dilatation
The extrahepatic common duct is measured from

Biliary ducts outer wall to outer wall at the level of the crossing of
the right hepatic artery. The diameter at this level
Dilated biliary ducts in the acute patient represent should not exceed 6 mm [1]. The diameter of the
a relative emergency because sepsis in association common duct is slightly greater distally as it ap-
with dilated ducts requires rapid decompression. proaches the pancreas, sometimes as much as 1 to
Biliary duct dilatation may be the result of multiple 2 mm. There is still debate in literature as to whether
causes, including stones, tumor, stricture, or adjacent the bile duct dilates with age or after cholecystectomy
[1]. Most laboratories consider a duct smaller than
6 mm normal and a duct 8 mm or larger abnormal
[1,19]. Clinically, if a patient has dilated ducts but no
accompanying symptoms—elevated bilirubin, pain,
sepsis, or elevated liver enzymes, including alkaline
phosphatase—the dilated ducts are unlikely to be
clinically relevant. Similar to the presence of gall-
stones, when assessing the ducts for biliary disease,
the clinical scenario is of prime importance. Intra-
hepatic biliary ducts are normal if they are 2 mm or
smaller in the porta or no more than 40% of the
diameter of the accompanying portal vein [1]. With
the advent of newer equipment, however, it is possi-
ble to see intrahepatic biliary ducts in normal patients,
especially with the use of harmonic imaging, which
Fig. 8. Acalculous cholecystitis. Longitudinal US of a debris- diminishes scatter. Clinical correlation is important,
filled (asterisk) gallbladder with a thick, striated wall (ar- because many young and slender patients may show
rows). No stones are visualized. At surgery, this was acute normal ducts with high-frequency transducers
acalculous cholecystitis. (Fig. 11A). In general, intrahepatic biliary duct dila-
Fig. 10. Emphysematous cholecystitis. (A) Transverse supine view of the gallbladder reveals nondependent echoes anteriorly
(arrowheads), which cast a dense posterior shadow. (B) When viewed longitudinally from the flank, the dependent echogenic
gallstones (arrows) can be seen. Note that the shadow cast by the gas in (A) is denser and sharper than that from the stones (B).
The bowel gas does not necessarily cast a ‘‘dirty’’ or reverberant echo-filled shadow. Thus, the shadow cannot distinguish gas
from the stones.
Fig. 11. Normal ducts. (A) Normal intrahepatic ducts (cursors) in a post-cholecystectomy patient. Multicolored vessel in the
center of the color box is the hepatic artery (HA), and dark red adjacent vessel is the portal vein (PV). (B,C) Patient with
abdominal pain, nausea, and jaundice, 1 month after cholecystectomy. Note multiple anechoic irregularly branching tubes with
confluence in the porta hepatis. Color Doppler image (C) confirms that some are avascular and represent ducts (arrowheads), and
the portal veins (red), hepatic veins(blue) and hepatic arteries (HA) are correctly identified. The inferior vena cava (IVC) and
hepatic vein (HV) as shown can be recognized by its anatomic position.
drink water to displace gas or by using large a

footprint curvilinear transducer to compress bowel
and bowel gas away from the distal duct. Ninety
percent of obstruction occurs in the distal duct be-
cause of common duct stones, pancreatic carcinoma,
or pancreatitis [1]. Obstruction also may occur at the
level of the porta hepatis, usually because of tumor
(cholangiocarcinoma) or adenopathy. Sclerosing
cholangitis gives rise to segmentally dilated ducts,
often only in one portion of the liver (Fig. 13). These
patients may develop infection and present with
sepsis. Other causes of obstruction between the
pancreas and the porta hepatis include masses of
the colon or duodenum (Fig. 14), primary biliary
malignancy, or adenopathy.
Pitfalls include patients who have obstruction
without dilatation, which can occur in ascending
Fig. 11 (continued). cholangitis, intermittent obstruction from stones, or
sclerosing cholangitis. As many as one third of
common bile duct calculi are found in nondilated bile
tation can be diagnosed by irregular angular branch- ducts (see Fig. 1B) [1]. In this group of patients, US is
ing, a central stellate configuration, and acoustic relatively insensitive to make the diagnosis. MR
enhancement posteriorly to the ducts (Fig. 11B) [1]. cholangiopancreatography (MRCP) and endoscopic
The use of color and power Doppler may be valuable retrograde cholangiopancreatography (ERCP) should
to demonstrate that the dilated structures are ducts be considered the alternative diagnostic modalities,
and that the normal portal veins and hepatic arteries especially for stone disease.
course adjacent to them (Fig. 11C). Biliary duct
necrosis is a critical complication that occurs after
liver transplant. In this situation, the ducts may not be Acute hepatic disease processes
filled with bile but may be filled with pus or necrotic
debris. They also may appear echogenic and irregular Multiple abnormalities of the liver may present
and enlarged without any fluid component (Fig. 12). with right upper quadrant pain. Some of these situa-
If the diagnosis of biliary disease is in question on tions involve medical emergencies, including lesions
US, CT scan or transhepatic cholangiography may be that are hemorrhagic or patients who have infection
helpful in posttransplant patients. and sepsis. Space-occupying disorders that stress the
liver capsule also may present with right upper
quadrant pain. These disorders range from acute fatty
infiltration to hepatitis to diffuse metastatic disease.
Diagnosis of biliary obstruction
The important clinical features to determine are
whether the patient has infection or sepsis and if
Assuming a patient has a dilated duct (6 mm or
the pain is localized to the liver or is more diffuse
larger) associated with clinical signs of obstruction
(peritoneal signs). Anatomically the hepatic processes
(including elevated bilirubin or elevated alkaline
can be divided into diffuse disease, focal disease, and
phosphatase), how well does US identify the level
diseases that involve the vasculature.
and cause of obstruction?
With good technique, the level of obstruction can
be defined in up to 92% of patients and the cause in
up to 71% [1]. Important technical factors include Hepatitis
positioning the patient in the erect right posterior
oblique or right lateral decubitus position to minimize Hepatitis is a viral infection of the liver. The most
overlying bowel gas from the antrum or the duode- common acute presentation is from hepatitis A,
num and using transverse scans to follow the duct which is spread via oral ingestion with a 99%
accurately [1]. Additional technical improvements recovery rate [20]. Patients present acutely with
sometimes can be achieved by having the patient jaundice, fever, and hepatomegaly. Sonographically,
Fig. 12. Biliary duct necrosis. (A) Transverse US of a liver transplant patient who presented with sepsis. Amorphous echogenic
debris (arrows) is seen on gray scale. (B) Two months later, the process has progressed. The echogenic areas (arrows) are more
confluent and linear and cast acoustic shadows, which obscure the adjacent parenchyma. (C) Color Doppler image shows
echogenic debris in a ductal distribution (arrows) and a low resistive index (less then 0.5) in the hepatic artery, which signifies
hepatic arterial stenosis or thrombosis. (D) The extensive biliary duct necrosis (arrows) and the resulting liver abscess
(arrowheads) are documented by CT. The abscess was obscured on the US because of shadowing from the ducts.
most often the liver parenchyma is normal [20,21]. be obtained by checking the echogenicity of the
Rarely, the liver may have diffusely decreased echo- spleen relative to the left kidney to confirm that there
genicity with relatively increased echogenicity of the is no medical renal disease [20]. More commonly,
portal triads—the ‘‘starry-sky’’ appearance [21]. The hepatitis has associated gallbladder findings, includ-
overall echogenicity of the liver is decreased relative ing gallbladder wall thickening (see Fig. 6) and
to the adjacent kidney (Fig. 15). Confirmation should sometimes a contracted gallbladder [20,21]. When
Fig. 13. Sclerosing cholangitis. Patient presented with sepsis and abdominal pain. (A) Longitudinal US of the right lobe is
normal, with a common duct (cursors) measuring 2 mm. (B) Longitudinal US of the left lobe shows multiple markedly enlarged
ducts (arrows). (C) CT shows the asymmetrically enlarged ducts (arrows) with enhancing walls, which indicates inflammation.
Emergent biliary drainage was performed, which alleviated the patient’s symptoms.
the patient recovers from hepatitis, the gallbladder lesions smaller than 2 cm, may be widely scattered in
wall and distention return to normal. Other viral the liver or may cluster in a single focus. Pyogenic
infections that involve the liver, such as mononucleo- abscess cavities probably begin as a small cluster of
sis, may cause a similar pattern, with liver swelling, microabscesses, which coalesce into a larger drainable
tenderness, and gallbladder wall thickening (Fig. 16). collection [22]. Sonographically, abscess margins are
often indistinct; which make abscesses less conspicu-
ous than on contrasted CT scans. This is particularly
Liver abscess true in small clustered microabscesses (Fig. 17A, B).
Predominately abscesses are hypoechoic (see Fig. 7A)
The most common liver abscesses are pyogenic, but also may be isoechoic, solid appearing, or even
caused by bacteria. Patients most often present with hyperechoic if they contain gas and debris (Fig. 17C).
right upper quadrant pain, fever, and malaise. The Fifty percent or less have enhanced through transmis-
cause may be biliary (ascending cholangitis or from sion. Because of this variable appearance, the differ-
the adjacent gallbladder), portal venous (from diver- ential diagnosis is large and includes tumor, simple
ticulosis or Crohn’s disease), or arterial. Fifty percent cyst with hemorrhage, hematoma, or other forms of
of liver abscesses do not have a clear source [20]. The infection, including amebic abscess or ecchinococcal
appearance of liver abscesses varies. Microabscesses, infection. The absence of flow centrally helps to
Fig. 14. Duodenal mass with biliary, pancreatic, and bowel obstruction. Patient presented to the emergency department with
nausea and rising bilirubin. (A) Transverse US of the pancreas shows a 1.8-cm common duct (CD) and a dilated pancreatic duct
(arrowheads). (B) Longitudinal US shows a distended gallbladder with a soft-tissue mass (arrows) behind it. (C) On transverse
imaging, the mass (arrows) obstructs the duodenum (Duod), which has a fluid-filled proximal lumen. GB, gallbladder. (D) CT
confirms the circumferential duodenal tumor (arrows). Note distended gallbladder (GB) and common duct (CD).
confirm that these are not solid tumors; however, abscess involvement. In this case, contrast-enhanced
necrotic neoplasm remains in the differential diagno- CT is often helpful in detecting the total abscess
sis. The most helpful feature is a clinical scenario that burden and may identify the cause, especially if the
includes signs of infection. Abscesses are frequently abscess arises from the bowel. After liver transplant,
multiple, and US may be limited near the dome or patients are particularly prone to abscesses, especially
underneath the ribs for identifying the extent of if biliary necrosis is present because of hepatic arterial
that of cholecystitis or hepatitis. On imaging, meta-

static disease may be of any type from cystic metas-
tases of carcinoid to echogenic metastases from colon
carcinoma or any other primary lesion. The liver is
enlarged and tender to palpation, usually because of
stretching of the liver capsule (Fig. 18A). Another
disease process that causes rapid hepatic enlargement
is acute fatty infiltration of the liver, which may be
diffuse and homogenous fatty infiltration (Fig. 18B)
of the liver or segmental fatty infiltration with areas
of focal sparing. The liver may enlarge rapidly and
give rise to the clinical symptoms of right upper
quadrant tenderness. Vessels are not distorted, how-
ever, and if there are areas of focal fatty infiltration,
they should have a geographic margin. If metastatic
disease is in the differential diagnosis, a sulfur colloid
Fig. 15. Acute hepatitis. Transverse image shows a hypo- nuclear medicine scan can be performed, which
echoic liver relative to the kidney (K) and bright portal triads should produce normal results in the setting of fatty
(arrowheads), the ‘‘Starry Sky’’ appearance. Although strik- infiltration. An MR imaging scan with and without
ing, this appearance is rare. Most often the hepatic echo- fat suppression also defines the cause of the US
genicity is normal.
abnormalities. Acute fatty liver of pregnancy is a
relatively rare but serious complication that occurs in
thrombosis. If a transplant patient presents with a the third trimester and peripartum. Two-thirds of
hepatic abscess, the patency of the hepatic arteries patients have associated pre-eclampsia or the hemo-
should be assessed (see Fig. 12). lysis, elevated liver enzymes and low platelets
(HELLP) syndrome [23]. Patients present with vari-
ous symptoms, most commonly nausea, vomiting,
Noninfectious diffuse enlargement of the liver abdominal pain, fever, and jaundice [23,24]. Symp-
toms commonly mimic hepatitis. Laboratory ab-
Patients with diffuse metastatic disease may pres- normalities include elevated liver enzymes and
ent with right upper quadrant pain, sometimes with coagulopathy (prolonged prothrombin time [PTT]).
fever and jaundice. When patients are questioned Disseminated intravascular coagulation occurs in up
closely, their symptoms are usually not as acute as to 50% [23]. US and CT may have high false-
Fig. 16. Mononucleosis. (A) Initial longitudinal US in a patient 18 weeks pregnant with right upper quadrant pain, nausea, and
vomiting. The gallbladder is thick walled (arrows) and contains debris. A diagnosis of acute acalculous cholecystitis was offered.
(B) One week later the galbladder wall (arrows) has returned to normal and the sludge is diminishing. The patient tested positive
for mononucleosis.
Fig. 17. Liver abscesses. (A) Transverse US of nearly invisible microabscesses (cursors) within the liver. There are no specific
US features to identify this as an abscess. The area is slightly heterogeneous and lacks a normal vessel pattern. (B) CT of the left
lobe contains a typical rosette pattern diagnostic of clustered small abscesses with enhancing rims (arrows). A right lobe abscess
(arrow) could not be seen by US. (C) Mixed abscesses and gas. Longitudinal US of a patient with multifocal abscesses. The
fluid-containing abscess (A) anteriorly contains gas (arrow) with a reverberant echo posteriorly. The isoechoic abscess more
posteriorly (arrowheads) with central gas is more difficult to detect. (D) CT scan shows both abscesses. The more central abscess
(arrowheads) is much more extensive on CT than on US.
negative rates (as high as 80%), and the diagnosis subsequent presentation of the patient for emergency
largely depends on clinical features and biopsy, if US. Even innocuous lesions, such as benign liver
necessary [23,24]. cysts, occasionally can hemorrhage with resultant
symptoms. Hemangiomas, the most common benign
tumors of the liver, are mostly small and asympto-
Focal lesions with hemorrhage matic and discovered incidentally. Lesions larger than
5 or 6 cm occasionally may present with either
Any focal hepatic lesion can potentially bleed, hemorrhage or thrombosis [20]. Hepatic adenoma, a
which leads to acute right upper quadrant pain with benign tumor associated with estrogen or anabolic
Fig. 18. Diffuse liver enlargement. (A) Carcinoid metastases. Longitudinal US of a patient with acute right upper quadrant pain to
‘‘rule out (R/O) cholecystitis.’’ The gallbladder is normal; however, the liver was enlarged at 21 cm and riddled with cystic thick-
walled metastases (arrows) from a carcinoid primary. (B) Acute fatty infiltration. Longitudinal US in a patient with acute right
upper quadrant pain and abnormal liver function tests. The liver is enlarged at 18.4 cm with diffusely increased echogenicity, loss
of the normal vascular pattern, and increased attenuation, which causes poor delineation of the diaphragm posteriorly (arrows).
steroid therapy, does have a predisposition for bleed- if larger than 5 cm. On US, hepatic adenomas have a
ing [25]. The rate of intratumoral or intra-abdominal variable appearance that ranges from hypoechoic
hemorrhage with adenomas is reported as high masses to mixed heterogeneous masses, which cor-
50% to 65% [26]. Contrary to focal nodular hyper- respond pathologically with intratumoral hemorrhage
plasia and hemangioma, which are usually managed and necrosis [25]. Masses also may be isoechoic to
conservatively, except if the patient has significant the liver with a hypoechoic rim or even hyperechoic
symptoms, adenomas are usually resected, especially if they contain fat. The mixed echogenic pattern is
Fig. 19. Hemorrhagic adenoma. (A) Transverse US in a patient with acute right upper quadrant pain who is taking oral
contraceptive pills shows a mixed echogenicity mass (arrows) with through transmission (asterisk) displacing the gallbladder
(arrowhead). The through transmission indicates fluid. (B) CT shows a heterogenous mass (arrows). The tumor portion (A)
enhanced, whereas the remaining hemorrhage did not.
most likely to correspond to hemorrhagic necrosis; lesions varies greatly and ranges from echogenic to
however, it cannot be distinguished from other tu- hypoechoic or mixed [21]. Tumors even may be
mors that can hemorrhage (Fig. 19) [25]. diffuse and infiltrative and relatively invisible by
After adenoma, the other hepatic tumor likely to US. A clue to the presence of an underlying malig-
present with hemorrhage is hepatocellular carcinoma. nancy is increased hepatic arterial flow in the lesion
Similar to adenomas, the US appearance of these compared with the remaining normal liver (Fig. 20).
Fig. 20. Hepatocellular carcinoma with hemorrhage. (A) Transverse US shows a heterogeneous liver echogenicity with
hypoechoic fluid (F) and an echogenic region that has a straight-line margin (arrows) with the more superficial hypoechoic tissue
(H). (B) Color Doppler image from the liver shows an area with high velocity (1.6 m/second) and low resistance (resistive index
of 0.49) flow, which indicates tumor shunt flow. (C, D) CT confirms enhancing tumor at the dome (arrows), and a more caudal
image (D) shows the acute clot (H) bordering the lateral liver margin (arrows). This accounted for the straight margin seen in
Fig. 19A. F, fluid.
Most patients with hepatocellular carcinomas also including stem cell transplantation [28]. Septic throm-
have predisposing risk factors, including cirrhosis or bophlebitis has a mortality rate as high as 50% [27].
hepatitis B or C. The most common cause is diverticulitis, with inflam-
The important feature to remember about acute matory bowel disease, bowel perforation, and suppu-
hemorrhage is that it may mimic the adjacent liver rative pelvic and pancreatitis infections as potential
parenchyma. Color Doppler imaging is useful for sources. Most patients present with sepsis, fever,
showing vessels in a normal liver or in the tumor, chills, and upper abdominal pain because the primary
whereas the hemorrhage has no vascularity within the bowel source is often asymptomatic [27].
hematoma. Straight lines and geographic margins are Patients without sepsis and acute portal vein
also a clue to the presence of hemorrhage (Fig. 20). thrombosis present with nonspecific right upper
Usually this indicates a subcapsular component with quadrant or epigastric pain. Some patients also have
compression of the adjacent liver capsule. Because abnormal liver function tests without hyperbilirubi-
US can have difficulty differentiating between the nemia [29]. On US, the portal vein is dilated and may
acute blood and the adjacent liver, CT scan is often be completely anechoic, but it is more often filled
used to map the extent of the process and differentiate with low-level echoes and shows no flow on color or
hepatic tissue from blood and tumor. power Doppler (Fig. 21). The main portal vein is seen
on 97% of upper abdominal US [30]. Failure to
visualize a patent main portal vein on gray scale
and Doppler US should indicate portal vein throm-
Abnormalities of hepatic vasculature
bosis. False-positive results may occur in patients
with slow flow caused by portal hypertension. In
Pathologic processes that involve the hepatic
these cases, maximum Doppler sensitivity should be
vasculature may result in acute symptoms and emer-
achieved with low wall filter and lower Doppler
gent presentations of the patient for US examination.
angles and lower Doppler frequencies to improve
The liver has three vascular systems: the hepatic
penetration at depth. Spectral Doppler always should
arterial and portal venous for incoming blood and
be used to confirm absent flow on color or power
the hepatic venous for outgoing blood.
Doppler images [29]. If flow remains absent but no
thrombosis can be visualized, contrast-enhanced US,
CT, or MR imaging could be used to confirm the
Acute portal vein thrombosis presence of thrombosis [31]. In the subacute to
chronic phase, older thrombosis becomes hyper-
Acute portal venous thrombosis has multiple echoic and recanalizes, or the patient forms collater-
causes, including septic thrombophlebitis [27], as- als. These smaller multiple portal channels are called
sociated pancreatitis, and hypercoagulable states, cavernous transformation of the portal vein. On
Fig. 21. Portal vein thrombosis. (A) Longitudinal US in a patient with right upper quadrant pain on oral contraceptives. The
portal vein (arrows) is distended and hypoechoic with no flow on color Doppler. (B) Contrasted CT scan shows low-attenuation
portal vein (arrow), which fails to enhance. Thrombus also involves the splenic vein (paired arrows).
spectral Doppler they have the typical monophasic sponse to a Valsalva’s maneuver [30]. Findings may
spectral waveform of the portal system. be confirmed with either CT or MR imaging. CT in
acute cases shows global ascites and liver enlargement
with decreased attenuation in the affected areas before
Acute hepatic venous thrombosis contrast and heterogeneous patchy enhancement after
contrast with rim enhancement of the hepatic veins
Acute hepatic venous thrombosis is otherwise [34]. MR imaging may show heterogeneous enhance-
known as Budd-Chiari syndrome. This rare entity ment of the hepatic parenchyma with edema and
results from venous obstruction usually caused by relative caudate sparing because the caudate drains di-
thrombosis of the hepatic veins, although proximal rectly into the IVC and does not go through the hepa-
suprahepatic webs or obstruction of the inferior vena tic veins [35]. Severe involvement of the veins may
cava (IVC) also can cause it [30,31]. Etiologic factors lead to liver failure, which requires transplantation.
include hypercoagulable states, including pregnancy,
birth control pill use, and post – bone marrow trans-
plant status, and other malignancies, including hepa- Hepatic artery thrombosis
toma, which may directly invade the veins [30].
Patients present with abdominal pain, ascites, and liver Hepatic arterial thrombosis is a major contributor
enlargement. US findings include abnormal flow in to acute hepatic dysfunction in patients after liver
one or more hepatic veins [32]. Flow may be absent or transplant. In particular, the biliary ducts depend on
completely monophasic on spectral Doppler, which adequate hepatic arterial perfusion for oxygenation.
indicates loss of cardiac pulsatility because of inter- Hepatic arterial thrombosis or stenosis occurs in up to
ruption between the vein and the heart. Reversed or ‘‘to 13% of patients after liver transplant and is a major
and fro’’ flow also may be seen in these excluded cause of graft failure [36]. Clinically, hepatic arterial
segments if they form collaterals with the portal veins thrombosis is suspected when liver function studies
or the IVC [30,33]. Nonvisualization of the veins on deteriorate, fever of unknown origin occurs, or the
color or power Doppler is nonspecific because they biliary tract is involved, with either a delayed biliary
may be compressed in the setting of cirrhosis [32]. leak secondary to ischemia or development of liver
Portal venous flow is present, although it may be abscesses [37]. Without treatment, mortality rate may
biphasic or reversed in fairly severe cases [30]. Ob- be as high as 70%. Graft salvage may be achieved by
struction of the suprahepatic IVC also can be docu- arterial revision, or retransplantation may be required
mented by US, visualization of the thrombus, or absent [38]. The diagnosis could be made by Doppler US in
flow in the obstructed segment. The inferior IVC and as many as 10% of patients who are clinically
iliacs may be patent but should have a monophasic asymptomatic by using aggressive US screening in
spectral Doppler waveform and lack the normal re- the early postoperative period (days 1 – 3) [37]. US
Fig. 22. Hepatic artery thrombosis with infarction postpartum. A liver transplant patient presented with acute pain and liver
failure 3 days postpartum. (A) US shows a diffusely disorganized liver pattern with no discernable vessels anteriorly
(arrowheads). Echogenic lines (arrows) represent gas. (B) CT scan shows the large infarct (arrowheads) and the gas in the biliary
ducts (arrows).
Fig. 23. Hemorrhagic adrenal adenoma. Patient presented with fever and acute right upper quadrant pain. Clinically the attending
surgeon was convinced she had acute cholecystitis. (Left) Longitudinal US shows mass (M) posterior to retroperitoneal reflection
(arrows) and separate from kidney (K). The gallbladder was normal. (Right) Transverse CT shows non-enhancing adrenal mass
(M) caused by hemorrhage of an adrenal adenoma.
diagnosis consists of color Doppler and spectral renal infarction, renal obstruction, and renal or adre-
Doppler examination. Absent hepatic arteries indicate nal hemorrhage (Fig. 23), also can present occasion-
thrombosis, although vessels may be small and diffi- ally with right upper quadrant pain, which mimics
cult to visualize in the immediate postoperative acute cholecystitis.
patient. This may be a situation in which US contrast
is useful. If flow is visualized in the vessels, a
resistive index is obtained (peak systolic velocity = Summary
end diastolic velocity divided by systolic velocity). A
resistive index of less than 0.5 or acceleration from In summary, US is the initial imaging modality for
beginning of systolic to systolic peak of more than the evaluation of acute right upper quadrant pain. It
0.08 seconds yields 73% to 81% sensitivity for permits accurate diagnosis of acute cholecystitis and
hepatic thrombosis or stenosis [39,40]. Additional successfully identifies multiple other causes of patient
diagnostic criteria include a resistive index of 1 in symptomatology. Some of these processes lie outside
the extrahepatic artery with no flow visualized in the the hepatobiliary system and include renal infection
intrahepatic arteries [37]. Confirmation of US find- and obstruction, pancreatitis and its sequelae, duode-
ings is usually performed angiographically. Prompt nal or colonic perforation or mass lesions, peritoneal
revascularization or retransplantation is desirable be- tumor spread, adrenal hemorrhage, and even remote
cause asymptomatic patients may achieve up to an problems, such as pneumonia. The limitations on US
80% graft salvage rate versus 43% on symptomatic include incomplete imaging of the liver, most often at
patients [37]. Massive acute hepatic arterial throm- the dome or beneath ribs on the surface, and incom-
bosis may result in liver infarction (Fig. 22). plete visualization of lesion boundaries, particularly
with some infections and tumors. For these clinical
scenarios, contrast-enhanced CT is complementary to
Acute right upper quadrant pain, outside the US and should be encouraged. In the biliary tree, US
hepatobiliary system has limitations in situations in which the ducts are not
dilated and sometimes with imaging the extrahepatic
The differential diagnosis for patients with right ducts, especially distally. For these patients, CT or
upper quadrant pain is extensive and includes pneu- MR imaging (MRCP) is especially useful. If one
monia, appendicitis, peritoneal tumor, primary bowel keeps the clinical scenario in mind and always images
disease, pancreatitis, and peritonitis caused by either a patient where he or she hurts, US is a powerful and
bowel or pelvic pathology, such as hemorrhagic effective diagnostic method for evaluating acute right
adnexal masses. Retroperitoneal processes, such as upper quadrant pain.
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Radiol Clin N Am 42 (2004) 279 – 296
Venous protocols, techniques, and interpretations of the

upper and lower extremities
James D. Fraser, MDa,*, David R. Anderson, MDb
a
Department of Diagnostic Radiology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, 3rd Floor,
Victoria Building, 1278 Tower Road, Halifax, Nova Scotia, Canada B3H 2Y9
b
Division of Hematology, Department of Medicine, Dalhousie University, Queen Elizabeth II Health Sciences Centre,
Victoria General Site, 4th Floor, Bethune Building, 1278 Tower Road, Halifax, Nova Scotia, Canada B3H 2Y9
Deep venous thrombosis (DVT) and pulmonary Clinical presentations

embolism (PE), collectively known as venous throm-
boembolism, are common problems and are frequent- Patients who eventually require assessment for
ly in the differential diagnosis of patients presenting potential venous thromboembolic disease may pres-
to the emergency department and in the acute care ent with symptoms suggestive of DVT of the upper or
setting. In the United States, the annual combined in- lower extremity, PE, or both. Most commonly, DVT
cidence of DVT and PE is at least 70 per 100,000 in- begins in the veins of the calf and moves proximally
dividuals [1,2]. Clinical signs and symptoms of both with time. Patients who present with acute calf-
of these entities are nonspecific and it is important popliteal vein thrombosis experience pain and swell-
to perform objective testing to confirm the diagnosis ing in the calf of one leg, which is exacerbated with
and initiate appropriate therapy. This approach leads ambulation and improved with rest. There may be
to a demand for emergent diagnostic studies. Com- associated warmth, redness, and tenderness in the calf
pression ultrasonography (CUS) is the diagnostic pro- area [3]. Over time, these symptoms tend to become
cedure of choice for the assessment of patients with more severe and may progress proximally to the
suspected DVT. It has been shown to be highly sen- popliteal fossa and into the medial thigh area. On
sitive and specific for the diagnosis of DVT, particu- average, these patients’ symptoms persist for about
larly in the lower extremities in symptomatic patients. 7 days before presenting for medical assessment
Bilateral leg CUS combined with assessment of the [4,5]. Less than 20% of patients who are confirmed
clinical pretest probability and D-dimer testing has to have lower-extremity DVT have thrombi isolated
also been shown safely to reduce the need for pul- to the calf veins.
monary angiography in patients with suspected PE. In approximately 10% of patients with lower-
This article reviews the clinical indications, diag- extremity DVT, the thrombus is isolated in the
nostic techniques, and interpretation of CUS for the iliofemoral region (Fig. 1) [6]. These patients initially
assessment of DVT in the upper and lower extrem- present with symptoms of pain in the buttock or
ities and evaluates the role of CUS in the assessment groin region, which over time extend to the medial
of patients with suspected PE. thigh and cause swelling and dusky discoloration of
the proximal leg. Superficial veins in the groin and
proximal thigh become prominent because of venous
engorgement [7]. Iliofemoral disease is a common
presentation of DVT during pregnancy with over
* Corresponding author. 90% occurring on the left side usually caused by
E-mail address: J.D.Fraser@Dal.Ca (J.D. Fraser). extrinsic compression of the left iliac vein. Iliofe-
doi:10.1016/j.rcl.2004.01.001
280 J.D. Fraser, D.R. Anderson / Radiol Clin N Am 42 (2004) 279–296
Fig. 1. Iliofemoral DVT. A 35-year-old pregnant woman with isolated iliofemoral DVT, who presented with left buttock pain.
(A) Longitudinal image with color flow Doppler shows a small amount of spontaneous venous flow around the thrombus (T).
(B) A transverse image of the iliac with compression was obtained with the maximum compressed anteroposterior diameter
measured. Normal compressibility of the (C) superficial femoral vein and (D) popliteal veins (arrowheads), which are free of
thrombus. Arrowheads in (A) and (B) delineate the left iliac vein. The arrows in (C) and (D) designate the accompanying artery.
The asterisk in (C) denotes the deep femoral artery branch. Note the superficial position of the vein relative to the artery in the
popliteal fossa.
J.D. Fraser, D.R. Anderson / Radiol Clin N Am 42 (2004) 279–296 281
Fig. 1 (continued).
moral DVT is associated with pelvic masses, recent leg veins. Accuracy studies using CUS for evaluation
pelvic surgery, oral contraceptive use, and the anti- of the calf veins have been relatively few and have
phospholipid antibody syndrome. demonstrated much greater variation. The range of
In contrast, patients presenting with upper-extrem- sensitivities varies between 11% and 100%, whereas
ity DVT (Fig. 2) usually have thrombosis initiating in the specificity ranges between 90% and 100% [9 – 12].
the proximal veins (subclavian and brachiocephalic). A meta-analysis of methodologically high-quality
Pain and swelling of the proximal arm and superficial studies reported the sensitivity of CUS for the diag-
vein distention in the upper chest and proximal arm nosis of DVT isolated to the calf to be 73% [11]. The
are commonly seen. Functional impairment also may rate of technically inadequate studies has been re-
be present. Upper-extremity DVT most commonly ported to be much higher than those for the evaluation
occurs in patients with malignancy and incidence is of proximal DVT (ie, in the range of 20% – 40%)
much higher when they have indwelling central ve- [12,13].
nous catheters. It occasionally occurs in otherwise In contrast to patients with suspected DVT of the
healthy individuals or following strenuous upper- lower extremities, the validity of ultrasound for the
extremity exercise, such as weight lifting [8]. evaluation of upper-extremity DVT is less well estab-
Patients with acute PE may present with dyspnea, lished. In a recent systematic review of the sensitivity
pleuritic chest pain, dizziness, and loss of conscious- and specificity of ultrasonography in the diagnosis of
ness with or without symptoms of DVT. Tachypnea, upper-extremity DVT, Mustafa et al [14] found only
tachycardia, and hypotension may be noted on phys- six original prospective studies, only one of which
ical examination. The range of presentation of PE is met their predefined criteria for adequately determin-
great, from minimal chest symptoms to life-threatening sensitivity and specificity and included a total of
ing shock. 58 patients [8]. The sensitivity of duplex ultrasound
from this review ranged from 56% to 100% with a
specificity ranging from 94% to 100%. None of
The role of ultrasound in the evaluation of these studies evaluated the safety of withholding
thromboembolic disease anticoagulation therapy in a patient with a negative
result on ultrasound evaluation who did not undergo
Because of the nonspecific nature of the presen- further testing and concluded that the safety of this
tation of venous thromboembolic disease, clinical approach is uncertain [14]. More recently in a pro-
assessment is certainly not sufficient to make a spective study published in 2002 comparing color
diagnosis. Given the possible serious consequences Doppler with contrast venography in 126 patients,
of a misdiagnosis, objective testing for DVT and PE Baarslag et al [15] reported a sensitivity and speci-
is crucial. ficity of 82%. He also noted that incompressibility of
In the lower extremities, CUS is the method of the vein during ultrasound correlated well with
choice to evaluate patients with symptoms suspected thrombus, whereas only 50% of isolated flow-related
to be DVT. The sensitivity and specificity exceeds abnormalities proved to be thrombus-related. He
97% for the diagnosis of DVT involving the proximal concluded that patients with isolated flow abnormal-
Fig. 2. Upper-extremity DVT. Cancer patient who developed a painful swollen right arm secondary to extensive DVT of the
upper extremity. (A) Longitudinal color flow image of the internal jugular vein with spontaneous flow above the thrombus.
(B) Thrombus (arrow) can be seen within the distal jugular vein (arrowheads). (C) Clot is seen (arrowheads) extending down to
the confluence with the subclavian vein (arrows). (D) Color flow Doppler demonstrates complete occlusion of the subclavian
vein (arrowheads). The presence of clot in the axillary (arrowhead) vein (E) and basilic vein (arrowhead) (F) is confirmed
because of the inability to compress the vein in the transverse plane. The arrows denote the associated arteries.
ities on duplex color ultrasound should have contrast PEs are believed to originate in the veins of the legs.
venography performed for further evaluation. Patients with nondiagnostic pulmonary investigation
The optimal strategy to diagnose PE remains may be confirmed to have venous thromboembolism
controversial. Spiral CT and ventilation-perfusion by leg ultrasonography and thereby avoid the need
scanning are used routinely for the evaluation of for angiography [16]. A definitive diagnosis or ex-
patients with suspected PE, but neither test is partic- clusion of PE may not be possible at the initial
ularly sensitive. Ultrasonography may be added to presentation using noninvasive testing. Most cases
diagnostic algorithms for suspected PE to increase of DVT (approximately 90%) start in the calf and
the sensitivity of noninvasive testing because most rarely cause clinically important PE unless they
Fig. 2 (continued).
extend into the proximal deep venous system. Eighty Clinical assessment and the use of D-dimer
percent of clots isolated to the calf are asympto-
matic; however, if left untreated approximately 25% Clinical assessment
extend to involve the proximal veins. This usually
occurs within the first week or so after presentation. Although the clinical presentation of DVT is
Seventy-five percent of patients diagnosed with PE nonspecific and clinical assessment alone is unreli-
have DVT, two thirds of which are located in the able, recent studies have shown that with explicit
proximal veins (Fig. 3). Up to one-quarter of patients clinical criteria, patients can be categorized accurately
with symptomatic PE have clinical evidence of DVT into high, moderate, or low pretest probability groups
[17]. Given this information, various algorithms have based solely on a clinical evaluation [18]. These
been developed that incorporate the use of CUS in the criteria combine the signs and risk factors for DVT
work-up of patients with suspected PE (Fig. 4). and take into consideration the likelihood of an
Fig. 2 (continued).
alternate diagnosis as the cause for the patient’s D-dimer

presentation. A simple, nine-point clinical criteria
scoring system has been developed to determine the Several serologic markers of thrombosis have
pretest probability for DVT (Table 1) [19]. Using been investigated for their predictive value in the
such criteria, patients with a high pretest probability diagnosis of DVT. The test that has emerged as the
have a greater than 75% prevalence of DVT con- most useful is the D-dimer test. D-dimer represents a
firmed by objective testing. Patients in whom the breakdown product of the cross-linked fibrin clot.
diagnosis of DVT cannot be excluded on clinical Several D-dimer assays have been validated to be
grounds but who have a low pretest probability have sensitive but nonspecific markers of DVT and PE,
less than a 5% prevalence of DVT. The use of this indicating that a positive test has a low predictive
clinical categorization tool has proved to be a valu- value but a negative test has a reported negative
able adjunct to noninvasive testing for the evaluation predictive value of more than 97% [16,22 – 29].
of patients with suspected DVT and PE [16,20,21]. Combinations of clinical assessment and D-dimer
Fig. 3. Lower-extremity DVT with PE. Patient presenting with shortness of breath and chest pain who underwent chest CT as
per PE protocol. (A) It revealed bilateral pulmonary emboli (arrowheads). CUS of the legs confirmed DVT involving the
popliteal and superficial femoral veins (arrowheads) to the mid thigh (B,C) with normal venous flow and no clot present within
the superficial femoral veins (arrowheads) above the mid thigh (D). Arrows in (B) and (C) designate the accompanying arteries.
Fig. 3 (continued).
results have been shown safely to reduce or eliminate Ultrasound technique for the evaluation of deep
the need for noninvasive testing in certain patient venous thrombosis of the extremities
groups [30,31]. For example, patients with a low
suspicion of DVT or PE but in whom a diagnosis Lower extremities
cannot be excluded on clinical assessment alone may
safely avoid the need for radiographic imaging on the The venous anatomy of the lower extremity is
basis of a negative D-dimer study (see Figs. 4 – 6). D- shown in Fig. 7. CUS of the deep venous system of
dimer is less useful for excluding venous throm- the lower extremities is performed with the patient
boembolism in hospital patients, particularly those in the supine position ideally with the head elevated
having had major surgery or trauma in whom the test
is highly likely to be positive [32].
A variety of D-dimer assays have been validated Table 1
Clinical evaluation table for predicting pretest probability of
for diagnostic testing for venous thromboembolism.
deep vein thrombosis
The accuracy parameters of these assays (sensitivity,
specificity) vary and physicians need to be aware of Clinical characteristics Score
these and of the validated laboratory cut-off points Active cancer (treatment ongoing, within 1
for defining a positive and negative test. previous 6 mo or palliative)
Paralysis, paresis, or recent plaster 1
Non-diagnostic Ventilation Perfusion (VQ)/ immobilization of the lower extremities
Computerized axial Tomography (CT) Scan Recently bedridden > 3 d or major surgery 1
within 12 wk requiring general or regional
Bilateral Compression Ultrasound (CUS) anesthesia
Localized tenderness along the distribution 1
Pretest Probability (PTP) of the deep venous system
+ D-dimer (DD) Entire leg swollen 1
+
Calf swelling 3 cm larger than asymptomatic 1
Low PTP
Mod/High PTP side (measured 10 cm below tibial tuberosity)
and + DD Pitting edema confined to the symptomatic leg 1
or - DD
Collateral superficial veins (nonvaricose) 1
- + Alternative diagnosis at least as likely as deep 2
PE excluded Pulmonary angiogram Treat for PE
or 1 wk CUS vein thrombosis
A score of 3 or higher indicates a high probability of deep
Fig. 4. Algorithm for investigation of patients with sus- vein thrombosis; 1 or 2, a moderate probability: and 0 or
pected PE. CUS, compression ultrasound; DD, D-dimer; PE, lower, a low probability. In patients with symptoms in both
pulmonary embolism; PTP, pretest probability. legs, the more symptomatic leg is used.
Clinically Suspected
Deep Vein Thrombosis (DVT)
plane; compression in the longitudinal plane is unre-
liable because the transducer may slide off the vessel,
Pretest Probability (PTP) possibly resulting in a false-negative interpretation.
In a mobile patient, the popliteal vein is assessed
Low Moderate/High most easily with the patient in the lateral decubitus or
prone position with the knee passively flexed to
+
D-dimer (DD) Compression approximately 10 to 15 degrees to avoid collapse of
- Ultrasound (CUS) the vein. Very often the patient is not able to move
from the supine position but the popliteal vein can
DD/PTP usually be assessed adequately by lifting the affected
- +
leg with a hand sufficiently under the distal thigh to
Low PTP Mod/High PTP
or - DD and + DD place the transducer behind the knee. The popliteal
vein is superficial to the popliteal artery (see Fig. 1D)
in the popliteal fossa and can be compressed easily by
- +
DVT Excluded 1 wk CUS Treat for DVT the extended knee. It is important to keep the knee
slightly flexed while interrogating the popliteal vein.
Fig. 5. Algorithm for clinically suspected DVT. CUS, There remains controversy over the value of
compression ultrasound; DD, D-dimer; DVT, deep vein performing CUS of the calf veins if the more proximal
thrombosis; PTP, pretest probability. veins are normal. Approximately 10% to 20% of
patients with symptomatic DVT have thrombus iso-
lated to the calf veins of, which 20% to 30% eventu-
20 to 30 degrees to promote venous pooling and ally extend into the proximal venous system [33,34].
distention of the veins. A linear transducer with a The positive predictive value of CUS for detecting
frequency in the 5- to 10-MHz range is used, ideally DVT in the calf is significantly lower than it is for
with duplex and color Doppler capability, although proximal DVT, and there are a relatively large number
these are not required but can be helpful in localizing of cases in which the studies are considered non-
the vessels and characterizing their flow. The leg is diagnostic or inadequate. Reported rates of nondiag-
rotated externally and flexed slightly at the knee. The nostic studies vary in the literature from 9.3% to
transducer is placed transversely in the groin area to 82.7%. Gottlieb et al [35] had a nondiagnostic rate
identify the common femoral vein just medial to the of 41% for the evaluation of calf veins. The same
common femoral artery. Gentle pressure is applied to study found no significant difference in adverse out-
the vessels with the transducer and in the absence of comes in patients undergoing a protocol in which the
DVT, the lumen of the vein should collapse with deep calf veins were routinely evaluated or a protocol
complete apposition of the anterior and posterior walls in which the calf was evaluated only if physical signs
(see Fig. 1C, D). In the presence of DVT, the lumen or symptoms were present.
does not collapse completely even with enough pres-
sure to occlude the adjacent artery (Fig. 8). This Clinically Suspected DVT
compression is performed at 1-cm intervals moving
Pretest Probability (PTP)
down the leg following the common femoral vein,
superficial femoral vein, and popliteal vein until it Low Moderate/High
divides into the three calf branches at the popliteal
trifurcation. Compression of the veins within the +
D-dimer (DD) Compression
muscular adductor (Hunter’s) canal is often difficult - Ultrasound (CUS)
and visualization limited because of the depth of the
vein. This can usually be overcome by placing one DD/PTP
hand underneath the medial aspect of the distal thigh - +
Low PTP Mod/High PTP
and compressing the vein between the fingers and the or - DD and + DD
transducer. This not only aids in compressing the
vein but also brings the vein closer to the transducer
- +
head, allowing better visualization. DVT Excluded Venogram Treat for DVT
Scanning along the axis of the vein is often ad-
vantageous for following the course of the vein and Fig. 6. Algorithm for suspected DVT in the upper extremity.
for assessing flow (see Figs. 2A, 3D). It is important, CUS, compression ultrasound; DD, D-dimer; DVT, deep
however, to confirm compressibility in the transverse vein thrombosis; PTP, pretest probability.
Inferior vena cava
Common iliac vein
External iliac vein
Common femoral vein
Superficial femoral
vein
Great saphenous vein

(superficial)
Popliteal
vein
Popliteal
vein
Anterior
tibial vein
Peroneal
Peroneal vein
vein Small
Saphenous
Anterior tibial (superficial)
vein Posterior
tibial vein
Fig. 7. Diagrammatic representation of the veins of the lower extremity.
The authors have previously described the tech- such as a hematoma, which might explain the pa-
nique for the evaluation of the calf veins [1]; however, tient’s symptoms.
their present protocols for the evaluation of patients
with suspected thromboembolic disease do not in- Upper extremities
clude evaluation of the calf and the technique is not
discussed in this article. It should be stressed, how- The venous anatomy of the upper extremity is
ever, that when assessing the proximal venous system, shown in (Fig. 9). The technique for evaluating the
one should ensure that the examination includes the upper extremities for DVT is similar to that for the
distal popliteal vein all the way down to its trifurca- lower extremities; however, compression of the deep
tion point to have the highest possible sensitivity for venous system is more limited particularly in the area
DVT. In addition, if there is focal tenderness or where the subclavian vein passes beneath the clavi-
swelling within the calf region, it is useful to scan cle. Because of this limitation, technical modifications
this area to evaluate for nonvenous focal pathology, are required, such as the use of adjunctive procedures
and the findings of Doppler and color flow Doppler course of the vessel just below the clavicle and
analysis (see Fig. 2). Once again, a linear transducer angling it slightly cephalad. The vein can be differen-
with a frequency in the 5- to 10-MHz range with tiated from the adjacent artery by its generally larger
Doppler or color flow Doppler is preferable. With the size, lack of internal pulsations, and its vascular flow
patient in the supine position, the head is tilted slightly pattern as assessed by Doppler. Attempts to compress
away from the side of interrogation. It is often easiest the vein with the transducer in the transverse plain
to begin by evaluating the internal jugular vein, often fail because of the presence of the clavicle. At-
following this down to the confluence with the sub- tempts should then be made to compress the vein with
clavian vein (see Fig. 2C), which is located under the the transducer along the length of the vessel. If
proximal third of the clavicle, and is best visualized compression is not possible, one must evaluate with
by placing the transducer longitudinally along the spectral or color flow Doppler to determine if the lack
Fig. 8. Extensive lower-extremity DVT involving the iliac vein. Patient with painful swollen left leg with extensive DVT
involving the popliteal vein (A) and extending up to involve the superficial femoral veins (not shown), CFV (B), and the iliac vein
(C) (arrowheads), all of which are not compressible despite sufficient pressure to partially compress the adjacent artery (arrows).
Fig. 8 (continued).
of compressibility is caused by thrombus or by over- pression and color Doppler is used for assessment of
lying structures preventing adequate force to be trans- patency, it is important to pay close attention to the
mitted to the vein. The subclavian vein is followed color flow gain settings to avoid oversaturation,
distally to the axillary, cephalic, brachial, and basilic which may obscure small intraluminal clots or areas
veins, which are assessed with transverse compression of incomplete thrombosis [37]. Similar to assessment
similar to the evaluation of the lower-extremity veins of the leg, if thrombosis is discovered it is important to
(see Fig. 2E, F). Assessment of the axillary, brachial, document the full extent of the disease including
and basilic veins is performed using an axillary ap- evaluation of the contralateral neck and proximal
proach by raising the arm. High in the axilla, the vein is arm because this information may be important for
superficial to the artery [36]. In such areas as the sub- subsequent evaluation for progression or recurrence of
clavian where the vein may not be accessible to com- disease or for the effectiveness of treatment.
Internal jugular vein

External jugular vein
Subclavian vein
BCP vein
SVC
Axillary vein
Cephalic vein
Brachial vein
Basalic vein
Median cubital vein
Fig. 9. Diagrammatic representation of the veins of the upper limb and thoracic inlet. BCP vein, brachiocephalic vein; SVC,
superior vena cava.
Diagnostic criteria for the diagnosis of deep Adjunctive procedures, pitfalls, and limitations
venous thrombosis of the extremity
There are a number of procedures that may be
In the absence of DVT, the vein being evaluated helpful when examining a patient whose deep venous
should collapse and the walls of the vein should system is difficult to localize. Placing the patient in a
be completely apposed with less pressure than re- position that promotes venous pooling in the extrem-
quired to occlude the adjacent artery. The inability ity of interest distends the veins, making them easier
completely to compress the vein lumen is the prin- to localize and assess. Similarly, having the patient
cipal criterion for the diagnosis of DVT [6,7,38 – 40]. perform a Valsalva’s maneuver also results in venous
Other adjunctive findings are often observed in the distention [7]. When duplex or color flow Doppler is
presence of DVT but have much poorer sensitivi- available, it can be used to localize the venous system
ties and specificities. These include distention of based on its flow characteristics. The presence of
the involved vein in acute DVT and the absence of spontaneous flow, normal respiratory phasic flow
or reduced spontaneous blood flow on Doppler variation, and flow augmentation with manual com-
evaluation (see Fig. 8). In patients with incomp- pression of the limb suggests patency. It is, however,
lete obstruction, there is usually loss of the normal important to remember that spontaneous flow and
phasic respiratory venous flow pattern, often giving flow augmentation can occur in the presence of
a reduced continuous flow pattern (monophasic incomplete thrombosis (see Fig. 1A), adequate collat-
flow), which is minimally affected by the Valsalva’s eralization, and in patients with duplication of the
maneuver or attempts to augment flow, such as deep venous system. Augmentation may even force
gently squeezing the calf. The monophasic pattern blood around an area of complete thrombosis and
indicates some degree of obstruction to venous flow should probably be used only to aid in the localization
returning to the right side of the heart and should of venous segments that are difficult to visualize.
increase one’s suspicion for the presence of DVT. Patients in whom adequate compression studies of
This pattern can also be seen, however, in the ab- the proximal deep venous system may be difficult to
sence of thrombosis when sufficient external com- perform include obese patients, patients with tense
pression on the deep venous system exists. The swollen extremities, burn patients, and patients with
appearance of the vein alone is unreliable because recent surgery in the area of interest. These limitations
acute thrombus is often anechoic mimicking a patent seldom preclude evaluation of the areas where DVT
vein and internal echoes are not infrequently seen most commonly occurs (ie, the common femoral and
within a patent vein lumen in the presence of slow- popliteal veins).
flowing blood. Pitfalls occasionally encountered include missing
The ultrasound appearance of DVT changes over a thrombosed vein segment when a nonthrombosed
time with the clot retracting and becoming more duplicated vein segment is present (Fig. 11) and
echogenic. The vein wall in the area of previous occasionally mistaking a large collateral for a patent
thrombus may become thickened, echogenic, and venous segment when thrombosis is present in the
resistant to compression [41]. Over a 12- to 24-month underlying vein. The latter can usually be avoided by
period, only about 50% of patients have complete confirming the normal course of the vein in relation-
resolution of thrombus and normal compressibility of ship to the adjacent artery.
the proximal leg veins [41 – 43]. Although the ultra-
sound appearance in patients with previous DVT may
be suggestive of chronic disease, it is usually difficult Suggested protocols
to rule out acute or chronic disease unless the patient
has a posttreatment baseline study available for com- Diagnosis of acute deep venous thrombosis of the
parison. In the latter setting, unequivocal evidence of lower extremities
thrombosis in a venous segment previously demon-
strated to be free of disease or increase in compressed To maximize patient safety and the efficiency of
venous diameter greater than 4 mm from a baseline resources, clinicians should be encouraged to follow
study may be considered diagnostic of recurrent DVT validated nomograms that encompass consideration
in the appropriate clinical setting. of clinical probability, D-dimer testing, and venous
Compression ultrasound occasionally diagnoses ultrasound imaging. The algorithm outlined in Fig. 5
an alternative cause for pain and swelling of the has been demonstrated to be safe for patients with
lower extremity in the absence of DVT, such as a low pretest probability for DVT because only less
ruptured Baker’s cyst or a calf hematoma (Fig. 10). than 1% of these patients, if left untreated, develop
Fig. 11. Duplicated superficial femoral and popliteal veins. Patient with symptomatic DVT who has duplication of the poplit-
eal veins (A) and the superficial femoral veins (B) of the leg. Noncompressible clot is seen within the more superficial of the two
deep veins at both levels (2), with the deeper vein (1) demonstrating normal compressibility (A,B). Duplication of the artery
within the popliteal fossa is appreciated only on the color Doppler images with a more superficial artery (A) and a deeper
objective evidence of DVT or PE in follow-up over Using this approach, most patients can have a diag-
a 3-month period. nosis of DVT confirmed or excluded on initial
The ultrasound examination in this algorithm is testing. Recognizing that a small proportion of
restricted to the proximal venous system. Pretest patients may have DVT isolated to the calf veins, it
probability should be judged either by experienced is advisable that these higher-risk patients as defined
clinicians or by using a validated clinical model. by moderate or high pretest probability and positive
D-dimer testing should be done using a validated as- D-dimer should have the ultrasound repeated ap-
say for the diagnosis of venous thromboembolism. proximately 1 week following their initial evaluation.
Fig. 10. Calf hematoma. Patient who presented to the emergency department with a painful swollen calf area suspicious for
DVT. The deep venous system (arrowheads) within the common femoral (A) and popliteal regions (B) demonstrates patency
with normal compressibility. A hematoma was discovered (arrows) between the heads of the gastrocnemius and the soleus
muscles (C), explaining the patient’s calf pain and tenderness.
This is to detect patients whose calf DVT may have ography, particularly if the clinical pretest probability
extended to the proximal venous system, which has is high.
thereby increased the risk of PE.
Diagnosis of deep venous thrombosis of the upper Other considerations

extremities
Frequently, patients with suspected venous throm-
Unfortunately, validated diagnostic algorithms boembolism present at inopportune times when im-
are not available for patients presenting with DVT mediate access to diagnostic testing may not be
of the upper extremity. There also are no models to available. With the advent of low-molecular-weight
assist clinicians in determining pretest probability. heparin, diagnostic testing can be scheduled safely
Fig. 6 contains an algorithm based on one of the within 24 hours of presentation. Such patients may
principles of DVT investigation of the lower extrem- receive a single dose of subcutaneous low-molecular-
ities with the recognition that CUS is less sensitive in weight heparin designed to treat DVT or PE while
the evaluation of the upper extremities. This algo- awaiting diagnostic testing [16,30]. The only restric-
rithm is based on the opinion and clinical experience tion to this regimen is that patients are at increased risk
of the authors. It is their opinion that venography of major bleeding.
should be performed in patients in whom the clin-
ical suspicion of upper extremity DVT is moderate or
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Radiol Clin N Am 42 (2004) 297 – 314
Sonographic evaluation of first-trimester bleeding

Raj Mohan Paspulati, MD*, Shweta Bhatt, DMRD, DMRE, Sherif Nour, MD
Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University, 11100 Euclid Avenue,
Cleveland, OH 44106, USA
Vaginal bleeding in the first trimester of preg- and external cervical os. The internal os is the
nancy is a common presentation in emergency care junction of the uterine cavity and the cervical canal
facilities. About 25% of all gestations present with and the external os is the junction of the cervical
vaginal spotting or frank bleeding in the first few canal and the vagina. Transvaginal US (TVUS) of the
weeks of pregnancy; half of these progress into normal myometrium reveals three distinct layers.
miscarriage or abortion [1]. The acuity of these Arcuate vessels separate the thin outer layer from
symptoms may vary from occasional spotting to se- the thick middle layer, and both layers are homoge-
vere hemorrhage, associated with cramping and ab- neous with the outer layer more hypoechoic relative
dominal pain. The bleeding often is self-limited and to the middle layer [2]. The inner layer consists of a
is most likely caused by implantation of the concep- thin hypoechoic halo that surrounds the endometrium
tus into the endometrium. The important causes of and corresponds to the junctional zone seen on MR
first-trimester bleeding are spontaneous abortion, ec- imaging. The endometrial thickness measurements
topic pregnancy, and gestational trophoblastic dis- are optimally made on sagittal (long-axis) images of
ease. The clinical assessment of pregnancy outcome the uterus; this measurement should be performed
is unreliable and ultrasound (US) evaluation com- on the thickest portion of the endometrium excluding
bined with quantitative beta human chorionic gonado- the hypoechoic inner myometrium (Fig. 1). The en-
tropin (b-hCG) is an established diagnostic tool in dometrial thickness should be reported as the ‘‘dou-
these patients. This article reviews the role of ultra- ble thickness’’ measurement [3]. If endometrial fluid
sonography in the evaluation of patients presenting is present, its diameter should be omitted; in such
with first-trimester bleeding. cases the endometrial thickness should be reported
as the sum of the measurements obtained from the
anterior and posterior endometrial walls. An endo-
Sonographic anatomy metrial thickness of 4 to 14 mm is normal in an adult
premenopausal woman. Endometrial thickness and
The uterus is a pear-shaped, muscular organ that appearance vary with the phase of the menstrual
varies greatly in size and shape depending on age and cycle [4].
prior pregnancies. The normal postpuberty uterus in The position of the ovaries is variable but they are
an adult measures approximately 7.5 to 8 cm in usually found in the posterior fold of the broad
length, 4 to 5 cm in width, and about 2 cm in an- ligament, posterior and distal to the fallopian tubes.
teroposterior dimension. The normal cervix is 3.5 to On sonography the ovaries can be localized anterior
4 cm in length. The cervix is comprised of internal to the internal iliac vessels. The postpubertal ovary
measures approximately 3 cm in length, 2 cm in
width, and 1 cm in anteroposterior dimension. The
upper limit for normal ovarian volume is highest in
* Corresponding author. young adult women measuring approximately 9.8 to
E-mail address: paspulati@uhrad.com (R.M. Paspulati). 14 mL and declines with increasing age [5]. Normal
doi:10.1016/j.rcl.2004.01.005
298 R.M. Paspulati et al / Radiol Clin N Am 42 (2004) 297–314
ler US in early pregnancy, the concept of ‘‘as low as

reasonably achievable’’ is important [7] and the
advantages of the Doppler US should outweigh the
potentially harmful effects on the conceptus.
Normal first-trimester sonography
Scanning in the first trimester may be performed

either transabdominally or transvaginally. TVUS is
preferred and is the community standard. The first-
trimester milestones are given in Tables 1 and 2.
A gestational sac can be identified with TVUS at
Fig. 1. Sagittal TVUS of the uterus demonstrates a normal 5 weeks of gestational age, when it measures 5 mm.
endometrial lining (arrowheads). The yolk sac should always be seen by TVUS when
a gestational sac measures greater than 10 mm and
by transabdominal US when the mean sac diameter
fallopian tubes cannot be visualized with current US is greater than 20 mm [8,9]. An embryo with car-
imaging equipment diac activity should be seen transvaginally when the
gestational sac measures greater than 18 mm, and
transabdominally when the gestational sac measures
Scanning technique 2.5 cm. These discriminatory criteria should be used
as guidelines. If the findings of the US examination
Ultrasound evaluation of the female pelvis is are equivocal and the examination is technically
conducted with a real-time scanner, preferably using difficult, a follow-up examination should be obtained.
a sector or curvilinear transducer. The scanner is
adjusted to operate at the highest clinically appropri- Gestational sac
ate frequency, realizing that there is a trade-off
between the resolution and beam penetration. The blastocyst implants into the endometrium by
Transabdominal pelvic US is performed with a approximately 23 days of menstrual age [10]. It mea-
full bladder using transducer frequencies of 3.5 MHz sures 0.1 mm and is too small to be visualized on
and above. Adequate distention of the bladder dis- TVUS. Demonstration of peritrophoblastic flow by
places the bowel from the field of view. Transab- transvaginal color flow Doppler at this focal decidual
dominal US gives an initial overview of the uterus, thickening has improved the diagnostic sensitivity of
adnexa, and any intra-abdominal free fluid. TVUS is intrauterine pregnancy (IUP) from 90% with TVUS
performed with the patient’s bladder being empty, alone to 99% using transvaginal color flow Dopp-
using a transducer frequency of 5 to 7.5 MHz. TVUS ler [11,12]. The peritrophoblastic flow has a charac-
gives detailed information about the uterus and the teristic high-velocity and low-impedance flow caused
adnexa. Higher-frequency transvaginal probes can be by shunting of blood from the spiral arteries into the
positioned closer to the pelvic organs resulting in intervillous spaces. According to Emerson et al [11],
improved spatial resolution and diagnostic accuracy. the peak systolic velocity of peritrophoblastic flow
Currently available transducers of 10 MHz and above in a normal IUP ranges from 8 to 30 cm/second, be-
can identify the finer details of intrauterine gestation fore the visualization of the gestational sac. Yeh et al
and have greatly contributed to the early diagnosis of
abnormal gestation and to the management of first-
trimester bleeding. Color flow Doppler and pulsed Table 1
Doppler may be added to the examination, as indi- First-trimester scanning milestones
cated by the gray-scale US findings. It is important to Parameter Transabdominal US Transvaginal US
bear in mind that the energy output of Doppler US is Gestational sac — Present at 5 wk
substantially higher than that used for imaging and it (5 mm)
may have potentially harmful effects on the concep- Yolk sac Always present Always present
tus [6]. Because of this risk, caution has been if GS > 20 mm when GS > 10 mm
expressed over the routine use of Doppler US in Cardiac activity GS > 2.5 cm GS > 18 mm
early pregnancy evaluation. While performing Dopp- Abbreviations: GS, gestational sac; US, ultrasound.
R.M. Paspulati et al / Radiol Clin N Am 42 (2004) 297–314 299
Table 2
Land marks of normal first-trimester pregnancy
Gestational age Embryologic change Sonographic appearance
23 d Blastocyst implantation Blastocyst measures 0.1 mm and is too small to visualize
3.5 – 4 wk Decidual changes at Focal echogenic decidual thickening at implantation site
implantation site
4 – 4.5 wk Trophoblastic tissue High-velocity and low-impedance trophoblastic flow at the implantation site
on TVCFD
4.5 – 5 wk Exocoelomic cavity of Gestational sac (a sonographic term) is always seen when it measures > 5 mm
the blastocyst and the serum b-hCG is between 1000 and 2000 mIU/mL (IRP)
5 – 5.5 wk Secondary yolk sac Yolk sac is seen as a thin-walled cystic structure within the gestational sac and
should always be seen when the GS is > 10 mm; it is the first sign of a true
gestational sac before the visualization of embryo
5 – 6 wk Embryo Seen as a focal echogenic area adjacent to the yolk sac; should always be seen
when the GS is > 18 mm
5 – 6 wk Embryonic cardiac Embryonic cardiac activity should always be seen when the embryo is > 5 mm;
activity normal heart rate ranges from 100 – 115 beats/min between 5 – 6 wk of gestation
Abbreviations: CG, human chorionic goradotropin; GS, gestational sac; IRP, international reference preparation; TVCFD,
transvaginal color flow Doppler.
[13] described a focal, eccentric, anechoic area in the of the embryo is a more accurate indicator of gesta-
endometrium caused by the embedded blastocyst as tional age than the mean gestational sac diameter. The
the ‘‘intradecidual sign.’’ They described this sign as mean gestational sac diameter should be recorded,
early as 3.5 weeks of menstrual age on transabdomi- however, when an embryo is not identified.
nal US and reported a sensitivity rate of 92%, a Because hCG production and gestational sac
specificity rate of 100%, and an accuracy rate of growth are related to trophoblastic function, there is
93%. Laing et al [14] used TVUS to demonstrate this excellent correlation of the serum hCG level, sac size,
sign and found that the overall sensitivity, specificity, and the stage of pregnancy [19]. Kadar et al [20] first
and accuracy for the intradecidual sign were only introduced the concept of a discriminatory level of
48%, 66%, and 45%, respectively. With currently the b subunit of hCG. The range of the serum b-hCG
available high-frequency transvaginal probes, a ges- level at which an intrauterine gestational sac is
tational sac as small as 2 to 3 mm can be demon- visualized is the discriminatory zone. Although the
strated at 4 weeks of gestational age [15 – 17]. On discriminatory range of b-hCG varies from one labo-
TVUS, the gestational sac is seen as a well-defined ratory to another, the widely accepted range is from
fluid-filled cavity with a surrounding hyperechoic
rim, embedded eccentrically in the endometrial lining
of the fundus or midbody of the uterus (Fig. 2). The
sonographic term ‘‘gestational sac’’ represents the
exocoelomic cavity of the blastocyst and the sur-
rounding echogenic rim is caused by the developing
chorionic villi and decidual tissue. The echogenic rim
should have a minimum thickness of 2 mm and its
echogenicity should exceed that of myometrium [1].
The double decidual sac sign of intrauterine
gestation was first described in 1982 [18]. The double
decidual sac sign consists of two concentric echo-
genic rings encasing a central anechoic focus that im-
press on the endometrial stripe. The inner echogenic
rim represents the decidua capsularis and chorion
laeve, whereas the outer echogenic rim represents
the decidua parietalis; these echogenic rims are sepa-
rated by a thin rim of fluid in the endometrial cavity Fig. 2. Coronal TVUS of the uterus shows a gestational sac
(Fig. 3). This is a useful sign of IUP between 4 and with hyperechoic margins (arrow) and endometrial cavity
6 weeks of gestation. The crown-rump length (CRL) (curved arrow).
Fig. 3. Double decidual sac sign. (A) Coronal TVUS of the uterus reveals an intrauterine gestational sac (straight arrow),
decidua capsularis (curved arrow), decidua parietalis (arrowhead), and effaced endometrial cavity (asterisks). (B) Corresponding
line diagram.
1000 to 2000 mIU/mL international reference prepa- available high-frequency transvaginal transducers,
ration (IRP) for TVUS and 2400 to 3600 mIU/mL the embryonic disk is initially seen as a focal echo-
(IRP) for transabdominal US [10]. In normal preg- genic area of 1- to 2-mm thickness adjacent to the
nancy serum b-hCG should double or increase by at yolk sac between 5 and 6 weeks of gestational age
least 66% in 48 hours. [26 – 29]. Embryonic cardiac activity should always
be seen when an embryo measures greater than 5 mm.
Yolk sac Occasionally the heartbeat may be seen adjacent to
the yolk sac even before the embryo is clearly visible.
The first structure to be seen within the gestational
sac is the secondary yolk sac, which is a reliable
indicator of a true IUP with a positive predictive
value of 100%. The primary yolk sac is not seen by
US because it shrinks at 4 weeks menstrual age and
gradually disappears with the formation of the sec-
ondary yolk sac [21]. The secondary yolk sac is first
seen on TVUS as a thin-walled cystic structure by the
fifth gestational week and is virtually always seen by
5.5 weeks gestational age (Fig. 4) [22]. The yolk sac
is round, measures less than 6 mm, and should be
visualized by TVUS when a gestational sac measures
more than 10 mm [10]. The yolk sac is involved in
nutritive, metabolic, hemopoietic, and secretive func-
tions during early embryonic development and or-
ganogenesis [23,24]. Abnormalities in its size and
appearance are predictors of abnormal gestation [25].
Embryo
The embryo should always be visualized by Fig. 4. TVUS of the uterus demonstrates a yolk sac (thin
TVUS when the gestational sac measures greater than arrow) outside the amniotic membrane (arrowhead), which
18 mm, and transabdominally when the gestational has not yet fused with the chorion (curved arrow). Embryo
sac measures 2.5 cm (Fig. 5). With the currently (thick arrow) is seen within the amniotic sac.
branes before 14 weeks of gestation is considered

normal (see Figs. 4 and 5).
Spontaneous abortion
Spontaneous abortion is defined as pregnancy

terminating before the 20th completed week of ges-
tation. Approximately 80% of spontaneous abortions
occur in the first trimester. The causes of spontaneous
abortions fall into two categories: genetic and envi-
ronmental (maternal) as listed next:
Fig. 5. TVUS of the uterus shows a normal embryo and
Genetic or fetal causes
separate amniotic membrane (arrow) in close relation to the
embryo. This should not be mistaken for nuchal translucency.
Trisomy
Polyploidy or aneuploidy
Translocations
Environmental or maternal causes
Levi et al [3] suggested a 4-mm CRL cutoff because Uterine
their study demonstrated cardiac activity in all em- Congenital uterine anomalies
bryos with a CRL of 4 mm [30]. Other studies Leiomyoma
demonstrated 5 mm as the discriminatory CRL for Intrauterine adhesions or synechiae (Asherman’s
detecting cardiac activity [31,32]. Although visual- syndrome)
ization of a living embryo does not ensure a viable Endocrine
pregnancy, the abortion rate decreases for living em- Progesterone deficiency (luteal phase defect)
bryos as the gestational age increases, with a 0.5% Hypothyroidism
demise rate for living embryos between 6 and 10 mm Diabetes mellitus (poorly controlled)
[33]. If the length of the embryo is less than 5 mm, Luteinizing hormone hypersecretion
follow-up US should be performed until the expected Immunologic
CRL exceeds the discriminatory value. Most of the Autoimmunity: antiphospholipid syndrome, sys-
studies reported a heart rate of 100 to 115 beats per temic lupus erythematosus
minute between 5 and 6 weeks [34 – 36]. By 9 weeks Infections
of gestational age, the mean heart rate increases to Toxoplasma gondii, Listeria monocytogenes,
about 140 beats per minute. The cardiac activity Chlamydia trachomatis, Ureaplasma urea-
should be documented by M-mode. lyticum, Mycoplasma hominis, herpes simplex,
Treponema pallidum, Borrelia burgdorferi,
Amniotic sac Neisseria gonorrhoeae
The amniotic sac is formed in the fourth week Genetic abnormalities are the most common cause
of gestation between the ectoderm layer and the adja- of spontaneous abortions accounting for almost 50%
cent trophoblast. Before 6.5 weeks the amniotic to 60% of cases. Autosomal trisomy is the most
membrane is so close to the embryo that the amniotic frequently identified chromosomal abnormality re-
cavity around the embryo is not easily seen. The di- sulting in first-trimester abortions. The incidence of
ameter of the amniotic cavity is nearly equal to the abortions secondary to chromosomal abnormalities
CRL. Between 5 and 7 weeks of gestational age the markedly increases after the maternal age of 35 years.
embryo is located between the amniotic and yolk The environmental or maternal causes account for
sacs. On US, this amniotic sac – embryo – yolk sac a small percentage of spontaneous abortions. These in-
complex appears as two small sacs and is called the clude infection; anatomic defects (maternal mullerian
double bleb sign [9]. The embryo and the inner defects); endocrine factors (failure of corpus luteum);
amnion grow at a faster rate than the outer chorionic immunologic factors (antiphospholipid antibody syn-
cavity with eventual fusion of the amniotic and drome); and maternal systemic disease (diabetes mel-
chorionic membranes by 16 weeks of gestation litus, hypothyroidism). The algorithmic approach to
[37]. Separation of the amniotic and chorionic mem- first-trimester bleeding is summarized in Fig. 6.
A
First Trimester Ultrasound
Embryo not visualized
MSD > 18MM MSD < 18MM
YS present YS absent
MSD < 10MM MSD > 10MM
ED
ED F/U re: sac
growth and
embryo
1
B
Embryo visualized
Cardiac activity Cardiac activity

present absent
CRL > 5MM CRL < 5MM CRL > 5MM CRL < 5MM
YS present YS absent
YS normal YS abnormal
MSD-CRL MSD-CRL
> 5MM < 5MM
HR N HR AbN
? F/U F/U
F/U F/U ED
18 wks re: growth and
2 2wks
1 re: growth
cardiac activity
1
and cardiac
activity
1
Fig. 6. (A, B) Proposed algorithms for evaluating women with first trimester bleeding. ED, embryonal demise; F/U, follow-up;
HR ABN, heart rate abnormal; HR N, heart rate normal; YS, yolk sac. (From McGahan J, Goldberg B. Diagnostic ultrasound:
a logical approach. Philadelphia: Lippincott, Williams & Wilkins; 1998; p. 142 – 3; with permission.)
The most common morphologic finding in early Ultrasound findings in abortion

spontaneous abortions is an abnormality of devel-
opment of the zygote, embryo, early fetus, or the The US findings depend on the developmental
placenta. Spontaneous abortion is clinically classified stage of the pregnancy at which the patient presents
into threatened, inevitable, missed, incomplete, and with symptoms. Familiarity with normal sonographic
complete abortions (Table 3). landmarks of first-trimester pregnancy is essential
Table 3
Classification of spontaneous abortion
Types Clinical features US findings
Threatened abortion Vaginal bleeding before 20 wk gestation Depending on the stage of pregnancy, US may show an
without cervical dilatation empty uterus, intrauterine gestational sac with or without
an embryo
Incomplete abortion Vaginal bleeding with partial expulsion Thick, irregular endometrial lining caused by residual
of products of conception before 20 wk trophoblastic tissue and fluid
gestation and cervical dilatation
Missed abortion Embryonic demise before 20 wk of Embryo without cardiac activity; small size of the embryo
gestation without expulsion of products for the gestational age (see Fig. 10)
of conception; may or may not have
vaginal bleeding
Complete abortion Vaginal bleeding and expulsion of all Empty uterus
products of conception before 20 wk
gestation
Inevitable abortion Vaginal bleeding before 20 wk gestation Variable depending on the degree of bleeding and expulsion
with cervical dilatation of the products of conception
Abbreviations: US, ultrasound.
to diagnose a failing pregnancy. TVUS features of and high diastolic component caused by trophoblastic
failing pregnancy are summarized in Table 4. The arterial flow are noted [40].
sonographic findings are to be correlated with serum
b-hCG and menstrual age. In the pre-embryonic stage, Intrauterine gestational sac without an embryo
the pregnancy outcome depends on the presence of
the gestational sac and yolk sac and their morpho- A common and difficult problem arises when the
logic features. gestational sac in the uterus lacks an embryo or yolk
sac [41 – 43]. This can be caused by early normal IUP,
Absent intrauterine gestational sac
Failure to demonstrate intrauterine gestational sac

by TVUS may be secondary to early IUP (b-hCG < Table 4
1000 mIU/mL) or secondary to ectopic pregnancy. TVUS features of pregnancy failure
When the serum b-hCG is more than 1000 mIU/mL Ultrasound findings Comments
(IRP) and there is no IUP, an ectopic pregnancy Absence of IUGS with serum Ectopic pregnancy
[19,20] must be excluded by careful evaluation of b-hCG above the has to be excluded
the adnexa. If there is no identifiable ectopic gesta- discriminatory level
tional sac, adnexal mass, or a large amount of adnexal (1000 mIU/mL)
fluid in the cul-de-sac, follow-up with b-hCG and IUGS > 10 mm without Follow-up with serum
TVUS is necessary until a definite diagnosis is made. a yolk sac b-hCG and TVUS
When the endometrial lining is thick with echoes in IUGS of >18 mm without Anembryonic pregnancy
the endometrial cavity and no intrauterine gestational an embryo
sacs, an incomplete abortion with retained products Embryo of 5 mm and above Embryonic demise
without cardiac activity
of conception must be distinguished from decidual
Embryo with bradycardia Poor prognosis and
reaction of ectopic gestation. Transvaginal color flow (< 100 beats/min) needs close follow-up
Doppler of the endometrial contents is useful in dif- with TVUS
ferentiating trophoblastic tissue from blood clots and Subchorionic hematoma Correlation of pregnancy
pseudogestational sac. Sparse flow on color Doppler outcome with the size
with low peak systolic velocities (< 6 cm/second) and of hematoma is not well
low to absent end diastolic flow suggests decidual re- established and needs
action of an ectopic pregnancy (Fig. 7) [38,39]. With TVUS follow-up
early IUP (< 5 weeks) multiple flashes of color with a Abbreviations: hCG, human chorionic gonadotropin; IUGS,
peak systolic velocity of greater than 8 cm/second intrauterine gestational sac; TVUS, transvaginal ultrasound.
Fig. 7. Decidual reaction. (A) Sagittal TVUS shows thick echogenic endometrial lining without a gestational sac (arrowheads).
This sonographic appearance can be seen in molar pregnancy; correlation with beta hCG is very important. (B) Sagittal TVUS
with color Doppler did not demonstrate trophoblastic flow, confirming it to be decidual reaction (arrowheads). Patient’s beta
hCG was 650 IU. On follow-up, the patient was shown to have a normal intrauterine pregnancy.
anembryonic gestation, or a pseudogestational sac of 0.6 mm/d on follow-up US [46]. Other minor crite-
ectopic pregnancy. Anembryonic gestation is a form ria of an abnormal gestational sac include distorted
of failed pregnancy defined as a gestational sac in sac shape and weakly echogenic or irregular chorio-
which the embryo failed to develop (Fig. 8A). A decidual reaction (Fig. 9). The presence of gestational
mean gestational sac diameter greater than 18 mm sac in the lower uterine segment or cervix is usually
(TVUS) without a visualized embryo is unequivocal seen in patients with abortion in progress (Fig. 10),
evidence of a failed, anembryonic pregnancy [44]. but can also be seen secondary to low implantation.
This also is referred to as an ‘‘empty amnion’’ sign Demonstration of trophoblastic vascular flow on
(Fig. 8B) because of its sonographic appearance of a color Doppler is useful in differentiating low implan-
large well-defined amniotic sac without an embryo tation from abortion.
[45]. The growth rate of an anembryonic gestational
sac is slower than that of a normal gestational sac, Yolk sac criteria of an abnormal gestation
which increases by 1.13 mm/day. An abnormal ges-
tational sac can be identified confidently when the The absence of a yolk sac when the mean sac
rate of increase of the mean sac diameter is less than diameter of the gestational sac is more than 10 mm is
Fig. 8. Anembryonic pregnancy. (A) TVUS of uterus shows a large (> 18 mm) gestational sac (arrow) without an embryo. (B) An
‘‘empty amnion sign’’ of anembryonic gestation (arrow).
the viability of the gestation. The most convincing

evidence that a pregnancy has failed is to document
absence of cardiac activity when CRL length is
greater than 5 mm. In a missed abortion, the embryo
may be small for the gestational age with a discrep-
ancy between the mean sac diameter and the CRL
(Fig. 11). Embryonic bradycardia is a poor prognos-
ticator of pregnancy viability and requires follow-up
[58]. Embryonic bradycardia is defined as a heart rate
of less than 100 beats per minute before 6.2 weeks
gestational age and less than 120 beats per minute
between 6.3 and 7 weeks [59].
Fig. 9. Abnormal shape of the gestational sac. A 30-year-old Intrauterine growth restriction
woman with 5 week’s of amenorrhea presents with vaginal
spotting. A TVUS of the uterus shows an intrauterine gest- First-trimester growth restriction is a sign of a
ational sac of abnormal shape and lobulated contour. On fol- failing pregnancy. Growth restriction is detected by
low-up patient had a spontaneous complete abortion. comparing the mean sac diameter with the CRL or
by serial follow-up of these growth parameters. The
average gestational sac diameters should be at least
5 mm larger than the CRL. A difference in size be-
indicative of an abnormal gestation and is associated tween mean sac diameter and CRL of less than 5 mm
with spontaneous abortion [47 – 49]. A failing or caries a high risk of subsequent embryonic demise
failed pregnancy is also suggested when the yolk [60]. When there is sac size and CRL discrepancy, a
sac is abnormal in size and shape. Large (> 6 mm) follow-up US examination is recommended because
irregular and calcified yolk sacs have been found to these fetuses have higher incidence of low birth
correlate with early pregnancy failure [50 – 52]. A weight and premature delivery [61,62].
large yolk sac is considered to be caused by an
alteration of the metabolic functions of the yolk sac Subchorionic hematoma
membrane with accumulation of secretions following
embryonic death [53]. The association of a large yolk Up to 20% of women with a threatened abortion
sac with aneuploidy has also been reported [50]. have a subchorionic hematoma [44]. Perigestational
Although abnormal large yolk sac size is reported
to be associated with subsequent pregnancy failure,
another study with yolk sac diameter greater than the
95th percentile for gestational age reported normal
pregnancy outcomes [54]. Because of this controver-
sial issue, any patient with a large yolk sac should
have a follow-up US because there is increased risk
of spontaneous abortion. Apart from size, irregular,
echogenic, calcified, or double yolk sacs (vitelline
duct cyst) also are associated with early pregnancy
failure [55,56].
Gestational sac with an embryo
Although visualization of a living embryo does

not ensure a viable pregnancy, the abortion rate
decreases for living embryos as the gestational age
Fig. 10. Abortion in progress. A TVUS of the uterus shows a
increases, with a 0.5% demise rate for living embryos low-lying gestational sac (arrow). Mixed hyperechoic and
between 6 and 10 mm [29]. Because cardiac activity hypoechoic contents in the endometrial cavity of the fundus
may not be demonstrated [57] in early normal em- (arrowheads) represent decidual reaction and hemorrhage.
bryos (CRL < 4 mm), follow-up US and correlation The patient had a complete spontaneous abortion a few
with the serum b-hCG level is useful in determining hours after the scan.
with that in younger women (13.8% versus 7.3%, re-

spectively), and was 2.3 times higher in women who
presented with vaginal bleeding at 8 weeks gesta-
tional age or less compared with that in women who
presented with bleeding at more than 8 weeks gesta-
tional age (13.7% versus 5.9%, respectively). Some
investigators have calculated the volume of a sub-
chorionic hematoma as a percentage of the gesta-
tional sac volume. When the volume of a hematoma
is less than 40% of the gestational sac volume, the
pregnancy outcome is favorable [64,66].
Retained products of conception

Fig. 11. Missed abortion. A 35-year-old woman with
10 weeks of amenorrhea presents with intermittent vaginal
bleeding. TVUS shows a relatively small-sized embryo (ar-
Retained products of conception typically consist
row) compared with the gestational sac. No cardiac activity of retained placental tissue. An echogenic mass in the
was demonstrated on pulsed Doppler. uterine cavity is the most suggestive US finding. A
heterogeneous mass or collection in the central cavity
may represent a blood clot, or some combination of
retained placenta, necrotic debris, and clot (Fig. 13).
Color Doppler may help to differentiate vascularized
hemorrhage from chorionic frondosum is the most trophoblastic tissue from nonvascularized blood clots.
common source of vaginal bleeding in the first A normal-appearing endometrial stripe or punctate
trimester of pregnancy. Subchorionic hemorrhage is echogenic foci not associated with a discrete mass
secondary to abruption of the edge of the chorion makes retained products of conception unlikely.
frondosum – decidua basalis complex or may be
caused by marginal sinus rupture [63,64]. Although
the hemorrhage usually abuts or elevates the edge of Gestational trophoblastic disease
the chorion frondosum – decidua basalis complex, the
bulk of the hemorrhage is usually situated between Gestational trophoblastic disease is a spectrum of
the decidua capsularis, chorion laeve, and the decidua pregnancy-related trophoblastic proliferative abnor-
vera. Acute hemorrhage may be hyperechoic or malities that can present with first-trimester bleeding.
isoechoic relative to the chorion, and it becomes
isoechoic with the chorionic fluid in 1 to 2 weeks
(Fig. 12). Several studies have correlated the preg-
nancy outcome in these patients with the size of the
subchorionic hematoma, gestational age, and the
maternal age. One of the largest studies [65] showed
that the rate of pregnancy loss increases with hema-
toma size, advancing maternal age, and earlier gesta-
tional age. In this study, the size of the hematoma was
graded according to the percentage of the chorionic
sac circumference elevated by the hematoma. It was
graded as small when it involved less than one third
of the chorionic sac circumference, moderate when it
involved one-third to one-half of the chorionic sac
circumference, and large when two-thirds or greater
of the chorionic sac circumference was involved.
There was little difference in the rates of spontaneous
abortion between pregnancies with small- and mod-
erate-size hematomas (7.7% and 9.2%, respectively),
but the rate doubled with large hematomas (18.8%). Fig. 12. Subchorionic hemorrhage. TVUS shows a gesta-
The spontaneous abortion rate was also twice as tional sac (curved arrow), chorion (straight thick arrow),
high in women 35 years of age or older compared and a subchorionic hemorrhage (straight thin arrow).
Fig. 13. Retained products of conception with variable appearance. Sagittal (A) and coronal (B) TVUS in two different patients
with persistent vaginal bleeding after spontaneous abortion show retained products of conception with increased echogenicity
(arrowheads) in (A) and heterogeneous appearance in (B). This appearance is secondary to necrosis and blood clots. (C) Increased
vascularity on color flow Doppler evaluation in a patient with retained products of conception.
Classification of gestational trophoblastic disease is eration and edema of villous stroma. Its incidence is
as follows: 1 in every 1000 to 2000 pregnancies [67] and is
estimated to be as high as 1 in 41 in patients with
Hydatidiform mole miscarriages [68]. Hydatidiform mole constitutes
Complete mole 80% of the cases of gestational trophoblastic disease
Partial mole with relatively high frequency of molar pregnancy at
Gestational trophoblastic tumors the beginning and end of the childbearing period.
Choriocarcinoma Mole recurrence is seen in about 1% to 2% of cases
Invasive mole [69]. The absence or presence of fetus or embryonic
Placental site trophoblastic tumor elements is used to classify a molar pregnancy into
complete or partial moles. Complete molar pregnan-
cies are most often 46 XX, with the chromosomes
Hydatidiform mole (molar pregnancy) completely of paternal origin and are referred to as
‘‘androgenesis.’’ The karyotype in partial mole is usu-
Molar pregnancy is a noninvasive process charac- ally triploid (69 XXY) or even tetraploid (92 XXXY)
terized by varying degrees of trophoblastic prolif- with one maternal and two paternal haploid compo-
nents. The fetus in partial mole is usually nonviable agnosis is made by markedly elevated serum b-hCG
and exhibits features of triploidy, which include levels expected for the stage of gestation and by the
multiple congenital anomalies and growth restriction characteristic sonographic appearance.
[70]. Histologically, the molar tissue has prominent
villi with central acellular space corresponding to the Sonographic features of molar pregnancy
macroscopic appearance of vesicles. In partial mole
these changes are focal and less advanced. Molar changes can be detected from 8 weeks of
The clinical presentation of molar pregnancy, pregnancy by US. The uterine cavity is filled with
listed below, has changed appreciably over the last multiple sonolucent areas of varying size and shape.
decades because of early diagnosis with TVUS and This has been described as a ‘‘snow storm’’ appear-
quantitative b-hCG estimation. ance with low-frequency transabdominal scanning.
With high-frequency transvaginal transducers, nu-
Uterine bleeding, which may vary from spotting merous discrete, anechoic (cystic) spaces are visual-
to profuse hemorrhage ized corresponding to the hydropic villi (Fig. 14).
Uterine enlargement out of proportion to the These cystic spaces range from 1 to 30 mm in size
duration of pregnancy in 50% of cases and increase in size with gestational age. Large sono-
Absence of fetal parts or fetal heart sounds lucent areas or maternal lakes resulting from the stasis
despite an enlarged uterus of maternal blood are seen between the vesicles. In
Pregnancy-induced hypertension before partial mole, an intrauterine embryo is noted along
24 weeks gestation with molar changes [71,72]. Because the trophoblas-
Hyperemesis tic changes develop at a slower rate in partial mole,
Thyrotoxicosis, which is usually subclinical it may present as enlarged placenta without macro-
History of passage of grape-like vesicles trans- scopic vesicular changes [73]. Women with a high
vaginally b-hCG level for the gestational age without sono-
graphic molar changes should have follow-up US to
Uterine bleeding is the most common presentation exclude partial mole. In missed abortion, impaired
and it may vary from spotting to profuse bleeding. trophoblastic vascularity leads to hydropic degenera-
Occasionally patients may pass grape-like vesicles tion of villi and can resemble a partial hydatidiform
transvaginally. Clinically the uterine fundal height is mole on US. The serum b-hCG is not elevated, how-
more than is expected for the gestational period. Di- ever, and may be normal or at a lower level than for
Fig. 14. Complete hydatidiform mole. (A) Transabdominal sonogram of the uterus shows a complex mass with multiple well-
defined anechoic cystic areas (arrows) corresponding to the vesicles of hydatidiform mole. There was no associated embryo.
(B) Corresponding T1-weighted postgadolinium image of the uterus demonstrates intrauterine complex mass (arrowheads) with
multiple well-defined hypointense lesions that are not enhancing and represent vesicles of hydatidiform mole (arrow).
the expected gestational age. Rarely, a viable fetus or without myometrial invasion. Doppler interroga-
may be associated with complete molar pregnancy tion reveals typical trophoblastic flow and differen-
[74] and is caused by the coexistence of a true mole tiates trophoblastic tissue from areas of hemorrhage
and a normal fetus in dizygotic twin gestation. Dem- and necrosis. Ovarian theca-leutin cysts are identified
onstration of the typical trophoblastic flow is useful in more than a third of such cases. Cross-sectional
in differentiating the trophoblastic tissue of molar imaging with CT and MR imaging is more accurate in
pregnancy from intrauterine blood clots in a patient demonstrating invasion of the myometrium and para-
with abortion. Theca-leutin ovarian cysts are seen in metrium. Radiologic evaluation for distant metastases
up to 25% to 60% of cases because of hyperstimu- is mandatory in all cases of choriocarcinoma.
lation of the ovaries by chorionic gonadotrophin
secreted by the trophoblastic tissue [75]. In this con- Invasive mole
dition, the ovaries are enlarged with multiple cysts This is defined as excessive trophoblastic over-
having a soap bubble or spoke-wheel appearance. growth with invasion of the myometrium and oc-
Treatment of hydatidiform mole consists of im- casional extension to the peritoneum or adjacent
mediate evacuation of the mole and subsequent fol- parametrium. Unlike choriocarcinoma there are no
low-up with serial measurement of serum b-hCG for distant metastases. Invasive mole presents clinically
detection of persistent trophoblastic proliferation as heavy vaginal bleeding after the evacuation of the
or malignant change. TVUS is useful in monitor- molar pregnancy with persistent elevation of serum
ing patients following evacuation and chemotherapy b-hCG. On TVUS it appears as focal areas of in-
[76 – 79]. If the b-hCG levels plateau or continue to creased echogenicity within the myometrium [86].
rise, persistent trophoblastic tissue is diagnosed. Fol- Doppler color flow mapping of this area can evaluate
lowing evacuation of a hydatidiform mole, 18% to the extent of this lesion and its subsequent response
29% with complete hydatidiform mole and 1% to to chemotherapy (Fig. 15) [87 – 89].
11% with partial mole develop a persistent tropho-
blastic tumor [80 – 83]. TVUS reveals nodules of Placental site trophoblastic tumor
residual echogenic trophoblastic tissue and central This is a very rare trophoblastic tumor, which arises
hypoechoic blood spaces. Doppler interrogation from the placental implantation site following either a
reveals typical low-resistance and high-peak systolic normal term pregnancy or abortion. These patients
velocity vascular flow of trophoblastic tissue. present with either abnormal bleeding or amenorrhea
and might be presumed to be pregnant. Moreover, the
Gestational trophoblastic tumors b-hCG levels are not as high as in other forms of
gestational trophoblastic disease [90,91]. They may
Gestational trophoblastic tumor refers to chorio- invade the myometrium and in 15% to 20% cases
carcinoma, invasive mole, and placental site tropho- behave in a malignant fashion with distant metastases.
blastic tumor. It may follow a normal or a molar US features are indistinguishable from those of other
pregnancy, abortion, or ectopic pregnancy. Diagnosis gestational trophoblastic tumors [92,93].
is made primarily by persistent elevation of the serum
b-hCG. Fifty percent of these tumors arise following
hydatidiform mole, 25% following abortion, and 25% Arteriovenous malformation of the uterus
following normal or ectopic pregnancy [84].
It is important to consider arteriovenous malfor-
Choriocarcinoma mations in the differential diagnosis of first-trimester
Choriocarcinoma is a malignant form of tropho- bleeding because of their sonographic resemblance
blastic tumor that invades uterine myometrium and to retained products of conception and gestational
blood vessels resulting in distant metastasis. The ab- trophoblastic disease. Vascular malformations of the
sence of villous pattern is characteristic of chorio- uterus are rare and potentially life-threatening le-
carcinoma, in contrast to hydatidiform mole and sions. They can be congenital or acquired following
invasive mole. The most common sites of metastases uterine trauma (surgery or curettage); use of intra-
are the lungs (over 75%) and the vagina (50%). Other uterine contraceptive devices; endometrial or cervi-
sites of metastases include the vulva, liver, kidneys, cal carcinoma; and previous treatment of gestational
brain, ovaries, and bowel [85]. The US appearance trophoblastic tumors [94]. Congenital arteriovenous
is indistinguishable from a complete mole, except malformations have multiple arteriovenous commu-
in cases with myometrial and parametrial extension. nications and may extend through the myometrium
TVUS reveals a heterogeneous intrauterine mass with into the parametrium. Acquired lesions are arterio-
Fig. 15. Invasive mole. (A) TVUS showing molar tissue invading the myometrial wall (arrowheads) of the fundus and
endometrial cavity (arrow). (B) Color flow Doppler evaluation shows vascularity of the invaded myometrium. Endometrial
cavity is shown by arrow. (C) Corresponding T2-weighted, sagittal image of the uterus demonstrates hyperintense myometrium
(arrow) representing invasive molar tissue. Uninvolved endometrial lining is shown (arrowheads).
venous fistulas between a single artery and a vein. Uterine arteriovenous malformations are one of the
Vascular malformations persist following treatment common causes of spontaneous abortions. Contrast-
in 10% to 15% of patients with gestational trophoblas- enhanced CT, MR imaging, and angiography are other
tic tumors. Gray-scale US shows multiple anechoic imaging modalities used to diagnose uterine arterio-
spaces with mosaic pattern of color signals within the venous malformations. The diagnosis of uterine arte-
cystic spaces on color Doppler US. Spectral analysis riovenous malformations as the cause of vaginal
of the vessels shows high-velocity blood flow with a bleeding is crucial because treatment is entirely dif-
low resistive index [95,96], indistinguishable from a ferent from that for retained products of conception or
gestational trophoblastic disease (Fig. 16). These gestational trophoblastic disease, which can mimic
vessels can be distinguished from gestational tropho- arteriovenous malformations. The treatment of arte-
blastic disease because the serum b-hCG is normal. riovenous malformations is by embolization if the
Fig. 16. Uterine arteriovenous malformation in a 35-year-old woman with history of spontaneous abortion presenting with
vaginal bleeding. She was referred to exclude retained products of conception. (A) TVUS shows complex endometrial mass
(arrowheads) with anechoic spaces (arrow). (B) Corresponding color flow Doppler demonstrates the mosaic pattern of flow
within the mass (arrowheads). Arrow points to endometrial cavity. Pulsed Doppler (C) shows arterialized venous flow,
diagnostic of arteriovenous malformation.
patient desires fertility and by hysterectomy if fertility of early pregnancy failure can be made even before
is not an issue. the embryo is visible.
Summary
Acknowledgment
Vaginal bleeding is a leading cause of presentation
for emergency care during the first trimester of the The authors thank Bonnie Hami, MA, Department
pregnancy. Clinical assessment of the pregnancy of Radiology, University Hospitals of Cleveland,
outcome at this stage is less reliable. US examination Ohio, for her editorial assistance in the preparation of
is crucial in establishing IUP and early pregnancy this article.
failure and to exclude other causes of bleeding, such
as ectopic pregnancy and molar pregnancy. Diagnosis
of a normal IUP at this stage not only assists the References
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of partial hydatidiform mole. Lancet 1990;335:1074. partum hemorrhage: treatment with selective arterial
[83] Chen RJ, Huang SC, Chow SN, et al. Persistent gesta- embolization. Radiology 1999;212:385 – 9.
Radiol Clin N Am 42 (2004) 315 – 327
The role of ultrasound in pregnancy-related emergencies

Noam Lazebnik, MD*, Roee S. Lazebnik, PhD
Department of Obstetrics and Gynecology, MacDonald Women’s Hospital, University Hospitals of Cleveland,
Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA
Although most births are uneventful, about 15% Ultrasound examinations in emergency situations
of all birthing women experience potentially life- are ordered to obtain specific, limited information
threatening complications, and at least 1% to 2% when it is necessary or impossible to perform a
require major surgery. Although some complications complete fetal, placental, or pelvic organ survey.
can be prevented, and some predicted preemptively, Limited examinations in antepartum and intrapartum
most of the severe complications cannot be antici- emergency settings may include identification of
pated. To reduce mortality, a key component of ma- fetal number, fetal presentation, presence or absence
ternal health care is the ability to diagnose, confirm, of fetal cardiac activity, localization of the placenta,
and treat women whose medical status is unstable assessment of amniotic fluid volume, and a biophysi-
in the antenatal, delivery, and postpartum periods. cal profile. The relevant clinical information can be
Sonography is the imaging modality of choice for obtained by performing transabdominal study, trans-
diagnosing maternal-related abnormalities both dur- vaginal study, or combination of the two modalities.
ing and following pregnancy and delivery. Pelvic Occasionally, additional ultrasound studies are needed
ultrasound has long been the mainstay for evaluation in cases of medical or surgical complications of the
of the female pelvis. It is widely used during preg- pregnant patient. Examples of such disorders include
nancy in countries where antenatal care is available. renal and gastrointestinal abnormalities and maternal
Most pregnant women are referred for ultrasound vascular abnormalities.
study to confirm gestational age and to rule out fetal
malformations, abnormal placentation, and uterine
and cervical abnormalities. At University Hospitals Sonographic technique
of Cleveland, Case Western Reserve University, a
tertiary care medical facility, more than 12,000 ob- Modern ultrasound devices have variable-focus
stetric ultrasound studies are performed yearly. About depths that allow the examiner to study structures
13% of the total studies are performed in an emer- in the near or far field as needed without changing
gency obstetric setup. This article describes the transducers. A 2- to 5-MHz and 4- to 9-MHz trans-
emergency conditions during pregnancy and the ducer for transabdominal and transvaginal study,
immediate postpartum period that might lead to a respectively, is very well suited. For a pelvic sono-
life-threatening situation for the pregnant patient or gram, performed transabdominally, the patient’s uri-
her fetus, and the spectrum of imaging findings nary bladder should be distended. A full bladder
associated with these conditions. usually is unnecessary. The more advanced the preg-
nancy, the lesser the need for a full bladder. When-
ever cervical and lower uterine segment or pelvic
organs images are needed, endovaginal scanning is
superior to transabdominal scanning. Improved visu-
* Corresponding author. alization may be achieved using the vaginal ap-
E-mail address: noam@cwru.edu (N. Lazebnik). proach, because the transducer is brought closer to
doi:10.1016/j.rcl.2004.01.006
316 N. Lazebnik, R.S. Lazebnik / Radiol Clin N Am 42 (2004) 315–327
the area being examined. It can be very helpful in sea and vomiting, upper right quadrant abdominal
studying the lower uterine segment and its relation pain, and headache are usually the most common
to the placenta, evaluating the uterus, or measuring a symptoms. During the physical examination, the
cyst in an ovary in the early stage of pregnancy. The physician notes impressive abdominal tenderness,
sonologist performing the study decides whether especially in the right upper quadrant. The liver
one or a combination of approaches is best for the may be enlarged and liver function tests are abnor-
particular case. mally elevated with evidence of hemolysis on a
There are no known contraindications to abdomi- peripheral blood smear and the red blood cell and
nal ultrasound study. Transvaginal studies are not platelet counts may be low. When the disease is not
recommended in case of premature rupture of the treated early, up to 25% of affected women develop
membranes. The use of this modality is controversial serious complications. Without treatment, approxi-
in cases of placenta previa, as discussed later. Careful mately 1.1% to 3.5% of patients die from HELLP
judgment should always be applied in choosing to syndrome, usually because of liver rupture or other
perform a transvaginal study because it might be related maternal complications [1]. The pathophysio-
contraindicated for maternal or fetal reasons. Further- logic process of this condition begins with arteriolar
more, regardless of the indication for the study, one vasospasm, which causes endothelial damage and
should always perform a transabdominal evaluation fibrin deposition in the vessel lumen. This leads to
before considering vaginal scanning. The added the following events: (1) platelet deposition on the
views obtained by combining the two scanning fibrin aggregates, reducing the number of circulat-
modalities might be of significant help in establishing platelets (unlike disseminated intravascular co-
ing a correct diagnosis. agulation, coagulation factors are not involved);
It is highly advisable to follow a strict routine (2) erythrocyte destruction by the fibrin aggregates
when one performs ultrasound study for an obstetric (a microangiopathic hemolytic anemia), leading to
emergency. The first priority in a true obstetric abnormal cells in the peripheral smear (burr cells and
emergency is to document a live in utero gestation, schistocytes), an elevated indirect bilirubin level, and
with a stable and normal heartbeat. Once this has anemia; and (3) hepatocyte destruction caused by
been achieved one should document that there is no hepatic microemboli [2]. HELLP syndrome occurs
suspicion for a significant volume of free fluid or in approximately 10% of pregnant women with
blood clots inside the gestational sac, the abdominal preeclampsia or eclampsia. Preeclampsia may be mild
cavity, or the posterior cul-de-sac. The bladder and or severe. Severe cases with high blood pressure and
uterus should appear normal and intact, and no protein in the urine can progress to seizures (eclamp-
adnexal mass should be present. sia). Severe cases are life-threatening to both the
mother and fetus. Many women have a high blood
pressure and are diagnosed with preeclampsia before
Second- and third-trimester obstetric emergencies they develop the HELLP syndrome. In some cases,
however, HELLP symptoms are the first warning of
Pregnancy-induced hypertension preeclampsia and the condition is misdiagnosed as
hepatitis, gallbladder disease, idiopathic thrombocy-
Pregnancy-induced hypertension complicates 6% topenic purpura, hemolytic uremic syndrome, or
to 8% of pregnancies in the United States and ac- thrombotic thrombocytopenic purpura.
counts for 15% of maternal deaths. It ranks second The fatality rate among neonates born to mothers
only to embolic events as a cause of maternal mor- with HELLP syndrome varies, depending on such
tality. It also is an important cause of perinatal mor- factors as birth weight. The main treatment is delivery
bidity and mortality. In pregnant women, two distinct of the baby as soon as possible, because liver func-
hypertensive disorders are common: chronic hyper- tion in the mother rapidly deteriorates with this con-
tension and pregnancy-induced hypertension. Women dition, a harmful state for both the mother and fetus.
with chronic underlying hypertension are at risk for
pregnancy-induced hypertension, a multiorgan patho- Sonographic findings
logic state with various subsets. One of the more Unlike the traditional role of sonography during
severe forms of hypertensive disorder during preg- pregnancy where the fetus, placenta, or the pelvic
nancy is HELLP syndrome. organs are the targets of the study, sonography plays a
The HELLP syndrome in a pregnant woman is different role in HELLP syndrome; it can exclude
characterized by hemolytic anemia, elevated liver biliary tract disease and identify altered hepatic
enzymes, and a low platelet count. Progressive nau- and renal echo textures. Possible findings include
N. Lazebnik, R.S. Lazebnik / Radiol Clin N Am 42 (2004) 315–327 317
patchy areas of increased echogenicity in the liver, the myometrium near the level of the internal os, and
diffusely increased renal echo texture and size, peri- a cesarean scar defect was present when there was
renal fluid, and hepatic subcapsular hematoma [3,4]. an anechoic area (fluid) within the scar. Women who
had prolonged labor before cesarean section were
Uterine rupture more likely to show a cesarean scar defect, and so
were women who had multiple cesarean deliveries.
One of the major causes of maternal and perinatal The researcher reported that real-time transvaginal
mortalities is rupture of the uterus. This obstetric ultrasound was 87% sensitive and 100% specific
hazard is also associated with short-term maternal for detecting cesarean scars [11].
morbidities, such as vesicovaginal fistula, rectovagi-
nal fistula, bladder rupture, foot drop, psychologic
Abnormal placentation
trauma, and anemia [5]. In the long-term, because of
the surgical intervention, the woman may become
Abnormal placentation in the form of placenta
infertile as a result of indicated hysterectomy.
accreta, percreta, or increta is a rare but potentially
Uterine rupture is defined as separation that
life-threatening complication of pregnancy that is
requires operative intervention or is symptomatic. It
an increasingly frequent cause of maternal morbidity
involves the full thickness of the uterine wall. Uterine
and mortality. The term refers to any placental im-
rupture may occur spontaneously but is more com-
plantation resulting in abnormal adherence to the
monly associated with history of uterine surgery,
uterine wall. Life-threatening hemorrhage can occur
such as dilation and curretage, classical cesarean or
at delivery because of failure of placental separation
low transverse cesarean section, and myomectomy.
from the uterine wall and occurs in about 40% of
Induction of labor using low- and high-dose regi-
cases. It is associated with significant maternal mor-
mens of prostaglandin E2 or with misoprostol might
bidity and in rare cases maternal mortality [12].
also result in uterine rupture. Prolonged deceleration
Pathologically it occurs when the decidua basalis is
(alone or proceeded by either severe late or variable
partially or totally absent in conjunction with an
decelerations) is the most reliable clinical finding
imperfect development of Nitabuch’s membrane, a
occurring in 100% of cases when total fetal extrusion
fibrinoid layer that separates the decidua basalis
occurred [6]. The incidence of uterine rupture is
from the placental villi [13]. The placental villi are
0.05% of all pregnancies [7], occurring between 1 in
in direct contact with the myometrium without in-
140 and 1 in 300 of women with a pre-existing scar
tervening endometrial decidua. Clark et al [14] dem-
[8]. The risk of uterine rupture increases with the
onstrated the effect of previous cesarean section
number of caesarean sections [9]. The perinatal mor-
deliveries on the incidence of placenta accreta. They
tality is 10 times that of the maternal mortality [7].
showed that the risk of placenta previa increases
Leung et al [6] evaluated 78 cases of uterine rupture
proportionately with the number of previous cesarean
in a large tertiary care medical center and reported
section deliveries (0.26% in an unscarred uterus, and
significant neonatal morbidity when 18 minutes or
up to 10% in women with four or more previous
more elapsed between the onset of prolonged decel-
cesarean sections). Surgical intervention in the form
eration and birth. When the prolonged deceleration
of total abdominal hysterectomy is often indicated
was preceded by severe late or variable decelera-
because of life-threatening hemorrhage at delivery,
tions, fetal asphyxia occurred as early as 10 minutes
secondary to failure of placental separation from
from the onset of prolonged deceleration.
the uterine wall.
Sonographic findings
The sonographic findings of uterine rupture dur- Sonographic findings
ing pregnancy include extrauterine blood collection, Placenta accreta can be diagnosed using gray-
fetal parts outside the uterine cavity, intra-amniotic scale and color Doppler sonography. Gray-scale
hemorrhage, and focal bulging of membranes through findings include loss of the normally visible retropla-
the site of dehiscence [10]. In a recently published cental hypoechoic rim corresponding to the decidua
study the authors raised numerous questions regard- basalis and dilated venous vessels [12]. Progressive
ing the significance of cesarean scar defects and the thinning of the retroplacental hypoechoic zone on
ability of transvaginal ultrasound to predict the risk serial examinations is an important clue (Fig. 1).
of uterine rupture in women choosing trial labor after Multiple placental lakes that may represent dilated
cesarean section [11]. Transvaginal ultrasound dem- vessels extending from the placenta through the myo-
onstrated a cesarean scar as an echogenic line through metrium form the so-called ‘‘Swiss cheese’’ appear-
lakes with focal lacunar flow, hypervascularity linking

the placenta to the bladder, dilated vascular channels
with pulsatile venous flow over cervix, and poor
vascularity at sites of loss of hypoechoic zone.
Placenta previa
Placenta previa occurs in approximately 1 in

200 to 250 pregnancies and is associated with po-
tentially serious consequences from hemorrhage,
abruption of the placenta, or emergency cesarean
delivery. Abruption of the placenta occurs 14 times
more frequently in pregnancies with placenta previa
than in normal pregnancies, and cesarean delivery
occurs four times more frequently because of the
potentially serious consequences of persistent pla-
centa previa at delivery. There are three types of
placenta previa: (1) marginal previa where the edge
of the placenta is less than 2 cm from the opening
Fig. 1. Placenta accreta. Longitudinal color Doppler image of the cervix, (2) partial placenta previa where the
of placenta demonstrates thinning of the retroplacental placenta partly covers the cervical opening, and
hypoechoic zone (arrowheads). Color flow Doppler ultra- (3) total previa where the placenta completely covers
sound highlights areas of increased turbulent flow that the cervical os (Fig. 2A).
extend from the placenta into the surrounding uterine wall Marginal placenta previa is also known as ‘‘low-
and cervix (arrows). lying’’ placenta. The natural history of marginal
placenta previa was studied by Rizos et al [19].
Placental localization by diagnostic ultrasound was
performed at 16 to 18 weeks’ gestation in 1098 pa-
ance of the placenta [15]. Depending on the location tients before amniocentesis for genetic indications.
of the implantation, the condition is referred to as Marginal placenta previa was diagnosed in 58 pa-
‘‘placenta accreta,’’ ‘‘placenta increta,’’ or ‘‘placenta tients, 47 of whom went on to delivery uncompli-
percreta.’’ If the placental villi extend beyond the cated by placenta previa. There were five patients
confines of the endometrium and attach to the super- with placenta previa at delivery, four of whom had
ficial aspect of the myometrium, the term ‘‘placenta third-trimester bleeding. One patient was diagnosed
accreta’’ is used. Placenta increta refers to a situation as having a normal placental implantation at mid-
in which the villi invade the myometrium, whereas trimester but placenta previa was demonstrated at
the term ‘‘placenta percreta’’ is used if the villi ad- delivery. The incidence of placenta previa at 16 to
vance into the serosa or parametria. Although this 18 weeks’ was 5.3% and fell to 0.58% at delivery,
classification scheme is widely accepted, most pub- indicating a 90% conversion rate. This conversion
lished literature discusses these abnormalities collec- occurs secondary to rapid growth of lower uterine
tively as placenta accreta [16]. Doppler ultrasound segment in the third trimester resulting in superior
highlights areas of increased turbulent flow that migration of placenta relative to the internal cervical
may extend from the placenta into the surrounding os. Most cases of asymptomatic low-lying placenta
uterine wall and cervix (see Fig. 1). Lerner et al [17] convert to normal location of the placenta before
reported a sensitivity of 100% and a specificity of delivery. The authors concluded that these patients
94% for the prenatal detection of placenta accreta should be observed with serial ultrasound studies at
using color Doppler. 6- to 8-week intervals until delivery or unequivocal
This technique also allows turbulent flow to be conversion. They also recommended no restriction
visualized in cases of placenta percreta where placen- in activity unless the placenta previa persists beyond
tal vessels extend beyond the uterine serosa and may 30 weeks or becomes clinically manifest [19].
involve other pelvic organs, such as the bladder. Traditionally, transabdominal study is used to
Chou et al [18] have described the following findings document sagittal midline images of the lower uter-
associated with placenta accreta: dilated vascular ine segment and cervix, preferably with a full bladder
channels with diffuse lacunar flow, irregular vascular to document the presence of placental tissue extend-
Fig. 2. Placenta previa. (A) Transvaginal sonographic view at 10 weeks gestation reveals the placenta completely covering the
internal cervical os. (B) Transabdominal view of the same case at 34 weeks gestation. The placenta covers the entire internal
cervical os. The retroplacental hypoechoic zone is invisible in the lower uterine segment adjacent to the cervix also suggesting
placenta accrete (arrows).
ing down to the region of the cervix (Fig. 2B). Be- alize the extent of subchorionic or retroplacental
cause of concerns regarding the use of transvaginal hematoma (Fig. 3). The diagnostic sensitivity for
study in patients with vaginal bleeding, possibly as a abruption has not improved despite significant
result of placenta previa, translabial (transperineal) improvements in ultrasound technology. Only one of
study has been suggested as an alternative to trans- every nine sonograms obtained to rule out placental
abdominal study [20]. abruption revealed evidence of a subchorionic or
Farine et al [21] compared the accuracy of the retroplacental hematoma [23]. Ultrasound study
diagnosis of placenta previa using transvaginal so- performed specifically to document placental abrup-
nography with that of the traditional transabdominal tion is usually unremarkable and is positive in only
sonography. They concluded that transvaginal sonog- 25% of cases of placental abruption that are con-
raphy was superior to transabdominal sonography in firmed at delivery [24]. These researchers noted that
diagnosing placenta previa and invariably correct in there were no significant differences in clinical char-
ruling it out. Timor-Tritsch and Yunis [22] confirmed acteristics between women with positive or negative
the safety of transvaginal sonography in patients sonographic findings. They concluded that sonogra-
suspected of placenta previa. They concluded that phy is not sensitive for detecting abruption, but
the angle between the cervix and vaginal probe is when a clot is visualized on sonography, the positive
sufficient to prevent the probe from inadvertently predictive value for abruption at delivery is high.
slipping into the cervix and initiating or further They also noted that the shorter the scan-to-delivery
aggravating vaginal bleeding. interval, the greater the positive predictive value.
When delivery occurred within 2 weeks of a positive
Placental abruption sonographic finding, the diagnosis of placental abrup-
tion was confirmed in 100% of cases. Given that
Third-trimester placental abruption complicates sonography is not a sensitive tool to diagnose pla-
less than 1% of pregnancies but is associated with cental abruption, sound clinical judgment suggests
increased risk of preterm delivery and fetal death that even if the placenta appears grossly normal, a
when it does occur [23]. The clinical diagnosis is diagnosis of abruption should be considered when
usually based on bleeding, abdominal pain, and con- vaginal bleeding, abdominal pain, and uterine hyper-
tractions, but sonography is often performed to visu- tonicity are present.
Fig. 3. Placental abruption. (A) Retroplacental blood clot (arrows). (B) Large blood clot resulting from placental abruption
occupying most of the fundal region of the uterus. Hyperechoic and hypoechoic irregular areas are seen within the clot (arrows).
(C) A second blood clot is seen in the anterior lower uterine segment (arrows).
Vasa previa of suspicion, however, vasa previa can be diagnosed

prenatally using ultrasound and color Doppler, allow-
Despite dramatic improvements in diagnosis of ing for elective delivery by cesarean section before
maternal, fetal, and placental abnormalities vasa membrane rupture with almost universal fetal sur-
previa remains a true diagnostic challenge and con- vival [25]. Fung and Lau [26], Oyelese et al [27], and
tinues to be a fatal condition for the fetus. For many Lee et al [28] showed that a good outcome in vasa
years even following the introduction of ultrasound previa depended entirely on antenatal diagnosis
technology the diagnosis was made only after the of the condition by ultrasound. Screening all patients
membranes were ruptured and fetal exsanguina- for vasa previa is time consuming and unnecessary
tion occurred. because of low incidence. Documentation of placen-
Vasa previa is a condition in which vessels run tal cord insertion, however, should be part of any
through the membranes below the presenting part, detailed obstetric sonographic examination. Recently
running over, or in close proximity to, the internal Fung and Lau [26] and Oyelese et al [27] indepen-
cervical os, unsupported by placenta or cord (Fig. 4) dently concluded that a low-lying placenta in the
[25]. Spontaneous or artificial rupture of the mem- second trimester was the most important risk factor
branes in labor often leads to fetal exsanguination, for vasa previa at term, whether or not the placenta
with mortality approaching 100%. With a high index subsequently remained low-lying at term. Other risk
especially if it is less than 2 mm, retained blood in

the endometrial cavity is more likely than retained
products of conception.
Hertzberg and Bowie [30] reviewed the ultra-
sound images of 53 postpartum patients referred for
possible retained products of conception and corre-
lated specific ultrasound patterns with clinical and
pathologic follow-up. The most common finding in
patients with retained placental tissue was an echo-
genic mass in the uterine cavity, seen in 9 of
11 patients with pathologically proved retained pla-
cental tissue. In the remaining two patients with
pathologically confirmed retained placenta, a hetero-
geneous mass was seen in the uterine cavity some-
time during the course of serial sonography. Retained
placental tissue was found unlikely when ultrasound
demonstrated a normal uterine stripe endometrial
fluid, or hyperechoic foci in the uterine cavity with-
Fig. 4. Vasa previa. The placenta is posterior in location out an associated mass. The latter finding often was
with marginal previa. The vessels (red and blue) commu- associated with recent uterine instrumentation. The
nicate with an accessory placental lobe implanted on the left sonographic appearance of retained placental tissue
anterior lower uterine segment. Arrow points to the cervix. was shown to be variable, but detection of an echo-
genic mass in the uterus strongly supported the
factors for vasa previa include multiple pregnancies, diagnosis. The authors concluded that solid echogenic
pregnancies resulting from in vitro fertilization, and masses in the lumen or uterine wall are the most
those with succenturiate lobe and bilobed placen- specific findings for a retained placenta, whereas
tae [25]. In all such pregnancies it is prudent to heterogeneous mass could be caused by retained pla-
examine the region overlying the internal cervical centa or from blood clots or infected or necrotic ma-
os for evidence of vessels running over it. terial in the absence of placental tissue [30]. The
Postpartum hemorrhage
Obstetric delivery has been associated with the

potential for acute, massive blood loss to a degree
unparalleled by other surgical procedures. Data from
the Maternal Mortality Collaborative in 1988 indicate
that hemorrhage was responsible for 11% of direct
maternal deaths occurring in 1980 through 1985 [29].
No other condition in obstetrics, except perhaps
shoulder dystocia, requires such rapid recognition
and skillful response by the clinician to prevent
loss of life.
The sonographic findings of retained placental
tissue are often nonspecific because blood clots and
retained products feature considerable overlap in
sonographic appearance. In the first and early second
Fig. 5. Retained products of conception. An echogenic area
trimester on transabdominal or transvaginal views
(calipers) representing placental tissue, debris, and blood is
of the endometrial cavity, thickened hyperechoic present in the endometrial cavity following manual removal
endometrial stripe greater than 5 mm, gestational of the placenta. Patient underwent dilation and curettage for
sac (with or without a nonliving embryo), and round continued uterine bleeding. The arrows point to retained
to ovoid fluid sac are suggestive of retained prod- products of conception still present subsequent to the
ucts. If the endometrial stripe is less than 5 mm, dilation and curettage.
authors suggested that sonographic evaluation for din E1 analogue. It was developed and marketed for
retained products of conception is best performed prevention of peptic ulcer disease caused by prosta-
before uterine instrumentation to avoid confusion glandin synthetase inhibitors, but with its potent
with iatrogenically introduced air. An example of uterotonic and cervical ripening activity has found
retained products following term vaginal delivery is applications in the management of gynecologic and
illustrated in Fig. 5. obstetric problems. In the United States it has been
Di Salvo [10] noted anecdotally that low-resist- marketed as Cytotec, in 100- and 200-mg tablets. Simi-
ance Doppler signals in these masses also can be lar effectiveness has been shown when it is given
predictive. When using Doppler sonography in this for a ‘‘failed’’ pregnancy or missed abortion [34,35].
setting, however, it is important not to confuse low- Potential hypertonus as a result of drug accumu-
resistance arterial signals that arise within the myo- lation has been associated with uterine rupture in the
metrium, which represent the placental implantation second or third trimester, and retained products of
site, with similarly appearing Doppler signals arising conception with significant bleeding [36]. Transvagi-
from tissue within the endometrial cavity, which nal sonography is a useful supplement to the clinical
represent retained products [10]. assessment in women who experience a spontaneous
first-trimester abortion. Its use results in reduction
of unnecessary general anesthesia and uterine curet-
Retained products of conception tage. Wong et al [37] showed that a first-trimester
vaginal ultrasound study has a sensitivity and speci-
A spontaneous abortion is the loss of a fetus dur- ficity of 100% and 80%, respectively, using a bilayer
ing pregnancy because of natural causes. The term endometrial thickness of 8 mm or less. The ultra-
‘‘miscarriage’’ is the spontaneous termination of a sound findings suggesting retained products of con-
pregnancy before fetal development has reached ception are a thickened endometrium of greater than
20 weeks. The term ‘‘spontaneous abortion’’ refers 8 mm; complex hyperechogenic (blood and tissue
to these naturally occurring events, not elective or debris) and hypoechogenic fluid material inside the
therapeutic abortion procedures. More specific terms endometrial cavity; a gestational saclike structure; or
include missed abortion (a pregnancy demise where a space-occupying collection.
nothing is expelled); incomplete abortion (not all of
the products of conception are expelled); complete Uterine fibroids
abortion (all of the products of conception are ex-
pelled); threatened abortion (symptoms indicate a Fibroid tumors are benign growths that develop
miscarriage is possible); inevitable abortion (the in the muscular wall of the uterus. Although fibroids
symptoms cannot be stopped and a miscarriage will do not always cause symptoms, their size and loca-
happen); and infected abortion. Any one of these tion could lead to complications during pregnancy for
conditions might be associated with some degree of some women including recurrent miscarriage, infer-
vaginal bleeding. The bleeding in incomplete abor- tility, premature labor, fetal malpresentations, and
tion in which parts of the fetus or placental material complications of labor [38]. Lev-Toaff et al [39]
are retained within the uterus might be associated reported their ultrasound findings of uterine fibroids
with significant blood loss, however, and mandate during pregnancy. Fibroid size changes were ana-
surgical intervention in the form of uterine curettage lyzed on the basis of trimesters. In the second tri-
to remove the remaining material from the uterus [31]. mester, smaller fibroids increased in size, whereas
In the last decade with the introduction of mife- larger fibroids decreased in size. In the third trimester,
pristone (RU 486) and oral or vaginal misoprostol to a decrease in size was documented regardless of
induce abortion in the first trimester, vaginal bleeding initial size.
secondary to retained products of conception became The most common patterns of echotexture were
more common [32]. Studies clearly establish miso- hypoechoic, heterogeneous, and echogenic rim. The
prostol as an effective agent to ‘‘empty’’ the pregnant development of a heterogeneous pattern or anechoic-
uterus in the first trimester [33]. Chia and Ogbo [32] cystic spaces on a follow-up study was accompa-
showed medical evacuation of missed abortion with nied by severe abdominal pain. The development
misoprostol to be an effective, safe, and cost-effective of these patterns apparently indicates significant
alternative to surgical evacuation of the uterus, and degeneration of the fibroid (Fig. 6). Fibroids located
particularly suited for women not desiring hospital in the lower uterine segment were accompanied by
admission or a surgical procedure under general a higher frequency of cesarean section and retained
anesthesia [32]. Misoprostol is a synthetic prostaglan- placenta. Fibroids located in the uterine corpus were
create loss of heart rate variability, presumably by

anesthetizing the brainstem center that modulates
intrinsic cardiac automaticity. In addition, vasoactive
agents cross the placenta and produce predictable
changes to fetal heart rate and further influence the
interpretation of the fetal tracing, rendering fetal
heart rate monitoring through the use of standard
external Doppler probes useless. In many similar
challenging cases, the use of real-time ultrasound
and color Doppler adds valuable data to assess the
fetal status. Intermittent abdominal real-time ultra-
sound assessment of the fetus and placenta can be
used for abdominal procedures that do not permit
the use of standard external Doppler probes by
covering the ultrasound transducer with a sterile
Fig. 6. Color flow Doppler of uterus demonstrates a poste- sleeve. Abrupt changes in heart rate, baseline rates
rior lower uterine segment degenerating fibroid. The outside the acceptable range of 120 to 160 beats per
heterogeneous pattern with anechoic-cystic spaces suggests
minutes, and abnormal Doppler readings of the fetus
degeneration process within the fibroid. A ‘‘feeding’’ ves-
or the placental vasculature should prompt the
sel can be seen between the myometrium and the fi-
broid (arrow). anesthesiologist to look for obvious causes of ute-
roplacental insufficiency.
more frequently associated with early abortions.

Multiple fibroids were accompanied by a higher Maternal nonobstetric emergencies during
frequency of malpresentation and premature con- pregnancy
tractions compared with cases with one or two
fibroids (Fig. 7) [39]. Venous thromboembolism
Abdominal surgery and trauma during pregnancy Venous thromboembolism occurs infrequently
during pregnancy. It is a leading cause of illness
Emergency surgery is indicated during pregnancy and death during pregnancy and the puerperium and
for the management of trauma, malignancy, or acute
medical illness. Women in the childbearing years
are among the population at greatest risk for trauma.
Trauma occurs in 5% to 10% of pregnancies and is
responsible for 36 maternal deaths per 100,000
pregnancies, which is considerably higher than preg-
nancy-related mortality [40]. Penetrating abdominal
injury from gunshot and knife wounds or associated
with motor vehicle accidents results in 5% maternal
mortality. A much higher perinatal death rate in the
range of 41% to 71% is reported [41]. Fetal death
can be the result of maternal instability, placental
abruption, direct fetal injury and hemorrhage, or as a
consequence of premature delivery. The fetal status
must be assessed carefully for evidence of develop-
ing compromise. Monitoring fetal heart rate is an
Fig. 7. Gray-scale ultrasound longitudinal view shows a
important aspect of these procedures, and is techni-
posterior lower uterine segment fibroid undergoing degen-
cally feasible after the 16th week for nonabdominal
eration. The patient experienced premature uterine con-
surgery. The surgeon and obstetrician alike must be tractions starting at 29 weeks and delivered prematurely at
aware that fetal heart rate monitoring helps guide the 31 weeks by cesarean section secondary to lower uterine
management of maternal cardiorespiratory parame- segment obstruction from the fibroid. Arrowhead points to
ters, and is useful even if it does not influence a the internal cervical os and calipers depict the whole length
decision to deliver the fetus [42]. Anesthetic drugs of the cervix.
remains a diagnostic and therapeutic challenge [43]. and include steady, severe pain in the upper abdomen
In the general population the incidence of pregnancy- that increases rapidly and lasts from 30 minutes to
associated venous thromboembolism has been esti- several hours, pain in the back between the shoulder
mated to vary from 1 in 1000 to 1 in 2000 deliveries blades, pain under the right shoulder, nausea or
[43]. The risk of venous thromboembolism is five vomiting, abdominal bloating, recurring intolerance
times higher in a pregnant woman than in a nonpreg- of fatty foods, belching, and indigestion. Ultrasound
nant woman of similar age. Postpartum venous scans are highly sensitive to the detection of gall-
thromboembolism is more common than antepartum stones. Sonographic findings with biliary disease
venous thromboembolism [43]. Women with congen- include gallstones, sludge, wall thickening, the sono-
ital thrombophilic abnormalities, such as mutations graphic Murphy’s sign, biliary dilatation, and ductal
within factor II or V of the coagulation factors, stones [47]. In a study done in Dublin, Ireland, real-
mutations leading to deficiency of protein S, or time ultrasound scanning was used to examine the
protein Cor persistent presence of antiphospholipid pelvic area and the upper part of the abdomen in a
antibodies have an increased risk of venous throm- prospective study of 512 healthy, pregnant women to
boembolism during pregnancy and the puerperium. In determine the prevalence of gallstones [47]. Twenty-
individuals with well-defined hereditary thrombosis three women (4.5%) had gallstones. Fourteen
risk factors, such as the factor V:R506Q mutation, the (60.9%) of the pregnant women were unaware of
factor II:G20210A mutation, antithrombin deficiency, the presence of gallstones. Ultrasound technique was
or protein C deficiency, a relative risk of pregnancy- shown as the modality of choice to diagnose gall-
associated venous thromboembolism between 3.4 and bladder disease in the parous and nonparous state
15.2 has been found [43]. Women with previous including acute gallbladder disease [46]
venous thromboembolism have an approximately
3.5-fold increased risk of recurrent venous thrombo- Acute renal disorders
embolism during pregnancy compared with nonpreg-
nant periods [43]. Acute renal failure has become a rare complica-
tion of pregnancy [48]. This is the result of the
Pelvic thrombophlebitis significant decline of septic abortion and its related
complications; the improvement of prenatal care; the
Pelvic thrombophlebitis is considered to be a rare prevention of volume contraction, which is mainly
disorder of the puerperium with an incidence of caused by uterine hemorrhage; early diagnosis; and
0.05% to 0.18% [44]. The ovarian veins are the most the treatment of other classic maternal complications,
frequently involved veins in puerperal pelvic venous such as preeclampsia and acute pyelonephritis [48].
thrombosis. The clinical manifestations of the condi- The incidence of bilateral renal cortical necrosis has
tion range from asymptomatic or dull abdominal pain also been declining during the last decade. Acute
to sepsis, pulmonary embolism, and even death. fatty liver, a potentially fatal disease, often is com-
Unremitting fever and lower-quadrant or flank pain plicated by acute renal failure [48].
usually occurs within the first 1 to 2 days after Ultrasound often is the first imaging technique
delivery [45]. An abdominal mass is palpable in to be used in patients with renal failure, hematuria,
about half of the patients, which may lead to the or proteinuria. Gray-scale ultrasound evaluation,
suspicion of acute appendicitis. Torsion of the ovar- color flow Doppler, and resistive indices provide
ian pedicle, broad ligament hematoma, and pelvic adequate renal evaluation. In the initial clinical stages
abscess may also occur. This condition is usually of renal parenchymal diseases, the kidneys may
managed conservatively, with intravenous heparin present normal ultrasound appearance and normal
and antibiotics, and rarely surgically. Imaging mo- resistive indices values. Different renal parenchymal
dalities used in the diagnosis include sonography, CT, diseases may reveal similar appearance on ultrasound
and MR imaging [44]. and Doppler ultrasound evaluation [48]. Percutane-
ous renal biopsy is often necessary to reach definite
Gallbladder disease diagnosis. Renal vasculitides and tubular-interstitial
nephropathies are identified more frequently by
Gallbladder disease is four times as common in gray-scale ultrasound and Doppler ultrasound than
women as in men, and pregnancy seems to contribute glomerular nephropathies, because glomerular com-
to the development of gallstones [46]. The symptoms ponent accounts only for 8% of the renal paren-
of gallbladder disease during pregnancy do not differ chyma, whereas the highest percentage is occupied
from those reported for the nonpregnant population by vascular and tubulointerstitial component [48].
Follow-up of acute renal failure, during and after nography and pulsed Doppler, however, are prefera-
medical treatment, is the most useful field of use of ble in pregnancy [54]. Gray-scale sonography might
gray-scale ultrasound and Doppler ultrasound techni- fail to detect the unruptured splenic artery aneurysm
ques, because a progressive lowering of resistive if marked calcification of the aneurysmal wall is
indices is correlated to a progressive recovery of present [54]. Pulsed Doppler sonography has been
renal function [48]. used to document turbulent pulsatile flow along the
Hydronephrosis in pregnancy occurs in more than aneurysmal wall. When patients with ruptured splenic
80% of pregnancies and begins as early as 11 to artery aneurysm present with acute abdominal pain,
15 weeks [49]. The dilatation of the ureters in the an emergency ultrasound scan may reveal free fluid
early months of pregnancy is probably caused by in the upper abdomen and the diagnosis is subse-
atony of the neuromuscular apparatus, but what un- quently confirmed at laparotomy [54].
derlies this is not clear. The cause of the later dilata-
tion of the abdominal segment of the right ureter
and renal pelvis is a somewhat controversial sub-
ject. It is believed to be caused by pressure on the Summary
right ureter at the pelvic brim by the natural inclina-
tion to the right of the enlarged uterus, whereas the Most complications of pregnancy allow time for
left ureter is protected by the rectosigmoid. transfer to specialized obstetric ultrasound units, but
Urolithiasis during pregnancy is a difficult clinical many women present to the emergency room or the
problem in which carefully selected radiologic stud- labor and delivery unit with signs and symptoms
ies play an essential role. It has been shown that suggesting genuine acute medical emergencies,
sonography, particularly Doppler sonography, plays where successful outcome depends on prompt diag-
a major role in the diagnosis of urolithiasis in preg- nosis of the disorder and rapid appropriate medical
nancy [49]. Studies evaluating the intrarenal resistive management. The use of ultrasound technology in
index in asymptomatic pregnant patients have shown obstetric emergencies is well established. Ultrasonog-
that both right and left kidneys have similar resistive raphy plays a major role in such cases as the most
indices, and there is no change in resistive indices important tool clinicians are using to identify the
during pregnancy [50]. In the absence of underlying correct etiology and diagnosis, whereas in other cases
renal disease, however, a difference of greater than it helps limit the differential diagnosis. One of the
0.1 in resistive indices should prompt further sono- goals of any advanced training program in obstetrics
graphic confirmation of mechanical ureteral obstruc- and gynecology and radiology is to allow the skilled
tion. This includes unilateral absence of a distal physician to perform the proper ultrasound study in
ureteral jet or direct visualization of a stone either case of an obstetric emergency to facilitate the proper
at the ureterovesical or ureteropelvic junction [10]. diagnosis, enabling the medical team to provide the
Unilateral absence of a ureteral jet with the patient best possible care.
supine should always be confirmed by re-evaluation
with the patient in the contralateral decubitus posi-
tion, because the cause of the absent jet may merely
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Radiol Clin N Am 42 (2004) 329 – 348
Adnexal mass with pelvic pain

Emily M. Webb, MD, Gretchen E. Green, MD, Leslie M. Scoutt, MD*
Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
The routine use of ultrasound (US) in the evalua- and unnecessary surgery can be avoided, to the
tion of pregnant patients has resulted in more fre- benefit of mother and fetus.
quent detection of adnexal masses, which occur in
approximately 2% of pregnancies. This estimation in-
cludes masses with a wide variety of appearances Follicular cysts and corpus luteal cysts
and etiologies that range from asymptomatic ovarian
cysts to surgical emergencies, including ovarian tor- Most adnexal masses identified during pregnancy
sion, ectopic pregnancy, and tubo-ovarian abscess [1]. are non-neoplastic, physiologic cysts, including cor-
Although many adnexal masses are detected inciden- pus luteal cysts and follicular cysts. These cysts can
tally, this article focuses on the evaluation of preg- be seen in early pregnancy but usually involute by
nant women who present with an adnexal mass in midterm [1]. Follicular cysts vary in size from 3 to
the setting of acute pelvic pain. Clinical diagnosis in 8 cm in diameter. They result from failure in ovu-
pregnancy is a challenge because the differential dilation, most likely secondary to changes in the re-
agnosis for an adnexal mass that presents with pelvic lease of pituitary gonadotropins. The fluid contained
pain is broad and includes pregnancy-related and within the immature follicle is not completely re-
unrelated causes. The clinical presentation and natu- absorbed, which produces an enlarged follicular cyst
ral history of abdominal and pelvic disease may be [2]. On US examination, a follicular cyst should ap-
altered in pregnancy. US is an ideal tool for evaluating pear as a thin-walled, anechoic, round, or oval struc-
a pregnant patient. It is excellent in defining pelvic ture that demonstrates increased through transmission
anatomy and pathology without the risks of ionizing (Fig. 1). After ovulation has occurred from a mature
radiation inherent to many imaging techniques. follicle, the granulosa cells, which line the follicle,
become luteinized. Blood accumulates in the central
cavity during vascularization and then resorbs to form
Pregnancy-related disease the corpus luteum [2]. The corpus luteum is described
as a cyst when it reaches more than 2.5 to 3 cm [2].
Several disease processes, either specific to preg- Corpus luteal cysts are typically thin-walled, uni-
nancy or with an increased incidence in pregnant locular cysts that can range in diameter from approxi-
patients, can cause acute pelvic pain and an associ- mately 3 to 11 cm [2]. The corpus luteum can have
ated adnexal mass. These disease processes vary a wide range of appearances on US in the first tri-
from benign, often asymptomatic entities to diseases mester of pregnancy, however. The most common ap-
that require emergent treatment. Differentiation is pearance is that of a round, thin-walled hypoechoic
critical so that appropriate treatment can be provided structure that demonstrates diffuse, homogenous, low-
level echoes (Fig. 2) [3]. Other reported gray scale
appearances in order of decreasing frequency include
a cyst with a thick wall and anechoic center (Fig. 3), a
* Corresponding author. cyst that contains scattered internal echoes, or a thin-
E-mail address: scoutt@biomed.med.yale.edu walled simple cyst that is similar in appearance to
(L.M. Scoutt). a follicular cyst [3]. In most cases, color Doppler
doi:10.1016/j.rcl.2003.12.006
330 E.M. Webb et al / Radiol Clin N Am 42 (2004) 329–348
Fig. 1. Simple ovarian or follicular cysts. These two ovarian

cysts are completely anechoic, with thin, nearly impercep-
tible walls (arrow), and they demonstrate increased through
transmission (arrowheads).
Fig. 3. Atypical corpus luteal cyst. This exophytic cyst has

an anechoic center with a thick, relatively hypoechoic wall
evaluation of the corpus luteum demonstrates a cir- (arrow) with a thin rim of vascularity. Although it may be
difficult to differentiate such a structure from an ectopic
cumferential ‘‘ring of fire’’ of vascularity with a low
pregnancy, in general the wall of an ectopic pregnancy is
resistance waveform pattern. In a study by Durfee more echogenic and usually not so thick.
and Frates [3], 92% of corpus luteal cysts demon-
strated this pattern of blood flow with a mean resist-
ance index of 0.49 and mean peak systolic velocity of
17 cm/second. level echoes. The wall may be vascular but should
Acute pelvic pain in pregnancy is commonly be thin and regular. In a study by Baltarowich et al
caused by hemorrhage into a follicular or corpus [6], most hemorrhagic cysts (92%) demonstrated
luteal cyst. Cyst rupture or leakage also may cause increased through transmission. Over time as the clot
severe pelvic pain and hemorrhage, sometimes re- forms, a lace-like, reticular pattern of internal echoes
quiring laparoscopy or laparotomy [2,4]. The US develops because of the presence of fine fibrous
appearance of hemorrhagic ovarian cysts varies be-
cause the US characteristics of hemorrhage change
over time [4 – 7]. Initially a hemorrhagic cyst dem-
onstrates a diffuse, homogeneous pattern of low-
Fig. 4. Hemorrhagic cyst. Note lace-like or spider web

pattern of internal echoes. The cyst wall is smooth and
Fig. 2. Corpus luteal cyst. This exophytic corpus luteal cyst regular. Increased through transmission is present. Doppler
contains low-level internal echoes. The cyst wall is mark- interrogation reveals no evidence of internal blood flow,
edly vascular on color Doppler evaluation, which dem- and the appearance changes over time as the blood clot
onstrates ring of fire (arrows). continues to resorb.
E.M. Webb et al / Radiol Clin N Am 42 (2004) 329–348 331
risk factors include presence of an intrauterine device,

exposure to diethylstilbestrol, adhesions from prior
surgery, and previous ectopic pregnancy (Box 1).
The reported increased incidence of ectopic preg-
nancy is also likely in part accounted for by an
‘‘apparent’’ increase because of early US evaluation
of symptomatic pregnant patients. Endovaginal US
almost certainly documents some early ectopic preg-
nancies that otherwise would have resolved without
coming to medical attention. Endovaginal US, com-
bined with quantitative b-human chorionic gonado-
tropin (b-HCG) analysis, is an excellent tool for
identifying ectopic pregnancy and differentiating
from other causes of adnexal mass in the pregnant
patient with pelvic pain. The first goal of endovaginal
Fig. 5. Hemorrhagic cyst. Clot within a hemorrhagic cyst
US in the patient suspected of harboring an ectopic
often adheres to the cyst wall and is lenticular in shape
(arrow). Doppler examination does not demonstrate internal
pregnancy is to assess for an intrauterine pregnancy
vascularity within adherent clot but may do so in a neo- because ectopic pregnancy can be reasonably ex-
plastic mural nodule. Despite the absence of vascularity on cluded when an intrauterine pregnancy is identified
this color Doppler image, follow-up imaging in 6 weeks is [9]. Only rarely does an ectopic pregnancy occur
recommended to ensure that the clot continues to resolve. synchronously with an intrauterine gestation. Hetero-
Occasionally Doppler interrogation does not demonstrate topic pregnancy is estimated to occur in only 1 in
vascularity in tumor nodules because of low velocity, low 2600 to 1 in 30,000 pregnancies in the general
volume flow, or sampling error. population [10], but it likely occurs in up to 1 in
100 in patients with multiple risk factors who are
undergoing infertility treatment [11].
septae (‘‘fish net’’) (Fig. 4). The clot may appear as An intrauterine gestational sac should be seen
an echogenic mass either mobile or adherent to the on endovaginal US when the b-HCG is more than
cyst wall but without evidence of vascularity. Typi- 2000 mIU/mL (approximately 4 – 6 weeks’ gestation).
cally, the clot retracts over time and adheres to the The earliest positive sign of an intrauterine pregnancy
cyst wall in a lenticular shape (Fig. 5). Lysis of red is the intradecidual sign, which is defined as a fluid
blood cells may result in layering fluid or debris. collection with an echogenic rim located eccentrically
Follow-up examination at a 6- to 8-week interval within either the anterior or posterior layer of the
should demonstrate that a hemorrhagic cyst changes endometrium adjacent to the echogenic line that
in appearance and decreases in size [7]. In patients represents the endometrium [12,13]. The intradecid-
with rupture or leakage of fluid from the corpus luteal ual sign should be visible at 4.5 weeks’ gestation, but
cyst, the cyst may have an angular or crenated it can be confused with a pseudosac or decidual cyst.
appearance, and free fluid that contains low-level A study reported by Laing et al [12] demonstrated a
echoes or frank clots may be observed in the cul- low enough sensitivity and specificity to warrant a
de-sac or surrounding the ovary [2,7]. recommendation to document the development of
a yolk sac or fetal pole on follow-up examination to
Ectopic pregnancy
The incidence of ectopic pregnancy has increased Box 1. Conditions that predispose to
over the past three decades, and it recently reached a ectopic pregnancy
plateau at a reported rate of 19.7 per 1000 pregnan-
cies [8]. Ectopic pregnancy remains the leading cause Prior pelvic inflammatory disease
of maternal death in the first trimester and the second Presence of an intrauterine device
leading cause of maternal mortality overall [8]. Im- Treatment of infertility
proved treatments for infertility and pelvic inflam- Tubal surgery
matory disease and an increase in the size of the Previous ectopic pregnancy
patient population at risk for ectopic pregnancy in Diethylstillbestrol exposure
large part account for the increased incidence. Other
confirm an intrauterine pregnancy. The double decid-

ual sac sign is formed when the gestational sac is
surrounded, at least in part, by two echogenic
layers—decidual capsulans (inner) and decidual parie-
talis (outer)—and is separated by the hypoechoic
endometrial cavity [9]. It should be seen when the
mean sac diameter is more than 10 mm. Because
endovaginal US (when using a high-frequency trans-
ducer) typically demonstrates a yolk sac with an
intrauterine pregnancy by the time the mean sac
diameter (MSD) is more than 8 mm, the double
decidual sign is of limited use in the evaluation of
patients with suspected ectopic pregnancy. The pres-
Fig. 7. Ectopic pregnancy. Note echogenic tubal ring
ence of trophoblastic flow (high velocity, low imped-
(arrow) medial to the right ovary (cursors). Amorphous
ance) around an endometrial fluid collection further
hypoechoic material between ovary and ectopic pregnancy
supports the diagnosis of an intrauterine pregnancy, likely represents hemorrhage.
although pulsed Doppler should be used with caution
because of concerns regarding heat deposition in the
developing fetus. is the next most specific US finding for ectopic
A pseudosac, an intrauterine fluid collection pregnancy (Fig. 7) [15]. Adnexal rings are usually
formed in response to hormonal influences on the located between the ovary and uterus. In 14% to 33%
endometrium as the result of the presence of an of cases, the adnexal ring is contralateral to the cor-
ectopic pregnancy, can be distinguished from an pus luteum [16]. The echogenic adnexal ring typi-
intrauterine pregnancy by its central location in the cally has a relatively anechoic center and vascular
endometrial cavity, oval shape, poorly defined mar- wall (sometimes only focally). It may be difficult to
gins, absence of decidual reaction, single decidual differentiate the tubal ring of an ectopic pregnancy
layer, and absence of trophoblastic flow. from an exophytic corpus luteal cyst. An anechoic
Ectopic pregnancy most commonly (95%) occurs structure with an echogenic, vascular rim truly lo-
in the ampullary or isthmic portions of the fallopian cated within the ovary is statistically much more
tube. An ectopic pregnancy can be diagnosed with likely to be a corpus luteal cyst, because true intra-
confidence when an adnexal mass that contains a ovarian ectopic pregnancies are rare.
yolk sac or viable embryo is identified (Fig. 6) [14]. Frates et al [17] reported that the wall of the
In the absence of a visualized yolk sac or fetal pole, adnexal ring is more echogenic compared with the
the so-called echogenic adnexal (or tubal) ring sign ovarian stroma in 88% of ectopic pregnancies, where-
as the wall of the corpus luteal cyst was usually
relatively hypoechoic. Corpus luteal cysts and ectopic
pregnancy demonstrate low-resistance arterial flow
on Doppler examination [18]. Color Doppler is
helpful primarily for increasing conspicuity. Differ-
entiation between an ectopic pregnancy and an
exophtic corpus luteal cyst can be aided by gently
tapping on the ovary with the transducer. Independent
movement of the ovary indicates an extraovarian
location of the adnexal ring, which confirms ectopic
pregnancy. A hemorrhagic ovarian cyst occasionally
can produce an adnexal ring sign, and when associ-
ated with significant hemoperitoneum, it may mimic
ectopic pregnancy [19].
Evaluation of the cul-de-sac and Morrison’s pouch
Fig. 6. Ectopic pregnancy. A yolk sac (arrow) and fetal pole
is important to detect echogenic fluid that could
(arrowhead) are present within this echogenic tubal ring represent blood (Fig. 8) [20]. Transabdominal US is
(curved arrow) located in the cul de sac. U, uterus. Note that particularly helpful for evaluation of these areas and
the wall or ring of this ectopic pregnancy is much more visualization of the patient’s point of maximal ten-
echogenic than the wall of the corpus luteal cyst in Fig. 3. derness if not imaged on endovaginal US. Blood need
second trimester. A ruptured interstitial pregnancy

poses a significantly increased risk of severe, life-
threatening hemorrhage. On US examination, the sac
is eccentrically located within the uterine wall, and
the surrounding myometrium is thinned (<5 mm) or
even absent laterally. The ‘‘interstitial line sign’’
describes an echogenic line that reflects the two
opposing layers of endometrium seen adjacent to
the gestational sac but not surrounding it. This sign
has been reported to be 80% sensitive and 99%
specific for diagnosing interstitial ectopic pregnancy,
compared with 40% sensitive and 62% specific for
eccentric location or 40% sensitive and 74% specific
for myometrial thinning [23]. Even more convinc-
ing is visualization of myometrial tissue interposed
Fig. 8. Hemoperitoneum from a ruptured ectopic pregnancy.
between the gestational sac and echogenic line (en-
Note echogenic free fluid (arrow) outlining loops of bowel.
dometrial cavity). It may be difficult to distinguish
interstitial and cornual pregnancies. Braxton Hicks
contractions or fibroids occasionally can cause a nor-
neither be echogenic nor the consequence of tubal mal intrauterine pregnancy to be eccentrically placed.
rupture, however; hemoperitoneum may be anechoic If there is doubt about the diagnosis, follow-up may
(albeit rarely) and can occur secondary to leakage be helpful.
from the fimbriated end of the fallopian tube or even Cervical pregnancies are rare but are important
from a ruptured hemorrhagic corpus luteal cyst. to diagnose accurately because routine dilation and
Endovaginal US has replaced culdocentesis as the curettage may cause life-threatening hemorrhage.
method of choice for detecting hemoperitoneum Cervical ectopic pregnancies may be difficult to
[21]. Brown and Doubilet [14] reported that demon- differentiate from pregnancies implanted in the lower
stration on US of an extrauterine gestational sac that uterine segment or miscarriages. An hourglass ap-
contains a yolk sac or embryo or a tubal ring has high pearance of the uterus, a gestational sac seen within
specificity rate (99.5% – 100%) and high positive the cervical canal or in an eccentric location, invasion
predictive value (97.8% – 100%) for the diagnosis of the cervical stroma or the presence of trophoblastic
of ectopic pregnancy. Sensitivity rate was, however, flow, and visualization between the external and
found to be low (20.1% – 64.6%). When the most non- internal cervical os may be helpful in differentiating
specific finding that suggests ectopic pregnancy— a cervical pregnancy from an impending miscarriage,
the presence of any adnexal mass other than a simple although trophoblastic flow occasionally can be noted
cyst—was used as the sole diagnostic criterion, sen- during miscarriage.
sitivity rate was improved (84.4%) with only slightly Abdominal pregnancy, defined as an ectopic preg-
diminished specificity rate (98.9%) and positive pre- nancy located in the peritoneal cavity, occurs in 1 in
dictive value (96.3%) [14]. The sonographer should 10,000 pregnancies. It is a medical emergency be-
remember that in up to 26% of ectopic pregnancies, cause of high associated maternal and fetal morbidity
no intrauterine pregnancy or adnexal abnormality and mortality. Surgery is indicated as soon as the
may be detectable by endovaginal sonography [22]. diagnosis is made. In rare cases of undetected ad-
Clinical correlation and close follow-up are of para- vanced abdominal pregnancy with fetal demise, litho-
mount importance. pedion formation (fetal calcification) can occur.
Although the terms are occasionally used inter- This is usually found incidentally and can appear
changeably, the term ‘‘cornual pregnancy’’ should be on US as a large echogenic mass.
reserved for an intrauterine pregnancy implanted in Treatment for ectopic pregnancy increasingly in-
one horn of a bicornuate or septate uterus, whereas an cludes medical and even expectant management,
interstitial ectopic pregnancy (approximately 2% – 4% in addition to laparoscopic surgery. Close interval
of all ectopic pregnancies) occurs in the interstitial follow-up with endovaginal US, monitoring serial
(or intramyometrial) portion of the fallopian tube. An b-HCG levels, and reassessment of the patient’s clini-
interstitial ectopic pregnancy typically develops much cal stability are crucial elements of expectant therapy
longer before becoming symptomatic, and it often [24]. Methotrexate is a folic acid antagonist that in-
presents late in the first trimester or early in the hibits the synthesis of purines and pyrimidines, which
prevents DNA synthesis and cell multiplication. It

Box 3. Medical contraindications to
acts primarily on the rapidly dividing trophoblastic
methotrexate therapy
cells of the embryo [87]. Although exact eligibility
criteria continue to change with increasing experience Abnormal liver function tests (LFTs)
and vary somewhat among institutions, medical man-
(elevated transaminases)
agement with methotrexate is most effective when an Immunodeficiency
ectopic pregnancy is small (<3 – 4 cm), b-HCG is Any type of blood dyscrasia
low (<15,000 – 20,000 IU/mL International Reference Leukocyte count of <2000
Preparation [IRP]), and cardiac activity is absent. Platelet count of >100,000
Medical management of ectopic pregnancy may, Peptic ulcer disease
however, be attempted despite one or more of these Active pulmonary disease
criteria not being met. These patients have a higher Renal disease
incidence of failure of treatment and may require Known sensitivity to methotrexate
multiple doses of methotrexate [88]. Absolute
contraindications to medical therapy include pain,
hemodynamic instability, or evidence of large hemo-
peritoneum. Eligibility criteria and absolute contra-
indications of methotrexate treatment are further more than a 15% fall in b-HCG from the baseline, a
discussed in Boxes 2 and 3 [87,88]. second injection of methotrexate is not required [88].
In the 2 to 4 weeks after methotrexate adminis-
tration, an ectopic pregnancy can demonstrate persist-
ent vascularity and can increase in size secondary to Theca lutein cysts
infarction and hemorrhage. These findings are nor-
mal, and, in an asymptomatic patient, do not represent Theca lutein cysts are caused by elevated levels
failure of treatment. To avoid confusion, sonographic of chorionic gonadotropin and are seen in patients
follow-up is sometimes avoided during this time as with hydatidiform mole or choriocarcinoma and in
long as the patient remains asymptomatic. If a patient the setting of exogenous chorionic gonadotropin ad-
develops pain, US follow-up is necessary to evaluate ministration for treatment of infertility [2]. The cysts
for signs of tubal rupture, such as a dramatic increase are lined by theca cells, which may or may not be
in the size of the ectopic pregnancy or large hemoperi- luteinized [2]. Cysts are usually multiple and bilateral
toneum. Pain can develop during the normal course and typically range in diameter from 3 to 20 cm [25].
of methotrexate therapy, 4 to 5 days after adminis- Symptoms are usually mild, including pelvic fullness
tration, because of the infarction of trophoblastic and dull pelvic pain. Acute pain can occur in the
tissue. The development of pain does not necessarily setting of cyst rupture or hemorrhage [2]. The cysts
indicate failure of treatment or tubal rupture. Pain resolve spontaneously after treatment of gestational
secondary to trophoblastic tissue infarction should trophoblastic disease or cessation of fertility therapy.
resolve within 12 to 24 hours. Baseline b-HCG levels Theca lutein cysts may persist for long periods,
are recorded before methotrexate administration. The however, despite relatively low levels of b-HCG
b-HCG begins to fall gradually after 4 days. If there is [25]. US examination demonstrates multiple simple
cysts in both ovaries (Fig. 9).
Box 2. Eligibility criteria for methotrexate Ovarian hyperstimulation syndrome

therapy
Ovarian hyperstimulation syndrome (OHSS) is a
Hemodynamically stable potentially dangerous iatrogenic complication of
Absence of large hemoperitoneum pharmacologic ovulation induction for the treatment
Absence of pain of infertility [26]. It occurs in the setting of abnor-
Ectopic size <3.5 – 4 cm mally high levels of b-HCG and less frequently has
C-HCG levels with peak values been reported in spontaneous singleton and multi-
>15,000 – 20,000 mIU/mL (IRP) ple pregnancies, sex hormone – producing tumors,
F Cardiac activity in gestational sac and choriocarcinoma [26 – 28]. Although the precise
Absence of any contraindications pathophysiology remains unknown, b-HCG seems to
trigger an increase in vascular permeability that
ovulation cycles, but only a small percentage of these

cases are severe (0.5% to 5%) [35,36].
OHSS is more severe in patients who become
pregnant after ovulation induction. The spectrum of
clinical presentation ranges from nausea, vomiting,
and abdominal pain to massive ascites, acute respi-
ratory distress syndrome, and hypotension, classified
according to severity by Golan et al [30]. Pain may be
caused by rupture of or hemorrhage into the enlarged
cysts or ovarian torsion. Approximately 20% of
patients who receive gonadotropin therapy develop
mild to moderate ovarian enlargement [37]. Ovarian
diameter more than 5 cm is a criterion for diagnosis
of mild OHSS, although the ovaries are frequently
Fig. 9. Theca lutein cysts. Note multiple simple bilateral more than 10 cm in diameter. US is the most exact
ovarian cysts in this patient with a hydatidiform mole. method of detecting ovarian enlargement. It is also
A pocket of free fluid is present between the two ova- preferable to bimanual examination because of the
ries (arrow).
risk of ovarian rupture [30]. On US, multiple large,
thin-walled cysts are identified. Pulsed Doppler may
demonstrate increased intra-ovarian arterial diastolic
results in ovarian enlargement, cyst formation, and flow or nonphasic venous flow, which indicates de-
third spacing of fluid. The renin-angiotensin system, creased venous return [38]. Acute pain may be caused
vascular endothelial growth factor, and cytokines are by hemorrhage into a cyst, cyst rupture, or ovarian
believed to be chemical mediators in this process torsion. Debris or low-level echoes within the cysts
[29,30]. Whelan and Vlahos [31] emphasize risk may be seen when hemorrhage occurs. Cyst rupture
stratification as the key to preventing OHSS or can result in an irregularly shaped cyst with adjacent
minimizing its severity. Generally accepted risk fac- free fluid or fluid in the cul-de-sac (Fig. 10).
tors include young age, presence of theca lutein Because ovarian enlargement predisposes to ovar-
cysts, and elevated estradiol levels. Known polycys- ian torsion, documentation of ovarian blood flow is
tic ovarian syndrome or the presence of multiple pe- important in patients who present with acute pain (see
ripheral ovarian follicles (the ‘‘necklace sign’’) on US next section). In severe cases of OHSS, US can be
in a patient with a clinical presentation that suggests used to detect and monitor complications. US exami-
polycystic ovarian syndrome is also a risk factor for nation may demonstrate ascites or pleural fluid,
OHSS [32]. criteria used in determining whether hospitalization
Women who undergo ovulation induction ther- is necessary [31]. Oliguria may prompt a request for
apy whose ovaries contain several small or interme- renal US evaluation, although in the setting of OHSS
diate-sized follicles are at greater risk for developing this is usually secondary to impaired venous return
OHSS than women with large (>15 mm) follicles, from the kidneys secondary to extrinsic compression
especially when seen in conjunction with high levels by ascites. Patients with OHSS are at increased risk
of estradiol (>3000 pg/mL) [33]. Higher baseline of thromboembolism caused by hemoconcentration
ovarian volume of more than 10 mL also has been and may benefit further from US examination for
shown by Danninger et al [34] to predict subsequent various complications, such as deep venous throm-
development of OHSS and may become a more bosis. Thoracic complications, such as pulmonary em-
important predictor with the widespread availability bolism (1.9%), acute respiratory distress syndrome
of US units capable of providing three-dimensional (2.4%), infection (3.8%), atelectasis (20%), and pleu-
images with highly accurate, reproducible measure- ral effusion (29%; usually right-sided), may occur
ments of ovarian volume. A patient at higher risk for [39]. Unilateral pleural effusion has been reported
OHSS may require more intensive monitoring (in- as an isolated finding in OHSS [40,41]. A large pleu-
cluding US) or undergo an alternative pharmacologic ral effusion often predicts hemodynamic instability.
ovulation induction technique. It is estimated that Treatment is supportive: hemodynamics, hemato-
mild OHSS may occur in as many as 65% of women crit, electrolytes, liver and kidney function (includ-
who undergo ovulation induction. The incidence of ing urine output), and coagulation parameters are
clinically important (moderate to severe) OHSS monitored. Some authors have advocated an out-
ranges from 1% to 10% of exogenously induced patient treatment approach, facilitated in part by
Fig. 10. Ovarian hyperstimulation syndrome. (A) Note marked enlargement of the right ovary within calipers. Numerous cysts
are seen, several of which contain internal echoes. There is a small amount of free fluid adjacent to the enlarged ovary. (B) Pulse
Doppler interrogation reveals high-velocity systolic and diastolic flow, which excludes the diagnosis of ovarian torsion. The
patient’s pain is likely caused by hemorrhage into these cysts or rupture of these hemorrhagic cysts.
US-guided follicular aspiration [42]. Navot et al [32] during pregnancy, and ovarian torsion occurs in ap-
reported US-guided paracentesis as the treatment of proximately 1 in 1800 pregnancies [1,43]. Approxi-
choice when medical therapy is insufficient; alter- mately 25% of adnexal torsions occur in pregnant
natives include transvaginal aspiration of ascites or patients [1]. Adnexal torsion most commonly occurs
follicular cysts. OHSS typically resolves in 7 to between 6 and 14 weeks’ gestation and in the
10 days unless pregnancy ensues, in which case immediate puerperium [1,44]. Ovarian torsion is the
recovery is more prolonged. result of partial or complete rotation of the ovarian
pedicle on its axis, which results initially in impaired
lymphatic and venous drainage and eventual loss of
Ovarian torsion arterial perfusion [43,45]. It occurs more commonly
on the right side [44]. Torsion can be difficult to
Ovarian or adnexal (ovary and fallopian tube) diagnose clinically because the presenting symptoms,
torsion is a surgical emergency that requires prompt including pain, nausea, and vomiting, are nonspecific
diagnosis and treatment. There is increased risk and similar to many causes of acute abdomen [43,45].
Because ovarian enlargement of more than 6 cm (Fig. 11A) [44]. With frank infarction, cystic, clotted
predisposes to ovarian torsion [46,47], women who areas may be observed. Free fluid within the pelvis
undergo ovulation induction have the highest inci- or adjacent to the ovary also can be seen [44,50].
dence because of the development of numerous theca Although the range of gray scale features varies, the
lutein cysts, which can massively enlarge the ova- ovary rarely has a completely normal appearance.
ries [2,30]. Mashiach et al [47] reported that tor- Classically, Doppler interrogation demonstrates ab-
sion was more common in women with OHSS sence of arterial flow (Fig. 11B). It is important,
who subsequently became pregnant, compared with however, to remember that early in the process there
women with OHSS alone. Enlargement of the ovary may be obstruction of lymphatic and venous flow with
secondary to a corpus luteal cyst or incidental benign preservation of arterial perfusion [49 – 51]. Occasion-
ovarian neoplasm, most commonly a mature mature ally only diastolic or venous flow is lost early on.
cystic teratomas or cystademoma, also can predispose Because the ovary has dual arterial supply, in
to ovarian torsion [44]. Ovarian torsion rarely occurs early torsion only one may be occluded [51]. In a
in the presence of ovarian carcinoma or endometri- patient who presents with acute pain and an ovary
osis because of fixation of the ovaries to adjacent that demonstrates real-time findings consistent with
structures by adhesions. ovarian torsion, the diagnosis should be suggested
The US appearance of ovarian torsion varies de- even in the presence of documented arterial blood
pending on the degree of ischemia and infarction flow (Fig. 12) [48 – 51]. When color Doppler imaging
and the time course [44]. The ovary is typically and pulsed Doppler sampling do not demonstrate
enlarged. Numerous small follicles are often seen at arterial flow within the ovarian parenchyma, the
the periphery of the ovary [43,45,48]. The central diagnosis is more easily made. All Doppler parame-
ovarian stroma becomes heterogeneous with areas of ters must be set carefully to maximize detection of
increased echogenicity, which represent hemorrhage, slow flow to avoid a false-positive diagnosis caused
and more hypoechoic areas, which represent edema by technical factors. Sampling error also may cause
Fig. 11. Ovarian torsion. (A) The ovary is enlarged with several small peripherally located cysts (arrows). The central ovarian
stroma is heterogeneous, with echogenic areas representing hemorrhage and hypoechoic areas representing edema. No flow is
detected with color Doppler. (B) Because pulse Doppler is more sensitive to low-velocity, low-volume flow, meticulous sampling
with pulse Doppler should be performed. No flow could be demonstrated in this case.
and masses spontaneously resolve several months

after delivery [53]. The diagnosis should be enter-
tained to avoid unnecessary oophorectomy. In case
reports, the lesions have been described on US as
solid ovarian masses. Cystic components may be
present secondary to necrosis [53].
Disease unrelated to pregnancy
Diagnoses such as ectopic pregnancy and ovarian

torsion are likely to be at the top of the differential
list in a pregnant patient who presents with acute
Fig. 12. Early ovarian torsion. Note classic gray scale pelvic pain and an adnexal mass. There are, however,
features of torsion: ovarian enlargement, central amorphous, many gynecologic and nongynecologic causes of
heterogeneous stroma, and small peripheral cysts. Pulse acute pelvic pain and pelvic mass that are unrelated
Doppler interrogation revealed some arterial flow in this to pregnancy and may still occur in this population.
woman, who presented less than 2 hours after the acute
onset of severe pelvic pain.
Pelvic inflammatory disease and tubo-ovarian
abscess
false-positive diagnoses. Fleischer et al [52] reported
that the preservation of parenchymal venous flow Pelvic inflammatory disease (PID) is most com-
is a useful indicator of ovarian viability. The twisted monly caused by sexually transmitted infection by
vascular pedicle also can be seen on color Doppler Chlamydia species or Neisseria gonorrhea. Uterine
sonography. Demonstration of flow within the instrumentation and the placement of intrauterine
twisted vascular pedicle may be a useful marker of contraceptive devices also are risk factors [44]. Less
ovarian viability (Box 4). frequently, PID may be caused by direct extension
Adnexal torsion that is diagnosed before tissue
infarction is managed with laparoscopic ‘‘detorsion’’
surgery followed by progesterone replacement if
the corpus luteum is removed. If tissue infarction
and necrosis have occurred, then laparotomy with Box 4. Sonographic findings of ovarian
salpingo-oophorectomy is usually required to pre- torsion
vent peritonitis.
Gray scale findings
Ovarian enlargement
Luteoma of pregnancy
Peripherally located follicles
Heterogeneous central ovarian stroma
Luteoma of pregnancy is a rare entity, with fewer
than 200 cases reported in the literature [53]. Luteo- Internal hemorrhage (echogenic)
mas consist of non-neoplastic tumor-like masses of Internal edema (hypoechoic)
lutein cells and are often multifocal and bilateral
[2,53]. The luteoma range up to 20 cm in diameter, Cystic necrosis of the ovary
but most are in the 5- to 10-cm range [2]. Luteomas Free fluid
are usually clinically occult, only coming to attention F Underlying precipitating mass
when visualized during cesarean section or postpar-
tum tubal ligation [2]. Occasionally, luteomas can Range of color/pulsed Doppler findings
have androgenic effects that result in fetal hirsutism Normal
and virilization. As is the case with any large adnexal Loss of venous flow
mass, however, luteomas may precipitate ovarian Loss of diastolic flow
torsion that results in acute pelvic pain. Although Absence of flow
their morphologic appearance can be ominous and Twisted vascular pedicle
suggest malignancy, biopsy is adequate for diagnosis,
of infection from appendicular or diverticular ab-

scesses, and in these instances disease tends to be
unilateral [44,46]. Fortunately, acute PID is a rare
entity in the pregnant patient. The cause of PID in
pregnancy is uncertain, but recurrence of old in-
flammatory disease is considered the most common
cause [54]. PID is typically an ascending infection
that begins as a cervicitis, progresses to endometritis,
and ultimately involves fallopian tubes or ovaries
(tubo-ovarian complex). Only approximately 5% of
patients with PID progress to abscess formation.
PID can be difficult to diagnosis secondary to vague
or confusing symptoms. It should be suspected in
the setting of fever, pelvic discomfort, and purulent
Fig. 14. Tubovarian abscess. Note complex fluid collection
vaginal discharge. Many patients do not demonstrate engulfing right ovary (arrow).
these classic symptoms, however, and US imaging
often plays a crucial role in diagnosis and patient
management [4]. although relative sparing of the ovary has been re-
Pelvic US is frequently normal in the early stages ported. The ovary is sometimes enlarged with indis-
of PID [44,46]. As disease worsens or becomes tinct margins secondary to peri-ovarian inflammation,
more chronic, several appearances can be identified termed the tubo-ovarian complex [4].
on US imaging. US may reveal dilatation of one or Pressure from the transducer often causes pain
both fallopian tubes. Hydrosalpinx is characterized during the examination, and the pelvic organs may
by its tubular shape or folded configuration [55]. A appear fixed to the surrounding tissues. The serosal
well-defined echogenic wall and linear echoes that contour of the uterus may be indistinct because of
protrude into the anechoic tubal lumen are also surrounding inflammatory exudate. Pus may be seen
characteristic [55]. Hydrosalpinx can be differentiated within the cul-de-sac or around the liver with an
from fluid-filled bowel loops by the absence of appearance of free fluid – containing low-level echoes
peristalsis [55]. Dilated fallopian tubes also may [4,44,46]. A US that demonstrates findings that sug-
contain diffuse, low-level echoes that represent debris gest PID (ie, a thick-walled, fluid-filled tubular ad-
or hemorrhage (Fig. 13) or appear as a complex cys- nexal mass with or without free intrapelvic fluid) has
tic adnexal mass that demonstrates multiple fluid been reported to have a sensitivity rate of 85% and a
levels and septations [4,44]. Once the disease has specificity rate of 100% for the diagnosis [56]. Any
progressed to abscess formation (Fig. 14), a complex complex multilocular adnexal mass in an appropriate
adnexal mass is observed on US examination. The clinical setting can represent PID, however. Hydro-
ovary may not be identifiable separate from the salpinx is not always present. Abscess drainage or
mass but actually may be engulfed by the infection, conservative surgical procedures with antibiotic
therapy are often recommended in managing PID
complicated by tubo-ovarian abscess during preg-
nancy. There is no true consensus on management
in this population, however [54].
Endometrioma
Endometriosis is a common cause of abdominal

pain. In younger women, endometriosis is defined
as the presence of functional endometrial tissue out-
side of the uterus [43]. The classic triad of clinical
symptoms includes pelvic pain, dysmenorrhea, and
infertility [43,57]. Endometriosis has an estimated
prevalence of 1% in reproductive age women [57];
Fig. 13. Pyosalpinx. Note layering debris or pus (curved however, the incidence of endometriosis in women
arrow) in the dilated fallopian tube. with infertility is closer to 40% [43]. Overall, endo-
that of a hemorrhagic cyst [60]. The pattern of in-

ternal echoes within a hemorrhagic cyst is more
often lace-like, however, as opposed to the homoge-
neous hypoechoic internal echoes characteristic of
endometrioma, and hemorrhagic cysts more often
present with acute pain [43].
Endometriomas are more frequently multiple,
and their appearance is more stable over time when
compared with hemorrhagic cysts. Hemorrhagic cysts
and endometriomas may have vascular walls on color
Doppler interrogation [61]. An increased likelihood
of mural vascularity in endometriomas has been re-
ported in patients with acute pelvic pain and may
serve as a relative marker of disease activity, although
Fig. 15. Endometrioma. The cystic lesion medial to the right this is somewhat controversial [62]. Endometriomas
ovary contains diffuse low-level echoes (arrow) and demon-
can be bizarre looking and cannot always be distin-
strates increased through transmission. The wall is thin
guished readily from malignancy. The presence of
and regular.
irregular walls or vascular nodularity should raise
concern, because clear cell or endometroid carcino-
metriomas account for approximately 4% of adnexal mas rarely may develop within endometriomas (<1%).
masses diagnosed during pregnancy [1]. Endometrio- MR imaging may be useful to document the presence
mas can have a diverse range of appearances on US, of hemorrhage within an ovarian mass when US
from anechoic cysts to complex cystic masses that examination is equivocal.
contain multiple septations to heterogeneous echo-
genicity. Classically endometriomas appear on US as
thin-walled unilocular cystic masses that contain Leiomyomata
diffuse, low-level echoes (Fig. 15) [43,57 – 59]. Patel
et al [59] reported that hyperechoic wall foci and Leiomyomata are the most common benign uter-
multilocularity, in the absence of malignant features, ine neoplasms and are composed of smooth muscle
highly suggest endometrioma. Layering or anechoic cells with varying amounts of fibrous connective
foci within a background of homogeneous low-level tissue and collagen. Leiomyomata are most com-
echoes also have been described. Margins may be monly diagnosed in premenopausal women, with an
indistinct and angulated secondary to associated incidence of 20% to 30% in women over the age
adhesions. The appearance on US may be similar to of 30 [43]. Some studies have indicated that careful
Fig. 16. Acute hemorrhagic infarction of a fibroid in a patient who presented with acute pelvic pain 4 days postpartum.
(A) Sagittal US image of the uterus (U) reveals an echogenic subserosal fibroid (arrow) with a small amount of adjacent free
fluid. (B) Follow-up CT scan demonstrates lack of enhancement of the uterine mass (arrow), which is consistent with acute
hemorrhagic infarction.
cystadenomas [1]. Mature cystic teratomas are benign

neoplasms that usually contain tissue derived from
all three germ cell layers [2,43]. Occurring most
commonly in the active reproductive years [43],
dermoids account for 40% to 50% of benign ovarian
neoplasms and are bilateral in 10% to 15% of cases
[43]. Malignant transformation is rare (<2% of
cases) and is most common in older women [47].
Dermoids are usually asymptomatic unless torsion
or rupture occurs [43]. US appearance of mature
cystic teratomas ranges from that of a solid homo-
Fig. 17. Pedunculated leiomyoma. Note large left leiomyoma
geneously echogenic mass with posterior attenuation
connected to the uterus by a thin pedicle (arrowhead).
(Fig. 18) to a completely anechoic structure that
mimics an ovarian cyst.
pathologic evaluation can demonstrate leiomyomas Several US features, however, have been described
in up to 80% of women of reproductive age [1]. as specific to mature cystic teratomas. A predomi-
Uterine leiomyomata are diagnosed in 0.3% to 4% of nately cystic mass with an echogenic mural nodule
pregnancies, usually because a pedunculated subse- is a characteristic appearance. The mural nodule, or
rosal leiomyoma simulates an ovarian neoplasm dermoid plug, may contain hair, teeth, or fat [65]. If
[1,45]. Pedunculated leiomyomata may undergo tor- calcium is present, distal acoustic shadowing is ob-
sion and necrosis, which results in acute pelvic pain served. [43,66]. Linear echogenic foci that represent
[45]. Fibroids are hormonally dependent and can hair fibers, an echogenic hair ball floating at a fluid-
rapidly increase in size during pregnancy, which fluid interface (Fig. 19), and fat-fluid levels are also
results in hemorrhagic infarction, which may cause specific features [43,67,68]. A study by Patel et al
acute, severe pelvic pain (Fig. 16). Leiomyomata [66] found that the positive predictive value was
have variable appearance on US. They most fre- 100% when an ovarian mass had two or more US
quently appear as round, homogeneous solid, well- features considered specific for mature cystic terato-
circumscribed masses that are usually hypoechoic or mas. In this study, the sensitivity of US for detection
isoehoic to the myometrium and more rarely rela- of dermoids was reported as 85% [66]. Diffusely
tively echogenic. Areas of decreased echogenicity echogenic mature cystic teratomas can escape detec-
secondary to degeneration and necrosis may be seen, tion by US because they appear similar to bowel [43].
especially in lesions larger than 5 cm. Distal acoustic When a palpable adnexal mass can be diagnosed
shadowing, often in a striated pattern, is commonly confidently as a mature cystic teratoma, surgery can
noted. Calcification is most common in older women be delayed safely until after delivery. If US is non-
[63]. It may be difficult to identify the site of myo- diagnostic but suspicious, CT or MR imaging may
metrial attachment of a pedunculated leiomyoma on
gray scale imaging. Both ovaries should be identifi-
able separate from the mass, however (Fig. 17), and
color Doppler imaging may help to identify a vascu-
lar pedicle. When sonographic evaluation of an
adnexal lesion is indeterminate in differentiating a
pedunculated leiomyoma from a solid ovarian neo-
plasm, MR imaging can be useful in further charac-
terization [64].
Benign and malignant neoplasms
Ovarian neoplasms are most often asymptomatic

unless they precipitate ovarian torsion, although such
lesions may present with vague abdominal or pelvic
pain and urinary frequency. Most ovarian neoplasms
detected during pregnancy are benign. The most Fig. 18. Mature cystic teratoma of the ovary. Note large
common of these are mature cystic teratomas and echogenic mass on the left (arrowheads).
increase the likelihood of malignancy (Figs. 21, 22)

[68,69]. The likelihood of malignancy also increases
with age, elevation of serum CA-125 level, and
positive family history [70]. It is not possible to dif-
ferentiate benign solid lesions (eg, fibromas or theco-
mas) from malignant germ cell or stromal tumors [69].
The presence of a purely solid tumor indicates a
higher probability of metastatic carcinoma than pri-
mary ovarian cancer (Fig. 23) [71]. Numerous authors
have reported that ovarian malignancies tend to have
increased peak systolic flow (peak systolic velocity
>35 cm/second) and low resistance perfusion (resis-
tive index <0.4 or perfusion index <1) [68,70,72,73].
There is significant overlap in the distribution
of peak systolic velocity, resistive index, and perfu-
sion index values between benign and malignant
Fig. 19. Mature cystic teratoma of the ovary. Note echogenic
lesions, however, and no discriminatory value is
hairball ‘‘floating’’ (arrow) at the fat/fluid interface. The
liquid fatty layer contains low-level echoes. Becuase the fat accepted [68,70,72,73]. Lack of detectable flow by
is lighter than the serous fluid, the more echogenic layer is means of color Doppler US does not exclude ovarian
more anterior in this supine patient. malignancy [72]. The management of an ovarian
mass during pregnancy is controversial. Surgery in
the first trimester is associated with pregnancy loss,
and surgery in the third trimester can result in
document the presence of fat within dermoids, thereby premature labor [1]. Although US is excellent at
confirming the diagnosis. detecting adnexal masses, it is not always accurate
Serous and mucinous cystadenomas are benign in differentiating benign from malignant lesions.
neoplasms that most commonly occur in reproductive Although the previously described morphologic char-
age women [43]. They can be difficult to differentiate acteristics and internal vascularity with high peak
sonographically from malignant cystadenocarci- systolic velocity and low resistive index suggest
nomas because of the wide spectrum of appearances malignancy, these features are nonspecific, with a
on US. Serous cystadenomas typically are large, positive predictive value of approximately 50% [73].
unilocular, thin-walled cystic lesions that may demon- The real value of US lies in the high negative
strate thin septations or papillary projections (Fig. 20). predictive value (nearly 99%) of US features con-
They are bilateral in 20% of cases [43]. Mucinous sidered to be benign [73]. In a pregnant patient with a
cystadenomas are typically larger, measure up to palpable adnexal mass and US features diagnostic of
30 cm, and may contain internal low-level echoes a benign entity, such as a serous or hemorrhagic cyst,
secondary to mucin content. Septations are common. dermoid or pedunculated fibroid, surgery may be
Papillary projections are less common and the mass postponed safely until after delivery or avoided
usually unilateral [43]. Malignant neoplasms com-
prise approximately 3% of adnexal masses diagnosed
in pregnancy [1]. The most common malignant neo-
plasms that come to attention during pregnancy in-
clude germ cell tumors, low-grade ovarian cancers,
and invasive epithelial ovarian cancers. Most women
diagnosed with ovarian cancer during pregnancy
present with stage 1 disease [1].
In many cases the US appearance of complex
cystic adnexal masses is indeterminate and the differ-
ential diagnosis of cystadenoma or cystadenocarci-
noma must be considered. The presence of thick
vascular septations (>3 mm), mural nodularity, papil-
lary processes, thick, irregular walls, solid areas,
invasion or fixation of adjacent structures, and asso- Fig. 20. Serous cystadenoma. Note thin, regular septations
ciated findings, such as ascites or serosal implants, (arrow) in this cystic adnexal mass.
Fig. 21. Stage 1 serous cystadenocarcinoma. This 28-year-old patient presented at 12 weeks’ gestation with a palpable right
adnexal mass. (A) US reveals mural irregularity (arrow), which represents small papillary projections. (B) These papillary
projections (arrow) are seen on corresponding MR image. Gravid uterus (U) is anterior.
altogether. Masses with multiple malignant features dence of gestational appendicitis has been reported
require prompt surgery. Masses that appear more as 0.05% to 0.14% [45,74]. Although the incidence
benign are often followed by serial examinations of acute appendicitis is not increased in pregnancy,
until the second trimester, which is the optimal time appendiceal rupture occurs two to three times more
for surgery in terms of maternal and fetal safety. In frequently and occurs in up to 25% of cases, second-
equivocal cases, MR imaging may be useful in ary to delay in diagnosis and surgery [1,45]. Patients
further characterizing an adnexal mass. with appendicitis typically present with fever, leuko-
cytosis, nausea, vomiting, and peri-umbilical pain,
which gradually moves to the right lower quadrant.
Perforated appendicitis These symptoms may be altered, muted, or absent in
pregnancy, however, which contributes to delays in
Appendicitis is the most common cause of non-
gynecologic acute pelvic pain in women and the most
common diagnosis that requires emergent surgical
intervention during pregnancy [4,74]. The inci-
Fig. 23. Krukenberg tumor (metastasis from gastric carci-

noma). This 27-year-old woman presented at 32 weeks’
gestation with acute abdominal pain, bilateral solid ovarian
masses, and ascites (only one mass is shown here). Although
Fig. 22. Serous cystadenocarcinoma. Note large complex the differential diagnosis would include benign lesions, such
adnexal mass on color Doppler with a vascular solid com- as fibroma and fibrothecoma, the pronounced vascularity
ponent (arrow). and ascites are worrisome for malignancy.
diagnosis and the increased incidence of perforation The examination is performed with a linear array
and associated morbidity and mortality in this popu- transducer. The cecum and psoas muscle can be used
lation [1,45,74 – 76]. as landmarks to help localize the appendix. Graded
In pregnancy, the most common presenting symp- compression is used to displace overlying bowel at
tom is right-sided abdominal pain, regardless of the the point of maximum tenderness [4,78]. An abnor-
gestational age [76]. The position of the appendix is mal appendix appears as a blind-ending, aperistaltic
elevated above McBurney’s point after the first tri- loop of bowel that does not compress [4,79]. Trans-
mester, however, and pain may be more localized to versely, the loop should be more than 6 mm in
the right upper quadrant than the right lower quad- diameter (outer wall to outer wall) (Fig. 24) [4,
rant and is often confused with cholecystitis [45]. 80 – 82]. This measurement criterion provides high
Although CT is the imaging modality of choice in sensitivity but limited specificity, because the normal
evaluating patients with suspected appendicitis, it is appendix has been reported to have a diameter of up
to be avoided in pregnant patients because of the to 13 mm secondary to intraluminal contents [81,82].
risks of ionizing radiation to the fetus. US examina- The combined wall thickness should not exceed 6 mm
tion is often the first-line imaging modality in this in a normal appendix [4,82]. Increased vascularity
patient population. US is a specific, although rela- may be noted on Doppler interrogation. In some
tively insensitive, test for the diagnosis of acute cases, a shadowing appendicolith is seen [4]. The
appendicitis. Prospective studies have reported US surrounding area also should be evaluated carefully to
specificity rates of 86% to 100% and sensitivity rates exclude loculated periappendiceal fluid or gas, which
as high as 75% to 90% in patients with clinically suggests abscess formation [4,78]. Recent reports
suspected appendicitis [4]. In most clinical practices, suggest that MR imaging may be beneficial in eval-
however, the appendix is infrequently visualized, uating patients for suspected appendicitis when US is
which limits the sensitivity and negative predictive nondiagnostic [83,84]. Appendicitis in pregnancy
value of the examination. In one study, on-call requires prompt surgery. Maternal mortality from
residents were only able to detect the appendix by appendicitis has diminished to approximately 0.1%
US in 13% of cases in which appendicitis was but still exceeds 4% when perforation occurs [1].
clinically suspected [77]. Sensitivity for detection Fetal mortality is less than 2% but is more than 30%
of appendicitis was 50% on US compared with in the case of perforation [1].
100% on CT [77].
Diverticulitis
Diverticulitis is uncommon in pregnant women.

Patients present with lower quadrant (usually left)
pain, fever, and leukocytosis [4]. Whereas CT is the
gold standard in evaluation of suspected diverticu-
litis, US is a preferred modality in the pregnant
patient, and a small body of literature has indicated
that US can be used to make this diagnosis accu-
rately. Pradel et al [85] reported that CT and US
had an accuracy rate of 84% in diagnosing diverticu-
litis. US and CT findings were not statistically
significantly different in terms of sensitivity rates
(85% and 91%, respectively) and specificity rates
(84% and 77%, respectively) [85]. Although trans-
abdominal US scanning seems less sensitive in iden-
tifying diverticular abscess compared with CT,
endovaginal US scanning is just as sensitive if the
area is within reach of the vaginal probe [4]. US
may identify an abnormal loop of bowel in the re-
gion of the patient’s pain with an irregular lumen
Fig. 24. Acute appendicitis. Transverse view demonstrates a and outpouchings beyond the bowel wall. The co-
thick-walled (arrow), noncompressible appendix with a lonic wall may appear thickened but less concentri-
surrounding fluid collection (F). cally so than in primary colitis. An adjacent walled
off fluid collection or extraluminal shadowing air with an adnexal mass can occur in pregnant patients,
suggests perforation and abscess formation [4]. These however. Some causes are benign and others require
results are operator dependent; however, US should urgent management and treatment. Clinical presenta-
not be overlooked as a viable alternative imaging tion and physical examination can be misleading
modality for diagnosing diverticulitis in the preg- in pregnancy. The location of pain may be atypical
nant patient. for the pathologic entity, the pain may be muted, and
in the case of infection, fever and leukocytosis can
be absent. US examination is a safe and effective
Epiploic appendigitis method for evaluating these patients. Sonographic
characterization of adnexal masses may make a de-
Epiploic appendigitis is an uncommon entity. It finitive diagnosis or focus the differential, which al-
is caused by torsion or ischemic infarction of one of lows for prompt and appropriate treatment of patients.
the epiploic appendages of the colon, which incites a
subsequent inflammatory reaction [4,86]. Epiploic
appendages are rudimentary in children and reach
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Radiol Clin N Am 42 (2004) 349 – 363
Acute painful scrotum

Vikram Dogra, MD*, Shweta Bhatt, DMRD, DMRE
Department of Radiology, Case Western Reserve University, University Hospitals, 11100 Euclid Avenue,
High-frequency transducer sonography using across the testis in the craniocaudal direction. If
gray scale along with pulsed and color Doppler is imaged at an angle, it may resemble a testicular tumor.
the imaging modality of choice for evaluating pa- Each lobule is composed of many seminiferous tu-
tients who present with acute scrotal pain. Disease bules that open via tubuli recti into dilated spaces
processes such as testicular torsion, epididymo-orchi- called the rete testes within the mediastinum. The
tis, and intratesticular tumors have the common normal rete testis can be identified at high-frequency
symptom of pain at presentation, and sonographic ultrasound (US) in 18% of patients as a hypoechoic
evaluation helps in differentiating patients who re- area with a striated configuration adjacent to the
quire surgical from patients for whom conservative mediastinum testis [1]. These in turn communicate
management is sufficient. Sonography with a high- via efferent ductules with the epididymal head. The
frequency transducer helps to characterize better the epididymis is composed of a head, body, and tail,
testicular flow and, in many instances, suggests more the ducts of which continue as the vas deferens in
specific diagnoses. This article is organized on the the spermatic cord. The epididymis is seen as a 5- to
basis of the pathophysiology of the disease process 12-mm pyramidal structure lying atop the superior
with emphasis on color Doppler when applicable. pole of the testes. The head of the epididymis is usu-
This article is intended to familiarize the reader with ally isoechoic to the testis, and its echotexture may be
new technology and provide new insights into the coarser than that of the testicle [2,3]. High-frequency
sonographic diagnosis of painful scrotum. transducer sonography permits visualization of the
body of epididymis, which measures 2 to 4 mm.
The right and left testicular arteries—branches of
Imaging anatomy the abdominal aorta—provide the vascular supply to
the testis. A transmediastinal artery branch of the
A normal adult testis has medium-level echoes testicular artery occurs in approximately one half of
and measures 532 cm [1]. The tunica albuginea is normal testes (Fig. 3) [4]. It courses through the
the fibrous sheath that covers the testicle. The tunica mediastinum to supply the capsular arteries and is
albuginea is covered by the tunica vaginalis. Septae usually accompanied by a large vein. The deferential
extend from the tunica albuginea into the testicle and artery, a branch of the superior vesicle artery, and the
divide the testes into lobules (Fig. 1). The posterior cremasteric artery, a branch of the inferior epigastric
surface of the tunica albuginea is reflected into the artery, supply the epididymis, vas deferens, and
interior of the gland, which forms the incomplete peritesticular tissue [5]. Branches of the pudendal ar-
septum known as the mediastinum of the testis. Sono- tery supply the scrotal wall [6]. Venous drainage is
graphically, the mediastinum of the testis is an echo- via the pampiniform plexus.
genic band (Fig. 2) of variable thickness that extends Four testicular appendages have been described:
the appendix testis, the appendix epididymis, the vas
aberrans, and the paradidymis. They are remnants of
* Corresponding author. embryologic ducts [7]. The appendix testis and the
E-mail address: Dogra@uhrad.com (V. Dogra). appendix epididymis are usually seen on scrotal so-
doi:10.1016/j.rcl.2003.12.002
350 V. Dogra, S. Bhatt / Radiol Clin N Am 42 (2004) 349–363
Fig. 1. Diagrammatic transverse representation of the anatomy of the testis illustrates the relationships of the tunica albuginea
to the mediastinum testis and the mediastinum testis to the rete testis. (Courtesy of Vikram Dogra, MD.)
nography. The appendix testis is attached to the upper are obtained with 7- to 14-MHz high-frequency
pole of the testis in the groove between the testis and linear-array transducers.
the epididymis (Fig. 4A). The appendix epididymis, The testes are studied in two planes (ie, along the
another appendage (Fig. 4B), is attached to the head long and transverse axes). The size and echogenicity
of the epididymis and is encountered unilaterally in of each testicle and the epididymis are compared with
34% and bilaterally in 12% of postmortem series. those on the opposite side. In patients being evaluated
Presence of minimal fluid facilitates their visualiza- for an acute scrotum, the asymptomatic side should
tion on sonography. be scanned initially to set the gray scale and color
Doppler gains to allow comparison with the affected
side. Color Doppler and pulsed Doppler are opti-
Scanning technique mized to display low-flow velocities, and blood flow
in the testis and surrounding scrotal structures is
Scrotal sonography is performed with the patient documented, including the spectral Doppler recording
lying in a supine position and the scrotum supported of the intratesticular arterial flow in both testes.
by a towel placed between the thighs. Optimal results Transverse images with portions of each testis on
the same image should be recorded in gray scale and
color Doppler. Power Doppler also may be used to
Fig. 2. Longitudinal view of a normal testis demonstrates Fig. 3. Transverse oblique view of the testis demonstrates the
the mediastinum testis (arrow) as an echogenic band. transmediastinal artery as a linear hypo-echoic band (arrow).
V. Dogra, S. Bhatt / Radiol Clin N Am 42 (2004) 349–363 351
Fig. 4. (A) Appendix testis (arrow) directly attached to the testis (T). Presence of fluid (asterisk) facilitates its visualization.
(B) The appendix of the epididymis (cystic appearance) (arrow) is seen attached to the head of the epididymis (E).
visualize intratesticular flow in patients with an acute was first described in 1883 as an idiopathic condition
scrotum. Additional techniques, such as the Valsal- of the scrotum. The disease currently differs from
va’s maneuver or upright positioning, can be used as the original description in that it includes women and
needed for venous evaluation. is known to be secondary to a defined source of in-
fection in 95% of the cases.
Conventional radiography, CT, and sonography
Inflammatory causes can aid in determining the location and cause of gas
in the scrotum. Crepitus (gas in the tissue) has been
Fournier’s gangrene reported in 18% to 62% of cases and can be detected
by US, CT, and conventional radiography. Subcuta-
Fournier’s gangrene constitutes a urologic emer- neous gas within the scrotal wall is the sonographic
gency that demands early recognition because of its hallmark of Fournier’s gangrene [12]. Sonographi-
high mortality rate, which is reportedly as great as cally, the gas appears as numerous discrete hyper-
75% [8]. The diagnosis of Fournier’s gangrene is echoic foci with reverberation artifacts (Fig. 5A, B)
based primarily on clinical examination rather than [12,13]. Other sonographic findings include scrotal
on imaging studies. When clinical findings are am- wall thickening while the echotexture of the testis
biguous, however, diagnostic imaging is useful [1]. and epididymis remains normal. Inguinoscrotal her-
Fournier’s gangrene is a synergistic polymicrobial nia can present with gas on sonographic examination
necrotizing fasciitis of the perineum or perirectal or and can be differentiated from Fournier’s gangrene
genital area that predominantly affects the scrotum in by the presence of gas within the protruding bowel
men and frequently extends to involve the lower lumen and away from the scrotal wall [1].
abdominal wall. Predisposing conditions include di-
abetes mellitus, alcoholism, advanced age, and im- Epididymo-orchitis
munodeficiency syndrome [9]. Fournier’s gangrene
is characterized by obliterative endarteritis, which re- Acute epididymo-orchitis or epididymitis is the
sults in a cutaneous and subcutaneous vascular necro- most common cause of acute scrotum in adolescent
sis. The most common pathogens isolated in patients boys and adults. Sexually transmitted Chlamydia
with this syndrome are Klebsiella, Proteus, Strepto- trachomatis and Neisseria gonorrhea are common
coccus, Staphylococcus, Peptostreptococcus, Esche- pathogens in men younger than 35 years. In prepu-
richia coli, and Clostridium perfringens [8,10,11]. It bertal boys and men over 35 years of age, the dis-
Fig. 5. (A) Surgically confirmed case of Fournier gangrene. Longitudinal US of the testis (T) shows sparing of the testis. Both
sonograms show air (arrowhead) parallel to the transducer face with reverberation artifact (arrow). (B) Axial CT in another
patient with proven Fournier gangrene, which shows subcutaneous air (arrowhead) dissecting the fascial planes.
ease is most frequently caused by E coli and Proteus epididymis. Orchitis develops in 20% to 40% of cases
mirabilis [14]. Prehn [15] described the clinical dif- of epididymo-orchitis by direct spread of infection.
ferentiation of scrotal pain associated with epididy- On gray scale, the epididymis is enlarged and
mitis and acute torsion. Pain associated with acute usually appears hypoechoic or hyperechoic (second-
epididymo-orchitis is usually relieved when the tes- ary to hemorrhage) (Fig. 6) [17]. Other signs of in-
ticles are elevated over the symphysis pubis; how- flammation, such as reactive hydrocele or pyocele
ever, the scrotal pain associated with testicular torsion with scrotal wall thickening, are present in most cases.
is not lessened with this maneuver (Prehn’s sign). Diffuse testicular involvement is confirmed by testicu-
Other causes, such as sarcoidosis, brucellosis, tuber- lar enlargement and an inhomogeneous testicular
culosis, cryptococcus, and mumps, also may cause echotexture. Gray scale sonographic findings are non-
epididymitis and orchitis. Drugs, such as amiodarone, specific, but acute epididymo-orchitis is the most
also may cause epididymitis (chemical epididymitis) common disorder with this combination of findings.
[16]. Complications of acute epididymitis include In one study that involved 20 cases of epididymo-
chronic pain, infarction, abscess, gangrene, infertility, orchitis, 11 of 20 cases had enlarged and heteroge-
atrophy, and pyocele. neous appearance of the epididymis or testis [18].
Epididymitis first affects the tail of the epididymis In orchitis there is edema of the testis contained within
and then spreads to involve the body and head of the an unyielding tunica albuginea, which results in var-
ious scales of reflectivity, seen as heterogeneity on
sonography [16,19]. This variable reflectivity may be
seen as a diffuse process or focal involvement, the
latter manifested as multiple hypoechoic lesions
within the testicular parenchyma. It is difficult to
differentiate focal areas of heterogeneity from neo-
plastic lesions. A heterogeneous echo pattern does not
always signify orchitis.
The increased blood flow to the epididymis and
testis on color Doppler examination is a well-estab-
lished criterion for the diagnosis of epididymo-orchi-
tis (Fig. 7) [20]. Normally, epididymal arterial flow is
of a low-resistance, high-flow state. With the US
machines currently in use, blood flow can be seen in
a normal epididymis on color Doppler sonography. In
one study it was seen in 100% of the cases [21]. The
Fig. 6. Clinically proven epididymo-orchitis. Transverse mere presence of color flow in epididymis is not
US of the testis (T) shows a markedly enlarged epididymis equivalent to epididymitis; therefore, it is important
(arrows) with variable echotexture. to compare the vascularity in both epididymii.
mumps-related epididymo-orchitis, 9 of 11 cases were

unilateral, and all 11 cases had an enlarged testis and
increased testicular vascularity. Testicular echogeni-
city was uniformly decreased in all 11 cases [26].
Hyperemia and heterogeneity isolated to the testis can
be seen in cases of orchitis, tumor, infarction, and
especially transient torsion of the testis. Because
intratesticular venous flow is difficult to detect in
normal testes, increased and easily detected venous
flow in the testes greatly suggests orchitis [20].
Cellulitis
Scrotal wall cellulitis is common in patients who

Fig. 7. Clinically proven epididymo-orchitis. Color Dopp-
are obese or immunocompromised or have diabetes.
ler of the testis (T) shows marked hyperemia of the epi-
didymis (arrow).
The sonographic signs are an increase in scrotal wall
thickness and the presence of hypoechoic areas with
increased blood flow shown on color Doppler. Scrotal
Increase of vascularity in acute epididymitis is
wall cellulitis may lead to scrotal abscess. Such ab-
secondary to the increased number and concentration
scesses are usually well loculated, with irregular
of identifiable vessels with hyperemia, which results
walls and low-level internal echoes [1].
in a high-flow/low-resistance pattern [22 – 24]. Analy-
sis of the spectral waveform also can provide use-
ful information, because inflammation of epididymis
Intratesticular abscess
and testis is associated with decreased vascular resist-
ance to that seen in normal individuals. In the testes
This condition is usually secondary to epididymo-
of a normal healthy volunteer, the resistive index (RI)
orchitis, but other causes include mumps, trauma, and
is rarely less than 0.5, but more than half the patients
testicular infarction (Fig. 9). The sonographic features
with epididymo-orchitis have an RI of less than 0.5
include shaggy irregular walls, an intratesticular lo-
(Fig. 8) [22,24,25]. In normal testes, intratesticular
venous flow is difficult to detect. Easy detectability
and increased venous flow in the testes greatly
suggest orchitis. The absence of venous flow in the
presence of arterial signal in orchitis is abnormal
and suggests venous occlusion, which may be sec-
ondary to impending infarction or underlying coagu-
lopathic disorder. Reversal of the spectral Doppler
diastolic plateau in acute epididymo-orchitis suggests
venous infarction. In all cases of testicular inhomo-
geneity diagnosed as epididymo-orchitis, if there is
no demonstrable improvement with antibiotic treat-
ment, the diagnosis should be reconsidered. Tumor
markers, a hypercoagulation profile, or repeat US
may reveal a different diagnosis, such as testicular
tumor or thrombosis.
Primary orchitis
Mumps is the commonest cause of orchitis without

accompanying epididymitis and is bilateral in 14% to Fig. 8. Duplex Doppler evaluation of the testis demonstrates
35% of cases [1]. Sonographically, the testes appear an RI of 0.44 and increased vascularity of the testis in a
enlarged with decreased echogenicity. In one study of patient with epididymo-orchitis.
compromise, which results in testicular ischemia. The

extent of testicular ischemia depends on the degree of
torsion, which ranges from 180° to 720° or more.
Experimental studies indicate that 720° torsion is
required to occlude the testicular artery [32]. When
torsion is 180° or less, diminished flow is seen. The
testicular salvage rate depends on the degree of tor-
sion and the duration of ischemia. A nearly 100%
salvage rate exists within the first 6 hours after the
onset of symptoms, a 70% rate in 6 to 12 hours, and a
20% rate in 12 to 24 hours [33].
Intravaginal torsion occurs within the tunica va-
ginalis. In patients with ‘‘Bell-Clapper deformity’’
(Fig. 10), tunica vaginalis completely encircles the
epididymis, distal spermatic cord, and the testis
rather than attaches to the posterolateral aspect of the
testis [1,34]. This leaves the testis free to swing and
rotate within the tunica vaginalis, much like a clapper
Fig. 9. Surgically confirmed testicular abscess. Transverse inside a bell. Bell-Clapper deformity is bilateral in
US of the testis (T) shows fluid-debris level (arrow) con- 80% of patients.
sistent with intratesticular abscess that developed secondary
Testicular perfusion can be evaluated by color
to epididymo-orchitis.
Doppler, power Doppler, or spectral Doppler sonog-
raphy. Color Doppler sonography can demonstrate
cation, low-level internal echoes, and occasional intratesticular flow reliably [17,24,35]. Power Dopp-
hypervascular margins [27]. ler sonography uses the integrated power of the
Doppler signal to depict the presence of blood flow.
Higher power gains are more likely with power
Vascular Doppler sonography than with standard color Dopp-
ler sonography, which results in increased sensitivity
Testicular torsion for detecting blood flow. Power Doppler sonography
is valuable in scrotal sonography because of its
Testicular torsion and epididymo-orchitis com- increased sensitivity to low-flow states and its inde-
monly present with pain. The main role of US is to pendence from the Doppler angle correction [36,37].
differentiate acute testicular torsion, which is a sur- Pulsed Doppler sonography is a useful method to
gical emergency, from epididymo-orchitis. Clinical identify flow in the testis using the time-velocity
differentiation of these conditions is difficult, with spectrum to quantify blood flow [38]. The spectral
a nearly 50% false-positive rate for diagnoses of waveform of the intratesticular arteries characteristi-
testicular torsion based solely on clinical findings, cally has a low-resistance pattern [35], with a mean
which often results in unnecessary surgical explora- RI of 0.62 (range, 0.48 – 0.75) [17]. This is not true for
tion [28]. Hunter described the first case of testicular testicular volumes less than 4 cm3, however, which
torsion [15]. Torsion of the spermatic cord occurs
most commonly from 12 to 18 years of age but can
occur at any age. The chance of torsion of the testis or
its appendage developing by age 25 is approximately
1 in 160 [29], with 2% of testicular torsions being
bilateral [30].
Patients with acute torsion present after a sudden
onset of pain followed by nausea, vomiting, and a
low-grade fever. Physical examination reveals a swol-
len, tender, and inflamed hemiscrotum. The cremas- Fig. 10. Diagram represents abnormal (Bell-Clapper defor-
teric reflex is usually absent [31], and the pain cannot mity) and normal insertion of the tunica vaginalis. (From
be relieved by elevation of the scrotum [15]. Dogra V, Ledwidge ME, Winter III TC, et al. Bell-Clap-
Testicular torsion causes venous engorgement that per deformity. AJR Am J Roentgenol 2003;180:1176 – 7;
results in edema, hemorrhage, and subsequent arterial with permission.)
Fig. 11. Surgically confirmed testicular torsion. (A) Color Doppler US of the testis (T) demonstrates the absence of intrates-
ticular blood flow with peripheral hyperemia (arrows). (B) Involvement of the epididymis in testicular torsion. There is no blood
flow within the testis (T) or epididymis (E). Peripheral hyperemia is seen (arrow).
are often found in prepubertal boys, in whom dia- Gray scale images are nonspecific for detecting
stolic arterial flow may not be detectable [39]. testicular torsion [22] and often appear normal if the
The role of color Doppler and power Doppler torsion has just occurred. Testicular swelling and
sonography in the diagnosis of acute testicular torsion decreased echogenicity are the most commonly en-
is well established [24,40]. Using the presence or ab- countered findings 4 to 6 hours after the onset of
sence of identifiable intratesticular flow as the only torsion. Twenty-four hours after the onset, the testis
criterion for detecting testicular torsion, color Dopp- has a heterogeneous echotexture secondary to vascu-
ler was 86% sensitive, 100% specific, and 97% ac- lar congestion, hemorrhage, and infarction, which is
curate in the diagnosis of torsion and ischemia in referred to as late or missed torsion. An enlarged and
painful scrotum (Fig. 11A, B) [23]. The high degree hypoechoic epididymal head may be visible because
of accuracy is attributable to the improved depiction the deferential artery that supplies the epididymis is
of power Doppler sonography over color Doppler often involved in the torsion (Fig. 12A, B). In the
sonography in normal prepubertal and postpubertal setting of testicular torsion, normal testicular echo-
testes [41]. Sonographic findings vary with the dura- genicity is a strong predictor of the testicular viability
tion and degree of rotation of the spermatic cord. [42]. Gray scale findings of testicular torsion are sum-
Fig. 12. Surgically confirmed testicular torsion. Gray scale US of the testis (A) shows an enlarged testis with a hypoechoic
appearance. (B) Epididymal involvement in testicular torsion in another patient. The epididymis (E) is enlarged and appears
hypoechoic. There was no blood flow in the testis or epididymis on color Doppler examination (not shown).
Table 1 enlarged, heterogeneous testis, ipsilateral hydrocele,

Gray scale findings of testicular torsion skin thickening, and no color flow Doppler signal
Testicular torsion Gray scale patterns in the testis or the spermatic cord [51]. In children,
Acute torsion with Normal power Doppler US is more sensitive than color Dopp-
viable testis ler US for detection of intratesticular blood flow. In
Acute torsion Hypoechoic pattern that may be one study, power Doppler US demonstrated intra-
with infarction total or partial in case of a testicular blood flow in 66 (97%) testes, whereas
partial infarct color Doppler US demonstrated intratesticular blood
Acute torsion with Hyperechoic and heterogeneous flow in 60 (88%) testes. Combined techniques de-
hemorrhagic infarction echo patterns picted blood flow in all 68 (100%) testes [52].
Chronic torsion Hypoechoic with small testis
Appendiceal torsion
marized in (Table 1). Other indicators include the pres-
ence of scrotal wall thickening and reactive hydrocele. The normal appendix testis appears as an ovoid
Because gray scale findings are often normal in the structure 5 mm in length in the groove between the
early phases of torsion, the Doppler component of the testis and the epididymis. The appendix testis is iso-
examination is essential. The absence of testicular echoic to the testis and occasionally may be cystic.
flow on color and power Doppler sonography is con- The appendix epididymis is of the same approximate
sidered diagnostic of ischemia provided that the US dimensions as the appendix testis but is more often
scanner is optimized to detect slow flow, is limited to pedunculated [53]. These appendages may become
the use of a small color-sampling box, and is adjusted twisted. Torsion of either appendage produces pain
for the lowest repetition frequency and the lowest similar to that experienced with testicular torsion, but
possible threshold setting [43]. The threshold should the onset is more gradual. The classic finding on
be set just above the detection of color noise. The physical examination is a small, firm nodule that is
absence of color flow Doppler on US examination is palpable on the superior aspect of the testis and
not synonymous with testicular torsion, because other exhibits a bluish discoloration through the overlying
conditions, such as testicular polyarteritis nodosa, skin; this is called the ‘‘blue dot’’ sign [54]. The cre-
can mimic torsion [44]. The color flow Doppler and masteric reflex still can be elicited, although it is usu-
spectral Doppler waveform findings in testicular tor- ally absent in testicular torsion. Approximately 91%
sion are summarized in Box 1. to 95% of twisted testicular appendices involve the
Torsion may be complete, incomplete, or transient. appendix testis and occur most often in boys aged 7 to
Cases that show partial or transient torsion present a 14 years.
diagnostic challenge. The ability of color Doppler Sonographic evaluation of torsion of the append-
imaging to diagnose incomplete torsion accurately ages of the testes usually reveals a circular mass with
remains undetermined. The role of spectral Doppler variable echogenicity adjacent to the testis or epididy-
analysis is not well established for diagnosing partial mis (Fig. 14) [55,56]. Reactive hydrocele and skin
torsion, but the findings may be useful (Fig. 13A, B) thickening are common in these cases. Increased
[45]. No studies are available to validate the role of peripheral flow may be seen around the torsed testicu-
spectral Doppler in partial torsion; however, sporadic
case reports exist to suggest its usefulness [46,47].
Asymmetry in the testicular RIs with decreased dia- Box 1. Testicular torsion: color flow
stolic flow or diastolic flow reversal may be seen. The Doppler patterns
presence of a color or power Doppler signal in a
patient with the clinical presentation of torsion does 1. Absent arterial and venous flow
not exclude torsion [47]. 2. Increased RI on affected side (dimin-
Extravaginal testicular torsion occurs exclusively ished or reversed diastolic flow)
in newborns. Torsion occurs outside the tunica vagi- 3. Decreased flow velocity difficult to
nalis when the testis and gubernaculums are not fixed measure because of small vessels/
and are free to rotate [48]. The affected neonate angle correction but may be subjec-
presents with swelling, discoloration of the scrotum tively inferred by relative difficulty in
on the affected side, and a firm painless mass in the finding small, low-amplitude flow on
scrotum [49,50]. The testis is typically infarcted and symptomatic side
necrotic at birth. Sonographic findings include an
Fig. 13. Surgically confirmed partial torsion. (A) The left testis shows normal intratesticular arterial spectral waveform. (B) In
the same patient, the right testis demonstrates diastolic flow below the baseline, which indicates loss of tissue perfusion. This
waveform pattern is abnormal and suggests partial testicular torsion. (From Dogra VS, Sessions A, Mevorach A, et al. Reversal
of diastolic plateau in partial testicular torsion. J Clin Ultrasound 2001;29:105 – 8; with permission.)
lar appendage on color Doppler US [14,23,24]. These the inferior vena cava and the left testicular vein
cases are managed conservatively with attention given into the left renal vein. Abnormal dilatation of the
to pain management. The pain usually resolves in 2 to veins of the pampiniform plexus results in varicocele,
3 days with atrophy of the appendix that may calcify. which is usually caused by incompetent valves in the
The role of sonographic examination in torsion of the internal spermatic vein. This results in impaired
testicular appendages is to exclude testicular torsion drainage of blood into the spermatic cord veins when
and acute epididymo-orchitis. the patient assumes an upright position or during a
Valsalva’s maneuver. Varicoceles have been noted in
approximately 15% of the general population and in
Varicocele up to 40% of men with infertility [57]. Patients with
idiopathic varicoceles usually present between the
Idiopathic varicocele ages of 15 and 25 years. The veins of the pampini-
form plexus normally range from 0.5 to 1.5 mm in
Venous drainage of the scrotum is via the pam- diameter, with the main draining vein as large as
piniform plexus of draining veins; it is formed around 2 mm in diameter. Varicoceles are more common
the upper half of the epididymis in a variable fashion on the left side for the following reasons: (1) the left
and continues as the testicular vein through the deep testicular vein is longer, (2) the left testicular vein
inguinal ring. The right testicular vein empties into enters the left renal vein at a right angle, (3) in some
men, the left testicular artery arches over the left renal
vein, thereby compressing it, (4) the descending
colon distended with feces may compress the left
testicular vein [58], and (5) a ‘‘nutcracker’’ effect of
compression of the left renal vein may occur be-
tween the superior mesenteric artery and the abdomi-
nal aorta [59].
Varicocele is a clinical diagnosis, and palpation
reveals a scrotal mass that may feel like a bag of
worms with or without a palpable thrill. In one study,
all patients with palpable varicoceles had a spermatic
vein diameter of 5 to 6 mm [60]. The clinical gra-
Fig. 14. Clinically proven case of appendiceal torsion. Lon- dation of varicoceles is given in Table 2.
gitudinal view of the testis (T) shows a predominantly Sonography should be performed in supine and
hypoechoic area (arrow) adjacent to the epididymis (E). upright positions. The sonographic appearance of
Table 2 Secondary varicoceles

Grade I Not visible but palpable on
Valsalva’s maneuver. Secondary varicoceles result from increased
Grade II Less visible but palpable pressure on the spermatic vein produced by disease
without Valsalva’s maneuver processes, such as hydronephrosis, cirrhosis, or ab-
Grade III Always visually identifiable dominal neoplasm. Neoplasm is the most likely
and palpable without cause of nondecompressible varicocele in men over
Valsalva’s maneuver.
40 years of age. It is classically from a left renal
malignancy invading the renal vein [3]. Nondecom-
pressible varicoceles on the left or right should
prompt evaluation of the retroperitoneum to exclude
varicocele consists of multiple, serpigenous, tubular retroperitoneal masses and thrombus or tumor exten-
structures of varying sizes larger than 2 mm in diam- sion to the left renal vein. An abdominal mass always
eter, which are usually best visualized superior or should be suspected when an older man presents with
lateral to the testis. When large, they can extend a new varicocele.
posterior and inferior to the testis. Occasionally, low-
level internal echoes can be detected in these dilated
veins secondary to slow flow. Color flow and duplex Intratesticular varicocele
Doppler sonography optimized for low-flow velocities
confirms the venous flow pattern with phasic variation An intratesticular varicocele can occur in associa-
and retrograde filling with Valsalva’s maneuver. The tion with an extratesticular varicocele, but intrates-
sensitivity and specificity rates of varicocele detec- ticular varicoceles are more commonly found alone
tion approach 100% with color Doppler sonography. [63]. Clinical implications and the pathogenesis of
The relationship between nonpalpable (subclini- the newly defined condition, intratesticular varico-
cal) varicocele and infertility remains controversial. cele, are not yet well established. Patients with intra-
After treatment, however, these patients’ partners testicular varicocele may have pain related to passive
have a 40% pregnancy rate [61]. Approximately one congestion of the testis, which eventually stretches
third of men who undergo evaluation for infertility the tunica albuginea. The sonographic findings of
present with varicocele; however, not all patients with intratesticular varicocele are similar to those of pam-
infertility have a palpable varicocele. In a study of piniform plexus varicocele [58].
1372 infertile men, varicocele was found in 29% by Sonographic features include multiple anechoic,
sonography; however, only 60% had a palpable vari- serpigenous, tubular structures of varying sizes within
cocele [62]. Diagnosis of subclinical varicocele is the testis. Color flow and duplex Doppler sonography
important because treatment improves sperm quality demonstrate the venous flow pattern with a charac-
in as much as 53% of these cases. teristic venous spectral wave form, which increases
Fig. 15. Intratesticular varicocele. (A) Longitudinal view of the testis (T) shows tortuous anechoic, tubular areas (arrow)
within the testis. (B) Corresponding spectral Doppler waveform demonstrates characteristic venous flow with positive Valsal-
va’s maneuver.
with Valsalva’s maneuver (Fig. 15A, B) [58]. The

main differential considerations are cyst, hematoma,
epidermoid cyst (echogenic rim), and tubular ectasia.
Use of color flow and duplex Doppler affords easy
differentiation. In every longstanding case of varico-
cele that presents with pain, this entity should be
considered and sought [58].
Intratesticular arteriovenous malformation
Intratesticular arteriovenous malformation is a

rare, benign entity. Its pathogenesis may be congeni-
tal or posttraumatic. The characteristic arterialized
venous spectral waveform is universal to all arterio-
venous malformations [64], and the main differential
consideration is intratesticular hemangioma [65]. Fig. 17. Surgically confirmed testicular fracture secondary
to trauma. Color Doppler US of the testis demonstrates a
linear hypoechoic area (arrow) that runs obliquely across the
testis and represents the testicular fracture line.
Testicular trauma
Testicular trauma typically results from athletic

injury, a motor vehicle accident, a direct blow, straddle ruptured testes can be saved if surgery is performed
injury, or penetrating gunshot trauma. Blunt trauma within 72 hours after injury [66,67].
accounts for approximately 85% of these cases, and Trauma can result in contusion, hematoma, frac-
penetrating trauma comprises the remaining 15%. A ture, or rupture of the testis [1]. Scrotal US with color
direct blow to the testis with impingement against the flow Doppler is helpful in determining the nature and
symphysis pubis or ischial ramus is the most common extent of the injury. The scrotal sonography has 100%
mechanism of injury from blunt trauma. Approxi- sensitivity for testicular injuries and 80% specificity
mately 50 kg of pressure is necessary to rupture the for tunica albuginea fractures [68]. Approximately
tunica albuginea during blunt trauma. Testicular rup- 20% of patients who seek medical attention after
ture is a surgical emergency, and more than 80% of testicular trauma have testicular rupture [69]. Sono-
graphic findings in testicular rupture include inter-
ruption of the tunica albuginea, contour abnormality
(Fig. 16), a heterogeneous testis with irregular, poorly
defined borders, scrotal wall thickening, and a large
hematocele [70,71]. Color and power Doppler sonog-
raphy are helpful because either can detect disruption
of the normal capsular blood flow of the tunica
vasculosa. Heterogeneous intratesticular lesions are
caused by hemorrhage or infarction. Direct visual-
ization of a fracture line is rare and is seen only in
17% of cases (Fig. 17) [71]. Sonographic findings in
testicular trauma are summarized in Box 2.
Hematocele is a blood collection within the tu-
nica vaginalis. On sonography, acute hematoceles
are echogenic, whereas older hematoceles appear as
fluid collections with low-level echogenicity, fluid-
fluid levels, or septations. Hematoceles may be
Fig. 16. Surgically confirmed tunica albuginea rupture. In
caused by extratesticular or intratesticular bleeding,
this case of testicular trauma, color Doppler US shows a although there is no definite US evidence of testicular
contour abnormality (arrow) that represents extruded tes- rupture. The presence of associated hyperechoic or
ticular contents through the ruptured tunica albuginea. The hypoechoic changes in the testicular parenchyma
asterisk represents accompanying hematocele. suggests testicular rupture.
Hernias occur because of persistent patency of the

Box 2. Sonographic findings in testicular
process vaginalis with protrusion of the peritoneal
trauma
contents, such as omentum or bowel, through it into
1. Contour abnormality of the testis the tunica vaginalis [32].
2. Disruption of the tunica albuginea US is helpful for patients with equivocal physical
(evidenced by interruption of tunica findings and patients who present with acute inguino-
vasculosa) scrotal swelling. Herniation of the abdominal or
3. Direct visualization of a fracture line pelvic contents in the groin region may be divided
4. Presence of hematocele into two main categories: inguinal and femoral. In-
5. Intra- or extratesticular hematoma guinal hernias are the most common and can be sub-
6. Heterogeneous appearance of the divided into direct and indirect types. Direct inguinal
testis hernias travel through the Hassalbach’s triangle, a
7. Hyperemia of the epididymis weakness in the anterior abdominal wall. The borders
of this triangle are formed by the lateral border of
Note that any of the above mentioned the rectus sheath medially, the inferior epigastric
findings may be seen in isolation or in artery laterally, and the inguinal ligament inferiorly
any combination. [74]. Indirect hernias travel lateral to the inferior
epigastric artery and through the inguinal canal; they
constitute 80% of all hernias. A femoral hernia occurs
Hematomas can involve the testis, epididymis, or within the femoral canal that lies medial to the femo-
scrotal wall. Their sonographic appearance varies ral vein. Because of the narrowness of the femoral
with time. Acute hematomas appear hyperechoic ring (the opening that forms the neck of a femoral her-
and subsequently become complex with cystic com- nia), it is more likely than an inguinal hernia to be-
ponents. Hematoma appears avascular on color come incarcerated [75]. Femoral hernia is common in
Doppler sonography [14,40]. Color Doppler sonog- women, with the right side more frequently affected.
raphy in posttrauma patients may reveal focal or
diffuse hyperemia of epididymis, which is called
traumatic epididymitis [72].
Patients with intratesticular hematomas fare
poorly without exploration, and 40% of the hema-
tomas result in testicular infection or necrosis, which
often requires orchiectomy. Scrotal exploration is
warranted if there is compelling evidence of testicular
fracture or rupture on scrotal sonography or physical
examination. The presence of a large hematocele is
another indication for exploration. Small hematoceles,
epididymal hematomas, or contusions of the testis
generally pose little risk to the patient and do not
require surgical exploration [73]. In posttrauma
patients with sonographic testicular abnormality, if
surgical exploration is not immediate, their progress
should be followed to demonstrate sonographic reso-
lution of the lesion, because 10% to 15% of testicular
tumors first present after an episode of scrotal trauma
[6]. Complications of testicular trauma include testic-
ular atrophy, infection, infarction, and infertility.
Miscellaneous conditions
Inguinal hernia Fig. 18. Surgically confirmed case of inguinal hernia. Gray
scale US of the testis (T) shows the presence of air (arrow-
A hernia may present acutely as a nonpainful head) in a loop of bowel away from the skin surface with
mass or as a painful swelling with incarcerated bowel. reverberation artifact (arrow). (Compare with Fig. 5A.)
Sonographic appearance depends on the hernial infarction, hemorrhage, infection, or non – germ-cell
sac contents. Most commonly it contains bowel; the tumor [79]. The presence of epididymal involvement
next most common content is omentum. Other rare strongly suggests a nonneoplastic process.
contents include Meckel’s diverticulum and urinary All patients with a heterogeneous echo pattern of
bladder. Gray scale findings are a fluid- or air-filled testis should be followed to demonstrate their sono-
loop of bowel in the scrotum (Fig. 18). Finding real- graphic resolution so that tumors with epididymo-
time peristalsis indicates the presence of bowel. Oc- orchitis presentation are not missed.
casionally, because contraction of the dartos also can
mimic peristalsis on real-time sonography; the exam-
iner should be aware of this possibility to avoid Summary
misdiagnosis [1]. If the omentum has herniated, areas
of high echogenicity are present, which correspond to The ability of US to diagnose the pathogenesis of
omental fat. the acute scrotum is unsurpassed by any other imaging
Bowel strangulation is more common with indi- modality. It is the first imaging performed in patients
rect than direct inguinal hernia. An akinetic dilated with acute scrotum. Knowledge of the normal and
loop of bowel observed sonographically in the hernial pathologic sonographic appearance of the scrotum and
sac is reported to have high sensitivity (90%) and proper sonographic technique is essential for accurate
specificity (93%) rates for the recognition of bowel diagnosis of acute scrotum. High-frequency trans-
strangulation [76]. Hyperemia of the scrotal soft tis- ducer sonography combined with color flow Doppler
sue and bowel wall suggests strangulation [17]. sonography provides the information essential to
Patients with Richter’s hernia, a strangulated hernia reach a specific diagnosis in patients with testicular
in which only a portion of the circumference of the torsion, epididymo-orchitis, and testicular trauma.
bowel is obstructed [77], usually present with gastro-
enteritis. Such cases can present a diagnostic chal-
lenge because of the hernia’s small size and the Acknowledgments
eccentric bowel wall involvement with limited lumi-
nal compromise. This hernia commonly occurs at a The authors would like to acknowledge Bonnie
femoral site. It is important to recognize this condi- Hami, MA, for her assistance in the preparation of the
tion because preoperative delays in diagnosis and manuscript and Joseph Molter for his assistance in
high postoperative morbidity are common compared preparation of photographs.
with other types of strangulated hernias [78].
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Radiol Clin N Am 42 (2004) 365 – 381
Ultrasound evaluation of abdominal aortic and iliac

aneurysms and mesenteric ischemia
Kathryn Hermsen, MD*, Wui K. Chong, MB, FRCR
Department of Radiology, CB #7510, University of North Carolina, 101 Manning Drive, Chapel Hill, NC 27599, USA
Ultrasound (US) has been used routinely since of an endothelial lining, a connective tissue layer, and
the mid 1980s to evaluate the abdominal aorta. Color an internal elastic membrane. The endothelium con-
Doppler imaging allows characterization of flow pat- sists of squamous cells oriented parallel to the direc-
terns [1]. It is the preferred method for diagnosis and tion of blood flow and connected by tight junctions.
surveillance of abdominal aortic aneurysms (AAAs) The tunica media is composed of smooth muscle
because of its accuracy, ease of use, and cost effec- and connective tissue. The tunica adventitia of the
tiveness [1,2]. US has been used to characterize aor- aorta is thin and consists of connective tissue fibers,
tic diseases, such as mycotic aneurysm, posttraumatic fibroblasts, and macrophages. It also contains the in-
pseudoaneurysm, dissection, and detection of mural nervation of the aorta and its blood supply (vasa va-
thrombus and AAA rupture [3,4]. Other applications sorum) [7].
of sonography include characterization of iliac arterial The aorta bifurcates to form the common iliac ar-
disease and postoperative evaluation of endovascular teries near the level of the umbilicus (approximately
AAA repair. US plays a role in noninvasive diagnosis L4). The common iliac arteries proceed anterolaterally
of mesenteric vascular occlusive disease in patients in association with the common iliac veins and bifur-
with suspected chronic intestinal ischemia. cate into the internal and external iliac arteries [5].
Major branches of the abdominal aorta routinely
visualized by US include the celiac axis, superior
Anatomy and histology mesenteric artery (SMA), and renal arteries. The ce-
liac axis is the first major division of the abdominal
The aorta enters the abdomen at the aortic hiatus aorta. It generally gives rise to the left gastric, hepatic,
at the T12 level. It descends anterior to the lumbar and splenic arteries, although anatomic variants are
vertebrae immediately left of midline and tapers dis- frequent [3]. The left gastric artery is seldom visual-
tally [5]. The normal luminal diameter of the in- ized by US [8]. The SMA arises anterior to the L1
frarenal abdominal aorta varies according to age and vertebra and posterior to the body of the pancreas [9].
gender. In young patients without vascular disease, it It travels with the superior mesenteric vein anterior to
measures 2.3 cm in men and 1.9 cm in women [6]. the duodenum and inferiorly to divide within the
It increases in size with age. In one study, average mesentery 5 to 6 cm from its origin. The normal
luminal diameter in men without aneurysm with a inferior mesenteric artery is infrequently visualized by
mean age 70.4 years was 2.8 cm [2]. US. In disease states it may hypertrophy and become
The aorta is an elastic artery composed of three visible [8]. The renal arteries arise from the lateral
layers: the tunica intima, tunica media, and tunica ad- wall of the aorta within 1.5 cm of the SMA [3].
ventitia. The aortic intima is thick and is composed Supernumerary renal arteries are frequent [3].
Branches of the aorta and the iliac arteries are
classified as muscular arteries. When compared with
* Corresponding author. the elastic arteries, such as the aorta, their intima
E-mail address: khermsen@unch.unc.edu (K. Hermsen). are thinner and have less subendothelial connective
doi:10.1016/j.rcl.2003.12.003
366 K. Hermsen, W.K. Chong / Radiol Clin N Am 42 (2004) 365–381
tissue. Likewise, the tunica media contains less elas- SMA, PSV, end diastolic velocity (EDV), and mean
tic material. The tunica adventitia is thicker and has velocity increased with all except water. The great-
greater collagen content [7]. est changes were demonstrated in end diastolic flow
[10]. The neurohumoral mechanisms behind this
response are incompletely understood. Hormones re-
Flow characteristics leased in the presence of fat, carbohydrates, and pro-
teins, including cholecystekinin, vasoactive intestinal
As characterized by color Doppler, the aorta is peptide, gastrin, secretin, and kinins, are released into
a high-resistance vessel. Velocity climbs rapidly in the bowel wall and act as vasodilators. Decreased
early systole and falls rapidly in early diastole [3]. oxygen concentration that results from increased con-
The proximal aorta demonstrates biphasic waveforms sumption associated with active transport of nutrients
with reversal of flow in early diastole. The distal aorta may act as a vasodilatory stimulus [11]. Postpran-
demonstrates triphasic waveforms (small component dial changes in vascular resistance are considerably
of forward flow in late diastole). Normal blood flow less pronounced in the celiac axis (CA), which indi-
is laminar (Fig. 1) [1]. cates that this is a low-resistance circuit regardless of
The celiac axis demonstrates high-resistance flow feeding [8]. In the study by Moneta et al, minimal
at its origin with rapid systolic upstroke and rapid de- changes were observed in the CA with feeding [10].
cline (Fig. 2). Hepatic and splenic arteries are low-
resistance vessels with substantial forward flow
throughout diastole [3]. Imaging techniques
The SMA is a high-resistance vessel in the fasting
state. In the fasting patient, flow is triphasic, with The primary limitations in imaging the abdominal
rapid systolic upstroke and reversal of flow in early aorta are patient body habitus and the presence of
diastole. In the postprandial state, spectral Doppler bowel gas. Thinner patients are more easily imaged.
waveform of the SMA changes to a low-resistance, No bowel preparations have proved effective in lim-
high-flow pattern secondary to decrease in splanchnic iting the effect of interposed bowel gas. In imaging of
vascular resistance. Peak systolic velocity (PSV) the abdominal aorta, patients are usually scanned after
increases and forward flow is seen throughout dias- an 8- to 10-hour fast. The presence of barium within
tole (Fig. 3) [8]. Moneta et al [10] described the the bowel attenuates US transmission, and imaging
effects of meal content on mesenteric vascular resist- should be postponed after gastrointestinal procedures.
ance. Test subjects were imaged after ingesting vary- The patient is initially scanned in the supine position
ing amounts of fat, proteins, and carbohydrates. using linear 4-, 3.5-, or 2.5-MHz transducers; curved
Control meals consisted of water or mannitol. In the 5- or 3.5-MHz transducers are also used, depending
Fig. 1. (A) Normal aorta with normal triphasic waveform. Note rapid systolic peak followed by rapid decline and brief reversal of
flow characteristic of a high resistance vessel. (B) Normal aortic transverse diameter measurement.
K. Hermsen, W.K. Chong / Radiol Clin N Am 42 (2004) 365–381 367
Fig. 4. (A, B) Importance of obtaining measurement per-

pendicular to plane of vessel. Oblique measurements may
overestimate lumen diameter.
Fig. 2. Normal celiac axis origin and bifurcation. The left

gastric artery is seldom seen.
may overestimate the lumen diameter (Fig. 4) [12].
The anteroposterior and transverse diameters are mea-
on patient body habitus [1]. The aorta is imaged in sured from outer wall to outer wall. The common iliac
sagittal and transverse planes at its proximal, mid, and arteries are imaged at the level of the bifurcation in
distal portions. In the presence of a tortuous aorta, it is anteroposterior and transverse diameter. In the upper
important to obtain measurements perpendicular to abdomen, a good acoustic window is often found in
the long axis of the vessel. Oblique measurements the midline between the rectus abdominus muscles.
The lateral aspect of the rectus muscles also may
provide a good window, especially for visualizing
the iliac vessels [3]. A left lateral decubitus or oblique
approach is often helpful in patients with excessive
bowel gas and for visualizing the mid and lower ab-
dominal aorta. Use of slow graded compression with
the transducer may displace bowel loops. Color
Doppler may aid in identifying the aorta [1]. Flow
characteristics (laminar versus turbulent) and mea-
surements, including PSV and EDV, are documented.
Flow within the renal arteries is demonstrated, and
each kidney is observed in long axis.
The aorta is visualized similarly after endovascu-
lar stenting using 2.5- and 3.75-MHz curved trans-
ducers. Duplex and color flow Doppler analysis is
obtained at the level superior to the stent, at its
proximal attachment, including right and left iliac
attachments. Flow within the SMA and renal arteries
is documented. The maximum transverse diameters
of the graft lumen and aneurysm sac are measured in
the anteroposterior and transverse planes. The clot
within the aneurysm sac is observed with color
Doppler in the transverse and longitudinal planes to
evaluate for leak around the stent or flow within the
sac. Detectable flow is considered an indication of
leak [13]. Another indicator of graft compromise is
enlargement of the aneurysm sac or failure of the
aneurysm sac to regress. Multiple types of endoleaks
have been described. In 1997, White first described
Fig. 3. (A) Fasting SMA. Note rapid systolic upstroke and endoleaks (Box 1) [14,15].
low diastolic flow. (B) Postprandial SMA. Note increased Cursory evaluation of the mesenteric arterial vas-
diastolic forward flow. culature is undertaken in routine imaging of the
Doppler angle of 60° or less while obtaining velocity

Box 1. White classification of
measurements [8,18 – 20].
endoleaks[15]
Type I: Direct communication between

Abdominal aortic pathology
the graft and aneurysm sac via an
ineffective seal at the graft ends or
Aneurysm
attachment sites.
Type II: Retrograde flow through lum-
An aneurysm is an abnormal expansion of a vessel.
bar arterials, the inferior mesenteric
Aneurysms are classified as false or true. True aneu-
artery (IMA), or accessory renal ar-
rysms include all three layers of the vessel wall. Mul-
teries feeds into the aneurysm sac.
tiple configurations of true aneurysms are described.
Type III: Seen in modular, multisegmen-
Most AAAs are true aneurysms and are fusiform; 97%
tal grafts. Leak occurs through defi-
are infrarenal. Only 2% to 7% extend to the juxtarenal
ciency in graft fabric and may be a
or suprarenal aorta [21]. Aneurysms that occur proxi-
result of altered hemodynamics sec-
mal to the renal arteries are more likely to be mycotic
ondary to aneurysm sac shrinkage.
or posttraumatic. AAA is a common condition, with
Type IV: On contrast, CT appears as a
a prevalence of 1% to 4% in people aged 50 or older
blush of contrast outside the graft
[1]. Most of these aneurysms are idiopathic. The
from contrast diffusion through the
strongest association with AAA is atherosclerotic
naturally porous graft fabric or
disease. Other risk factors for development of AAAs
through small defects in the fabric
include male gender, smoking, chronic obstructive
at the site of sutures or struts. May
pulmonary disease, age, and family history. Most pa-
require angiography to distinguish
tients with AAA are asymptomatic. Some patients
from Type III graft.
may present with abdominal or lower extremity pain
[3]. The most common physical examination finding
is a pulsatile abdominal mass. The physical examina-
tion, however, has poor predictive value in the detec-
tion of AAA [22].
abdominal aorta. More detailed examination to assess Sonography is the primary imaging study for
for mesenteric occlusive disease faces several techni- detection of aortic aneurysms. The accuracy of US
cal challenges. Bowel gas, respiratory motion, and in the diagnosis of AAA approaches 100% [3,27]. The
vessel depth confound identification of the mesen- typical US appearance of AAA is of a dilated vessel
teric vessels [8]. Various methods have been used to with an irregular lumen. Ulceration or cystic changes
reduce interference by gas, including cathartic bowel may be seen as focal hypoechoic regions within
preparation the night before, oral simethicone 15 min- the vessel wall [3]. Echogenic mural thrombus is
utes before examination, liquid diet the evening be- present in most large lesions and may be circumfer-
fore followed by 8- to 12-hour fast, and fasting alone ential or eccentric (Figs. 5, 6). Juxtarenal AAAs may
[16,17]. appear to involve the renal arteries at US because
The CA is scanned from its origin to its bifurca- of apparent overlap of the aneurysm wall with the
tion. The SMA is examined from its origin and renal ostia. Careful evaluation of the course of the
followed 5 to 6 cm distally. In the fasting state, the renal arteries and aorta in multiple planes may clarify
normal SMA waveform is triphasic. Should a biphasic the relationship of the aneurysm to the renal arteries.
waveform be observed, the sonographer searches for a Multidetector CT with coronal reconstruction or aor-
replaced hepatic artery. This anatomic variant occurs tography is usually required to evaluate renal artery
in approximately 20% of the population. It arises from involvement in juxtarenal aneurysms, however [1].
the lateral SMA and travels cephalad and right to Flow within AAAs may be laminar or turbulent.
supply the liver. The presence of a replaced hepatic Turbulent flow is associated with formation of mural
artery results in biphasic SMA flow [16,17]. The thrombus (Fig. 7). It has been proposed that thrombus
position of the CA and SMA in the upper abdomen imparts tensile strength to the aneurysm wall by
often requires high Doppler angles of insonation. absorbing forces generated by flow. Mower used
Unfortunately, this introduces error in determining computer-generated models of AAA that ranged in
flow velocities, which usually results in falsely ele- size from 2 to 4 cm to study the effects of thrombus
vated values [8]. Care must be taken to maintain a size and composition on wall stress [23]. In this
Fig. 7. Turbulent flow within AAA. Note the hypoechoic

thrombus (arrow).
study, the larger the mural thrombus, the greater the re-
duction in wall stress. Organized mural thrombi im-
parted greater tensile strength than more pliant ones.
The authors speculated that the tendency of eccen-
Fig. 5. (A) Transverse view of AAA with mural thrombus
(arrow). (B) Color Doppler demonstrates turbulent flow tric mural thrombi to collect along the ventral wall
within lumen outlining thrombus. may explain the rarity of ventral rupture [23]. The
presence of mural thrombus also may help to restore
laminar flow.
The most catastrophic complication of abdominal
aortic aneurysm is rupture. Rupture carries a high
mortality rate. Fifty percent of patients do not reach
the hospital alive. The overall mortality rate is 80% to
94% [1]. Signs and symptoms associated with rupture
include severe abdominal and back pain, nausea and
vomiting, and hypotension [1]. Aneurysm size and
rate of enlargement are the most important factors in
predicting potential rupture. In a 15-year study,
Brown et al [24] followed 476 patients with AAA
larger than 5 cm who were deemed unfit surgical
candidates. The risk of rupture in male patients with
AAA of 5 to 5.9 cm was 1% per year; in male patients
with AAA 6 cm or larger, the risk was 14.1%. Gender
differences also were noted in this study. Women with
aneurysms of similar size were at fourfold higher risk
for rupture [24]. Aneurysms are generally expected to
enlarge 2 to 4 mm per year. Aneurysms that enlarge by
5.5 to 6 mm per year are regarded as high risk for
rupture [12]. Sharp et al [25] identified 32 patients
with aneurysms less than 5.5 cm per year that had
enlarged 5 mm or more in the past 6 months. Over a
period of 50 patient years, none ruptured. Thus,
Fig. 6. Pitfalls in measuring AAA. (A) This echogenic line
(solid arrow) is easily mistaken for the aortic wall. It ac-
the risk of rupture was calculated to be 0 to 6 per
tually represents the surface of the thrombus that lines the 100 patient years [25]. CT is the imaging modality of
wall of a large AAA. Open arrow demarcates the true aortic choice in the setting of rupture because it is not subject
wall. (B) On the transverse view, the large mural thrombus is to technical factors, such as interposed bowel gas, and
better seen. (Open arrows mark the true vessel wall.) grants a greater perspective on the extent of bleeding
[3]. The US appearance of rupture is that of a large, Wanhainen et al [2] evaluated differences in observer
usually hypoechoic retroperitoneal fluid collection. measurements between CT and US in 475 patients.
Other complications of AAA include embolization Thirty-three were found to have AAAs (defined as
of mural thrombus, occlusion of the renal and splanch- diameter larger than 3 cm). In patients with normal
nic arteries, obstructive uropathy (usually on the left), aortas (<3 cm), US overestimated the diameter by
and arteriovenous fistula (usually with the inferior 2.8 mm in anteroposterior diameter and 3.8 in trans-
vena cava [IVC], or left renal vein) (Fig. 8) [2,3]. A verse diameter. The difference in aneurysmal aortas
less common complication is duodenal obstruction, was greater, with a variability of 8 mm or less in
which results from compression of the duodenum anteroposterior and 10.6 mm in transverse measure-
(SMA syndrome) between an enlarging AAA and ments. The authors found the variability in transverse
the SMA [26]. measurements to be unacceptably high and preferred
US is ideal for monitoring AAAs because it is using anteroposterior diameters in assessing aneurysm
inexpensive, does not require the use of contrast size [2]. There is no true ‘‘gold standard’’ modality in
material or radiation, and is highly accurate. CT is the measurement of AAA. Lanne et al [12] reported
often used in AAA evaluation, but it faces some greater reliability for US using an automated echo
technical limitations. Because the aneurysmal aorta is tracking device for measurement of the aortic lumen.
frequently ectatic, slices obtained in the axial plane Frequent indications for aortic US are the finding
only may be obtained with a degree of obliquity, of a pulsatile abdominal mass on physical exami-
which potentially overestimates the size of the aneu- nation and evaluation of an AAA incidentally dis-
rysm. Because changes in measurements of only a covered on a CT performed for another purpose.
few millimeters may influence management greatly, Unfortunately, however, many AAAs are not discov-
potential effects of measurement variability be- ered until rupture. Given the dismal prognosis of
tween CT and US are an important consideration. rupture and the relatively low mortality rate for repair
(2% – 5%), is screening for AAA in high-risk patients
a viable option? Lee et al [27] examined the cost
effectiveness of conducting a ‘‘quick screen’’ (ie, ab-
breviated US) evaluation of the abdominal aorta in at-
risk populations. The examination was limited to less
than 5 minutes and was performed at reduced cost.
The sensitivities and specificities for the quick screen
and standard duplex US were 100%. The emphasis
was on screening patients with known risk factors,
such as male gender, smoking, hypertension, hyper-
lipidemia, other peripheral vascular disease, and coro-
nary artery disease. They found screening in at-risk
populations to be cost effective and recommend
screening in men over age 60 [27].
Although most AAAs are idiopathic, certain con-
nective tissue disorders carry an increased risk of
AAA. Ehler-Danlos syndrome is a group of disorders
associated with abnormal collagen synthesis. Type IV
Ehler-Danlos syndrome is associated with vascular
abnormalities, including aneurysms of the elastic ar-
teries and their major branches. Catastrophic com-
plications have been reported with angiography in
patients with Type IV Ehlers-Danlos syndrome, and it
is generally avoided [28].
Pseudo or false aneurysms are generally the result
of a defect in the intima through which blood flows.
Blood escapes through a defect in the arterial wall
Fig. 8. Left ureteral obstruction by AAA. (A) Distal AAA. and is contained by the surrounding soft tissue. Blood
Lumen diameter is normal proximally and expands distally. flows into the aneurysm during systole and out during
(B) Mild left hydronephrosis secondary to compression diastole, which produces a characteristic appearance
by AAA. on color Doppler imaging that has been likened to the
changes [30]. They most frequently occur in the iliacs,

followed by the aorta. On sonography, the aneurysm
wall is thickened with surrounding hypoechoic fi-
brotic tissue. US and CT have proved the most useful
modalities in diagnosing inflammatory aneurysms
[31]. Inflammatory AAAs may be seen in the setting
of retroperitoneal fibrosis. In this setting, the fibrotic
tissue may extend laterally into the retroperitoneum,
and the ureters may become obstructed [32]. Inflam-
matory aneurysms carry a higher rate of morbidity and
mortality than idiopathic AAAs and are more likely to
present with pain in the absence of rupture [30].
Erythrocyte sedimentation rate is usually elevated.
Pennell et al [33] described a triad of chronic abdom-
inal pain, weight loss, and elevated erythrocyte sedi-
mentation rate in a patient with AAA as highly
suggesting inflammatory AAA.
Dissection
Aortic dissection occurs when a defect in the

aortic wall allows the entry of blood, which separates
Fig. 9. Classic color Doppler ‘‘Yin-Yang’’ appearance of the intima from the media [34]. Two lumens are
pseudoaneurysm. Blood enters the false aneurysm (red), created: a false lumen, which consists of blood within
strikes the back wall, and reverses direction (blue). the vessel wall, and the true vessel lumen. Although
the vessel does enlarge, dilatation is considerably less
pronounced than with true aneurysms. Most often,
Yin-Yang sign (Fig. 9). False aneurysms caused dissection occurs along a segment of varying length
by penetrating trauma show ‘‘to and fro’’ flow in the and ends with re-entry of the blood column into the
neck, with blood leaving the artery during systole and true lumen via a second intimal defect. This serves to
re-entering during diastole. Aortic pseudoaneurysms decompress the hematoma and delay rupture [35].
are most frequently posttraumatic or mycotic [3,28]. Isolated abdominal aortic dissection is exceedingly
Mycotic aneurysms refer to aneurysms of any type rare in the absence of blunt abdominal trauma [36].
that have become infected. They are more frequent in Most aortic dissections originate in the thoracic aorta,
patients younger than 50 years, unlike idiopathic usually the ascending aorta. Several classifications
AAAs, which are more frequent in patients over age exist; the most commonly used are the DeBakey and
60. Two broad categories of mycotic aneurysms have Stanford classifications. Two thirds of dissections
been described: those that form secondary to aortic involve the ascending aorta, usually within a few
wall factors (atherosclerosis or stents) and those that centimeters of the aortic valve. In DeBakey types 1
are seeded from a distant source. The second group is and 3, the dissection plane may extend into the
divided according to source of infection: intravascular abdominal aorta [37].
(frequently in the form a septic emboli) and extravas- The pathogenesis behind dissection remains con-
cular (usually formed by contiguous spread from a troversial. Dissection in the absence of a clear intimal
nearby infected site). The most frequent causative tear has been documented, which suggests that dis-
organisms are staphylococci and salmonella. An im- section occurs through a defect in the media created
portant feature of mycotic aneurysms is their tendency by intramural hemorrhage. The importance of abnor-
to enlarge rapidly and their propensity for rupture malities of the media has been a topic of interest in
[4,29]. Few specific US findings are reported. Naga- the pathogenesis of dissection. Increased incidence of
numa et al [4] described the presence of gas echoes in dissection in patients with Turner’s, Ehlers-Danlos, or
the wall of a mycotic aneurysm with sonography. Marfan syndrome, all of which have underlying ab-
Inflammatory aneurysms are a relatively uncom- normalities of the media, suggests that a primary
mon type of true aneurysm that constitutes approxi- defect of the media underlies dissection. To date, no
mately 4% of AAA. They are characterized by fibrotic specific histologic abnormalities have been demon-
thickening of the adventitia and chronic inflammatory strated [38]. Sonesson et al [39] used US to show that
patients with Marfan syndrome had abnormal com- pitfall in the use of US for characterization of dis-
pliance of the aorta. Most dissections occur in pa- section. Nguyen [41] described a case of ‘‘pseudo-
tients without connective tissue disorders, however. dissection’’ in which an intimal flap with flow on
In these cases, by far the strongest association with either side was described with sonography. This was
dissection is the presence of hypertension [37]. shown on CT to be an AAA with mural thrombus.
CT and MR imaging are the imaging modalities of The perception of flow within the ‘‘false lumen’’ was
choice in dissection that involves the abdominal attributed to mirror image artifact caused by a calci-
aorta. Dissection may be an incidental finding in fied thrombus surface layer or incorrect color flow
US evaluation of the aorta, however. The intimal flap assignment in the anechoic portion of the throm-
created between the true and false lumen is best bus [41].
visualized with US in the transverse plane [38]. The US is not the primary imaging modality for aortic
flap moves with arterial pulsation if flow through the dissection because most dissections involve the tho-
false lumen is preserved. (This may not be seen if racic aorta.
the flap is thickened.) Doppler waveforms in both lu-
mens may appear bizarre, with spectral broadening
and reversed flow. Velocity tends to be slower in the Ultrasound and aortic endografting
false lumen (Fig. 10).
A true AAA with organizing thrombus may look In the early 1990s, Parodi [42] first reported the
like a dissection on sonography. The outer layer of endoluminal repair of abdominal aortic aneurysm.
thrombus can appear echogenic and be mistaken for Given the relatively high operative morbidity and
an intimal flap, whereas deeper thrombus appears mortality rates associated with open repair (3% –
anechoic and can mimic the false lumen [40]. Color 10% mortality and 15% – 40% perioperative morbid-
Doppler increases the specificity of US in evaluating ity) [43], AAA repair using stent grafts offers a less
dissection. Flow in the false lumen may be too slow invasive alternative to open repair, with reduced
for detection with Doppler. Thrombosis within the morbidity and mortality rates. The most frequent com-
false lumen frequently occurs and is a significant plication of endografting is the development of leak-
Fig. 10. (A, B) Abdominal aortic dissection with intimal flap (arrow). (C) Turbulent flow within dissection.
age into the aneurysm sac excluded by the graft. This and CT demonstrated some discrepancy in measure-
may occur via direct communication with the graft ments. If a preoperative US is available as a baseline,
lumen at its attachment site or back flow from however, US can be effective in monitoring aneurysm
collateral arteries communicating with the aneurysm size [13]. Some authors suggest using both CT and US
sac. Leaks are frequent, with cited incidences as high when following endografts [13,45].
as 40% [13]. Lifelong monitoring is required. Al- In a recent study, Greenfield et al [46] found that
though the gold standard for postoperative monitor- US was more accurate than CT for characterizing
ing is CT, US has been used with varying success. It endoleaks. In a study of seven endoleaks classified as
offers several potential advantages, including avoid- type II by CT, US demonstrated two of these to be
ance of potentially nephrotoxic contrast agents and type I leaks. Type I leaks generally require immediate
radiation exposure [3,44,45]. Initial studies that repair, whereas type II are often managed conserva-
compared CT and US demonstrated promising results tively because they tend to resolve without treatment.
for US. In 1998, Kronzon et al [43] studied 17 pa- These findings dramatically altered care. US findings
tients after stent repair of AAA with color Doppler in proximal limb type I leaks were high velocity flow
imaging (CDI) and CT. US was successful in dem- at the site of the proximal attachment. Distal limb
onstrating flow within the excluded aneurysm lumen attachment site leaks demonstrated flow in the sac
using color Doppler and in measuring aneurysm size opposite the direction of that in the lumen. IMA flow
(Figs. 11, 12). was antegrade in type I leaks. Type II leaks were
Sato et al [44] reported a sensitivity rate of 97%, characterized by slower flow within the aneurysm sac
specificity rate of 74%, and accuracy rate of 82% for and retrograde flow in the IMA. These finding sug-
US in detecting endoleak. With the advent of im- gest an adjunct role for US in characterizing endo-
proved helical scanning techniques, including thinner leaks detected by CT [46].
collimation and delayed imaging, Golzarian et al [45]
demonstrated improved reliability of CT compared
with US. US detected clinically significant leaks Mesenteric vascular ultrasound
within the stent graft and iliac limbs; however, it
frequently missed small perigraft leaks. Using CT as Chronic intestinal ischemia
the standard for evaluating US performance, US
detected endoleak with a sensitivity rate of 77% and Chronic intestinal ischemia (CII) is caused by
specificity rate of 90% [45]. After this, Pages et al [13] inadequate blood supply to meet the metabolic de-
demonstrated a poorer sensitivity and specificity in mands of the enteric tract after feeding. In the post-
endoleak detection of 48% and 93%, respectively. prandial state, intestinal motility increases, as does
Although CDI did detect some endoleaks not detected oxygen demand from active transport of nutrients.
on CT, the use of delayed postcontrast CT imaging Clinically, this presents as postprandial pain.
could detect these leaks. CDI performed better in The clinical diagnosis is one of exclusion. It is a
monitoring aneurysm size, with a sensitivity rate of relatively rare entity with no pathognomonic find-
88% and specificity rate of 76% in demonstrating no ings. CII occurs most commonly in elderly women
change in AAA size. As with unrepaired AAA, US (75%) [8,20]. Patients typically present with colicky
Fig. 11. (A) Longitudinal image of AAA shows stent (arrow) and wall of aneurysm (thick arrow). (B) Application of color
Doppler demonstrates flow within the graft lumen and hypoechoic clot (arrow) in the excluded aneurysm sac.
Fig. 12. Type 2 endoleak. (A, B) Color Doppler demonstrates flow outside the graft lumen (arrow). (C) CT correlate: blush of
contrast outside the limbs of the stent (arrow).
postprandial epigastric pain, occasionally with radia- epithelial flattening has been shown in biopsy series.
tion to the back. Symptoms begin 15 to 30 minutes These findings are unreliable and nonspecific, how-
after eating and persist 1 to 3 hours. Patients associate ever [8,16,20,47].
feeding with pain and frequently develop ‘‘food Atherosclerotic narrowing at the origin of the mes-
phobia,’’ with anorexia and marked weight loss. enteric vessels is the most common factor that pre-
Changes in bowel habits are also frequent [16]. The disposes to CII. Other processes, such as vasculitis,
abdominal examination is usually nonspecific, with extrinsic or intrinsic compression, and drug reactions,
no localizing or peritoneal signs. An abdominal bruit also may produce symptoms (Box 2). Although CII
is often present, but this finding is too nonspecific to is relatively rare, atherosclerotic narrowing of the
make the diagnosis of CII to make the diagnosis of mesenteric vasculature is common. In one autopsy
CII. Laboratory data are neither sensitive nor specific. series, 6% to 10% of patients had stenosis of 50% or
Malabsorption of various nutrients has been de- more. High-grade CA stenosis is also frequently well
scribed in the setting of CII. Villous atrophy and tolerated. In high-grade CA stenosis or occlusion, the
its invasiveness, cost, and potential complications in

Box 2. Associations with chronic
elderly patients. Noninvasive screening tests in
intestinal ischemia
symptomatic patients are needed to evaluate the mes-
enteric vasculature.
Atherosclerotic disease
The successful application of Doppler sonography
Inflammatory vasculitis
for diagnosis of mesenteric ischemia was first de-
scribed by Jager in 1984 [47]. High PSVs were found
Radiation
at the origins of the SMA and celiac arteries. PSV in
Polyarteritis nodosa (PAN)
the SMA was more than 300 cm/second. Spectral
broadening and monophasic waveforms with loss of
Connective tissue disease
reversed diastolic flow also were noted [47].
In a subsequent validation study, Moneta [19]
1. Berger’s
sought to establish specific US criteria for high-grade
2. Systemic lupus erythematosus
SMA and CA stenosis. One hundred patients under-
(SLE)
went mesenteric duplex scanning followed by arteri-
3. Rheumatoid arthritis (RA)
ography. In this study, a PSV of 275 cm/second or
more predicted 70% stenosis, with a sensitivity rate of
Extrinsic compression
92% and specificity rate of 96%. In CA stenosis, a
PSVof 200 cm/second or more predicted stenosis with
1. Neurofibromatosis
87% sensitivity rate and 80% specificity rate (Fig. 13).
2. Median arcuate ligament
Although elevations in EDV were observed in stenotic
syndrome
vessels, use of EDV did not improve the sensitivity or
specificity of results. In a different study, Moneta [18]
Drug reactions
found that the ratios of PSV to EDV were not pre-
dictive. These studies addressed one important tech-
Cocaine
nical factor in acquiring PSV data. In patients with
peripheral atherosclerotic disease but no mesenteric
occlusive disease, PSVs were elevated over control
gastro- and pancreaticoduodenal arteries form an subjects. This result suggests that tortuousity of the
important collateral pathway. In SMA stenosis or mesenteric vessels in patients with atherosclerosis
occlusion, flow may be reconstituted via the hepatic may limit the sonographer’s ability to maintain Dopp-
artery and pancreaticoduodenal arteries. In high- ler angles less than 60° [18]. This inability could result
grade stenosis or occlusion of the SMA and CA, in falsely elevated PSVs.
the IMA may form sufficient collaterals via the Bowersox [20] found that EDV and PSV were
middle colic artery and pancreaticoduodenals (the elevated in confirmed SMA stenosis . The study
arch of Riolan) to supply the foregut. IMA stenosis accepted 50% or more stenosis as being significant.
is most frequently asymptomatic [8]. Because the In normal control subjects, SMA flow was triphasic
splanchnic vessels are able to form extensive collat- with a normal PSV of 134 (F 18) cm/second and
eral pathways, significant stenosis or occlusion of EDV of 24 (F 4) cm/second. (except in replaced
two of the three mesenteric vessels is generally hepatic artery, in which flow was biphasic). PSVs
required to produce symptomatic ischemia, although increased with increasing SMA stenosis. PSV of 300
high-grade stenosis of the SMA alone may produce cm/second diagnosed 50% or more stenosis with a
symptoms. Collateralization also makes prediction of sensitivity rate of 63% and specificity rate of 100%.
CII difficult. The presence of two-vessel disease or Unlike Moneta, however, Bowersox [20] found that
complete SMA occlusion does not imply the presence EDV was more sensitive and specific than PSV. An
of CII in the absence of symptoms [8]. EDV of more than 45 cm/second was found to be
The diagnosis of CII frequently is delayed because 100% sensitive and 92% specific in detecting severe
of its tendency to mimic more common disorders, stenosis. Significant CA values could not be estab-
such as symptomatic gallstones, cholecystitis, pancre- lished in this study. One proposed reason is that col-
atic cancer, and peptic ulcer disease. The average time laterals through the gastroduodenal arcade can restore
from onset of symptoms to diagnosis is 18 months CA flow in the presence of severe stenosis [20].
[16]. Traditionally, CII has been diagnosed via an- Two more recent publications favor the use of
giography. There is reluctance to perform angio- EDVs in predicting significant stenosis. Perko et al
grams for nonspecific clinical findings because of [44] evaluated 39 patients with suspected intestinal
Fig. 13. Celiac stenosis. (A) Color Doppler with narrowing at the celiac origin and turbulent flow. (B) Doppler spectrum with
elevated PSV (>300 cm/second) and spectral broadening. (C) Angiogram demonstrates narrowing of the CA (arrow) and SMA.
ischemia using Moneta’s criteria in addition to the ond to predict more than 50% stenosis. As with SMA
following other parameters: EDV, early diastolic ve- disease, evaluation of EDV, EaDV, and PDV pre-
locity (EaDV), and PDV. A control group of hyper- dicted significant CA stenosis with 100% sensitivity
thyroid patients was included in this study. They and specificity. In this study, two false-positive results
found that the Moneta criteria (PSV >275 cm/second) were noted using PSV as a criteria, one in a hyper-
were 90% accurate for stenoses more than 50%. Ac- thyroid patient and the other in a hypertensive patient
curacy improved dramatically, however, when EDV, with extensive atherosclerotic calcification. Elevated
EaDV, and PDV were considered. EDV of more than PSVs occurred in the thyrotoxic group, likely related
50cm/second, EaDV of more than 50cm/second, and to increased stroke volume. EDV and EaDV were un-
PDV of more than 70 cm/second predicted signifi- affected. High output states may elevate PSV artifi-
cant stenosis with a sensitivity and specificity rate of cially [48].
100%. PSV in the CA also was examined according Zwolack et al [17] found similar results to the
to Moneta’s criteria. An accuracy rate of 94% was Perko study. In a retrospective study of 243 patients
demonstrated using a PSV of more than 200 cm/sec- with suspected mesenteric ischemia, an EDV of more
than 45 cm/second predicted more than 50% stenosis criteria of PSV 275 cm/second to predict lesions of
with an accuracy rate of 91% (sensitivity 90%, speci- 50% or more [17].
ficity 91%). Their results for using PSV to predict In conclusion, duplex US scanning of the mesen-
SMA stenosis were similar to the Bowersox study, teric vasculature has been demonstrated to be an
with a low sensitivity rate (60%) but high specificity effective screening test in patients with suspected
rate (100%) for PSVs of more than 300 cm/second. CII. An adequate examination of the splanchnic ves-
Similar to the Perko study, a PSVof more than 200 cm/ sels can be achieved in only 60% of the general
second and an EDV of more than 55 cm/sec predicted population. The remaining 40% are limited by body
CA stenosis with good accuracy, although EDV habitus and interposed bowel gas. Patients with CII
demonstrated the greatest accuracy (95% for EDV tend to be thinner than the general population and
versus 93% for PSV). This study also demonstrated are easier to scan. Although controversy still exists in
high-grade CA stenosis or occlusion in 100% of the literature as to the sensitivity and specificity of
patients with reversed hepatic flow. Because the CA using PSV to predict SMA stenosis, PSV is a reliable
is frequently difficult to visualize, this finding may be parameter for diagnosing CA stenosis. Reversal of
particularly helpful in inferring CA stenosis [17]. hepatic flow also has been shown to predict CA oc-
Several factors may account for disagreement clusion [17,19]. EDV reliably predicted significant
regarding the accuracy in PSV in SMA stenosis. SMA and CA stenosis in several studies. In clinical
Zwolack et al [17] described several potential explan- practice, the US finding of normal vasculature or
ations for the discrepancies in results. First, in the subcritical stenoses in patients with abdominal pain
Moneta study [18], 88% of subjects were men. In the and weight loss can exclude CII. Most patients
Zwolack study, 70% percent were women. Gender with positive duplex US proceed to CT or conven-
differences in flow characteristics in the mesenteric tional angiography. Mesenteric US may be a valuable
vasculature may be present, although to date these screening tool.
have not been explored fully. Second, aliasing is more
frequent at PSVs more than 200 cm/second and vary
according to the type of equipment used. This occur-
Splanchnic artery aneurysms
rence may account for the low sensitivity encountered
using the Moneta criteria for SMA stenosis of 300 cm/
Historically, splenic artery aneurysms have been
second, whereas PSVs of 200 cm/second predicted
the most common visceral artery aneurysms. In recent
CA stenosis in both studies [17]. Another potential
years, hepatic artery aneurysms have surpassed splen-
pitfall in the use of PSV, as described by Moneta et al
ic aneurysms in incidence with increasing use of
[19], is the difficulty encountered in acquiring veloc-
percutaneous biliary procedures [49]. Posttraumatic
ities at the level of stenosis. Stenoses usually arise at
pseudoaneurysms in the splanchnic vasculature, most
the origin of the vessel. Distal to this, the PSV is
commonly the hepatic artery, have been reported after
expected to fall. The reduced sensitivity in PSV
trauma in children (Fig. 14). Blunt trauma is most
described in some studies may be the result of
frequently implicated, although it has been described
sampling of the SMA distal to the stenosis.
in penetrating trauma. Embolization is the treatment
The studies described have used different percent
of choice, although spontaneous thrombosis has been
stenoses as significant values. The Moneta criteria
reported [50,51]. Splenic artery aneurysms are asso-
use 70% as a critical value, whereas the remaining
ciated with acute pancreatitis. They occur in 10% of
studies use 50%. Using different percentages to
elderly patients [52]. In women of childbearing age,
define significant stenoses did not significantly alter
more than half of ruptured splenic artery aneurysms
the findings between the studies. In the study by
are related to pregnancy, and survival is uncommon
Zwolack et al [17], the diagnosis of CII was sus-
[53]. Hepatic and splenic artery aneurysms appear as
pected in all patients. Approximately half were found
cystic structures in communication with the parent
to have occlusive disease; symptoms in the remaining
artery, which demonstrates arterial flow within the
patients were attributed to other causes. In the CII
cystic portion on color Doppler (Fig. 15).
group, most had stenoses of 70% or more at arteri-
ography. In the group without CII, most had stenosis
less than 50%. This finding created a bimodal distri-
bution of vascular lesions. Only 12% of patients fell Iliac artery aneurysm
between these two groups. This result suggests that
either value is acceptable and may explain the accu- Seventy-five percent of iliac artery aneurysms
racy the Perko group demonstrated using the Moneta (IAAs) occur in association with AAA either as a
Fig. 14. Traumatic hepatic artery aneurysm. (A) Cystic central area surrounded by thrombus (arrow). (B) Color Doppler
shows turbulent flow within cystic portion of aneurysm.
direct extension of AAA or coincident with AAA fusiform, saccular, or bilobed. Atherosclerotic disease
[54,55]. The common iliac artery is the most com- is the most common predisposing factor [54,55].
monly involved (99%), followed by the internal then Pseudoaneurysms are less frequent and may be asso-
external iliac [54]. According to standards created by ciated with trauma (accidental or iatrogenic), preg-
the Subcommittee on Reporting Standards for Arterial nancy, infection, or collagen vascular disease (Fig. 16)
Aneurysms, Ad Hoc Committee on Reporting Stan- [54]. Several hypotheses have been proposed to
dards, Society for Vascular Surgery and the North explain the association with pregnancy, including
American Chapter of the International Society for trauma and instrumentation associated with delivery,
Cardiovascular surgery, IAA is defined by a lumi- infection, and increased vascular demand associated
nal diameter that exceeds 1.5 cm [55]. They may be with pregnancy [56].
Fig. 15. Splenic artery aneurysm. (A) Cystic structure communicates with vessel lumen. Note disordered flow. (B) Color Dopp-
ler shows turbulent flow.
Santilli et al [55] recommended annual screening

with B-mode US of IAAs smaller than 3 cm and
biannually for those larger than 3 cm. Repair is
frequently undertaken in association with AAA repair.
Elective IAA repair is indicated in symptomatic IAA
and IAA larger than 4 cm. More urgent repair is
performed in IAA larger than 5 cm given their higher
risk of rupture [55].
IAAs, although uncommon, carry a risk of rupture
with high associated mortality. As in AAA, US is a
modality well suited to surveillance of IAA. Because
75% of IAAs occur in association with AAA [55], the
routing screening for AAA as proposed by Lee [27]
could potentially unmask most IAAs.
Other peripheral arterial aneurysms
The most common lower extremity aneurysms are

popliteal, which comprise 80% of all peripheral
arterial aneurysms. They tend to be bilateral (50%).
Fig. 16. Right internal iliac artery with surrounding hypo-
Patients often present with acute limb ischemia sec-
echoic fluid collection represents hematoma after stent pro-
cedure (arrow). ondary to embolization or thrombosis. This carries
a poor prognosis, with 15% requiring amputation
[59]. Forty percent of patients with popliteal aneu-
IAAs are frequently asymptomatic but may cause
rysms have coincident AAA [56]. In a prospective
pelvic, flank, or groin pain [54,55]. Ureteral obstruc-
study of patients with AAA, Diwan et al [60] found
tion may complicate IAA because of the close prox-
popliteal or femoral artery aneurysms in 51 of 313
imity to the genitourinary tract. Sciatic and femoral
patients. The association of femoral and popliteal
root compression may result in symptoms. Arteriove-
aneurysms with AAA suggests a common pathogen-
nous fistula with resulting lower extremity ischemia is
esis. Jacob et al [61] found reduced vascular smooth
a less frequent manifestation [54,56,57]. Santilli et al
muscle, increased inflammatory infiltrate, and in-
[55] found that rate of expansion depended on aneu-
creased expression of signaling molecules involved
rysm size. Common IAAs smaller than 3 cm expand-
in cell death in surgical specimens obtained from
ed approximately 1 mm per year; IAAs larger than
AAA, iliac, popliteal, femoral, and carotid artery
3 cm expanded 2.6 mm per year. In that study,
repairs. US is the imaging modality of choice in
approximately 50% of the patient population with
diagnosing popliteal aneurysm. In a series of 21
IAA was symptomatic. All symptomatic patients had
patients, MacGowan et al [62] found that sonography
aneurysms larger than 4 cm. The risk of rupture
was superior to angiography in detecting surgically
increased with increasing aneurysm size. For common
confirmed popliteal aneurysm. Popliteal aneurysm is
IAAs, the risk of rupture for aneurysms smaller than
diagnosed by focal dilatation of more than 20% of the
5 cm in diameter was 0%; for aneurysms larger than
vessel diameter. As with AAA, popliteal aneurysm
5 cm, it was 33% [55]. Richardson and Greenfield
can be followed sonographically. Popliteal aneurysm
[58] found that internal IAAs tended to be larger at
larger than 2 cm generally require surgical interven-
detection and carried a 33% incidence of rupture.
tion regardless of the presence or absence of symp-
Santilli et al [55] found that B-mode US and CT
toms although much controversy regarding this still
had similar accuracy in measuring iliac aneurysms.
exists [63,64].
US is most effective in diagnosing IAA when it is
large enough to cause a palpable mass. Under these
circumstances, IAAs are more likely to displace bowel
loops, which aids visualization. Gentle graded com- Summary
pression is also helpful in displacing bowel loops [54].
Color Doppler shows a characteristic swirling pattern The role of US in imaging of the abdominal
along with intraluminal thrombus, if present [54]. vasculature has broadened over recent years. Long
considered the modality of choice in the detection of Endoleak as a complication of endoluminal grafting of
AAA, its use has expanded to diagnosing and moni- abdominal aortic aneurysms: classification, incidence,
toring IAAs and PAAs, screening for mesenteric diagnosis, and management. J Endovasc Surg 1997;
4(2):152 – 68.
ischemia, and posttreatment monitoring of endovas-
[15] Pacanowski JP, Dieter RS, Stevens SL, Freeman MB,
cular stents.
Goldman MH. Endoleak: the Achilles heel of endovas-
cular abdominal aneurysm exclusion: a case report.
Wis Med J 2002;101(7):57 – 63.
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Radiol Clin N Am 42 (2004) 383 – 396
Arterial injuries: a sonographic approach

Brian D. Davison, MDa,*, Joseph F. Polak, MD, MPHb
a
Department of Radiology, Harvard Medical School, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA
b
Department of Radiology, Tufts Medical School, New England Medical Center, Box 299, 750 Washington Street, Boston,
MA 02111, USA
Acute arterial emergencies can arise from direct setting of proximity injuries or where a mechanism of
traumatic injury to the artery or be spontaneous. In the injury is not in accordance with other physical find-
case of spontaneous injuries, the likelihood of a spe- ings. Since the late 1980s studies have been conducted
cific arterial event increases in the presence of certain to screen patients with vascular injuries that need
risk factors or medical conditions. For example, the possible surgical management. Ultrasound can be up
incidence of acute arterial occlusions is increased in to 95% to 100% sensitive for diagnosing vascular
the presence of popliteal artery aneurysms or atrial injuries in the hands of highly qualified personnel
fibrillation. This article emphasizes the various pre- with a high index of suspicion [1]. This high diag-
sentations of arterial emergencies. These include acute nostic accuracy has actually been validated with
arterial occlusions; excessive bleeding; and hematoma animal studies. Panetta et al [2] created different types
formation caused by penetrating arterial wall injuries, of arterial injuries in the femoral and carotid arteries of
pseudoaneurysms, and arteriovenous fistulas. The dogs. These injuries including intimal flaps, crush
broad category of arterial occlusions includes trau- injuries, and lacerations, and were compared with
matic lacerations, embolizations, and arterial dissec- control limbs. The studies were performed by a
tions. The caliber of the artery can also, on occasion, sonographer blinded to the type and location of the
be significantly narrowed because of spasm. This of- injury. Results were correlated against operative ob-
ten exacerbates the clinical impact of the injury. servation and pathologic study of the injured artery
Modern ultrasound equipment is a rapid and con- 1 month after the injury. The sensitivity and specific-
venient imaging approach in many of these clinical ity of ultrasound were 96.5% and 86.4%, respectively,
scenarios. In combination with MR angiography and with an accuracy of 95%. The ultrasound findings
CT angiography, these noninvasive tests can diagnose correlated well with the histopathologic examination.
the presence of most arterial injuries, and be used to All arteries subjected to crush injury in these studies
measure their impact. Conventional angiography is showed abnormal duplex findings with measurable
reserved for problem solving or directed therapy. changes in the arterial wall thickness. The site of the
crush injury showed intramural hemorrhage or mural
thrombus at the site of injury. Most intimal flaps had
healed at the time of pathologic examination, 1 month
Validation studies: pathologic validation
after the injury. Overall, the findings of Doppler
ultrasound suggested that it has clinical use in the
In the emergency setting color Doppler imaging
evaluation of acute arterial trauma.
and duplex ultrasound have shown use in the evalua-
tion of potential vascular injuries, especially in the
Nonimaging Doppler techniques
* Corresponding author. The ankle-brachial index is a quick comparison of

E-mail address: bddavison@partners.org blood pressure readings. Doppler is used instead of a
(B.D. Davison). stethoscope. Systolic pressures are obtained in both
doi:10.1016/j.rcl.2004.01.007
384 B.D. Davison, J.F. Polak / Radiol Clin N Am 42 (2004) 383–396
brachial arteries. Pressures are obtained in the poste- these, iatrogenic compromise of the arterial wall
rior tibial artery, or the dorsalis pedis in both legs. By following medical interventions is most common.
dividing the highest left and right ankle values by the Diagnostic and interventional arterial catheterizations
highest brachial value an ankle-brachial index is are the most common sources of iatrogenic pseudo-
calculated. Someone with no disease should have a aneurysms. Other common sources are postsurgical,
ratio of greater than 0.96. For evaluation of periph- typically at the site of an arterial anastomosis or
eral vascular disease a value of 0.81 to 0.95 suggests following an arterial repair.
mild disease, 0.51 to 0.80 suggests moderate disease, Pseudoaneurysms following femoral artery cathe-
0.31 to 0.50 suggests moderate to severe disease, and terization have a reported incidence of 7% to 8% [5].
0.30 or below suggests severe disease. Simple mea- The likelihood of an iatrogenic pseudoaneurysm fol-
surement of the ankle-brachial index can be used to lowing arterial catheterization increases with the size
screen for lower-extremity arterial injuries. This adds of the catheter, the length of the procedure, and the
value to the clinical finding of depressed pulses or concurrent use of anticoagulants. Additional factors
pulses that change strength, waxing and waning over include poor puncture [6] and compression techniques
a few minutes. More direct comparisons of pressure [5]. Antegrade punctures and use of compression
in one limb with the other can also be done. Johansen devices increase the likelihood of pseudoaneurysm
et al [3] used the Doppler arterial-pressure index to formation. Other factors include poor coagulation
compare the systolic arterial pressure in the injured factors caused by liver failure and thrombocytopenia,
extremity to the arterial pressure in the uninvolved and other patient factors, such as obesity, hyperten-
side. A ratio of 0.9 or less was indicative of major sion, and stresses to the catheter entry site [5,7].
arterial injury with a sensitivity and specificity of The patient who presents acutely to the emergency
95% and 90%, respectively. The negative predictive room typically has suspicious physical signs, such as
value was high. Most physicians, however, consider swelling in the injured region, a pulsatile mass, or the
a negative arterial-pressure index as a poor indica- presence of a thrill. This occurs in the case of
tor of potentially unstable injuries, such as arterial postcatheterization pseudoaneurysm 1 to 10 days
dissections, disruptions, and pseudoaneurysms. These after the actual catheterization. Ecchymotic skin
findings were confirmed in a study by Lynch and Jo- changes are often present starting 1 to 2 days post-
hansen [4] where the arterial-pressure index calculated injury. If the mass of the pseudoaneurysm presses
in 100 consecutive injured limbs in 93 trauma vic- sufficiently on the native arteries, then blood flow can
tims. All of these patients subsequently had angiog- be decreased despite intact or even increased pulses.
raphy. An arterial-pressure index of less than 0.9 had A bruit may be heard on auscultation.
a sensitivity of 80% and specificity of 97% for the Gray-scale ultrasound analysis reveals anechoic
presence of arterial disruption. or hypoechoic areas resembling fluid collections
Overall, the sensitivity of the pressure index for (Fig. 1A). These are located adjacent to or can abut
detecting injuries requiring intervention ranges from the arterial wall. Color Doppler ultrasound, however,
44% to 95%, depending on clinical circumstances and is most useful in identifying the nature of the lesion.
extent of the injury. Angiography remains the gold Classically, the description of the blood flow pattern
standard for the evaluation of traumatic arterial inju- as seen on color Doppler ultrasound has been de-
ries. There are several disadvantages include cost, scribed as the yin and yang sign (Fig. 1B). These
time delay, and a 0.6% major complication rate. signals are caused by swirling motion of blood within
Vascular injuries requiring intervention are present the pseudoaneurysm cavity. The inflow jet of blood is
on only 1% to 1.5% of angiograms in patients missing directed along one wall causing a positive frequency
true signs of vascular injury. Impaired renal function shift (red color), and the outflow is along the opposite
and the amount of iodinated contrast already given wall causing a negative frequency shift (blue color).
should be weighed before an angiographic procedure. The presence of a communicating channel or neck
between the artery and the collection is needed,
however, to confirm the diagnosis. Blood flow in this
Pseudoaneurysm communicating channel has a very typical pattern.
Inflow of blood causes the pseudoaneurysm collection
Pseudoaneurysm or false aneurysm is defined by to expand during systole. Sampling of the Doppler
the loss of integrity of the three layers of the arterial waveform in the neck of the pseudoaneurysm shows a
wall. This results in a contained rupture of the blood positive inflow into the channel. During diastole,
vessel. The most common origin of pseudoaneurysms blood flows out of the collection into the artery. This
is traumatic, secondary to a penetrating injury. Of is caused by the release of elastic energy stored by the
B.D. Davison, J.F. Polak / Radiol Clin N Am 42 (2004) 383–396 385
Fig. 1. (A) Color Doppler image in a patient with a knife wound shows a superficial hematoma (arrow) and a collection
containing flow signals. (B) The presence of a pseudoaneurysm is confirmed by the alternating to-and-fro signals at the neck
of the pseudoaneurysm.
soft tissues surrounding the pseudoaneurysm cavity. Pseudoaneurysms involving surgical sites, most
Blood flow is directed out of the collection into the often the anastomosis of bypass grafts, typically have
artery. This biphasic to-and-fro blood flow pattern very wide necks. They tend to be large and have well-
with pandiastolic reversal of flow is characteristic of formed capsules. They often contain mural thrombus.
a pseudoaneurysm. Pseudoaneurysms caused by gunshot wounds or
Once diagnosed, gray-scale ultrasound can be penetrating knife wounds should be considered as
used to estimate the size of the neck of the pseudo- potentially being infected. This type of pseudoaneu-
aneurysm. Smaller diameter and long necks are more rysm seldom resolves spontaneously, and often re-
suitable for percutaneous interventions than pseudo- quires direct surgical intervention.
aneurysms with short (less than 1 cm) and wide necks Historically, treatment of pseudoaneurysms has
(larger than 2 – 3 cm), and location must be consid- been by open surgical repair, but evolution in endo-
ered. The natural history is varied. Most pseudo- vascular devices has allowed multiple options for
aneurysms spontaneously thrombose [8]. Over time treating these lesions. Ultrasonography should be
pseudoaneurysms can mature and a fibrous capsule used to assess the neck of the pseudoaneurysm. If it
may form. The dreaded complication of a pseudo- is wide or in a position not directly accessible for
aneurysm is continued expansion and bleeding into compression, other therapies should be considered.
the thigh or retrograde bleeding into the pelvis. With Ultrasound-guided manual compression of the pseu-
rapid enough expansion, the dissecting blood can doaneurysm has been used for over 15 to 20 years as
cause a compartment syndrome, compromise blood a treatment for pseudoaneurysms. The procedure
flow to the distal limb, and lead to ischemia and allows natural thrombosis of the pseudoaneurysm
irreversible tissue loss. Many pseudoaneurysms at cavity. Using gray-scale imaging as a guide, force
presentation contain varying degrees of clotted blood. can be applied directly to the skin overlying the neck.
Pseudoaneurysms can have multiple separate com- With enough pressure, blood flow stops and the con-
partments or collections connected by thin tracts or tents of the pseudoaneurysm thrombose. Success rates
canals. Expanding pseudoaneurysms can cause limb are reported in the range of 51% to 73% [10 – 13].
ischemia through compression. The thrombus form- The procedure is noninvasive, but can be time con-
ing within them theoretically can escape and cause suming and painful for both the patient and operator.
distal emboli [9]. Unfortunately, this technique may require several
attempts before complete obliteration of the pseudo- successful but invasive. Covered wall grafts have
aneurysm. Patients treated with anticoagulants can be been percutaneously placed to treat internal carotid
refractory to this form of therapy. The recurrence rate artery aneurysms [21]. In a small series, 16-month
of pseudoaneurysms after ultrasound-guided com- follow-up did not show evidence of occlusion or
pression may be as high as 20% [5]. stenosis or reperfusion to the pseudoaneurysm. In-
Direct thrombin injection using a sterile technique dications included penetrating trauma and compli-
and real-time Doppler ultrasound guidance into a cations of percutaneous interventions [5,7,22].
pseudoaneurysm causes thrombosis of the pseudo- Temporary balloon occlusion has been tried and can
aneurysm within seconds. The procedure usually takes be successful in properly selected patients. Repair of
less than 15 minutes. This procedure is safe and can be large neck aneurysm with balloon occlusion and
performed on outpatients. A 20-gauge can be used and thrombin injection has not been shown to be an
the tip should be directed away from the neck. acceptably safe procedure.
Percutaneous thrombin injection for the treatment of In the event that the previously described proce-
pseudoaneurysm has been described in the subclavian, dures fail or rupture is threatened by the rapid
brachial, radial, and tibial arteries and carotid and expansion of the pseudoaneurysm, surgery should
temporal arteries [14 – 16]. The proximity to these key be performed. Other surgical indications include
arteries requires that the operator have great technical infection, distal ischemia, an embolic event, or ex-
skills to prevent excess injection of thrombin and tensive tissue damage. There is significant morbidity
thrombosis of the native artery. Success rates for associated with emergently performed surgery [12].
thrombin injection vary between 93% and 100% in
the literature [12,14 – 19]. Patients on antiplatelet
therapy or heparin can have thrombin injection with- Hematoma
out decreasing success rates [14,19].
Pseudoaneurysms that have very short and wide A hematoma is the natural outcome of a vascular
necks or that are located posterior to the artery are at disruption. This can occur spontaneously in smaller
higher risk for failure or complications than those arteries especially in the setting of anticoagulation
with long necks and located near the skin. Compli- [2,23,24]. The hematoma can be the result of blunt or
cations include inadvertent direct injection of throm- penetrating trauma or represent a thrombosed pseu-
bin into the artery, or subsequent emboli emission doaneurysm (Figs. 2 – 4). The hematoma may remain
through a large neck. Sensitivity or allergy to throm- restricted to the surrounding soft tissue especially if it
bin has been reported [20]. The long-term effects of occurs in a muscle, or it can tract through fascial
bovine thrombin injection are not known. planes when caused by a larger arterial disruption.
Percutaneous transcatheter embolization and other Hematomas commonly occur in the retroperitoneum
endovascular techniques, such as exclusion of the [23,25], the rectus sheath [26], and in the extremities
pseudoaneurysm with covered stent placement, are around joints associated with muscle tears [24].
Fig. 2. (A) Transverse scan of the right groin in a patient with acute pain following a fall shows an avascular mass (arrow) me-
dial to the vein. (B) The CT of the pelvis shows a right pubic ramus fracture (arrow) and the hematoma lying superior to it.
Fig. 3. (A) Arteriogram of the upper limb shows an intact duplicated brachial artery (arrows) and a distal humeral fracture.
(B) The corresponding color Doppler image shows a hematoma (within calipers) and no evidence of a pseudoaneurysm.
A, duplicated brachial artery.
Physical finding include swelling in the injured here usually result in local groin swelling adjacent to
region, which is most often nonpulsatile, and silent on the puncture site. Rarely, they can expand to pelvis,
auscultation. Ecchymotic skin changes are almost al- leg, or retroperitoneum. Vigorously compressed to
ways present. If causing compression and narrowing, break apart, the hematoma ultimately decreases pa-
hematomas can present with diminished blood flow tient discomfort. Careful fluoroscopic checking of the
and pulses to the affected limb. If bleeding is severe anatomic landmark of the femoral head ensures proper
and within a fascial compartment, then a compartment needle placement, and is paramount in minimizing the
syndrome can ensue, causing severe pain, markedly risk of postprocedure hematoma.
diminished pulses, pallor, and paresthesias. Hemato- Gray-scale ultrasound analysis shows variable
mas should be delineated with a marking pen on the findings dependent on the time interval since the
skin and measured carefully on ultrasound to rule out a original hemorrhage and possibly intermittent nature
rapidly evolving hematoma. Although not a common of bleeding episodes. In the acute period (hours)
site of arterial puncture, a high brachial puncture used hematoma may present as solid or mixed echogenic
for catheterization is difficult to compress following structures because of mixing of liquid with clotting
catheter removal. This can result in an extensive blood [11,26]. It can be well or ill defined, and should
hematoma. Extension into the axilla is of great con- be imaged carefully to document its extent, location,
cern because the resulting hematoma can compress and dimensions. The size seen on ultrasound should
and injure the brachial plexus [27,28]. The common be compared with the physical effect on the extrem-
femoral artery remains the preferred site for arterial ity. Hematomas can often dissect in a diffuse fashion
access for catheterization procedures. Hematomas and not form a well-circumscribed mass. A baseline
Fig. 4. (A) Color flow Doppler image shows a large hematoma in a patient following penetrating trauma. (B) Doppler signals
confirm the presence of an additional arteriovenous fistula.
measurement of size should be done because this can trauma. Arteriovenous fistulas are often asympto-
help document possible rebleeding and expansion of matic, but when significant can cause rapid shunting
the hematoma. Over the course of days the clotted with return of oxygenated blood to the right heart.
blood breaks down to fluid in areas, giving a complex Rarely, they can contribute to high-output cardiac
cystic and solid appearance. At this point, without failure [29]. They can also shunt away blood from the
proper history, the collection can be misdiagnosed an extremity and cause symptoms of distal ischemia.
abscess cavity or perhaps a pseudoaneurysm. Cystic, Arteriovenous fistulas are often caused by
necrotic, or hemorrhagic neoplasms may also have low-arterial punctures, large-diameter catheters, anti-
similar imaging findings, and should be excluded coagulant use, and they are associated with pseudo-
with follow-up. As discussed previously, however, aneurysms [2,30 – 32]. The femoral artery and vein
color flow Doppler is most useful in identifying and are parallel and side-by-side in the region of the
differentiating these lesions from pseudoaneurysms groin. Variant anatomy or punctures in the lower thigh
(see Fig. 1). Over weeks liquefactive necrosis of the (where the femoral vein travels behind superficial
entire hematoma usually occurs [11,26]. Ultrasound femoral and profunda arteries) are risk factors for
at this point shows all fluid signals, but a hematocrit the formation of iatrogenic arteriovenous fistulas. Iat-
level may be seen within. A 2- to 3-month follow-up rogenic arteriovenous fistulas are not uncommon
scan is recommended to assess for decreasing size or elsewhere in the body, and not infrequently seen as
resolution to differentiate the hematoma from a mass. a consequence of a biopsy, such as in the kidney.
Secondary infections are relatively rare. Their Physical examination can reveal little to no swelling
likelihood increases if there is a persistent foreign or ecchymosis, but a palpable thrill is often present.
body in the case of penetrating trauma. Other exam- Patients may present with pain but are most often
ples where foreign material remains in the soft tissues asymptomatic, but have a bruit on local auscultation.
include after the use of closure devices used to seal Gray-scale ultrasound imaging is not helpful in
the needle access site following catheterization, or the evaluation of arteriovenous fistulas unless the
post – synthetic graft placement. arteriovenous fistula is chronic and the high flow
state has caused dilatation of the vein and artery.
Color Doppler imaging and pulsed wave Doppler are
Arteriovenous fistulas usually diagnostic. Tissue vibrations caused by tur-
bulent flow are the most notable color Doppler
Arteriovenous fistulas represent a direct connec- finding (see Fig. 4). Also, the track between artery
tion between a vein and an artery. Like hematomas and vein can sometimes be directly visualized. The
and pseudoaneurysms, arteriovenous fistulas can be Doppler waveform in the feeding artery shows a low
spontaneous, but are often the result of penetrating resistance pattern with increased diastolic flow. The
jet of arterial flow entering the vein can cause a artery are the most common. Internal carotid artery
marked flow disturbance and chaotic waveform or in dissections typically occur in the proximal internal
more severe case an arterial waveform is present. carotid artery, just beyond the carotid bulb. Primary
Compression repair is usually not successful for dissections of the intracranial portion of the internal
closing arteriovenous fistulas. Small arteriovenous carotid artery can occur but they are much less
fistulas can spontaneously remit [8]. Percutaneous common than the classic primary dissection of the
placement of a covered stent or surgical repair is internal carotid artery (Fig. 5). Dissections of the
often indicated. vertebral arteries are also seen but a careful investi-
gation is rarely done because symptoms, if present,
tend to be minimal. Patients with an internal carotid
Craniocervical dissections artery dissection have nonspecific presenting symp-
toms, such as a sensory or motor deficit. The classic
There are two types of dissections likely to affect presentation is that of a headache. The dissection
the carotid and vertebral arteries. The first is a often happens in a previously healthy individual and
primary dissection of the artery, sometimes associated develops either spontaneously or following various
with a vague history of trauma or rapid movement of degrees of trauma. As medical imaging equipment
the head. This is seen more often in young patents has evolved, better visualization of this area is pos-
less than 50 years of age. Secondary dissections occur sible. This fact coupled with more awareness has
as an extension of a ‘‘type A’’ dissection of the aortic made this diagnosis less difficult.
arch into the origins of the brachycephalic, carotid, A dissection is the disruption of the media or
and subclavian arteries. This is typically seen in older second layer of the artery. Once the dissection starts,
patients or patients with a weakness of the media in the intima along with a portion of the media is lifted
the aortic wall, typically with cystic medial necrosis. from the artery wall. Collagen is exposed to blood
and this usually starts a clotting cascade. The pathol-
Primary dissections ogy of the primary dissection of the internal carotid
artery is one of an intramural blood clot. If the size
Although any of the arteries in the neck may be and volume of the blood clot is large enough, the
affected, primary dissections of the internal carotid artery occludes. If the size of the clot is intermediate,
Fig. 5. (A) Spectral Doppler waveform demonstrates a high resistance and low amplitude in the internal carotid artery of a
25-year-old patient. (B) The corresponding arteriogram shows abrupt termination of the internal carotid artery (arrow) at the site
of an internal carotid artery dissection.
with proved dissections. Internal carotid artery dis-

sections may or may not cause symptoms depending
on the integrity of the circle of Willis. Atherosclerotic
disease may be present in the adjacent arterial seg-
ment. Spectrum analysis may demonstrate two sepa-
rate frequency curves when the dissected lumen is
still open. Doppler ultrasound has been used to
monitor and follow patients with internal carotid
artery dissection.
Secondary dissections
These dissections extend into the neck arteries

from a primary dissection arising from the ascending
aorta (Fig. 7). The patients present with the symptoms
of acute chest pain, radiating to the back. Because
Fig. 6. This patient was found to have an acute traumatic these ‘‘type A’’ dissections are, a priori, triaged to
intimal tear of the internal carotid artery on the carotid surgical intervention, it is very likely that the aorta
arteriogram (not shown). The internal carotid artery color will be repaired. The extension of the dissection into
Doppler image demonstrates evidence of a periarterial soft the neck arteries is rarely symptomatic, probably be-
tissue mass consistent with a hematoma (arrow). The inti- cause the dissecting lumen re-enters the lumen at varia-
mal tear seen in arteriogram could not be seen on color ble locations in the common or, less often, the internal
flow Doppler.
carotid arteries. Neurologic symptoms are rare.
Gray-scale imaging shows the typical luminal
then the lesion causes a stenosis or even occlusion of flap. Doppler waveforms are altered. If there is a site
the proximal internal carotid artery (see Fig. 5). If of re-entry, forward blood flow is mainly seen. If one
relatively small, the patient can present with acute of the lumens (the false lumen) does not re-enter the
symptoms and no neurologic deficit because the
lesion does not compromise blood flow in the internal
carotid artery. This can occur in spontaneous and
posttraumatic dissections (Fig. 6). The latter scenario
is typical of up to 40% of patients with primary
internal carotid artery dissections. Physical examina-
tion can reveal motor weakness or a sensory deficit.
Rarely, the patient can present clinically with cranial
nerve palsy, such as Horner’s syndrome [33 – 35].
A double lumen with a separating intimal flap can
be seen on gray-scale imaging in cases of primary
internal carotid artery dissections, but is less common
than an intramural hematoma. Typically, the dissec-
tion consists of an intramural hematoma or thrombus
that is hypoechoic and hard to perceive. The Doppler
findings are variable. In the absence of a significant
obstruction, the signals can be normal. A more
significant dissection with large intramural hematoma
shows direct evidence of a stenosis with a zone of
elevated blood flow velocities. Very severe dissec-
tions can occlude or subtotally occlude the internal
carotid artery. Doppler ultrasound is quite specific for
the detection of significant vessel obstruction when Fig. 7. Gray-scale ultrasound image shows the leading edge
the Doppler waveform is altered and shows a high- of an aortic dissection extending from the arch into the
resistance pattern (see Fig. 5). This pattern, however, common carotid artery. The leading edge of the dissection
is the least common of the patterns seen in patients has re-entered the lumen of the artery.
carotid lumen, then an alternating systolic-diastolic patients with strokes have nonsignificant lesions in
waveform is seen in that lumen. the carotid arteries. If a significant lesion is detected,
then the focus shifts to this lesion. It is then consid-
ered to be a ‘‘culprit’’ lesion. Significance is defined
Stroke and carotid artery stenosis in one of three ways. A 50% or greater narrowing of
the internal carotid artery is considered a hemo-
The patient who presents with a stroke (or sig- dynamic significant stenosis. In asymptomatic pa-
nificant transient ischemic attack) likely has an arte- tients, a 60% or greater narrowing of the lumen
rial embolus in the intracranial circulation or primary diameter of the internal carotid artery is considered
disease of the intracranial branches. Other and more significant. In symptomatic patients, the definition
common sources of stroke include emboli from the varies. The North American Symptomatic Carotid
heart and from the aorta. In the aggregate, most Endarterectomy Trial (NASCET) study showed that
Fig. 8. (A) Color Doppler image shows an abrupt termination of color Doppler signals before an echogenic filling defect in
the proximal internal carotid artery. This corresponds to an embolus in a 35-year-old patient. (B) Transverse gray-scale ultra-
sound image shows the filling defect. (C) The spectral Doppler waveform shows a high resistance pattern consistent with the
presence of the obstructing embolus.
a 70% diameter stenosis was a threshold above which a fully percutaneous approach with stenting of the
there was a high-risk for a permanent stroke in the carotid and lysis of the embolus offers a reasonable
next few months or years [36]. A second NASCET therapeutic option.
report indicated that a 50% or greater stenosis should
be considered to be significant [37]. Rarely, an acute
embolus can occlude the carotid artery proper; the Acute limb ischemia: arterial embolization
source of the embolus is then the heart or even the
aortic arch (Fig. 8). The normal appearance of an extremity artery is
Physical examination shows diminished pulses triphasic (Fig. 9). Pulse Doppler waveform shows an
only for the most severe stenoses. Presence of a carotid initial narrow antegrade systolic peak, followed by an
bruit can be heard on auscultation. A carotid bruit early diastolic retrograde peak or notch. Finally, a
is, however, an unreliable sign of significant stenosis. variable antegrade diastolic peak is seen. Under the
Gray-scale imaging can show the fibrofatty arterial envelope a clear area is seen. Extremity arte-
changes (hypoechoic) of carotid artery plaque. The rial waveforms convert to a lower resistance pattern
most common finding, however, is the presence of a during exercise, with a broadened spectral peak, and
heterogeneous plaque with mixed dense and hypo- pandiastolic antegrade flow.
echoic elements. Calcium deposits cause acoustic Acute limb ischemia is usually caused by a sudden
shadowing. Pulsed wave Doppler is the most impor- arterial obstruction. There are two main causes: acute
tant ultrasound approach to evaluating the degree of thrombosis of an existing arterial lesion; and embo-
carotid stenosis. The degree of carotid stenosis is lism from the heart or from a more central arterial
graded by the blood flow velocity elevation caused at lesion, such as an aneurysm or an ulcerated plaque.
the site of stenotic narrowing. The peak systolic and Emboli usually lodge at major branch points in the
end-diastolic velocity is correlated to the degree of arteries. Symptom onset is rapid. Depending on the
internal carotid artery stenosis. The ratio of the inter- physiologic impact of the occlusion, the patient may
nal carotid artery to common carotid artery peak have severe claudication, rest pain, or sensory loss.
systolic velocities is considered a sturdy diagnostic Emergent intervention by surgical embolectomy,
criterion that accounts for changes in blood flow ve- surgical bypass, or percutaneous thrombolysis is re-
locities caused by altered (either lowered or increased) quired to save the limb from necrosis of the muscles.
cardiac output. When a stenosis in the internal carotid In severe cases, amputation may be needed because
arteries lumen is reduced by 50%, a noticeable change further myonecrosis causes release of myoglobin and
in blood flow velocity can be measured. This corre- can trigger further metabolic pathways that lead to
sponds to a 50% diameter stenosis. When flow values organ failure and finally death. The impact of the
approach and exceed 230 cm/second, then the pres- arterial occlusion depends on the extent of arterial
ence of a 70% or greater stenosis is very likely. Rarely, disease and the presence of arterial collaterals. For
a critical stenosis is so severe as to decrease blood example, acute occlusion of an artery in a young,
flow volume and blood flow velocity to the point that relatively healthy patient can be devastating, because
the Doppler signal is no longer detectable. This there are almost no collateral branches to feed the
remains a limitation of Doppler ultrasound: mistaking more distal leg arteries. A patent with claudication
a subtotal occlusion to be a total occlusion is still a and slowly progressing arterial disease likely has
diagnostic limitation of ultrasound imaging. Patients
with a subtotal occlusion could still benefit from an
intervention, whereas there is no lasting benefit to
opening a previously occluded internal carotid artery.
In the setting of recurrent transient ischemic at-
tacks in a patient with an ipsilateral high-grade carotid
lesion, carotid endarterectomy should be considered.
Currently, appropriate therapy in an acute setting is
not necessarily surgical endarterectomy. Percutaneous
stenting of the carotid is a viable option in the
emergent setting, especially if the patient is evolving
toward a major stroke. There is increasing controversy Fig. 9. Triphasic spectral Doppler waveform. The systolic
as to how and when to treat the culprit lesion in the peak is marked (arrowhead) followed by an area of flow
neck, especially if an acute revascularization of the reversal (short arrow). This is followed by a small area of
intracranial arteries is being attempted. In this context, antegrade flow (long arrow).
Fig. 10. (A) This patient with acute onset of calf pain had evidence of a Baker cyst (within calipers) on ultrasound examina-
tion. (B) Imaging lower in the calf shows a hypoechoic mass extending along the fascia. This is consistent with an acute dis-
secting Baker cyst.
well-developed collateral branches. An acute occlu- echoic, especially if it originates from the heart.
sion in this patient may only cause an abrupt increase Thrombus is most often anechoic with echogenicity
in the severity of claudication. similar to that of blood. Dilation of the artery proxi-
Gray-scale imaging from the groin to the calf mal to an occlusion is rarely seen.
arteries is relatively easy, as is the upper arm. Diffi- Acute occlusions are most likely diagnosed by
culty can be experienced, especially in diabetic pa- combining color flow Doppler with pulsed wave
tients, when calcium deposits in the arterial walls Doppler waveform analysis. Absence of flow or
impair ultrasound beam penetration. Sometimes an low amplitude signal in the affected vessel is diag-
alternative diagnosis for acute pain can be made with nostic of occlusion (Fig. 11), whereas high-grade
gray-scale imaging (Fig. 10). Long-standing occlu- stenosis is associated with increased blood flow
sion can result in contraction of the artery to a small velocities. Care should be taken to reduce the pulse
scarred cord that runs parallel to the deep vein. New repetition frequency and to scan in orthogonal planes
thrombus in the vessel lumen can appear hyper- to assess for the presence of very slow blood flow.
Fig. 11. (A) Transverse color flow Doppler image shows low-amplitude signals in the brachial artery. (B) The corresponding
spectral Doppler waveform shows low-amplitude signals in the artery just proximal to an acute embolus to the brachial artery.
Fig. 12. (A) Spectral Doppler waveform from the superficial femoral artery shows a reversing component to blood flow during
diastole. This is caused by high peripheral resistance from a distal (calf) compartment syndrome following trauma. (B) The
contralateral normal superficial femoral artery spectral Doppler waveform is shown for comparison.
This helps distinguish an occlusion from a stenosis. widespread, and the larger vessels of the pelvis are
In transverse plane, tortuous small collaterals may be less affected than the small vessels of the calf and foot.
seen in both cases. One should look for reconstitution Falsely elevated pressures that are measured with
of the occluded vessel, distal to the occlusion. external pressure cuffs, typically greater than 30 mm
Extensive thrombosis extending over long seg- Hg above the brachial pressure, suggest the presence
ments is more difficult to treat using endovascular of noncompliant arteries. Of the run-off vessels, the
approaches than shorter occlusions. Thrombolysis dorsalis pedis artery is often spared [39]. The calcifi-
can be used alone or in combination with a surgical cation of the peripheral vasculature generally affects
bypass operation. Surgical thrombectomy alone or in the more distal vessels to a lesser degree. Distal pedal
combination with surgical bypass operations is a very pulses can be intact and the vessels remain compress-
common therapeutic option. Uncommonly, a compart- ible. This allows pressures measured at the toe to be
ment syndrome can occur where tissue pressures in used as an alternative noninvasive approach to assess
the compartment exceed systolic pressure (Fig. 12). lower-extremity arterial disease. A toe-to-brachial
index of greater than 0.6 is considered normal. A
vascular work-up including transcutaneous oxygen
Diabetic foot measurement [40], the ankle-brachial index, and the
absolute toe systolic pressure [41] is appropriate. In
Vascular disease in the diabetic patient is usually the acute setting, where lower-extremity ischemia is
insidious in its presentation and slowly progressive. strongly suspected, arteriography or MR imaging
Close control of the diabetic status and medical should be performed to confirm or rule out ischemia.
examination of known diabetics is the best way to
avoid an emergency. Careful routine clinical exami-
nation and self-inspection of the diabetic foot on a Ischemia of the upper limbs
regular basis is the most effective preventive mea-
sure. Peripheral neuropathy is a risk factor associated Acute ischemia in the upper extremity can be
with poor outcome. Loss of sensory feedback adds to caused by other etiologies than arterial embolization
the effects of arterial obstruction because symptoms from central arteries, heart, and aorta. An accurate
are ignored and the extent of tissue loss can increase diagnosis can sometimes be difficult in the presence of
without the patient noticing. The prevalence of lower- an underlying vascular disease. The most noticeable
extremity occlusive arterial disease in diabetics is four signs and symptoms are changes in color and sensa-
times more prevalent than in nondiabetics of a similar tion in the hand caused by Raynaud’s phenomenon.
age [38]. Calcification of the arterial wall is generally This can be seen in as much as a fifth of the
population, and is four times more likely to occur in ment replace ‘‘exclusion’’ arteriography in the diagno-
women. The disorder affects the smallest blood ves- sis of occult extremity arterial trauma? Ann Surg 1991;
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Radiol Clin N Am 42 (2004) 397 – 415
Emergency Doppler evaluation of the liver and kidneys

Michelle M. McNamara, MD*, Mark E. Lockhart, MD, MPH,
Michelle L. Robbin, MD
Abdominal Imaging Section, Department of Radiology, University of Alabama at Birmingham, 619 19th Street South, JTN 353,
Birmingham, AL 35249-6830, USA
Vascular complications of hepatic and renal trans- orly. The left intersegmental fissure separates the left
plants are potentially catastrophic. They may result lobe into the lateral and medial segments. The ana-
in loss of the allograft with significant morbidity for tomic boundaries of this fissure are the left hepatic
the recipient. Doppler evaluation of renal and he- vein superiorly and the falciform ligament inferiorly.
patic transplants may provide data that are essential The ascending portion of the left portal vein is at the
for preserving allograft function. Timely recogni- midportion of this fissure. The right intersegmental
tion of these problems improves the likelihood that fissure separates the right lobe into anterior and
intervention to correct vascular abnormalities will posterior segments. The right hepatic vein defines
be successful. this fissure superiorly.
Emergent applications of Doppler in the native The main portal vein divides into right and left
liver and kidneys are more limited. Sonographic branches in the liver hilum. The left portal vein
evaluation of patients with cirrhosis, with or without a courses horizontally (horizontal segment) and then
transjugular intrahepatic portosystemic shunt (TIPS), changes to a more vertical orientation in the left
may elucidate a cause for acute clinical decompen- intersegmental fissure, termed the ‘‘ascending por-
sation. Ultrasound is a readily available means of tion,’’ or umbilical segment of the left portal vein.
assessing patients with acute renal dysfunction. Im- The right portal vein divides into anterior and poste-
portantly, ultrasound can be used to determine if rior divisions. The anterior and posterior divisions
active hemorrhage is present at liver or renal biopsy of the right portal vein course centrally in the ante-
sites in the postbiopsy patient with a decreasing he- rior and posterior right hepatic lobe segments, respec-
matocrit level. tively, and are equidistant from the middle and right
hepatic veins.
The hepatic veins, surrounded by liver paren-
Hepatic ultrasound chyma, drain into the inferior vena cava. They are
in open communication with the right heart. Cardiac
Anatomy and appearance physiology and hepatic parenchymal compliance in-
fluence the hepatic vein waveform. The normal
The liver is divided into lobes and segments by hepatic vein waveform is phasic, similar to the in-
three fissures. The main lobar fissure divides the right ferior vena cava (Fig. 1A). Two large antegrade
and left lobes. The boundaries of this fissure are the waves reflect atrial diastole and ventricular systole.
middle hepatic vein superiorly, the gallbladder neck A small reversal in flow is seen between the larger
in the midportion, and the inferior vena cava inferi- antegrade waves at atrial systole.
The main portal vein provides 70% to 80% of
hepatic blood flow. Normal portal venous waveforms
* Corresponding author. reflect minimal undulations from respiratory and
E-mail address: mmcnamara@uabmc.edu cardiac activity, because they are normally isolated
(M.M. McNamara). from the central venous system (Fig. 1B). The hepatic
doi:10.1016/j.rcl.2003.12.001
398 M.M. McNamara et al / Radiol Clin N Am 42 (2004) 397–415
Fig. 1. Spectral Doppler of normal hepatic waveforms. (A) Right hepatic vein shows triphasic flow. (B) Portal vein waveform
demonstrates monophasic flow. (C) Hepatic artery with sharp systolic upstroke.
artery, which provides 20% to 30% of hepatic blood transplant [4]. Clinical manifestations include biliary
flow, originates from the celiac trunk. The common dysfunction and sepsis [4]. Hepatic artery anasto-
hepatic artery (Fig. 1C) becomes the proper hepatic motic stenosis usually precedes thrombosis [5]. He-
artery after it gives rise to the gastroduodenal artery. patic artery stenosis and thrombosis can be detected
The proper hepatic artery bifurcates into the right and with Doppler ultrasound.
left hepatic arteries. Variations in hepatic anatomy are Early arterial occlusion is associated with liver
common, however, and may not be sonographically failure and may require retransplantation. Alterna-
apparent [1]. tively, if significant hepatic artery stenosis can be
detected before life-threatening ischemia occurs, an-
gioplasty or surgical revascularization may salvage
the liver transplant [4 – 6]. Doppler spectral analysis
Transplant liver is an effective tool for evaluating a patient for hepatic
artery thrombosis or stenosis, and it has sensitiv-
Clinical ity and specificity rates of 97% and 64%, respec-
tively [6].
Hepatic artery thrombosis is the most common Other vascular complications include portal vein,
vascular complication of orthotopic liver transplant, hepatic vein, and inferior vena cava (IVC) stenosis
and it occurs in 3% to 10% of all recipients [2,3]. The and thrombosis, and pseudoaneurysm formation at the
incidence is at the higher end of the spectrum in arterial anastomosis [7]. The narrowing that results
pediatric recipients, and it occurs in up to 12% of from nonocclusive thrombus cannot always be differ-
transplant recipients [3,4]. If this complication oc- entiated sonographically from stenosis secondary to
curs, it is most often seen in the first 2 weeks after other causes [6]. These less frequent complications
M.M. McNamara et al / Radiol Clin N Am 42 (2004) 397–415 399
Sonographic criteria
Hepatic artery stenosis

Hepatic artery stenosis is suspected if RIs are less
than 0.5 [5] or if there is a focal peak systolic velocity
(PSV) more than 200 to 300 cm/second [2]. Other
indicators of significant hepatic arterial narrowing
include a systolic acceleration time (end diastole to
first systolic peak) more than 0.08 seconds [5]. In the
first 48 hours after transplant, RIs may be low or high
(Fig. 2) [10]. Essentially, the presence of an arterial
signal in the immediate postoperative period is satis-
factory, as long as a focal gradient is not found [6]. In
the authors’ experience, a PSV ratio at the anastomo-
sis of more than approximately 3:1 correlates with a
hemodynamically significant stenosis. A low resis-
tance arterial waveform may be seen downstream
from the stenosis (Fig. 3).
Portal vein thrombus

The portal vein is evaluated for presence or ab-
sence of flow, nonocclusive filling defects, and flow
direction. In the authors’ experience, a PSV gradient
equal to or more than approximately 3:1 at the anas-
tomosis is consistent with a hemodynamically signifi-
cant stenosis, a finding rarely encountered.
Hepatic veins and inferior vena cava

Fig. 1 (continued).
Flow direction and pulsatility are evaluated in the
hepatic veins with spectral Doppler. Monophasic
flow in the hepatic veins after transplant is a rela-
may develop independently or concomitantly. Prompt

diagnosis and treatment of vascular complications are
crucial to graft and patient survival [8].
Sonographic technique
For most adult patients, a 3.5-MHz or lower

frequency transducer is preferred, especially in the
immediate posttransplant period, when available
sonographic imaging windows may be limited. Lower
frequency transducers facilitate adequate tissue pene-
tration without compromising resolution for Doppler
evaluation. Optimum Doppler angle is less than 60°.
Low wall filter settings increase sensitivity for detec-
tion of low flow [9]. Direct gray scale inspection of
the vessels is performed, as is color and spectral
Doppler analysis of the main, right, and left hepatic
arteries, the main, right, and left hepatic veins, the Fig. 2. Immediate post – liver transplant hepatic artery
main, right, and left portal veins, IVC, and splenic Doppler. Color and spectral Doppler documents antegrade
vein. Patency, flow direction, velocities, resistive flow with RI of 1. In the perioperative period, a high re-
indices (RIs), and waveforms are assessed. Anasto- sistance waveform does not necessarily indicate a patho-
motic sites are interrogated for narrowing [7]. logic condition.
Pathologic mechanisms include cell death, fibrosis,

and regeneration, which result in the formation of
nodules. In the micronodular type of cirrhosis, nod-
ules measure less than 1 cm, whereas in the macro-
nodular type, nodules of varying size may measure up
to 5 cm. Alcoholism and viral hepatitis are common
causes. Other causes include biliary cirrhosis, scle-
rosing cholangitis, Wilson’s disease, and hemochro-
matosis. Cirrhosis is a common cause of intrahepatic
portal hypertension, with resultant ascites, portosys-
temic collateral formation, and gastrointestinal bleed-
ing. Doppler ultrasound is a useful noninvasive
means of assessing the status of a TIPS and portal
vein flow in patients with cirrhosis who present with
acute decompensation [11]. Depending on criteria
selected to define abnormal, Doppler ultrasound
sensitivity rate for detection of TIPS malfunction
ranges from 92% to 94% [12], with a specificity rate
of 72% to 100% [12].
Fig. 3. Hepatic artery stenosis in a transplant liver. Color and Sonographic technique
spectral Doppler of the right hepatic artery (Doppler gate)
shows abnormal waveform with RI of 0.37. RIs in the left
Comprehensive evaluation of the hepatic vessels
and main hepatic arteries (not shown) were 0.32 and 0.44,
includes acquiring angle-corrected color and spectral
respectively. Angiography documented 80% stenosis at the
hepatic artery surgical anastomosis. Doppler to determine flow direction, pulsatility, PSV,
and patency. As with transplant liver Doppler evalua-
tively common finding. Although it is not always tion, a lower frequency transducer may facilitate
clinically significant, monophasic flow in the hepatic penetration [13]. Low pulse repetition frequency
veins can be a result of outflow stenosis or obstruc- settings increase color Doppler sensitivity but may
tion at the cranial IVC anastomosis. In the authors’ result in aliasing, which can mimic flow reversal
experience, a distended IVC with a peak systolic ratio [11,14]. Direction of flow should be confirmed by
of more than approximately 3:1 can be seen in cases modifying pulse repetition settings or with spectral
with IVC anastomotic stenosis (Fig. 4A – C). An IVC Doppler [14]. High wall filter settings should be
venogram with measurement of pressures across the avoided because they may decrease the ability to
stenosis can be a useful confirmation of clinically detect low velocity flow [2].
significant abnormality. Hepatic vein thrombosis is The main, right, and left portal veins, middle left
uncommonly seen on Doppler (Fig. 5). and right hepatic veins, hepatic artery, splenic vein,
and IVC are evaluated with gray scale followed by
Pseudoaneurysm assessment with color and spectral Doppler. Varices
Pseudoaneurysms appear as a simple or complex are sought in the coronary, periumbilical, peripancre-
hypoechoic lesion on grayscale ultrasound. Unless a atic, and splenic regions, typically the most fruitful
pseudoaneurysm is completely thrombosed, typical locations for sonographic variceal detection. Vessels
‘‘to-and-fro’’ color and spectral Doppler findings are sampled proximal to (upstream) and at any abnor-
should be elicited (Fig. 6) [9]. mality. Parenchymal abnormalities are imaged in
transverse and longitudinal planes. Doppler interro-
gation of any thrombus seen is performed to aid in
Cirrhotic native liver determining if it is bland or tumor thrombus, particu-
larly in the presence of a liver mass. Tumor thrombus
Clinical may demonstrate flow on color or spectral Doppler.
Sonographic evaluation of TIPS is complex. Ve-
Cirrhosis is a diffuse process characterized by locities in as much of the shunt as is acoustically
fibrosis and alteration of normal liver architecture. visible should be evaluated. A complete assessment
Fig. 4. IVC stenosis after liver transplant. (A) Narrowing is visually apparent on gray scale images (arrows). (B) Spectral Doppler
demonstrates PSV of 24 cm/second 2 cm caudal to the infrahepatic anastomosis. (C) PSV at the anastomosis is 115 cm/second,
which results in a PSV ratio of 115/24, or 4.8. IVC venogram (not shown) showed stenosis without significant pressure gradient
at this level.
may require changes in patient position during the Sonographic criteria

examination—including the left lateral decubitus and
prone positions—to get the best angle and shunt Portal vein thrombosis
visualization. Main portal vein velocity and flow The presence of occlusive low-level echoes, or a
direction should be assessed. Values for the hepatic nonocclusive filling defect, may be observed at gray
venous end within the stent, mid-shunt and portal scale imaging. Color Doppler may be useful in
venous end within the stent, and highest and lowest finding hypoechoic thrombus not apparent on gray
intrashunt velocities (if at a different location) are scale imaging (Fig. 7). Normal portal vein caliber
recorded [2,13,15]. Flow direction and PSV in the ranges from 9 to 13 mm [16]. A small vessel in the
intrahepatic right and left portal veins and in the right, region of the portal vein is suspicious for prior
middle, and left hepatic veins are also evaluated [2]. portal vein thrombus, with subsequent vein sclero-
Stent diameter is measured. sis or collateral formation. Cavernous transformation,
Fig. 7. Cirrhotic liver with nonocclusive portal vein throm-

bus. Color Doppler demonstrates linear hypoechoic throm-
Fig. 5. Hepatic vein thrombosis after liver transplant. Color bus (asterisks) within the portal vein (arrows). Spectral
Doppler shows a hypoechoic linear structure (arrows) in the Doppler (not shown) also documented vessel patency.
region of the right hepatic vein without Doppler flow.
which represents multiple small periportal venous hypertension [17]. Bi-directional flow may precede
collaterals, suggests chronic portal vein thrombosis. reversal of flow [11].
Although cirrhosis is the most common cause of
Portal hypertension hepatofugal flow, there are exceptions. Large porto-
Portal venous hypertension may manifest sono- systemic collaterals may persist after transplantation
graphically as slow antegrade, stagnant, or hepatofu- and result in reversed flow in the absence of recurrent
gal flow in the main portal vein, intrahepatic branches portal hypertension. Liver function and portal vein
only, or extrahepatic collaterals only [11]. The portal patency may be compromised as a result. Hepatofu-
vein may be enlarged and measure more than 1.3 cm, gal flow in one or more intrahepatic portal veins may
a sensitive but not specific sign of portal venous occur with a focal arterioportal shunt from a biopsy or
tumor and is not specific for portal hypertension [11].
Transjugular intrahepatic portosystemic shunt

malfunction
TIPS is an effective and widely used means of
treating symptomatic portal hypertension. Timely
identification of TIPS malfunction increases the
probability of successful shunt revision with a conse-
quent decrease in recurrence of complications of portal
hypertension. Sensitivity and specificity rates for de-
tection of TIPS dysfunction range from 92% to 94%
and 72% to 100%, respectively, depending on the
number of abnormal criteria present [12,18]. Clinical
manifestations of TIPS dysfunction may include as-
cites recurrence, variceal bleeding, and splenomegaly.
A wide range of velocities is seen in patent shunts
[13,15], which necessitates determination of baseline
velocities in individual patients for long-term follow-
up [13]. Integration of data from several parameters is
Fig. 6. A 6.2-cm hepatic artery pseudoaneurysm at the ar- needed to suggest TIPS malfunction. If multiple
terial anastomosis. Liver transplant was performed at an abnormalities are identified, the likelihood of TIPS
outside institution. Color and spectral Doppler show typical dysfunction increases [12,18,19]. Stenosis most com-
biphasic ‘‘to and fro’’ pattern. monly involves the draining hepatic vein.
Direct signs of TIPS malfunction include lack of gradient [12,20]. Normal main portal vein velocity
flow with color and spectral Doppler, consistent with when a TIPS is present is approximately 43 cm/
shunt occlusion. Stenosis is suggested by a velocity second. Velocities in the main portal vein less than
within the shunt that is less than 90 cm/second or 30 to 33 cm/second correlate with TIPS malfunction
exceeds 189 cm/second. Velocity gradient across the (Fig. 8A – C) [12,18,20].
shunt also correlates with stenosis. Similar sensitivity Comparison with prior studies is helpful for
and specificity for detection of stenosis has been evaluating for TIPS malfunction. Decrease in main
shown when either 50 cm/second or 100 cm/second portal vein velocity of 20% from baseline or peak
is selected as the upper limit of normal for velocity shunt velocity decrease of more than 40 cm/second
Fig. 8. Stenotic TIPS. (A) Main portal vein velocity is abnormally low, 28 cm/second. (B) Spectral Doppler shows a velocity
gradient within the TIPS. Velocity at the hepatic vein side is 135 cm/second. Velocities mid-shunt and at the portal vein side
(not shown) were 60 and 50 cm/second, respectively. (C) The stenosis is located in the draining hepatic vein, where the velocity
is 206 cm/second.
Table 1
Indicators of transjugular intrahepatic portosystemic shunt stenosis [12]
Criteria Diagnostic threshold Sensitivity/specificity
Main portal vein velocity Less than 30 cm/sec Sensitivity 82%, specificity 77%
Decrease of 20% from baseline Sensitivity 78%, specificity 75%
Velocity within the TIPS <90 or >189 cm/sec Sensitivity 84%, specificity 70%
Decrease of >40 cm/sec or increase of Sensitivity 71%, specificity 88%
>60 cm/sec from baseline
Gradient across the TIPS More than 100 cm/sec Sensitivity 56%, specificity 78%
or increase more than 60 cm/second correlates with aneurysm are rare, usually sequelae to inflammatory
stenosis [12]. A change from retrograde to antegrade processes such as pancreatitis or septicemia. Portal
flow in a portal vein not drained by the TIPS and vein thrombus also may be seen with hypercoagula-
reappearance of varices or patent periumbilical col- ble states and malignancy.
lateral strongly suggests shunt malfunction [13] but
may be a relatively late sign (Table 1). Sonographic technique
Main portal vein velocity after TIPS placement
may be influenced by the size of the stent. Higher Comprehensive sonographic evaluation is similar
flow velocities may be observed with 12-mm versus to evaluation of the cirrhotic native liver. All anechoic
10-mm shunts. A higher main portal vein velocity structures are evaluated for flow. If the evaluation is
threshold for shunt malfunction may be necessary; for a postbiopsy complication, evidence of active
however, significant differences in maximum and hemorrhage also is sought.
minimum intrashunt velocities are not likely [19].
Sonographic criteria
Portal vein aneurysmal ectasia
Aneurysmal ectasia of the portal vein is uncom- Postbiopsy complications
monly seen and may be congenital or secondary to Active hemorrhage may be observed as a jet on
portal venous hypertension or vessel wall weakening color Doppler (Fig. 9) and demonstrate an arterial
related to inflammatory processes, such as acute spectral waveform. Additional findings consistent
pancreatitis. There is considerable variation in the with hemorrhage include the presence of hematoma
size of the portal vein. The measurement at which or fluid adjacent to the liver or in the pelvis. A non-
dilatation is called aneurysmal is somewhat arbitrary.
Aneurysmal ectasia is present if there is significant
focal portal vein diameter enlargement compared
with the rest of the vessel, especially if a saccular
or fusiform appearance is identified [21,22]. It gen-
erally appears as a cystic structure. Turbulent or ‘‘to
and fro’’ flow is identified with Doppler interrogation
[23], unless the vein is thrombosed.
Noncirrhotic native liver
Clinical
Applications of urgent Doppler ultrasound in

patients without cirrhosis include evaluation for
post – liver biopsy complications, sequela of inflam-
matory processes, and determination of the cause of
acutely elevated liver function tests. An acute drop in
hematocrit or unusual pain after biopsy may warrant Fig. 9. Postbiopsy hemorrhage. Color Doppler of native
sonographic evaluation for active hemorrhage or liver after biopsy shows active hemorrhage demonstrated
pseudoaneurysm. Portal vein thrombus and pseudo- by a jet from the biopsy tract to the liver surface (arrow).
thrombosed pseudoaneurysm demonstrates the typi- diastolic velocity. Flow should be laminar without
cal ‘‘to and fro’’ color and spectral pattern. aliasing. In the normal kidney, diastolic flow should
be present in the artery, and the upper limit of RI
Portal vein thrombosis has been described as 0.7 in adults [26,27]. Flow in
Evaluation is the same as for a cirrhotic liver. the main renal vein should have normal mild respi-
Portal vein thrombosis is rare in the native noncir- ratory phasicity.
rhotic liver and may not be detected on a routine
abdominal ultrasound. The authors have found that a
brief look at the main portal vein with gray scale and
Transplant kidney
color Doppler on routine abdominal ultrasound ex-
amination occasionally has been useful in detecting
Clinical
clinically unsuspected portal vein thrombus.
Ultrasound is the best initial imaging modality in
the renal transplant patient with elevated creatinine
Renal ultrasound
level. Using ultrasound as the initial screening test
avoids the use of radiation, increased cost, and the
Anatomy and appearance
potential nephrotoxic effects of iodinated contrast
associated with CT. Common allograft abnormalities
The kidney has several distinct anatomic features
include hydronephrosis with ureteral obstruction,
that may be differentiated by ultrasound. The renal
renovascular disease, acute tubular necrosis, and
cortex and medullary pyramids are similar in echo-
rejection. Peritransplant seromas or lymphoceles
texture in the normal kidney. Each pyramid and sur-
may cause hydronephrosis or compress the renal
rounding cortex converges into a renal papilla and
vessels. Rarely, a mass from posttransplant lympho-
collecting system infundibulum. In echogenic kid-
proliferative disorder may cause renal artery stenosis
neys, the pyramids of the renal medullary region are
or hydronephrosis [28]. Many of these etiologies
hypoechoic to the renal cortex. Each of these struc-
overlap in their clinical symptomatology, and the
tures may be distinguished easily from the echogenic
underlying problem must be diagnosed accurately to
fat of the central sinus. The anechoic renal calyces
guide therapy.
course into the renal pelvis and proximal ureter, struc-
Doppler ultrasound can document patency of a
tures that may be visualized if distended with urine.
transplant renal artery and vein and may aid in the
Normal cortical thickness averages 10 mm, but
detection of renal artery stenosis or an arteriovenous
differentiation of medulla and cortex may be difficult.
fistula. Decreased or absent perfusion in the post-
Instead, the combined thickness of the capsule to the
operative allograft is rare but requires immediate
renal sinus may be better depicted and normally mea-
intervention [29]. Gray scale ultrasound is sensitive
sures approximately 15 to 16 mm [24]. The length of
and specific for hydronephrosis, which is caused by
kidneys varies with patient height, but their median
obstruction in up to 8% of transplanted kidneys [30].
length is 11 cm; most kidneys measure 9.8 to 12.3 cm
Ultrasound may evaluate delayed function of the
long and are symmetric in length [24].
kidney or a sudden functional decline after good
A single renal artery arises from each side of the
initial results.
abdominal aorta caudal to the superior mesenteric
artery to supply each kidney. In up to 30% of
kidneys, however, accessory renal arteries may be Sonographic technique
present [25]. Accessory arteries may arise near the
main renal artery, distal aorta, or common iliac Sonographic characteristics of the renal transplant
arteries. The main renal artery bifurcates or trifurcates are similar to native kidneys with a few significant
into branches that supply the dorsal and ventral differences. Renal transplants are most commonly
portions of the kidney. Segmental renal arteries placed within the right or left pelvis. The superficial
course within the renal parenchyma near the pyra- location may allow easier visualization of the trans-
mids. Multiple renal vein branches join to form the plant vessels and anastomoses compared with the
main renal veins, which drain directly into the inferior vessels of the native kidneys. A higher frequency
vena cava. transducer—3.5 mHz or higher (usually a curved
The normal spectral waveform in the native renal transducer, which allows good visualization of the
artery is a rapid systolic upstroke with a small early near and far portions of the kidney)—is used. The
systolic peak followed by smooth tapering to the end entire course of the renal artery and vein should be
visualized, with special attention paid to the anasto- Doppler at each examination, because it is a relatively
moses, usually at the external iliac artery and vein. common site of abnormality. If a stenosis at the renal
Rarely, a transplant may be placed in the midabdo- artery anastomosis is suspected, a PSV is obtained in
men with anastomoses to visceral vessels. The kidney the proximal iliac artery approximately 2 cm from the
is often best visualized from an anterolateral approach anastomosis, which allows for the calculation of a
with displacement of any overlying bowel loops with renal artery anastomosis to proximal iliac artery PSV
gentle graded compression by the ultrasound trans- ratio. The main renal vein is also evaluated with color
ducer. Adynamic ileus in the perioperative period and spectral Doppler, which usually demonstrates a
may hinder the sonographic examination, however. normal antegrade venous waveform.
Once the allograft is localized, the renal vessels
can be traced to the areas of anastomosis. Angle-
corrected flow evaluation should maintain an angle Sonographic criteria
less than 60° from the sonographic beam. An initial
scan with power or color Doppler to demonstrate Postbiopsy complications
areas of decreased flow is useful. Regional decreased Interrogating the transplant kidney after instru-
flow may be the only suggestion of a segmental mentation or biopsy is important to assess for com-
stenosis or infarction. Subsequently, a representative plications that could result in loss of life or loss of the
segmental renal artery waveform in the upper pole, allograft. Color Doppler can detect active extravasa-
midportion, and lower pole is evaluated with spectral tion (Fig. 10A, B) of blood from the margin of the
Doppler, and an RI is calculated. The detection of an kidney at the point of biopsy. The biopsy tract is often
abnormal acceleration time or absence of the early visible, and active hemorrhage presents as a jet of
systolic peak may suggest transplant renal artery color that projects from this region into the perineph-
stenosis [31]. ric fat.
Color Doppler is used to identify turbulent vessel Pseudoaneurysm is a documented complication of
flow by the depiction of aliasing. Spectral Doppler is renal biopsy [32]. In a kidney with history of instru-
obtained in the areas of aliasing to evaluate for mentation, any anechoic structure should be evalu-
potential stenosis. PSV measurements are obtained ated with Doppler to exclude a vascular structure
at and approximately 2 cm proximal to the area of [33]. Flow that fills a cavity that does not conform to
aliasing or visual narrowing, which allows the calcu- the renal vessels confirms a pseudoaneurysm. Spec-
lation of a PSV ratio. The main renal artery anasto- tral Doppler may detect the ‘‘to and fro’’ waveform
mosis is specifically evaluated with color and spectral that diagnoses pseudoaneurysm in other sites.
Fig. 10. Postrenal biopsy hemorrhage. (A) Color Doppler of kidney after biopsy shows jet of active extravasation through the
capsule (arrow) into a perinephric hematoma. Renal parenchymal denoted by asterisk. (B) Spectral Doppler of the jet
demonstrates arterial waveform.
artery resistance downstream in the segmental arter-

ies, from an inflow, or intrinsic transplant abnormality
with high-resistance arterial waveforms.
Transplant vascular compromise

Severe vascular complications can result in rapid
loss of the transplant allograft. In this setting, emer-
gent Doppler may identify the cause of the dysfunc-
tion and allow intervention in a timely manner. In one
series, emergent ultrasound and intervention in pa-
tients decreased loss of the organ from 4.7% to
1.05%. In that series, the most common cause of
severe perfusional failure of the transplant was renal
artery stenosis [29], which may occur in as many as
8% to 16% of renal transplant allografts [39,40].
In the authors’ experience, there is an increased
incidence of transplant renal artery stenosis in living
related donor allografts compared with cadaveric
kidneys. This is likely because of different surgical
techniques in the cadaveric renal transplant versus
Fig. 11. Postbiopsy 0.6-cm arteriovenous fistula (cursors)
living related donor. In the cadaveric transplant, a
in a transplant kidney. Spectral Doppler (not shown) dem-
patch of the aorta is taken around the main renal artery
onstrated bidirectional flow in the renal parenchyma de-
noted by asterisks. Also, a needle track pseudoaneurysm is aorta takeoff. The anastomosis in the cadaveric trans-
seen (arrows). plant is actually a larger anastomosis than just that of
the main renal artery, from the aortic patch to the iliac
Arteriovenous fistula is a common complication artery, with resultant decrease in technical complica-
of renal biopsy (Fig. 11), and it is detected on follow- tions. Taking an aortic patch would not be desirable in
up imaging in 10% to 15% of biopsies [34,35]. It is the living related transplant. The main renal artery
important to find a fistula if present, because it can anastomosis with the iliac artery is generally a much
cause a significant steal from normal parenchyma, smaller diameter anastomosis, with increased poten-
which causes transplant dysfunction. A fistula may be tial for technical problems that cause stenosis.
suspected based on low resistance main renal artery Critical vascular compromise of a transplant kid-
flow in the absence of a vascularized collection. ney may be demonstrated with abnormal color Dopp-
There may be aliasing of signal on color Doppler ler perfusion. In the setting of rapid allograft failure,
[35]. On color Doppler, tissue reverberation may reduced or absent flow in the kidney and main renal
cause color artifact in the renal parenchyma [35,36]. artery suggests renal artery thrombosis [29]. This is a
High volume of flow may be present on spectral rare occurrence but may have severe impact on the
Doppler in the renal artery and vein [37]. Close to the allograft. Occasionally, only segmental arteries are
arteriovenous fistula (AVF), the draining vein typi- thrombosed. In these cases, segmental infarctions
cally has an arterialized waveform [35,38]. may be detected on color Doppler [41]. Power
Doppler may increase confidence for detection of
perfusional defects associated with areas of allograft
Intraoperative renal ultrasound infarction, however [42]. Renal artery stenosis also
Although intraoperatively the surgeon may note may cause allograft dysfunction.
by visual inspection that kidney perfusion is failing, In transplant renal artery stenosis, high PSVs of
the cause of the abnormal perfusion may not be clear. more than 200 cm/second have been described at the
The sonologist can be helpful to the surgeon during a site of a significant renal artery stenosis (Fig. 12A)
difficult surgical procedure by documenting renal [43]. The accuracy is improved if a PSV of more than
flow characteristics. Doppler ultrasound can docu- 350 cm/second criterion is used in combination with
ment patency of the main renal artery and main renal acceleration time and evaluation for dampened intra-
vein. It can detect an arterial dissection and may be renal waveforms [31]. Measurement of a tardus-par-
able to differentiate it from renal artery thrombosis. vus waveform (slow systolic acceleration with low
Intraoperative Doppler may assist the surgeon in peak flow velocity) of poststenotic flow in the allo-
differentiating an inflow problem with low renal graft also may suggest main renal artery stenosis
Fig. 12. Renal artery stenosis in a transplant kidney. Spectral Doppler shows an elevated velocity of 469 cm/second at the
arterial anastomosis (A) and parvus-tardus waveform (B) in an intrarenal segmental artery.
(Fig. 12B) [31,44]. Iliac artery stenosis proximal to

the transplant artery may affect a renal transplant
adversely in much the same way as renal artery
stenosis [45,46].
Renal vein thrombosis is rare, but it may cause
allograft loss if the diagnosis remains unrecognized.
Diastolic reversal of flow (Fig. 13) or absent flow in
the main renal artery has been documented in renal
transplant allografts with renal vein thrombosis
[43,47,48]. Both findings are nonspecific and may
occur with severe rejection [49], acute tubular necro-
sis, or acute interstitial nephritis [47]. Recognition of
the arterial waveform abnormality is useful to prompt
directed main renal vein evaluation for thrombus,
however. The normal main renal vein flow should
be antegrade with minimal variability, unlike the
rapid pulsatile waveforms of the renal artery.
Posttransplant allograft dysfunction

In a functioning, normal renal transplant, an RI of
0.5 to 0.7 has been generally reported [29]. Elevation
of the RI in a transplant has been described as an
indicator of allograft dysfunction (Fig. 14A) [50 – 52],
but it is not specific in determining the cause of the
allograft failure [52,53]. Elevated RIs may be associ-
ated with hydronephrosis (Fig. 14B). More worrisome
is a change in RIs over time without a morphologic Fig. 13. Spectral Doppler shows reversal of diastolic flow in
cause, such as hydronephrosis [54]. Interval increases the main renal artery. The renal vein was not definitely iden-
in RI are also nonspecific, however, and may be tified (not shown). At surgery, a large peritransplant hema-
caused by acute rejection, chronic rejection, acute toma was evacuated, which restored flow in the renal vein.
Fig. 14. Elevated RIs in two separate renal allografts. Spectral Doppler demonstrates increased RIs in segmental arterial
branches. (A) The RI of 0.91 was secondary to acute rejection 3 days after transplant, documented by Tc 99m MAG 3 study and
clinical findings. (B) The cause of the RI of 1 was severe hydronephrosis.
tubular necrosis, or cyclosporine toxicity. The RI in a abnormality. Renal vascular abnormality and hydro-
transplant kidney may be elevated in the perioperative nephrosis must be discerned from medical renal
period because of acute tubular necrosis [55]. disease, because the therapies differ. Renal artery
stenosis may be suggested by hypertension and renal
atrophy on gray scale images. Renal artery occlusion
Native kidney may occur secondary to embolus or thrombus and
may affect the main renal artery or branches. Renal
Clinical vein thrombosis is another cause of renal failure.
Renal vein thrombosis may occur acutely and is
Sonography is commonly used in the evaluation usually secondary to an underlying abnormality of
of abnormal renal function or evidence of urinary the kidney, abnormal hydration, or coagulation status.
pathology. In the emergency setting, ultrasound is The cause may be suggested in the presence of the
often the first imaging test to evaluate acute renal nonspecific finding of an enlarged kidney [56].
failure, flank pain, hematuria, or a postbiopsy drop in There are several situations in which the use of
hematocrit because it is rapid and inexpensive and Doppler ultrasound is more controversial. Doppler
does not use ionizing radiation or potentially neph- ultrasound is not considered adequate for exclusion of
rotoxic contrast agents. Ultrasound may help differ- acute renal trauma [57]. Although gray scale ultra-
entiate between various causes of renal dysfunction sound may grade the severity of hydronephrosis
that may be clinically similar in physical examination caused by acute obstruction by a renal stone, Doppler
and laboratory tests. assessment of RIs in this clinical setting is no longer
For most chronic renal pathologic conditions, gray generally performed. If hydronephrosis is detected
scale ultrasound is adequate to differentiate medical and there is clinical concern for ureteral calculus, a
renal disease from hydronephrosis or renovascular noncontrast CT for urinary calculi is obtained.
Sonographic technique RI criteria is limited because of the lack of sensitivity

of Doppler for partial obstruction or moderate hydro-
Sonographic settings and imaging technique for nephrosis [61]. In pregnant patients with clinical
evaluation of the kidneys must be optimized individ- concern for ureteral obstruction and additional con-
ually because the patient and scanning situation are cern about exposure to ionizing radiation, an RI more
often suboptimal in the emergent setting. Flow de- than 0.7 or more than the contralateral kidney may be
tection by color Doppler should be maximized with- accurate and useful for detecting obstruction [62].
out introducing too much color artifact in the adjacent Current clinical practice includes evaluating most
tissues. The gain should be increased until artifact patients with suspected renal colic with noncontrast
occurs and then slightly reduced below the level CT rather than ultrasound.
where artifacts are noted. Spectral Doppler should
use a gate that overlies most of the vessel diameter
and is angled with the direction of flow. Pyelonephritis
If evaluating for renal artery stenosis, complete Pyelonephritis is a common clinical diagnosis in
color and spectral Doppler of renal artery always the emergent setting that is often referred to a
should be attempted. Any areas of turbulent flow or radiologist for imaging. The differentiation between
aliasing on color Doppler should be evaluated closely pyelonephritis and cystitis may be difficult in a
with gray scale and spectral Doppler for stenosis. The patient with leukocytes in the urine. Ultrasound
arterial waveform of the aorta at the level of the renal may be requested to evaluate for renal abscess or
arteries should be obtained if renal artery stenosis is perinephric abscess. Color and power Doppler have
suspected. If there is a focal site of injury, such as in a been documented to show focal peripheral areas of
renal biopsy, the biopsy site should be investigated decreased perfusion in an infected kidney [63]. Al-
carefully with gray scale for adjacent hematoma and though not approved in the United States for clinical
Doppler for active hemorrhage. In this setting, any use within the urinary system, microbubble contrast
intrarenal anechoic structure should be checked with agents may demonstrate focal areas of infarction
Doppler for the possibility of pseudoaneurysm. associated with pyelonephritis with good detail and
may obviate the need for CT (Fig. 15) [64].
Postbiopsy complications
Immediately after renal biopsy, color Doppler is
useful for evaluating active bleeding from the site
of biopsy. The authors generally wait approximately
2 minutes after the biopsy before looking for sig-
nificant bleeding, however, because brief bleeding
is common with the large 14- to 16-gauge biopsy
needles used. Hemorrhage and urinoma are the most
common complications after renal biopsy [32]. Ac-
tive hemorrhage is detected as a fountain of color
that originates from the edge of the renal parenchyma
on color Doppler. The scale and filters must be ad-
justed to optimize for detection of flow. Typically
there is no sonographic evidence of arteriovenous
fistula in the immediate postprocedural setting. Arte-
riovenous fistulas and pseudoaneurysms from renal
biopsies occasionally can be seen on subsequent ul-
trasound evaluations, however.
Severe acute urinary obstruction

Severe acute urinary obstruction may be associ-
ated with Doppler abnormalities. The RI may be ele- Fig. 15. Pyelonephritis in a native kidney. Interval delay
vated in a severely hydronephrotic kidney [58 – 60]. transverse image using ultrasound contrast with agent detec-
Comparison of RIs with the contralateral normal tion imaging shows focal area of decreased perfusion (arrow)
kidney also may be helpful [26]. The usefulness of in the mid-kidney. Ps, psoas; SP, spleen.
Renal vein thrombosis injury is low [57]. Although demonstration of active

Renal vein thrombosis is associated with dehy- hemorrhage may direct a surgeon to the appropriate
dration, hypercoagulability, renal disease, tumor, sur- area of the body, absence of visualization does not
gery, extension of existing venous thrombus, and exclude a significant renal injury. Patients with active
trauma [65]. Color or power Doppler may detect ab- extravasation of urine or blood are often treated with
sent renal vein flow or thrombus as a filling defect conservative management [69] or angiographically
within the detected flow [66,67] or demonstrate ab- directed embolization.
sent or slow flow. It is important to realize that
venous collaterals develop quickly after native renal Renal artery stenosis
vein thrombosis, in contradistinction to the renal Many sonographic criteria are reported for the
transplant. It is important to evaluate the entire evaluation of renal artery stenosis in the native
renal vein—and not just the renal vein at the hi- kidneys with variable degrees of success [70]. The
lum—if this diagnosis is a clinical consideration. most widely accepted criteria are based on direct
Monophasic venous flow is also abnormal and may visualization of the main renal artery with elevated
indicate collateral flow or incomplete thrombosis PSV of more than 180 to 200 cm/second [70 – 72].
[65]. Absent diastolic flow may be noted in the native Stenosis may be detected as a focal area of turbulence
renal artery. Absent or reversed diastolic flow is or an area aliasing on color Doppler, confirmed by
neither sensitive nor specific for renal vein thrombo- spectral Doppler [67,73]. Other direct criteria include
sis in the native kidney, however [68]. a ratio of the PSV within the renal artery divided by
the PSV of the aorta of at least 3.5:1 (Fig. 16A, B)
Renal trauma [74 – 76].
Gray scale ultrasound may detect a renal lacera- Several indirect criteria also have been suggested
tion or contusion in the emergency setting; however, and are sometimes reported in conjunction with direct
there is little use of color or spectral Doppler evalua- criteria to increase detection of renal artery stenosis.
tion of the kidneys in the setting of acute abdominal The loss of the normal early systolic peak was the
trauma. The ability of ultrasound to visualize a renal most sensitive of the indirect criteria in one series
Fig. 16. Renal artery stenosis in a native kidney. (A) Spectral Doppler demonstrates normal aorta (Doppler gate) waveform
with a PSV of 57 cm/second. (B) Elevated PSV of 610 cm/second is detected in the proximal main renal artery (Doppler gate),
which resulted in a renal artery to aorta PSV ratio of 10.7.
[77]. Other criteria include the tardus-parvus wave- References

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Radiol Clin N Am 42 (2004) 417 – 425
Emergency ultrasound in trauma patients

John P. McGahan, MDa,*, John Richards, MDb, Maria Luisa C. Fogata, MDa
a
Division of Diagnostic Radiology, University of California, Davis, School of Medicine, 4860 Y Street, Suite 3100,
Sacramento, CA 95817, USA
b
Division of Emergency Medicine, University of California, Davis, School of Medicine, 2315 Stockton Boulevard,
PSSB 2100, Sacramento, CA 95817, USA
Although ultrasound (US) was first described in documented that sonographic sensitivity for the de-
the detection of blunt traumatic splenic injuries more tection of free fluid could be improved by having a
than 30 years ago [1], it was never widely advocated full bladder. Often in traumatized patients a Foley
until approximately 10 years ago [2 – 4]. There are catheter is placed and the bladder is decompressed,
probably two reasons for the initial limited use of which eliminates the acoustic window in the pelvis
sonography in blunt traumatized patients. The first is needed to detect small or moderate amounts of free
that the use of CT evolved at approximately the fluid. More recently, in an article by Hahn et al [6],
same time and was shown to be highly sensitive for patients with proven intra-abdominal injuries after
evaluation of blunt abdominal trauma [5]. CT not blunt abdominal trauma were evaluated and it was
only detected free fluid but also directly demonstrated demonstrated that the finding of free fluid with
the organ injury. Sonography also was used initially sonography was important. Seventy-eight percent of
to detect specific organ injury rather than the free patients with free fluid on sonography required lapa-
fluid associated with the injury. There were limita- rotomy, whereas only 27% without free fluid needed
tions in the ability and sensitivity of sonography in laparotomy. They also showed that examination of
directly demonstrating the injured organ. It was not Morison’s pouch had the highest detection rate of
until the 1990s that the focused abdominal sonogra- free fluid in these patients (66%), whereas free fluid
phy for trauma (FAST) was developed for the main was detected 56% of the time in the upper quadrants,
objective of detecting free fluid in patients with blunt 48% of the time in the paracolic gutters, and 36% of
abdominal trauma [2 – 4]. the time in the pelvis. Examination of all areas was
important, however, because 3 of the 604 patients
with intra-abdominal injuries had free fluid only in
Sonographic examination paracolic gutters [6]. At our institution we always
include an examination of the heart for pericardial
The initial focus of sonographic examination was fluid as a part of the FAST scan. US is also useful in
a single view of the hepatorenal fossa (Morison’s examinations of the chest for pneumothorax or pleu-
pouch) [2]. It was soon realized that a more compre- ral effusion, which are discussed later in this article.
hensive examination of the abdomen improved de-
tection of free fluid, however [4]. This included
examinations of both upper quadrants, the paracolic Sonographic findings
gutters, and pelvis. In 1997, McGahan et al [4]
Free fluid
* Corresponding author. Free fluid typically appears as a hypoechoic

E-mail address: john.mcgahan@ucdmc.ucdavis.edu region within the peritoneal cavity or pelvis and is
(J.P. McGahan). usually linear or triangular in shape (Fig. 1). The
doi:10.1016/j.rcl.2003.12.005
418 J.P. McGahan et al / Radiol Clin N Am 42 (2004) 417–425
Fig. 1. Patterns of free fluid. (A) Real-time US examination of the right upper quadrant demonstrates small triangular-shaped
hypoechoic region (arrow) that corresponds to free fluid. (B) Real-time US of the right upper quadrant demonstrates larger
hypoechoic region, with acute angles (arrow), noted just inferior to the liver and the right kidney that corresponds to free fluid.
(C) In the same patient as B, linear hypoechoic region in the hepatorenal fossa (Morison’s pouch) corresponds to free
fluid (arrow).
shape of the fluid depends on its compression by the physiologic, it may be secondary to an injury. In
surrounding structures. For instance, in Morison’s this situation, searching for free fluid in other sites
pouch, the fluid between the kidney and liver usually is important.
has a linear shape (see Fig. 1). Fluid that surrounds Loops of fluid-filled bowel should not be con-
bowel often appears triangular. Fluid often accumu- fused with free intraperitoneal fluid. Bowel loops
lates at the site of injury but then flows throughout can be distinguished from free fluid because they
the abdomen and into the pelvis. At the site of in- are round and have peristalsis. This should cause little
jury, the blood may appear echogenic as it forms a confusion. In almost all recent studies of the use
clot adjacent to the injured organ (Figs. 2, 3). There of sonography for detection of free fluid in patients
maybe several pitfalls in recognition of free fluid with blunt abdominal trauma, the specificity of so-
within the abdomen (Box 1). nography is high [4]. In some cases sonography may
detect small amounts of free fluid that are not vi-
Pitfalls sualized with CT [4].
Sonographic sensitivity in detecting injuries in
Patients with pre-existing ascites or iatrogenic patients with blunt abdominal trauma may be de-
free fluid (eg, dialysis patients) may have false- creased for several reasons. The sensitivity of sonog-
positive sonogram results. It is impossible in these raphy for detection of free fluid in the pelvis may be
patients to know if the free fluid is caused by pre- decreased if a full bladder is not used. With the
existing ascites, traumatic injury, or a combination of bladder decompressed after placement of a Foley
the two. In women of childbearing age, a small catheter, free fluid in the dependant portion of the
amount of ‘‘physiologic’’ free fluid may be noted in pelvis can be missed. Another potential pitfall of US
the pelvis. It is important to recognize that although detection of free fluid is that hematomas may appear
this free fluid is most likely pre-existing and probably echogenic. With severe injury, clotted blood at the
J.P. McGahan et al / Radiol Clin N Am 42 (2004) 417–425 419
Fig. 2. Echogenic clot/liver laceration. (A) Real-time US examination of the right upper quadrant of the abdomen shows right
kidney (RTK) and echogenic clot anterior to the liver (RT LOBE). (B) Real-time examination of the liver demonstrates fairly well
marginated echogenic region in the liver (arrows) that corresponds to liver laceration.
site of the injury may be echogenic and should not be Free fluid scoring systems
overlooked (see Figs. 2, 3). Finally, there is often no
free fluid associated with contained injuries of solid Scoring systems have been developed to help
organs, such as the liver, spleen, or kidney. In the stratify patients into groups who may or may not
article by Hahn et al [6], in several patients no free require laparotomy. Others have stratified patients
fluid was detected, yet 27% of these patients required based on either the amount of free fluid in one
laparotomy. This may be the greatest pitfall of the location or the number of locations in which free
FAST scan and is discussed later in this article. fluid was detected. For instance, Sirlin et al [7,8]
Finally, sonography is limited and unable to show described a scoring system based on the location of
some types of injuries, including spinal and pelvic the fluid. For each anatomic region in which fluid
fractures, bowel and mesentery injuries, pancreatic was detected, one point was given. The percentage of
injuries, vascular injuries, diaphragmatic ruptures, patients with a score of 0 who had intra-abdominal
and adrenal injuries [4]. injury or required surgical intervention (based on this
scoring system) was 1.4% and 0.4%, respectively.
For the score of 1, the rate of intra-abdominal injury
was 59%, and the rate of surgical intervention was
13%. The rate of intra-abdominal injury increased to
85% and rate of surgical intervention was 36%, for
a score of 2. For a score of 3, the percentage of pa-
Box 1. Pitfalls in examination of the

abdomen for free fluid
Pre-existing fluid (ascites)

Iatrogenic free fluid as in dialysis or
direct peritoneal lavage
Fig. 3. Subcapsular hematoma of the spleen. Longitudinal
Pelvic fluid (female)
real-time US of the spleen demonstrates well-demarcated,
Loops of fluid filled bowel
slightly hyperechoic region along the anterior aspect of the
spleen (arrow) that corresponds to subcapsular hematoma. Incomplete or empty bladder
(From McGahan JP, Wang L, Richards JR. From the RSNA Echogenic clot
refresher courses: focused abdominal US for trauma. Ra- Contained injury
diographics 2001;21(Spec No):S191 – 9; with permission.)
tients with intra-abdominal injury remained static at nathan et al, 157 patients (34%) with intra-abdominal
83%, but rate of surgical intervention was 63%. The injury had no free fluid, and 26 of these patients
higher the score, the higher the injury rate and the required surgery or further intervention. Sonography
greater the need for laparotomy. Others have advo- can be used to triage patients, but one must remember
cated scoring systems based on the number of free that it may miss significant injuries that require
fluid sites or the vertical height of free fluid [9,10]. A further intervention. CT should be used for patients
common theme would be the more the amount of with a negative sonography result in whom there is a
free fluid, the greater the likelihood of injury or the suggestion of intra-abdominal injury [20,21].
need for surgical intervention.
Sensitivity of sonography Solid organ injury
The sensitivity of sonography depends on what is After the initial studies on the use of sonography
used as the ‘‘gold’’ standard to which US is com- in detecting organ injuries in the 1970s [1], more
pared. When sonographic results are compared with recent studies focused on the detection of free fluid
clinical outcome, the sensitivity rates of sonography [11 – 13]. A few recent studies have demonstrated the
are high, usually more than 95% [11 – 13]. McGahan ability of sonography to detect parenchymal organ
et al [4] calculated a sensitivity rate of only 63% abnormalities directly. Rothhin et al [12] reported a
when sonography was compared with CT or laparot- sensitivity rate of 41.4% for the direct detection of
omy and not using clinical observation as a gold solid organ injuries by sonography. McGahan et al [4]
standard. The probable reason for this discrepancy also reported a sensitivity rate of 41% detection in
in sensitivities is that McGahan et al [4] showed that solid organ injuries. More recently, Polletti et al [17]
several minor lacerations of the liver or spleen were showed a sensitivity rate of 41% for direct demon-
detected on CT but not detected by FAST. These stration of organ injury. Stengel et al [22] showed
patients did not require surgical intervention, and all that a 7.5-MHz linear ray probe detected solid or-
improved clinically. If clinical improvement had gan injuries much more readily than a 3.5-MHz
been used as the ‘‘gold’’ standard, these patients convex probe.
would have been deemed as having true negative
results. When using CT as the ‘‘gold’’ standard,
however, they were deemed as having false-negative Sonographic appearance of solid organ injuries
results. This is the main reason for discrepancies in
the sensitivities of FAST scan. Much of the work on sonographic classification
Numerous other studies have been published on and appearance of solid organ injuries has been
the topic of the sensitivity of FAST. For instance, in performed by McGahan et al [23,24] and Richards
744 pediatric patients with blunt abdominal trauma, et al [25,26]. When identified, acute solid organ
Richards et al [14] demonstrated a sonographic sen- injuries are often echogenic on sonography. A diffuse
sitivity rate of 68% for detecting free fluid or solid heterogeneous echogenic pattern is the predominant
organ injuries. In a large review of 3264 patients, this
same study group showed that sonography had a sen-
sitivity rate of 67% in detection of intra-abdominal
injury [15]. Other results from recent literature vary.
Miller et al [16] reported a sensitivity rate of 42%
for the FAST scan when compared with CT. Polletti
et al [17] demonstrated a sensitivity rate of 93% for
sonography, however. Other studies have shown that
sonography may miss injuries that may require sur-
gery. Dolich et al [18] reported on 43 patients with
false-negative sonography results, 10 of whom (33%)
required surgery. Shanmuganathan et al [19] studied
the use of sonography in more than 11,000 patients
with blunt abdominal trauma: 467 patients had intra- Fig. 4. Splenic laceration. US examination of the left up-
abdominal injury, 310 (66%) of whom had free fluid per quadrant demonstrates poorly marginated spleen with
detected by sonography. This detection rate is simi- mixed echo pattern (arrows), which corresponds to severe
lar to past studies. In this larger study by Shanmuga- splenic laceration.
pattern identified with splenic injuries (Fig. 4). A dis- can be used to diagnose pneumothorax or free fluid
crete hyperechoic or diffuse hyperechoic pattern is within the thorax. More recently, sonography also
seen with hepatic injuries (see Fig. 2). Renal injuries has been shown to be helpful in diagnosing peri-
are echogenic, with a disorganized appearance that cardial effusions [29,30] in traumatized patients. The
occurs with severe renal lacerations (Fig. 5). main reason for diagnosing pericardial effusions is to
More recently, contrast-enhanced abdominal US prevent patients from having a traumatically induced
has been used in the evaluation of solid organ inju- pericardial tamponade. We incorporate the subcostal
ries in trauma patients (Fig. 6). For instance, Marte- view of the heart as a portion of the FAST scan in all
gani et al [27] presented the preliminary evaluation patients with blunt abdominal trauma. This is helpful
of micro-bubble – enhanced US of abdominal organs in diagnosing pericardial effusions (Fig. 7). It must
in blunt and penetrating trauma. They evaluated be emphasized that inexperienced examiners often
14 patients with abdominal trauma who were scanned have problems diagnosing pericardial effusions. For
with unenhanced US and contrast-enhanced sonogra- instance, Blavias et al [30] set up a study with
phy. These authors use SonoVue (Bracco/ ALTANA emergency medicine residents and fellows trained in
Pharm, Konstanz, Germany), a phospholipid coated sonography. They had trouble discerning the epicar-
micro-bubble, at the dose of 1.2 to 2.4 mL scanned dial fat, which appeared hypoechoic on US, from a
with a low mechanical index. The liver, spleen, and true pericardial effusion. Sonography had a sensitiv-
kidneys were studied over a 3- to 5-minute interval. ity rate of 73% and a specificity rate of only 44%
They demonstrated that on the unenhanced scan, no in this study [30]. With more experienced examiners,
lesions were confidently visualized. Excellent en- sonography may be useful in detecting moderate
hancement of the parenchymal organs was obtained pericardial effusions.
in all cases using contrast-enhanced sonography, More recently, sonography also has been proved
however. They detected injuries in the liver in 5 pa- to be useful in diagnosing pneumothorax [31,32]. The
tients, the spleen in 5 patients, and the kidney in parietal pleura adheres to the inner muscle of the tho-
4 patients. In 7 patients there was confirmation with rax, whereas the visceral pleura adheres to the lung.
CT, and there was good correlation between contrast- During inspiration and expiration the visceral pleura
enhanced sonography and contrast-enhanced CT in ‘‘slides’’ back and forth adjacent to the parietal
terms of the position and size of the abnormality. pleura. The bright echogenic line of the visceral
The authors believed that the contrast-enhanced so- pleura, which adheres to the lung as it moves and
nography might expedite management of trauma slides during normal inspiration and expiration, may
patients [27]. be observed on real-time sonography and is a normal
finding (Fig. 8). Absence of the sliding lung is a
The chest direct sign of pneumothorax (Fig. 9). Remembering
that the free air within the thorax rises to the most
Sonography has been shown to detect pleural nondependent portion of the thoracic cavity, the US
effusions [28]. In traumatized patients, sonography probe is placed in this area to check for pneumotho-
Fig. 5. Renal laceration. (A) Longitudinal scan of the right upper quadrant of the abdomen demonstrates ill-defined region
without reniform shape, which corresponds to severe renal laceration (shattered kidney) (arrows). Right nephrectomy was
performed immediately after the US examination. (B) Real-time US examination of the right paracolic gutter demonstrates
an echogenic region inferior to the kidney in the right paracolic gutter that corresponds to hematoma (arrow).
Fig. 6. Contrast-enhanced US of splenic laceration. (A) Noncontrast US of the spleen appears normal. (B) Contrast-enhanced US
with SonoVue demonstrates a large, wedge-shaped defect in the central portion of the spleen. (C) Correlative CT demonstrates
splenic laceration. (Courtesy of Thomas Albrecht, MD, FRCR, Berlin, Germany.)
rax. Either a curved array probe or, better yet, a linear patient. The normal motion of the visceral pleura
array probe may be used to detect pneumothorax. The against the parietal pleura is absent with pneumotho-
US probe is placed in the intercostal space. The rax, however. In a normal patient, a ‘‘reverberation
normal ‘‘to and fro’’ motion of the visceral pleura artifact’’ usually is noted posterior to the parietal
against the parietal pleura is observed in a normal visceral pleura interface in a normal patient (see
Fig. 8). This is observed as lines that are equally
spaced from one another and gradually decrease in
echogenicity. This is the reverberation of the US
beam as it strikes the interface between the parietal
and visceral pleura and the air in the lung and is
reflected back to the transducer. This reverberation
produces multiple equally spaced echoes. The rever-
beration artifact is not identified when there is a
pneumothorax. A pneumothorax may produce acous-
tic shadowing. Absence or decrease of the reverber-
ation artifact also may occur in a normal patient if
the gain settings are set too low.
An article by Rowan et al [33] compared the
accuracy of sonography with that of the supine
Fig. 7. Pericardial effusion. Subcostal real-time US of the chest radiograph in detecting traumatic pneumotho-
heart demonstrates anechoic region (long arrow) anterior rax, with CT serving as the reference or ‘‘gold’’
to the heart, which corresponds to pericardial effusion. standard. They studied 27 patients who sustained
Fig. 8. Normal lung. (A) Real-time US examination using linear array probe demonstrates the appearance of the normal lung on
US. Note that the first echogenic line (open arrow) corresponds to the interface between the parietal and the visceral pleura.
Parallel equally spaced lines of decreasing echogenicity are observed posterior to this, which corresponds to reverberation
artifacts (arrows). (B) Drawing of reverberation artifact. The US probe is placed on the skin surface (S). R refers to the interface
between the parietal and visceral pleura. Lines labeled as numbers 1 and 2, which are of decreasing echogenicity posterior to this,
correspond to reverberation artifacts caused by the US beam ‘‘reverberating’’ or ‘‘bouncing’’ between the pleura and transducer.
(C) Similar pattern is seen with sector scan of the lung in another patient.
blunt thoracic trauma and had US. The radiographic specificity rate of sonography was 94%, and 1 of
and US findings were compared with CT findings. 16 patients had a false-positive diagnosis of pneu-
Eleven of 27 patients had pneumothoraces as seen mothorax. Supine chest radiography had a sensitivity
with CT. All of the pneumothoraces were detected rate of only 36% (4 of 11 patients), with a specificity
by sonography, for a sensitivity rate of 100%. The rate of 100%. In their study, US was more sensitive
shown to be sensitive in detecting pneumothoraces in

traumatized patients.
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Radiol Clin N Am 42 (2004) 427 – 443
Priapism
Hossein Sadeghi-Nejad, MDa,b,*, Vikram Dogra, MDc, Allen D. Seftel, MDd,
Mamdouh A. Mohamed, MDd,e
a
Division of Urology, University of Medicine and Dentistry of New Jersey, Medical School, 185 South Orange Avenue,
MSB G536, Newark, NJ 07103-2714, USA
b
Center for Human Sexuality and Male Reproductive Medicine, Hackensack University Medical Center, 20 Prospect Avenue,
#711, Hackensack, NJ 07601, USA
c
Division of Ultrasound, Department of Radiology, Case Western Reserve University, University Hospitals, 11100 Euclid Avenue,
d
Department of Urology, Case Western Reserve University, University Hospitals of Cleveland,
Cleveland Veterans Affairs Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106 – 5046, USA
e
Department of Urology, El-Mina University Hospital, El-Mina, Egypt
Priapism is a relatively uncommon medical con- Definition

dition that is defined as a pathologic prolonged en-
gorgement or erection of the penis or clitoris that is The term ‘‘priapism’’ is derived from Priapus, a
unrelated to sexual arousal. Recent advances in the minor god of fertility, luck, and the deity of gardens
study of erectile physiology and the pathophysiology and fields in Greek mythology [2]. A famous painting
of erectile dysfunction have resulted in better under- in the entrance to the House of Vettii in Pompeii
standing of the processes leading to various subtypes depicts Priapus with a disproportionately large phal-
of priapism and the factors implicated in its resolu- lus, leaning against a pillar and weighing his massive
tion or recurrence. Despite these advances, there is a penis. Conditions related to the prolonged engorge-
paucity of randomized studies and basic science ment of the penis were associated with Priapus in
investigations pertaining to priapism. The recently the Greek language and were later assimilated into
published American Urological Association (AUA) Latin and modern languages [2]. In the early twenti-
Guideline on the management of priapism sheds eth century, Hinman [3] classified priapism as either
further light on the management of this potentially mechanical or nervous in etiology and suggested
emergent condition, but the guideline ‘‘does not es- corporal vein thrombosis as the cause of mechanical
tablish a fixed set of rules or define the legal standard priapism. The condition is more common in men and
of care for the treatment of priapism’’ [1]. typically involves the paired corpora cavernosa, al-
though rare exceptions with involvement of the
corpus spongiosum and sparing of the cavernosal
spaces have been reported [4].
Priapism is broadly classified as low-flow (ische-
mic) or high-flow (arterial and nonischemic). Low-
* Corresponding author. Division of Urology, Univer-
sity of Medicine and Dentistry of New Jersey, Medical
flow priapism and the associated severe decrease in
School, 185 South Orange Avenue, MSB G536, Newark, venous drainage from the corpora cavernosa is a
NJ 07103-2714. potential medical emergency and may lead to irre-
E-mail addresses: hossein@ix.netcom.com, versible ischemic tissue changes. High-flow priapism
www.hsadeghi.com (H. Sadeghi-Nejad). is less commonly encountered and involves unregu-
doi:10.1016/j.rcl.2004.01.008
428 H. Sadeghi-Nejad et al / Radiol Clin N Am 42 (2004) 427–443
lated inflow that is typically secondary to some form The penile blood vessels arise from the internal
of arterial trauma. One of the earliest reports of pudendal artery. The common penile artery continues
arterial priapism was published in 1960 following a in the Alcock’s canal above the perineal membrane
case of traumatic coitus that was surgically managed and terminates in three branches to supply the erectile
by ligation of the internal pudendal artery [5]. Unlike bodies. The bulbourethral artery supplies the urethra,
the ischemic subtype, arterial priapism is not consid- spongiosum, and the glans. The cavernosal artery
ered an emergency: the patient does not have pain enters the corpora cavernosa on the superomedial
and spontaneous resolution is the likely outcome in surface of the penis. The cavernosal artery travels in
more than half the cases. Hauri et al [6] elaborated on the center of each corporal body and gives off straight
the different management approaches to arterial ver- and helicine arteries. Helicine arteries form a bridge
sus veno-occlusive priapism and was one of the first between the cavernosal artery and the lacunar spaces
to suggest that the prognosis of the latter is far less in the corpora cavernosa [7]. It is the cavernosal artery
favorable than arterial priapism. Nonetheless, the and its branches that dilate and bring extra blood to the
long-term outcome of nonischemic priapism has not erectile tissue during penile erection. The dorsal artery
been thoroughly investigated and it is clear that of the penis passes between the crus penis and the
completely normal erectile function after these epi- pubis to reach the dorsal surface of the corporal
sodes cannot be guaranteed in all cases. Stuttering bodies. The dorsal artery mainly supplies blood to
priapism refers to a condition of recurrent, intermit- the glans and runs between the dorsal vein and the
tent, painful erections. These episodes are more dorsal penile nerve. The venous blood is returned by
common in patients with various hemoglobinopa- the venous plexus beneath the tunica albuginea. The
thies. Stuttering priapism is especially troublesome emissary veins perforate the tunica albuginea, and
for both the affected patient, facing repeated painful the blood is drained by the venae circumflexae into
episodes and potential emergency room visits, and the deep dorsal veins.
the physician challenged to arrive at a practical and
efficacious management plan for the patient. Malig-
nant priapism is a rare clinical entity that is caused
by metastasis of solid tumors to the penis. Sonographic technique
A penile sonographic examination is performed

with the patient supine with the penis lying on the
Sonographic anatomy of the penis anterior abdominal wall or supported with towels
between the thighs. High frequency (7.5 – 12 MHz)
The penis is composed of two dorsal corpora linear array ultrasound transducers provide high-reso-
cavernosa and one ventral corpus spongiosum. The lution images of the penis [7]. Copious amounts of
two corpora cavernosa are enclosed in a fibrous acoustic gel should be used on the surface of the
sheath, the tunica albuginea, which partially covers penis to optimize visualization and avoid excessive
the corpus spongiosum. The tunica albuginea is com- compression by the transducer.
posed of elastic fibers that form an irregular, latticed Transverse images of the penis are recorded start-
network on which collagen fibers rest. The septum ing at the level of the glans and moving down to the
between the two corpora cavernosa is complete proxi- base of the penis. The two corpora cavernosa are iden-
mally and is incomplete in its distal two thirds. The tified as two adjacent circular hypoechoic structures.
corpora cavernosa join beneath the pubis (penile The tunica albuginea is identified as a hyperechoic
hilum) to form the major portion of the body of the linear structure covering the corpora. The cavernosal
penis. The corpora cavernosa are composed of si- artery is visualized on the medial portion of each
nusoidal spaces lined by smooth muscles (erectile corpora cavernosa. The corpus spongiosum is often
tissue) and endothelium. The glans penis is formed compressed and is difficult to visualize from the ven-
by the expansion of the corpus spongiosum. tral aspect (see Fig. 1). Longitudinal evaluation of the
The corpus spongiosum is traversed throughout corporal bodies should also be obtained and recorded.
its length by the anterior urethra, which begins at the During the transverse and longitudinal scanning, close
perineal membrane. The corpus spongiosum provides attention should be given to any plaques, calcific foci,
support to the urethra and helps with the expulsion or arteriovenous fistulas. In the case of veno-occlu-
of semen from the urethra. Buck’s fascia surrounds sive priapism, the sonographer should be extremely
both cavernosal bodies dorsally and splits to sur- gentle while performing the sonographic examination
round the spongiosum ventrally (Fig. 1). because this is an exceedingly painful condition.
H. Sadeghi-Nejad et al / Radiol Clin N Am 42 (2004) 427–443 429
A
Dorsal Artery Dorsal Veins
Cavernosal Tunica Albuginea

Artery
Corpus Buck's Fascia

Cavernosum
Corpus Spongiosum Urethra
C
Internal Pudendal Artery Cavernosal Artery
Dorsal Artery
Helicine Arteries
Spongiosal Artery
Bulbar Artery
Fig. 1. (A) Diagrammatic representation of penile anatomy in cross-section. (B) Corresponding gray-scale ultrasound image.
(C) Diagrammatic representation of penile anatomy in longitudinal view. (From Fitzgerald SW, Erickson SJ, Foley WD, et al.
Color Doppler sonography in the evaluation of erectile dysfunction. Radiographics 1992;12(1):3 – 17; with permission.)
The presence of the cavernosal artery in each [16,17]. No correlations are observed between the
corpora cavernosa along with a spectral Doppler average number of priapism episodes per year and
waveform of each should be obtained and recorded. the duration of a typical episode. A similar study from
Color Doppler images in both transverse and longi- Jamaica documented a 42% prevalence of priapism in
tudinal views should also be obtained. SCA patients [18]. Priapism was significantly associ-
ated with low hemoglobin F levels and high platelet
counts and over one fourth of those who had suffered
priapism had some degree of impotence. A more
Epidemiology and etiology recent survey of patients with homozygous SCA
(hemoglobin SS) and sickle cell b(0) thalassemia
Eland et al [8] have evaluated the incidence of (hemoglobin S-b[0]) between 5 and 20 years of age
priapism in the general population. These investiga- found an 89% actuarial probability of experiencing
tors conducted a population-based retrospective co- priapism by 20 years of age. The mean duration of an
hort study using a longitudinal observational database episode in this study was 125 minutes. Episodes
from the patient records of a group of general practi- typically occurred around 4:00 AM, and 75% of the
tioners in The Netherlands. They found an overall patients surveyed had at least one episode starting
incidence rate of 1.5 per 100,000 person-years. The during sleep or on awakening from sleep [19].
incidence rate in men 40 years old and older was Drug-induced priapism has been reported with a
2.9 per 100,000 person-years. The authors acknowl- variety of medications, most commonly related to
edged that not all patients with priapism seek medical the antihypertensive drugs guanethidine, prazosin,
care and the reported data may be an underestimation and hydralazine and psychotropic medications [20].
of the actual rate in the general population. The Antipsychotics are associated with a small, but defi-
incidence of priapism in special at-risk subpopula- nite risk of priapism and the most commonly cited
tions is much higher. At-risk populations include men agents are trazodone (Desyrel), thioridazine, and
with cocaine drug use, advanced pelvic or hemato- chlorpromazine [21]. Abber et al [22] investigated
logic malignancy, and those on antipsychotic medi- the mechanism of drug-induced priapism in dogs by
cations [9 – 12]. Pohl et al [13] evaluated various intravenous and intracorporeal injection of the anti-
etiologies for priapism in a study of 230 single case psychotic agent chlorpromazine and the antidepres-
reports in the literature: idiopathic causes comprised sant trazodone. The authors demonstrated that both
one-third of the cases, whereas 21% were attributed drugs induced erection in a manner similar to that of
to alcohol abuse or medications, 12% to perineal intracorporeal injection of papaverine and showed
trauma, and 11% to sickle cell anemia (SCA) [13]. venous restriction and slight increases in internal
For individuals on intracorporal injection ther- pudendal arterial flow at the beginning of tumescence.
apy for erectile dysfunction, the incidence range of The authors stated that the a-adrenergic antagonist
priapism episodes is from 1% for those on prostaglan- properties of chlorpromazine and trazodone probably
din E1 and as high as 17% for patients who receive cause priapism by local action. Psychotropic-induced
intracorporeal injections of papaverine [14]. The most priapism is almost always associated with low-flow
likely cause of prolonged erection as a result of pathology and is currently believed to be caused by
intracavernous injection therapy is overdosage. Proper the a1-adrenergic antagonism of these medications.
injection technique and gradual upward titration of the Chlorpromazine and thioridazine are conventional
dose by the patient helps decrease this adverse event. antipsychotics with the greatest a1-adrenergic affin-
Priapism associated with sickle cell disease is ity and have been most frequently reported to be
classically described as ischemic, although rare ex- associated with priapism [9]. The exact pathophysiol-
ceptions of high-flow priapism in association with ogy has not been elucidated, but is likely multifacto-
sickle cell disease have been reported. The pathophys- rial and may be related to the ratio of a-adrenergic
iology of high-flow priapism in patients with sickle blockade to anticholinergic activity. Risperidone,
cell disease is not known [15]. Fowler et al [16] olanzapine, and clozapine are the atypical antipsy-
evaluated the incidence and prevalence of priapism chotics that have been reported to cause priapism on
in sickle cell conditions. The authors reported fre- rare occasions [9].
quent self-limited priapistic episodes, mostly occur- It has been reported that trazodone and cocaine
ring during sleep, which last less than 3 hours. may have synergistic effects in promoting priapism
Priapism associated with SCA was unusual before and their combination may pose an additional risk of
puberty and in keeping with the previously reported priapism. Clinicians should be aware of the possible
6% prevalence of priapism in children with SCA additive risk of priapism in this patient population,
because trazodone is commonly used as a hypnotic from testis, lung, liver, bone, and sarcomas as the
and is often chosen for polysubstance abusers because primary source [39]. It has been reported that 20% to
of its low abuse potential [23]. Cocaine-induced 53% of cases of penile metastasis from other primary
priapism has been reported in association with topical tumors initially present with priapism [40].
application to enhance sexual performance, and intra- When Witt et al [41] published their paper on
nasal and intracavernous injections [24 – 26]. Priapism traumatic laceration of intracavernosal arteries and
has also been reported in association with the recrea- the pathophysiology of nonischemic high-flow pria-
tional drug ecstasy [27]. pism in 1990, only five additional cases of priapism
Androgens have been implicated as an important with similar features to the reported case were cited.
etiologic factor with reports of priapism in hypogo- Although more attention has been focused on this
nadal men receiving gonadotropin-releasing hormone subtype of priapism and numerous related papers have
or high-dose testosterone, testosterone-induced pria- been published since the early 1990s, there is general
pism in adolescents with SCA, and priapism after agreement that arterial priapism is far less common
androstenedione intake for athletic performance en- than the ischemic variant. It is estimated that the
hancement [28 – 31]. condition is rare enough that few urologists treat more
Examples of neurologic etiologic factors include than two cases in their lifetime [42]. Nonetheless,
priapism in patients with degenerative stenosis of because the presentation of arterial priapism is pain-
the lumbar canal, where symptoms may be fully re- less and far less distressful to the patient, it is entirely
lieved by surgical decompression, and priapism possible that many more cases of arterial priapism
secondary to cauda equina syndrome (following de- are unreported. Nonischemic priapism has been de-
generative stenosis of the lumbar canal and lumbar scribed in a variety of conditions causing perineal
arachnoiditis), herniated disk, or blockage of the trauma including bicycling and other straddle injuries
central inhibitory influences as seen during general [43 – 47]. The resultant injury to the arterial system
or regional anesthesia. and formation of an arteriolacunar fistula is most often
Noteworthy reports of systemic illnesses impli- implicated as the causative factor in nonischemic
cated as etiologic factors include reports of priapism high-flow priapism. The venous outflow system is
occurring in widespread amyloidosis [32]. Other un- typically unaffected in these conditions and the blood
common etiologies include glucose phosphate isom- in the corpora remains well oxygenated. The condi-
erase deficiency (third most commonly occurring tion may also be iatrogenic following deep dorsal
erythroenzymopathy), which can cause priapism vein arterialization for vasculogenic impotence [48].
through increased rigidity of red blood cell membrane This etiology is exceedingly unlikely to be reported in
and resultant increased blood viscosity, cell sludging the future, however, because deep dorsal vein arteri-
in the corpora, and increased acidity; Fabry’s disease alization is rarely performed anymore. The most
(glycosphingolipid lipidosis) presenting with a com- common etiology for high-flow priapism in children
bination of renal insufficiency and priapism; high is traumatic arterial laceration, but cases associated
concentration (ie, 20% rather than 10%) fat emulsion
in total parenteral nutrition; and paradoxical throm-
boembolic events in heparin- or warfarin-induced
priapism [33 – 37]. Possible etiologies for increased
thromboembolic events in total parenteral nutrition –
induced priapism include increased blood coagulabil- Box 1. Etiology (AFUD classification)
ity and fat emboli and direct cellular effects by high fat
content. Increased platelet function assessed by the Drug induced
levels of antiheparin platelet factor 4 and b-thrombo- Hematologic
globulin has been documented in priapism following Sickle cell disease and other hemo-
20% fat emulsion total parenteral nutrition [35]. globinopathies
The mechanism of malignant priapism has not Thrombophilia states (protein C and
been definitively elucidated, but may be caused by other thrombophilias, lupus)
extensive organ replacement by carcinoma, venous Hyperviscosity states (hyperleukocy-
obstruction by the tumor, or continual stimulus to the tosis, polycythemia)
erectile afferent or efferent neural pathways [38]. Idiopathic
Tumor infiltration is most frequently from the bladder Central nervous system mediated
and prostate (32% and 28%, respectively) followed by Other
kidney (17%), gastrointestinal tract (8%), and rarely
logic Disease (AFUD) Thought Leader Panel on Pria-

Box 2. Etiologic factors in priapism
pism [43,52]. A more detailed list of etiologic factors
based on low-flow versus high-flow subtypes of
Low-flow states (veno-occlusive or
priapism is shown in Box 2.
ischemic type)
Hemoglobinopathies and sickle cell

disease
Thrombophilia states (lupus, Pathophysiology
protein C)
In broad terms, priapism may be regarded as an
Warfarin or heparin induced
imbalance between arterial inflow and outflow. Bur-
Fabry’s disease
nett [53] has recently reviewed the pathophysiology
Dialysis
of priapism and suggested derangements in the di-
Total parenteral nutrition (high fat
verse systems of regulatory control in erectile func-
content)
tion. These dysregulatory functions include possible
Vasculitis
overactivity of the veno-occlusive mechanism, arte-
Hematologic malignancies
rial inflow, or neurogenic processes that can affect
Pelvic or lower genitourinary tract
inflow or outflow. Conversely, the problem may be
(bladder and prostate) cancer and
secondary to malfunction of the normal contractile
metastatic (ie, renal) malignancies
activities of cavernosal smooth muscle cells.
Psychotropics and antidepressants
(chlorpromazine, trazodone,
Low flow
risperidol)
Antihypertensives (guanethidine,
Ischemic or veno-occlusive priapism is a medical
hydralazine, prazosin)
emergency and the most common form of priapism.
Erectogenic agents (intracavernosal
It is characterized by a painful, rigid erection; absent
vasoactives; sildenafil; intraurethral
cavernosal blood flow; and severely acidotic corpora
prostaglandin E1)
(Fig. 2). The spectrum of clinical symptoms and signs
Spinal cord stenosis
is analogous to those found in other compartment
Amyloidosis
syndromes and mandates immediate decompression
Glucose phosphate isomerase
to minimize the chances of long-term sequelae. The
deficiency
combination of venous outflow obstruction, high-
Alcohol
pressure chambers, and poor-to-absent inflow can
Androgens or testosterone
lead to trabecular interstitial edema and ultrastruc-
tural changes in trabecular smooth muscle cells and
High-flow states (arterial or nonischemic
functional transformation to fibroblast-like cells. In
type)
priapism lasting more than 24 hours, severe cellular
damage and widespread necrosis may occur [54].
Penile or perineal trauma
Destruction of the endothelial lining, formation of
Straddle injury
blood clots within the corpora, and widespread trans-
Cavernosal artery injury
formation of the smooth muscle cells to fibroblast-like
Arteriosinusoidal fistula
cells or necrosis occurs in cases lasting beyond
Cocaine
48 hours and eventually results in irreversible erectile
Metastatic malignancy
dysfunction [54]. Lack of these changes in priapism
Fabry’s disease
lasting less than 12 hours emphasizes the importance
Iatrogenic (following deep dorsal vein
of patient education and early intervention.
arterialization)
In an animal model, anoxia has been shown to
eliminate spontaneous and drug-induced contractile
activity, suggesting a likely explanation for the failure
with inherited metabolic disorders (ie, Fabry’s dis- of penile injection of a-adrenergic agonists to reverse
ease) or hematologic diseases, such as SCA, also have prolonged ischemic priapism when the penis is in its
been described [49 – 51]. maximal rigid state [55]. The failure of detumescence
Box 1 is a classification of priapism by etiology seen in low-flow priapism may be secondary to failed
as agreed on by the American Foundation for Uro- a-adrenergic neurotransmission, endothelin deficit, or
tients must be instructed on the proper and early

use of phenylephrine self-injections. Most recently,
Lin et al [57] have postulated that the mechanism
of stuttering priapism in patients with sickle cell
hemoglobinopathies may involve abnormally low
expression of phosphodiesterase type 5 secondary to
hypoxia. In the human corpus cavernosum, phos-
phodiesterase type 5 is responsible for degradation
of cGMP and phosphodiesterase type 5 inhibitors,
such as sildenafil and vardenafil, have become the
mainstay of oral pharmacotherapy in the treatment of
erectile dysfunction.
Seftel et al [58] have reported on two cases of
veno-occlusive priapism refractory to conventional
therapy that later converted to high-flow priapism.
The authors suggested that the high-flow state ob-
served after treatment of veno-occlusive priapism may
represent a variant of nonischemic priapism or, alter-
natively, may be the pathophysiology of recurrent
idiopathic priapism.
Neurologic control of the efferent erectile pathway
is by the pelvic nerves that are joined by the pregan-
glionic parasympathetic nerves. The pelvic nerves
join the pelvic plexus that gives rise to the cavernous
Fig. 2. Low-flow priapism in a patient with sickle cell nerve of the penis. Normally, penile stimulation
disease. Longitudinal sonogram of the corpora cavernosa causes reflexogenic erections that are primarily con-
demonstrates high-resistance flow in the cavernosal artery trolled by the sacral parasympathetic nerves originat-
suggestive of priapism. Cavernosal arterial flow is usually ing from the S2-4 segment located at the T11-L1
absent in patients with low-flow priapism; however, high- vertebral levels. The afferent limb of the erection
resistance flow may be observed. response is mediated by the dorsal penile nerve
(a branch of the pudendal nerve), which transmits
inactivation of intracellular cofactors of smooth mus- sensory impulses to the spinal cord. The role of the
cle contraction caused by hypoxia or hypercarbia [55]. sympathetic nervous system in penile erection is not
Recurrent episodes of veno-occlusive priapism, entirely clear, but its activation is generally associated
occurring anywhere from a few times monthly to with contraction of corpus cavernosal smooth muscle
recurrent daily episodes, are quite disabling and often and penile detumescence. The neuropathophysiology
have an idiopathic etiology. Levine et al [56] evalu- of priapism in patients with lumbar stenosis has not
ated six patients with recurrent veno-occlusive pria- been fully elucidated, but it is postulated that it may
pism and ruled out mechanical occlusion of corporeal be caused by parasympathetic efferent hyperactivity
venous drainage by demonstrating elevated flows to in the S2-4 cauda equina nerve roots within the
maintain intracavernosal pressures following smooth narrowed thecal sac. The parasympathetic hyperactiv-
muscle contraction and markedly decreased flow rates ity may be secondary to increased intrathecal pressure
following smooth muscle relaxation. The authors at the stenotic level and altered circulation within the
proposed that a functional alteration of the adrenergic cauda equina during walking [59].
or endothelial-mediated mechanisms that control pe- Sickle cell hemoglobinopathy results from the
nile tumescence and maintain penile flaccidity may inheritance of one or two genes coding for an abnor-
develop secondary to the initial ischemic episode and mal S hemoglobin and manifests in 0.15% of black
reported that the use of oral phenylpropanolamine Americans in the form of sickle cell disease (homo-
reduced the frequency and duration of the recurrences, zygous for hemoglobin S) and in 8% as sickle cell trait
and markedly reduced the need for adrenergic self- (heterozygous for hemoglobin S). Inheritance of a
injection. Treatment of the recurrent episodes with combination of a hemoglobin S gene and a second
intracavernous self-injection of phenylephrine re- gene coding for abnormal hemoglobin (ie, B + thal-
sulted in successful detumescence in that series and assemia or C hemoglobin) is possible and, as in the
the authors’ experience with similar cases. The pa- homozygous type, may result in ischemic complica-
tions [16]. The pathophysiology of SCA-induced Diagnosis

priapism is thought to result from decreased oxygen
tension and pH developing in stagnant blood within Physicians caring for patients with priapism should
the corporal sinusoids, which in turn leads to a cycle remember at all times the significant anxiety and fear
of erythrocyte sickling and sludging followed by even experienced by most patients with this condition and
more hypoxemia and acidosis [60]. Although most make a genuine effort to alleviate their apprehension.
cases are of the low-flow ischemic type, high-flow A thorough history and physical examination are
priapism may be observed in patients with sickle cell prerequisites to diagnostic accuracy. The sexual and
hemoglobinopathy in rare instances [15]. medical history should especially focus on medica-
tions, trauma, and predisposing comorbidities. Pres-
High flow ence or absence of pain is a fairly reliable predictor of
low-flow versus high-flow priapism, respectively. The
Nonischemic or arterial priapism is a less common latter diagnosis is further suggested by a history
form of priapism that presents clinically as a painless of penile or perineal trauma. Absence of pain in arte-
erection that typically follows some type of penile or rial priapism frequently results in less patient anxiety
perineal trauma leading to unregulated arterial inflow and discomfort as compared with veno-occlusive
into the sinusoidal space. Unlike the veno-occlusive priapism. Consequently, those with arterial priapism
variant, high-flow priapism is not an emergency: the may present days or even weeks after the original
outflow mechanism is intact and the cavernosal milieu injury. The fundamental aim of the initial phase of
is not anoxic. The penis is often not maximally rigid assessment is to distinguish arterial from ischemic
in these cases, but intercourse may be possible. Other priapism. The AFUD panel recommendations for the
clinical observations include delayed onset of pria- management of priapism are illustrated in Fig. 3 and
pism after perineal trauma and a state of constant follow a step-care model that has been modified and
suboptimal rigidity that may become more rigid with refined over the years [43,52,63].
arousal [61]. Diagnosis is typically based on the Physical examination of the penis is critical and
aforementioned clinical history and physical exami- typically reveals firm corpora cavernosa and a soft
nation, and demonstration of arterial blood on aspi- glans, indicating sparing of the corpus spongiosum in
rated cavernosal blood gas studies. A number of low-flow priapism. Findings in high-flow states usu-
recent studies have pointed to cycling trauma as the ally reveal a partial to full erection and sparing of the
cause of both transient neurogenic impotence and corpus spongiosum in most cases (as in low-flow
vasculogenic pathologies in the form of arterial pria- states). General diagnostic tests include urine toxicol-
pism or permanent erectile dysfunction [43,46,62]. ogy screening for psychoactive drugs and metabolites
Spycher and Hauri [54] have shown that at the level of of cocaine [10,43]. These tests are particularly helpful
trabecular smooth muscle cells, the ultrastructural if the diagnosis is unclear. The AFUD panel has
changes and fibroblast-like cellular transformation additionally suggested reticulocyte count (if indi-
seen in low-flow states do not occur with arteriogenic cated); urinalysis (if indicated); complete blood count;
priapism, even when the latter has been present for platelets, and differential white blood cell count; and
prolonged (as late as 5 months) periods. A mechanism urologic consultation. The reticulocyte count is often
for the pathophysiology of high-flow priapism is elevated in men with SCA. The most important
described by Goldstein’s group in Boston: unlike a warning with regard to hematologic testing is to
traditional arteriovenous fistula, the condition is de- remember that hemoglobinopathies are not restricted
scribed as an arterial-lacunar fistula where the helicine to African American men and other groups, especially
arteries are bypassed and the blood passes directly into those of Mediterranean descent, may be affected
the lacunar spaces. In turn, the high flow in the lacunar (ie, thalassemia or sickle-thalassemia). The sickledex
space creates shear stress in adjacent areas, leading test and examination of the peripheral smear are less
to increased nitric oxide release, activation of the time consuming than hemoglobin electrophoresis and
cGMP pathway, and smooth muscle relaxation and may be more appropriate for the emergency room
trabecular dilatation [61]. The authors also postulate setting. These recommendations are similarly empha-
that the delay in onset of high-flow priapism may be sized in the more recent AUA guideline on pria-
secondary to a delay in the complete necrosis of the pism [1].
arterial wall after the initial penile or perineal trauma. Urologic management of priapism includes his-
Alternatively, the delay may be secondary to clot tory and physical (including penile) examination, and
formation at the site of injury followed by the normal assessment of corporal blood flow status (corporal
lytic pathways, which follow in a few days. aspirate and visual inspection by color and consist-
Fig. 3. Step-care treatment model for the management of priapism recommended by the AFUD thought leader panel. CA,
cavernosal artery; CBC, complete blood count; DDU, duplex Doppler ultrasonography; HB, hemoglobin; NB, nerve block; PE,
physical examination; PSA, prostate-specific antigen; UA, urinalysis; VS, vital signs. (Data from references [43] and [52].)
ency or corporal blood gas including pH, PO2, and nosal artery or pseudocapsule formation at the site of
PCO2, or penile duplex Doppler ultrasound) [43]. arterial sinusoidal fistula. These findings are helpful
Low-flow priapism is suggested by finding low if superselective arterial embolization is performed
oxygen, high carbon dioxide, and low pH in the [64]. The AUA Guideline states that the use of penile
blood gas analysis of the aspirate. When a high-flow arteriography for the identification of the site of a
state is suspected based on the bright red appearance cavernous artery fistula may be warranted in some
or blood gas analysis of the corporal aspirate, duplex cases, but that arteriography has been largely replaced
Doppler sonography may identify a dilated caver- by color duplex sonography and the former is only
used as part of an embolization procedure [1]. Fur- used to localize the fistula and subsequently apply
thermore, penile aspiration has mainly a diagnostic external compression to achieve permanent fistula
role in the management of arterial priapism (not occlusion and resolution of priapism.
therapeutic). Although the data reviewed by the In a posttraumatic case of priapism with an arterial
AUA guideline panel did not reveal any instances tear, gray-scale ultrasound reveals an irregular hypo-
of arterial priapism resolution after aspiration or echoic region secondary to tissue injury or distended
irrigation, two separate case reports in the literature lacunar spaces in the corpus cavernosum. This irregu-
have documented the rare resolution of arterial pria- lar area appears with well-circumscribed margins
pism after aspiration or irrigation in cases of adult analogous to a capsule formation if the injury has
and pediatric posttraumatic priapism [65,66]. been long-standing [69]. The arteries exhibit normal
Patients presenting with refractory low-flow or increased flows within the cavernosal arteries and
priapism who later convert to a high-flow state an irregular flow from the artery to the cavernosal
represent a less common cohort of priapism patients. body at the site of injury. Arterial signs may be seen
Because the management of the low-flow and high- in the pseudoaneurysm and, unlike veno-occlusive
flow states is radically different, sonography should priapism, increased venous flow may be observed in
be considered if conventional corporal irrigation and high-flow priapism [42]. The arterial lacunar fistula
intracavernosal sympathomimetics (ie, phenyleph- seen in high-flow priapism essentially bypasses the
rine) fail to resolve the initial veno-occlusive pria- helicine arteries and appears as a characteristic color
pism [58]. When a hemoglobinopathy is suspected, blush extending into the cavernosal tissue on color
hemoglobin electrophoresis may be performed. The duplex sonography. It is reported that 90% of fistulas
AFUD panel has also recommended testing for pros- in adults appear as unilateral, whereas at least 50% of
tate-specific antigen when indicated. arterial priapism in children is associated with bilat-
eral or multiple arterial lacerations [42,51]. Bertolotto
et al [69] recommend increasing the color Doppler
velocity scale for better detection of the cavernosal
Role of radiology in the diagnosis and treatment of artery tear region as a focal area with very high flow.
priapism Because aspiration is only used for diagnostic pur-
poses in cases of arterial priapism, if the history is
Most of the reports on the use of sonographic suggestive of high-flow pathology and color duplex
imaging in the diagnostic and therapeutic algorithms sonography is conclusive, the patient may be spared
of priapism are focused on the high-flow variant, the discomfort of needle aspiration. Kang et al [70]
although sonography may be used instead of blood warn about the potential difficulty of accurate lesion
gas sampling to differentiate ischemic (low-flow localization caused by pubic bone sonic attenuation
priapism) from high-flow priapism. Color duplex when the injury is in the region of the proximal
Doppler sonography has replaced arteriography as cavernosal artery or the distal common penile artery.
the imaging modality of choice for the diagnosis of They further reiterate the importance of accurate
priapism. Penile color duplex Doppler sonography is sonographic localization in cases where embolization
noninvasive, does not expose the patient to ionizing may be anticipated because internal iliac artery or
radiation, and can reveal important information re- internal pudendal artery cannulization is easier from
garding the location of arterial injury in high-flow the contralateral femoral artery.
priapism. Most published studies on the subject indi- The use of selective arterial embolization for the
cate that in experienced hands, differentiation of the management of arterial priapism is somewhat contro-
increased color flow on the affected side from the versial. The embolization of an arteriolacunar fistula
normal flow on the contralateral side is not problem- in nonischemic priapism with an autologous clot was
atic. Two important papers from Goldstein’s group first reported by Wear et al [71] in 1977. Numerous
at Boston University have shown color Doppler reports in the literature have since documented use
ultrasound to be as sensitive as angiography for the of this approach in high-flow priapism with variable
diagnosis of high-flow priapism [61,67]. More spe- success [72 – 82]. The recently published AUA guide-
cifically, penile duplex Doppler sonography had a line recommends that the initial management of
sensitivity of 100% and a specificity of 73% with a nonischemic priapism should be observation [1]. This
predictive value of 81% for a positive test and 100% approach is based on the finding that expectant
for a negative test [67]. Mabjeesh et al [68] have management results in spontaneous resolution in
reported therapeutic use of color duplex Doppler 62% of the reported cases (with erectile dysfunction
ultrasound in one patient in whom sonography was in one third of cases) reviewed by the AUA Guideline
panel. Many investigators have shown complete reso- surgery or embolization must be preceded by a thor-
lution of posttraumatic high-flow priapism without ough discussion of the various aspects of expectant
any invasive measures and the historical trend on the management and the chances of spontaneous reso-
management of high-flow priapism gradually seems lution. It should be noted that autologous clot is
to be moving from surgery to embolization to expect- reported to be unstable by some investigators and is
ant management [1,67,83]. Selective arterial emboli- not widely used [80].
zation with autologous clot and absorbable gels are Superselective transcatheter embolization (Fig. 4)
recommended for ‘‘patients who request treatment’’ has been performed to occlude the source of arterial
[1]. The AUA guideline further states that any dis- inflow with potential preservation of potency in up to
cussion of invasive treatment modalities including 80% of patients in one recent report [84]. In rare
Fig. 4. A 40-year-old man with cocaine-induced priapism. He was confirmed to have low-flow priapism on ultrasound
examination. After failure of urologic treatment, he was referred to radiology for embolization of the penile artery. The
angiography (A, B) demonstrates the internal pudendal artery (straight arrow), the artery to the scrotal wall (curved arrow), and
the dorsal artery of the penis (arrowhead). (C) Complete occlusion of the penile artery (arrowhead) after embolization with
absorbable gelatin sponge using coaxial microcatheter. Arrow indicates the artery to the scrotal wall. B, bladder; P, priapism.
(Courtesy of A. Blum, MD, and P. Kang, MD, Cleveland, OH.)
instances, this treatment has been associated with approach allows precise angiographic catheter place-
perineal abscess formation [85]. When embolization ment and is especially useful for reducing radiation
is used, serial penile duplex studies should be per- exposure in children because of the higher likelihood
formed in follow-up to ‘‘assure complete resolution of of multiple arterial lacerations.
the arterial lacunar fistula and ultimate restoration For patients requesting treatment in areas with no
of normal cavernosal blood flow’’ [67]. Based on access to tertiary care centers and angiographic ex-
the AUA Guideline recommendations and earlier pertise, a trial of cavernosal aspiration and corporal
work by the Boston University group, a course of irrigation with a-adrenergic agents may be tried early
watchful waiting with regular follow-up examinations in the course of priapism and has been associated
should be discussed with the patient as a reasonable with a positive outcome (resolution of priapism and
(if not preferred) alternative to maximize the chances ability to achieve normal erections with follow-up) in
of preserving potency and avoiding nonessential in- at least one case report [66].
tervention in high-flow priapism [67]. When avail-
able, arterial embolization of arteriocavernous fistulas
has been advocated by Volkmer et al [51] as the first Treatment
line of therapy in prepubertal boys with traumatic
high-flow priapism when hematologic or metabolic The duration of the veno-occlusive period in pri-
causes have been eliminated [51]. The authors report apism has a significant impact on the potential for
26-month mean follow-up in three cases of high-flow recovery of spontaneous erections. Conservative mea-
priapism diagnosed by color Doppler ultrasound that sures and a trial of medical therapy should always be
presented 4 to 7 days after the injury. After diagnosis attempted before surgical therapy. Immediate reduc-
of the fistula location by angiography (branches of the tion of intracorporeal pressure in low-flow states is
internal pudendal artery in two and the bulbourethral of paramount importance. Treatment options are fur-
artery in one patient), gelatin sponge (bulbourethral ther separated based on the etiology. For patients with
artery) or microcoil (internal pudendal artery) were non – sickle cell priapism, initial comfort measures
used to occlude the fistula and achieve detumescence include local penile or systemic anesthesia in the form
with preservation of erectile function in all three cases of dorsal nerve block, circumferential penile block,
[51]. Traditionally, when embolization is performed, a subcutaneous local penile shaft block, and oral con-
unilateral approach has been recommended to avoid scious sedation for the pediatric patient [43]. The
the dreaded complications of penile gangrene, gluteal initial diagnostic penile aspiration is also used as a
ischemia, or erectile dysfunction [61,86]. Langenhuij- therapeutic measure and, except where contraindi-
sen et al [80], however, have described highly selec- cated, should be combined with intracavernosal instil-
tive embolization of bilateral cavernous arteries in a lation of a sympathomimetic agent (ie, phenylephrine
case where unilateral embolization was unsuccessful. injection after aspiration) to induce detumescence.
The authors advocate the use of the highly selective This combination addresses the two important goals
technique (cannulization of the cavernosal arteries) to of therapy in low-flow states: decreased inflow
minimize the risk of distal embolization of embolic (phenylephrine), and increased outflow and reduced
material and use of resorbable materials (gelatin pressures (aspiration). Transient increases in systemic
sponge) to allow for later recanalization and potential blood pressure are possible and monitoring of vital
preservation of potency. The disadvantage of the signs is indicated when using sympathomimetic
absorbable materials is that they are not radiopaque agents. Because of its potent and selective a1-adre-
and accurate placement can only be accomplished by nergic stimulatory properties and lack of b1-stimula-
frequent control arteriography during the procedure tory effect, which could cause arrhythmias and angina
[80,87,88]. Callewaert et al [89] were the first to in susceptible patients, phenylephrine is a preferred
report superselective embolization in children using agent for achieving detumescence by intracavernosal
microcoils. Again, the advantage of the microcoils is injection and has been extensively reviewed by Lee
that they allow precise placement into the branch et al [90]. These authors also have prepared a useful
supplying the fistula and may be performed bilaterally chart for preparation of dilutions of a-adrenergic
and yet maintain adequate penile blood flow to agonists for intermittent injection or irrigation. Fail-
potentially preserve erectile function. Volkmer et al ing this approach, the next step in the process is
[42] advocate a combined interventional approach irrigation with saline with or without pharmacologic
with intraoperative penile color Doppler ultrasound agent except when contraindicated. The authors have
while performing arterial embolization to minimize successfully used a closed system for corporeal aspi-
iodinated contrast use and radiation exposure. This ration and irrigation as described by Futral and Witt
[91] that has the advantages of reduced risk of body ment and question the use of red cell transfusion.
fluid exposure and corporeal contamination and the Furthermore, they emphasize that blood volume and
capacity for extended irrigation without repeated viscosity must be monitored closely in patients un-
corporeal puncture. dergoing exchange transfusion or rapid single-unit
The authors agree with observations by Pautler transfusion, because there is an increased risk of
and Brock [64] indicating that most cases of veno- cerebrovascular accident, coma, and intracranial
occlusive priapism treated without excessive delay hemorrhage. Low-flow infarctive priapism is uncom-
(< 12 hours) respond to a-agonist therapy and that mon. Nonetheless, adolescent patients are more likely
failure of resolution after 20 minutes of injection to develop this condition compared with younger
(0.1 mL/minute of a 500 – 1000 mg/mL phenylephrine children who are more likely to respond to hydration,
solution for a total infused dose of 1 mg) calls for rest, analgesia, and warmth [95]. Failing conservative
alternative strategies for management because these measures as described, the rest of the management
patients are unlikely to respond. The AFUD panel algorithm for SCA patients with low-flow priapism is
highly recommended first-line treatments (aspiration very similar to that described for non-SCA priapism.
and irrigation) for low-flow priapism of more than Stuttering or recurrent painful priapism episodes in
4-hours duration before undertaking more invasive this population have been managed successfully with
surgical shunts and further suggested that these ther- instruction on sympathomimetic self-injection and
apies have not shown a benefit in preserving potency gonadotropin-releasing hormone analogue injection
when priapism has persisted beyond 72 hours [43]. in refractory cases [96,97]. This experience has been
Failure of resolution after conservative measures as corroborated by the authors. Rutchik et al [98] have
described moves the step-care process to the surgical reported on a single case of refractory veno-occlusive
level. A number of different surgical shunts for priapism (failure of response to intracavernosal
diversion of blood away from the corpus cavernosum a-adrenergic injection or irrigation and recurrence
have been described. The consensus among authori- after an Al Ghorab surgical shunt) that responded to
ties is that, in general, distal corporospongiosal shunts intracavernosal injection of 15-mg tissue plasminogen
should be undertaken before proximal shunts; how- activator [98]. The authors resorted to this therapy
ever, there is no consensus regarding the choice of because of severe penile congestion and risk of penile
percutaneous versus open surgical shunts. The necrosis with further shunting. It must be emphasized,
authors prefer to start with a transglandular Winter however, that experience with this approach is very
shunt (corporoglandular) using a biopty gun biopsy limited. A novel approach for treatment of priapism
device to create multiple channels between the corpus was suggested by deHoll et al [99] who described the
spongiosum and the corpora cavernosa [92]. If this use of methylene blue, a guanylate cyclase inhibitor,
technique is not successful, a larger communication in 11 patients with priapism and reported immediate
between the corpora cavernosa and the corpus spon- detumescence in 67%. A possible explanation for the
giosum may be created by a modified Al-Ghorab success of this therapy is blockage of cyclic GMP-
shunt in which the distal tunica albuginea of the induced muscle relaxation following the initial aspi-
corpora cavernosa is removed through a transglan- ration attempts. Recently, successful treatment of
dular incision. Proximal shunts have been described recurrent idiopathic priapism with oral baclofen has
by a number of authors and are recommended if these been reported in two patients [100]. The treatment
shunts fail and absent cavernosal artery flow is options for high-flow arteriogenic priapism mainly
assessed by Doppler sonography [43,93]. A few consist of conservative measures aimed at preserva-
authors have advocated early use of penile prostheses tion of sexual function. Mechanical measures include
in cases of refractory or recurrent priapism associated external compression with occlusion of arterial inflow
with corporal fibrosis and erectile dysfunction [94]. and topical application of ice. If these approaches fail,
The AFUD panel recommendations for manage- surgical, pharmacologic, or radiologic approaches
ment of priapism in patients with SCA include intra- may be used. Surgical and pharmacologic interven-
venous hydration and parenteral narcotic analgesia tions have not had great success in resolution of high-
while preparing for aspiration and irrigation, supple- flow priapism and restoration of potency [67]. A
mental oxygen, and exchange transfusion [43]. Initial detailed discussion of embolization therapy was pre-
efforts are directed at relief of pain and anxiety, and sented in the previous section. There are very limited
hydration with hypotonic fluids at 1.5 times mainte- data on the safety and efficacy of surgical procedures
nance. Powars and Johnson [95] state that in the static, for management of high-flow priapism and surgery
hypoxic, and acidotic corporal environment, it is was recommended as the ‘‘option of last resort’’ by the
unlikely that red cells can reach the area of involve- AUA Guideline panel [1].
Complications [2] Papadopoulos I, Kelami A. Priapus and priapism:

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Radiol Clin N Am 42 (2004) 445 – 456
Ultrasound evaluation of acute abdominal emergencies in

infants and children
Pauravi Vasavada, MD
Department of Pediatric Radiology, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106, USA
Ultrasonography is an essential component in the position. Close to 7% of children with HPS have pa-
evaluation of acute abdominal pain and vomiting in rents with the same condition [2,4].
children. Radiation exposure is a prime consideration Hypertrophic pyloric stenosis is characterized by
in the pediatric population. Ultrasonography, unlike a defect in contractility or relaxation of the circular
CT or fluoroscopy, allows the radiologist to acquire muscle of the pylorus that results in hypertrophy of
diagnostic information without the use of ionizing the pyloric circular muscle and narrowing of the
radiation. Ultrasound (US) can be performed in any pyloric channel [3,4]. This leads to stomach dilation
imaging plane, which is advantageous when evaluat- and gastric outlet obstruction of variable severity.
ing such structures as the pylorus and appendix, Pyloric stenosis should be suspected in neonates 3 to
which may not be fixed in their orientation. Small 6 weeks old with postprandial nonbilious vomiting.
children with abdominal pain often are not able to lie Symptoms, however, can be present in the first week
down quietly for a CT or MR image without the of life or as late as 5 months of age. The patient
use of sedation. US, however, is able to obtain diag- classically presents with nonbilious vomiting that is
nostic images in nonsedated children. It is also cost projectile secondary to the pressures generated by the
effective, being far less expensive than CT or MR hypertrophied gastric muscles [5]. Persistent vomiting
imaging. Real-time ultrasonography can be per- results in large losses of gastric secretions. Because
formed in the radiology department or at bedside in only gastric secretions are lost, prolonged vomiting
the emergency department [1,2]. leads to hypokalemic, hypochloremic metabolic alka-
losis. If uncorrected the condition can lead to malnu-
trition, weight loss, dehydration, and death. More
Hypertrophic pyloric stenosis recent evidence suggests, however, that more than
90% of infants with HPS present without any meta-
Hypertrophic pyloric stenosis (HPS) is the most bolic disorders. This lower incidence has been linked
common surgical disorder producing emesis in in- to proper diagnosis before protracted vomiting is
fancy [1,3]. The incidence of HPS is approximately allowed to occur, and it has been suggested that easy
2 to 5 per 1000 births per year and it varies with the access to ultrasonography may be contributing to
geographic area. HPS is less common in India, and earlier diagnosis [6]. Nonbilious vomiting can present
among black and Asian population, with a frequency in several other conditions including gastroesophageal
that is one third to one fifth compared with that in the reflux disease and pylorospasm [4].
white population [3]. Boys are four times more likely The clinical diagnosis of HPS has traditionally
to be affected than girls, with the incidence signifi- been made by palpation of an olive-shaped mass in
cantly higher in first-born boys [2 – 4]. Although it’s the epigastrium representing the hypertrophic pyloric
etiology remains unknown, there is a familial predis- muscle. Palpation of a tumor-like mass in the right
upper quadrant by an experienced examiner is usually
considered specific and diagnostic without further
E-mail address: vasavada@uhrad.com testing [3,4,7]. In those infants in whom a mass is
doi:10.1016/j.rcl.2004.01.003
446 P. Vasavada / Radiol Clin N Am 42 (2004) 445–456
thickened and protrudes into the distended portion

of the antrum resulting in the nipple sign. The upper
gastrointestinal tract provides indirect information
about the status of the pyloric channel based on the
morphology of the canal lumen as outlined by contrast
material. Secondary to this fact, failure of relaxation
of the pyloric channel, known as ‘‘pylorospasm,’’ may
be confused with pyloric stenosis. Upper gastro-
intestinal tract can be time consuming, because the ra-
diologist has to wait for contrast to pass through the
high-grade obstruction. Fluoroscopy time and radia-
tion exposure may be prolonged. Upper gastrointes-
tinal tract sensitivity rate has been reported to be
approximately 95% but error rate as high as 11%
has also been reported [3,7].
Sonography has become the modality of choice
Fig. 1. Fluoroscopic image from an upper gastrointestinal for the diagnosis of HPS. Sonography is documented
study in a patient with HPS. The double track sign (arrows) to be a highly sensitive (90% – 96%) and specific
is formed by contrast material coming through the mucosal modality for the diagnosis of HPS [4]. US avoids
interstices of the canal.
radiation and allows direct visualization of the py-
loric muscle as opposed to the upper gastrointestinal
not palpated unequivocally, an imaging examination tract where the morphology of the muscle is inferred
is required. The diagnosis of HPS can be established by the thinness and length of the barium through the
by imaging upper gastrointestinal tract with the help area [1 – 3]. The sonographic examination is typically
of a radiographic contrast, such as barium, or by performed with a 5- to 7.5-MHz linear array trans-
sonography. An upper gastrointestinal tract reveals a ducer. A transducer up to 10 MHz can be used
beak or a ‘‘string‘‘ sign because of the narrow open- adjusted to the size of the infant and the depth of
ing of the pylorus or the double tract sign (Fig. 1) [2]. the pylorus [3,4]. The patient is placed in the right
In patients with pyloric stenosis the muscle is hyper- posterior oblique position, which allows fluid in the
trophied and the intervening mucosa is crowded and stomach to distend the antrum and pyloric region.
Fig. 2. (A,B) Sonograms in a patient with a normal pylorus. Longitudinal views demonstrate normal measurement of the pyloric
muscle. The pyloric channel is not elongated measuring 1.1 cm, and the muscle wall is not thickened measuring 2.6 mm.
P. Vasavada / Radiol Clin N Am 42 (2004) 445–456 447
Because the stomach in infants with pyloric stenosis is The pylorus is viewed in longitudinal and trans-
normally distended it is usually not necessary to verse planes. The examination begins by placing the
introduce more fluid. If the antrum does not contain transducer in the transverse plane, beginning at the
adequate fluid, a glucose solution or water can be gastroesophageal junction and following the contour
given orally or through a nasogastric tube [3,4,7]. of the stomach to its antrum. The duodenal cap is
Occasionally, the stomach may become so distended recognized by its arrowhead shape. By positively
and displace the duodenal cap caudally and medially identifying the gastric antrum and the duodenal cap,
rendering the pylorus difficult to visualize. In these the interposed pyloric channel can be imaged [7]. A
cases, if the patient is placed in the supine or left pos- negative study hinges on the diagnosis of a normal
terior oblique (LPO) position, the pylorus is able to pyloric ring and a distensible pyloric portion of the
rise anteriorly for more optimal evaluation. stomach (Fig. 2) [3,7].
Fig. 3. Hypertrophic pyloric stenosis. (A,B) Longitudinal sonographic views demonstrate the hypertrophied pyloric muscle
measuring 5.8 mm. The pyloric channel is elongated measuring 23 mm. (C) Cross-sectional view shows the thickened
hypoechoic muscle surrounding the echogenic mucosa.
On longitudinal views the muscle has a uniformly ening of the pyloric channel may be a transient
hypoechoic appearance. In the short axis view, the phenomenon because of peristaltic activity or pylo-
hypertrophic pyloric muscle has a target or bull’s eye rospasm. During a normal examination, one can
appearance reflecting the thickened hypoechoic mus- document the pyloric canal changing from a rigid
cle surrounding the echogenic mucosa. The sono- linear morphology to a relaxed canal that permits
graphic hallmark of HPS is the thickened pyloric pockets of fluid within the lumen. If the stomach is
muscle (Fig. 3). The numeric value for the diagnostic empty and the antrum is collapsed a small amount of
muscle thickness has varied greatly. The exact recom- fluid may be fed to the infant to document a normal
mended measurement includes a range of numbers fluid-filled antrum (Fig. 4). Patients in whom the
with a broad range of sensitivities and specifications pyloric canal relaxes to a normal morphology do not
[8]. Controversy persists regarding the significance have pyloric stenosis. Patients in whom the muscle is
of muscle thickness between 3 and 4 mm. Some au- 2 to 3 mm thick during the examination and does not
thors consider 3 mm as diagnostic, whereas others relax warrant monitoring and follow-up examination.
believe that this diagnosis cannot be made reliably Because the cause and evolution of HPS are unknown,
until a muscle thickness of 3.5 to 4 mm has been it is uncertain whether a young infant in whom the
attained [3,8]. The length of the hypertrophic canal is canal fails to relax completely will go on to develop
variable and may range from as little as 14 mm to HPS requiring surgery or whether the changes will be
more than 20 mm. Despite this variability in numbers arrested and resolve with sequelae [3].
in the literature, a patient with HPS has an examina- Potential causes of errors in the diagnosis of
tion and overall morphology of the pylorus that is HPS are overdistention of the stomach, which may
characteristic of pyloric stenosis. The muscle thick- lead to displacement of the pylorus posteriorly
ness is at least 3 mm or more during the examination making identification and measurement of the py-
and the intervening lumen is filled with crowded or loric thickness more difficult. Additionally, off-
redundant mucosa through the center of the canal. midline or tangential images can lead to erroneous
Additionally, gastric peristaltic activity fails to distend diagnosis of a thickened muscle [3,4].
the preduodenal portion of the stomach [3]. The treatment of HPS is pyloromyotomy in which
In patients without HPS the muscle does not the hypertrophic muscle is split longitudinally. A
measure more than 3 mm at any given time. Thick- study by Yoshizawa et al [9] showed that although
Fig. 4. (A, B) Sonographic images of the pylorus after the infant was given a small amount of fluid. Both images show fluid
within the antrum passing through a normal pylorus (P, arrow) into the duodenum (D, arrow).
the pyloric muscle thickness remains abnormal after

surgery, by 5 months the dimensions gradually return
to less than or equal to normal values.
Intussusception
Intussusception is one of the most common causes

of acute abdomen in infancy. The condition occurs
when a segment of intestine (the intussusceptum) pro-
lapses into a more caudal segment of intestine (the
intussuscipiens). This condition usually occurs in chil-
dren between 5 months to 2 years of age. In this age
group most intussusceptions are idiopathic with no
pathologic lead point demonstrated. More than 90%
of intussusceptions are believed to be secondary to
enlarged lymphoid follicles in the terminal ileum.
Intussusception is more common in boys and the
condition is rare in children younger than 3 months.
The peak incidence is between 5 and 9 months of age.
Lead points are noted in children younger than
3 months of age or greater than 2 years of age. Lead
points include such entities as Meckel’s diverticulum,
duplication cysts, intestinal polyps, lymphoma, and
intramural hematomas [4]. Transient intussusception
is seen in patients with celiac disease (sprue).
Most intussusceptions involve the ileocolic region
(75%), where the ileum becomes telescoped into the
colon. This is followed in decreasing frequency by
ileoileocolic, ileoileal, and colocolic intussusceptions. Fig. 5. Intussusception. Plain radiograph demonstrates a
The classic clinical triad of acute abdominal pain round soft tissue density mass (arrows) in the right upper
(colic), currant jelly stools or hematochezia, and a quadrant protruding into the gas-filled transverse colon.
palpable abdominal mass is present in less than 50%
of children with intussusception [10,11]. Up to 20%
of patients may be pain free at presentation. Addi-
tionally, in some instances lethargy or convulsion is the diagnosis and treatment of intussusception.
the predominant sign or symptom. This situation Radiographs of the abdomen are useful and can
results in consideration of a neurologic disorder rather suggest the diagnosis by showing a mass usually
than intussusception. Given the uncertainty of achiev- located in the right upper quadrant effacing the
ing an accurate clinical diagnosis, imaging is required adjacent hepatic contour (Fig. 5). Other signs include
in most cases to achieve an early and quick diagnosis reduced air in the small intestine, gasless abdomen, or
to reduce morbidity and mortality. Delay may be life- obstruction of the small intestine [13 – 15]. Identifi-
threatening because of the development of bowel cation of a cecum filled with gas or feces in the
necrosis and its complications [12]. normal location is the finding that allows exclusion
Much controversy exists in the literature related to of intussusception with most confidence [10,13]. In
the diagnosis and management of intussusception. the presence of intussusception, plain radiography
Realistically speaking children with intussusception allows exclusion of bowel perforation, a major com-
can be managed successfully in a number of different plication of intussusception. The accuracy of plain
ways. It is best to use diagnostic tools that are as radiography in diagnosis on exclusion of intussuscep-
benign as possible, however, to avoid potential harm tion ranges from 40% to 90% [13,16,17].
to these children and to lessen the discomfort to the Barium enema examination has been the standard
children who are not shown to have intussusception. of reference for the diagnosis of intussusception for
Conventional radiography and the contrast enema many years. At many institutions liquid enema or air
examination have been the principal methods used for enema examination is the principal diagnostic tool.
transducer, 5 to 10 MHz, can be used to improve the

definition of the image. The abdomen and the pelvis
should be scanned in both longitudinal and transverse
planes [1]. The intussusception mass is a large struc-
ture, usually greater than 5 cm. Most intussusception
occurs in the subhepatic region often displacing adja-
cent bowel loops (Fig. 7). Even inexperienced opera-
tors can readily identify the intussusception on
sonography. An intussusception is a complex struc-
ture. The intussuscipiens (the receiving loop) contains
the folded intussusceptum (the donor loop), which has
two components: the entering limb and the returning
limb. The attached mesentery is dragged between the
entering and returning limbs. Sonographically, the
intussusception may demonstrate an outer hypoechoic
region surrounding an echogenic center, referred to as
a ‘‘target’’ or ‘‘doughnut’’ appearance (Fig. 8) [20].
The hypoechoic outer ring seen on axial scans is
formed by the everted returning limb, which is the
thickest component of the intussusception and the thin
intussuscipiens. The echogenic center of intussuscep-
tion contains the central or entering limb, which is of
Fig. 6. Meniscus sign. Image from barium enema reduction
normal thickness and is eccentrically surrounded by
shows the rounded apex of the intussusception protruding
into the column of contrast material.
hyperechoic mesentery [20]. Another pattern of imag-
ing that has been described is that of multiple con-
The classic signs of intussusception at enema exami-

nation are the meniscus sign and the coiled spring
sign. The meniscus sign is produced by the rounded
apex of the intussusception (the intussusceptum) pro-
truding into the column of contrast material (Fig. 6).
The coiled spring sign is produced when the edema-
tous mucosal folds of the returning limb of the in-
tussusception are outlined by contrast material in the
lumen of the colon. The enema examination, however,
can be a very unpleasant experience for both the
parent and child and is also associated with radiation.
The role of sonography in the diagnosis of intus-
susception is well established with a sensitivity of
98% to 100% and a specificity of 88% to 100% [18].
It has been suggested that sonography should be the
initial imaging modality and that the enema exami-
nation should only be performed for therapeutic
reasons [11,18,19]. Sonography not only aids in the
diagnosis of intussusception but it also allows the
identification of patients who are candidates for
therapeutic reduction. Sonography may also detect
other abnormalities that are overlooked by the enema
examination [4]. In addition, there is a high level of
patient comfort and safety with US.
A technique of graded compression is used for
the sonographic evaluation of suspected intussuscep- Fig. 7. Intestinal intussusception. Transverse sonographic
tion. Because deep penetration of the US beam is not image demonstrates a soft tissue mass in the right upper
necessary in small children, a linear high-resolution quadrant adjacent to the gallbladder (GB).
The pseudokidney sign is seen if the intussusception

is curved or imaged obliquely [1].
Although the target and pseudokidney signs are
the most common ultrasonographic signs used, they
are not pathognomic because they have also been
seen in normal or pathologic intestinal loops. Differ-
ential consideration for the US findings includes
other causes of bowel wall thickening, such as
neoplasm, edema, and hematomas. An inexperienced
operator may mistake stool or psoas muscle for
an intussusception.
In addition to diagnosing the intussusception US
has other advantages. US may detect the presence
of a lead point, which is present in approximately 5%
of intussusception. Various sonographic findings
Fig. 8. Target appearance. Transverse sonographic view de- have been reported to be predictive of success of hy-
monstrates the intussusception. The hypoechoic outer layer drostatic reduction. A study by Koumanidou et al [18]
represents the intussuscipiens and the central echogenic layer shows that the sonographic presence of enlarged
represents the intussusceptum (arrow).
mesenteric lymph node in the intussusception is a
prediction of hydrostatic irreducibility. Small amounts
of free peritoneal fluid are seen in up to 50% of cases.
centric rings. Within the bowel wall the mucosa and The presence of trapped peritoneal fluid within an
submucosa are echogenic, whereas the muscularis intussusception correlates significantly with ischemia
layer is hypoechoic. Multiple hypoechoic and hyper- and irreducibility, however, because it reflects vascu-
echoic layers are identified when there is little bowel lar compromise of the everted limb.
edema present. This represents the mucosa, submu-
cosa, and muscularis layers of the intussusceptum and
intussuscipiens. With increasing degrees of bowel
edema, the hyperechoic mucosal and submucosal
echoes are obliterated in the intussusceptum resulting
in fewer layers. On long axis scans the hypoechoic
layers on each side of the echogenic center may result
in a reniform or pseudokidney appearance (Fig. 9).
Fig. 10. Use of Doppler ultrasound to evaluate intussuscep-

Fig. 9. Long-axis sonographic view shows an elongated tion. Doppler ultrasound shows blood flow within the
appearance resulting in a pseudokidney appearance (arrow). intussusception, suggesting its reducibility.
Additionally, the absence of flow within the intus- with acute abdominal pain have self-limited non-
susception on color Doppler sonography correlates surgical disease. Upper respiratory tract infections,
with a decreased success of reduction and a higher pharyngitis, viral syndrome, gastroenteritis, and con-
likelihood of bowel ischemia [21 – 23], and presence stipation are the most common associated conditions
of color flow within the intussusception correlates noted in these children. The actual prevalence of acute
with higher success rate of its reduction (Fig. 10). appendicitis in children presenting in the outpatient
There are many different techniques used to reduce setting with acute abdominal pain ranges from 1% to
intussusception described in the literature. Water-sol- 4% [28,30].
uble contrast material, barium, air enema guided by The delayed diagnosis of acute appendicitis can
fluoroscopy, and physiologic saline solution com- carry serious consequences. Perforation, abscess for-
bined with US have all been used [24,25]. The use mation, peritonitis, wound infection, sepsis, infertil-
of sonography to guide hydrostatic reduction has ity, adhesions, bowel obstruction, and death have
been predominately performed in the eastern hemi- been reported. Morbidity and mortality in acute
sphere and is increasingly being used in Europe. The appendicitis are related almost entirely to appendiceal
reduction rate is high (76% – 95%), with only 1 perforation. The prevalence of appendiceal perfora-
perforation in 825 cases reported [25,26]. The proce- tion in various pediatric series has ranged from 23% to
dure may be performed with water, saline solution, or 73%, with the perforation rate even higher in young
Hartmann solution. The instilled fluid is followed as it children [28,31 – 33]. Up to half of children with
courses through the large bowel until the intussuscep- perforated appendicitis may experience a complica-
tion is no longer visualized and the terminal ileum and tion, with nearly all deaths associated with perforated
distal small bowel are filled with fluid or air. There has appendix [28]. For fear of missing the diagnosis and
been little experience with US-guided air enema allowing the development of perforation, peritonitis,
therapy. Because air prevents the passage of the US and sepsis, a low index of suspicion and early opera-
beam, it may be difficult to visualize the ileocecal tive intervention have been recommended. As a result,
valve; therefore, small residual ileoileal intussuscep- negative laboratory rates as high as 20% have been
tion can be observed. Additionally, it is difficult to de- reported with rates of 10% to 15% widely accepted
tect perforation resulting in pneumoperitoneum [24]. [29,34,35]. Unnecessary appendectomy carries po-
Sonography has been shown to be highly success- tentially major risks and substantial costs, however,
ful in the diagnoses and reduction of intussusception. prompting many to advocate increased efforts to avoid
The appropriate use of US in children with suspected unnecessary appendectomy [36]. The goal of imaging
intussusception obviates the necessity for diagnostic in a child with suspected appendicitis should be to
enema, and the use of enema should be limited to identify the presence of disease in patients with
therapeutic purposes [27]. equivocal clinical findings. Used correctly, imaging
should reduce the negative laparotomy and perfora-
tion rates and reduce the intensity and cost of care.
Acute appendicitis The ideal diagnostic test should be fast, noninvasive,
highly accurate, and readily available [37]. The pri-
Acute appendicitis is one of the major causes of mary imaging technique over the past decade for
hospitalization in children and it is the most common evaluating children with suspected appendicitis has
condition requiring emergency abdominal surgery in been graded-compression US because it is widely
the pediatric population. The condition typically available, noninvasive, and does not involve radiation
develops in older children and young adults with the [28,38 – 40].
diagnosis being rare under the age of 2. Clinical signs The reported diagnostic accuracy of US in the
and symptoms associated with acute appendicitis diagnosis of acute appendicitis has varied greatly. The
include crampy, periumbilical, or right lower quad- sensitivity of US has ranged from 44% to 94% and
rant pain; nausea; vomiting; point tenderness in the the specificity has ranged from 47% to 95% [28]. The
right lower quadrant; rebound tenderness; and leuko- clinical use of US lies primarily in the subgroup of
cytosis with a left shift [28]. When the history and children in whom the clinical findings are equivocal.
clinical findings are classic, the diagnosis of acute Not only can it establish the diagnosis of appendicitis
appendicitis is often straightforward [29]. Not only do but also it can identify other abdominal and pelvic
one-third of children with acute appendicitis have conditions, especially gynecologic, that present as
atypical findings, however, but also the presenting right lower quadrant pain [28,41].
signs and symptoms of many nonsurgical conditions The graded-compression technique of US is per-
may mimic those of acute appendicitis. Most children formed with a high-resolution, linear-array transducer
of 5 to 10 MHz. Graded-compression sonography tubular structure on longitudinal US image. The

primarily consists of anterior forced compression to maximal appendiceal diameter from outside wall to
reduce the distance between the pathologic process outside wall is greater than 6 mm in an inflamed
and the transducer and to displace or compress bowel appendix. A noncompressible enlarged appendix
structures to eliminate gas artifacts. Reducing the measuring greater than 6 mm in maximal diameter
abdominal cavity by compression enables clear visu- is the only US sign that is specific for appendicitis
alization of the retroperitoneal structures [42]. Ante- (Fig. 11). Other findings of appendicitis include an
rior compression is considered adequate when the appendicolith, which appears as an echogenic focus
iliac vessels and psoas muscles are visualized because with acoustic shadowing; pericecal or periappendi-
the appendix is anterior to these structures. ceal fluid; and enlarged mesenteric lymph nodes. On
Scanning is performed in both longitudinal and transverse imaging a target appearance is delineated.
transverse planes. The examination begins with the This is characterized by a fluid-filled appendiceal
identification of the cecum and the terminal ileum. lumen, which is surrounded by the echogenic mucosa
The ascending colon is a nonperistaltic structure and submucosa and hypoechoic muscularis layer.
containing gas and fluid. The terminal ileum is com- The US features of perforation include loss of the
pressible easily and displays active peristalsis. The echogenic submucosal layer and presence of a locu-
cecal tip where the appendix arises is approximately lated periappendiceal or pelvic fluid collection or
1 to 2 cm below the terminal ileum. The examination abscess (Fig. 12) [43,44]. The appendix is visible
can be expedited by asking the patient to point to the in 50% to 70% of patients with perforated appendi-
area of maximal tenderness. This can also aid in citis [44].
locating a retrocecal appendix [28]. The use of color Doppler has also been described
In early nonperforated appendicitis, an inner in the evaluation of appendicitis. Color Doppler US
echogenic lining representing submucosa can be of nonperforated appendicitis demonstrates periph-
identified. The inflamed, nonperforated appendix ap- eral wall hyperemia reflecting inflammatory hyper-
pears as a fluid-filled, noncompressible, blind-ending perfusion. Color flow may be absent in gangrenous
Fig. 11. Acute appendicitis. Longitudinal (A) and transverse (B) ultrasound images show an inflamed appendix (between the
calipers), which is enlarged.
secondary to causes other than appendicitis, such as

Crohn’s disease or pelvic inflammatory disease. The
use of US in patients with acute appendicitis is a
subject of controversy in the literature [42]. Many
studies have been performed to evaluate the use of
US in the ultimate outcome of children with suspected
appendicitis. Some studies have suggested that the
use of US has not improved outcome in children with
suspected appendicitis. A study by Roosevelt and
Reynolds [49] showed no significant differences in
the perforation rate or cost of care in children who
underwent US compared with those who did not. A
study by Lessin et al [29], however, suggests that the
early and selective US in clinically equivocal cases
could rapidly allow an accurate diagnosis, without the
need for prolonged observation or hospitalization.
There are several other tests that have been used to
facilitate the diagnosis of acute appendicitis but the
advantage of ultrasonography is its low cost, lack of
radiation exposure, easy availability, and noninvasive
nature [38].
Fig. 12. Right lower quadrant abscess. Two-year-old girl Summary

presented with abdominal pain. A complex mass in the right
lower quadrant consistent with an appendiceal abscess was Ultrasound is extremely beneficial in the evalua-
demonstrated on ultrasound. tion of acute pediatric abdominal disease, such
as HPS, intussusception, and acute appendicitis. As
techniques and equipment improve, its role in the eval-
appendicitis or early inflammation [45]. Color Dopp- uation of infants and children continues to increase.
ler findings of appendiceal perforation include hyper-
emia in the periappendiceal soft tissue or within a
well-defined abscess [46]. Color Doppler US does not References
increase the sensitivity of the examination but it does
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Radiol Clin N Am 42 (2004) 457 – 478
Emergent ultrasound interventions

Dean A. Nakamoto, MD*, John R. Haaga, MD
Department of Radiology, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA
Interventional radiologists are frequently asked to effusion. Ultrasound evaluation before the procedure
perform emergent diagnostic and therapeutic proce- confirms the presence of fluid and distinguishes
dures. The choice of image guidance depends on pleural fluid from atelectasis, mass, or elevated dia-
user preference; availability of CT, ultrasound, and phragm. Typically, the patient is seated upright. Pleu-
MR imaging; and the ability of the modality to ral fluid is generally anechoic, although debris or
visualize the target. Ultrasound is the most preferred septations may be present. The diaphragm must be
modality and has many advantages including real-time identified, and the underlying liver or spleen. A 3- to
imaging of the needle tip during the procedure; multi- 4-MHz sector or vector probe is usually sufficient to
planar imaging capabilities; its relatively low cost; and survey the hemithorax quickly.
the equipment is mobile, so procedures can be per-
formed at the bedside of critically ill patients in the Technique
intensive care unit. Ultrasound-guided interventions Most diagnostic and therapeutic thoracenteses are
have become very common in many institutions [1,2]. performed with ultrasound guidance. Typically, the
Emergent procedures frequently performed with ultra- patient is seated upright with his or her back to the
sound guidance include thoracentesis, paracentesis, interventionalist. To perform the procedure safely,
percutaneous nephrostomy, and percutaneous chole- there should be at least one rib interspace of fluid
cystostomy. The role of ultrasound guidance has also above and below the puncture site. If there is less
expanded to include abscess drainage, particularly in fluid, the procedure may be deferred depending on the
the pelvis, and chest tube placement. This article clinical urgency and the ability of the patient to
discusses various emergent interventions performed cooperate. Very small pleural fluid collections can
with ultrasound imaging guidance. be aspirated safely, however, if the patient can coop-
erate with breath-holding. Patients who cannot sit
upright are placed either supine or in a lateral decu-
Ultrasound-guided chest interventions bitus position. In either of the latter two positions,
there must be a larger amount of fluid to attempt
Thoracentesis thoracentesis. Because ultrasound can be performed
portably, ultrasound-guided thoracenteses can be per-
Ultrasound-guided thoracentesis is usually performed in an ICU, even on mechanically ventilated
formed easily because most pleural fluid collections patients [3]. If visualization is difficult because of
are accessible using percutaneous methods. In the patient body habitus, air in the pleural fluid, or the
septic patient, a diagnostic thoracentesis is usually patient’s inability to be positioned adequately, CT
performed to evaluate for empyema. Other indications guidance may be helpful.
include evaluation for chylous, bloody, or malignant Initial scanning should be performed with a sector,
vector, or curvilinear probe. This is to document the
amount of fluid and quickly to find the largest pocket
* Corresponding author. of fluid. At this time, it is important to verify the
E-mail address: Nakamoto@uhrad.com location of the diaphragm. Scanning can then be
(D.A. Nakamoto). performed with a linear probe of 6 MHz. This enables
doi:10.1016/j.rcl.2004.01.002
458 D.A. Nakamoto, J.R. Haaga / Radiol Clin N Am 42 (2004) 457–478
lung may mimic complex fluid (Fig. 3) and color

Doppler may be helpful to verify the presence of
pulmonary vessels in consolidated lung. Following
sterile preparation of the skin, local anesthesia should
be administered from the skin surface to the pleural
surface. Although one could use ultrasound to visual-
ize needle insertion directly, typically a site is marked
on the skin surface and the needle is advanced until
fluid is obtained.
A variety of needles and catheters are available for
thoracenteses. The simplest method is to use an 18- or
20-gauge angiocatheter. The angiocatheter with punc-
ture needle is advanced into the pleural space until
fluid is aspirated, and then the angiocatheter is ad-
vanced into the pleural space over the puncture
needle. Single-step 6F trocar-based catheters (Skater,
Medical Device Technologies, Gainesville, Florida)
Fig. 1. Aberrant intercostal artery. This sagittal color Doppler are also available, particularly if the procedure is
scan performed with a 6-MHz linear probe demonstrates an
both diagnostic and therapeutic. These are used in a
aberrant, tortuous course of the intercostal artery (arrow).
similar fashion.
Here the artery is situated close to the midpoint of the rib
interspace. In this location, the artery is more susceptible to After a thoracentesis, the authors obtain a chest
injury from a needle. radiograph in posteroanterior view to evaluate for
pneumothorax. The chance of pneumothorax is small
accurate localization of the rib interspace, particularly and generally ranges from 2.5% to 7.5% [4 – 7],
in obese patients. The location of the intercostal artery although rates up to 13.9% have been reported [8].
(Fig. 1) also is verified at this time. Although the Symptoms caused by pneumothorax include shortness
artery is usually directly adjacent to the inferior aspect of breath and shoulder pain on the affected side. Some
of the rib, it can be located more inferiorly and in the investigators do not advocate routine postprocedure
rib interspace. If the patient has a malignancy, pleural- chest radiograph for the asymptomatic patient, be-
based metastases can also be visualized at this time cause of the low complication rate [4,9,10]; however,
and avoided (Fig. 2). It is important to be able to because sizable pneumothoraces may be asymptom-
recognize hypoechoic, consolidated lung and not atic, the authors routinely obtain a chest radiograph.
mistake it for pleural fluid. Sometimes consolidated The mechanisms of postthoracentesis pneumothorax
Fig. 2. Pleural-based metastases. This patient with metastatic lung cancer was referred for therapeutic thoracentesis. The pleural-
based mass was noted (cursors); a different location was used.
D.A. Nakamoto, J.R. Haaga / Radiol Clin N Am 42 (2004) 457–478 459
Fig. 3. Consolidated lung mimicking complex pleural fluid. This patient was referred for possible thoracenteses. Longitudinal
vector scan of the left hemithorax demonstrates complex-appearing mixed solid and cystic foci in the hemithorax (arrowheads)
consistent with consolidation of the lung.
include (1) inadvertent introduction of air into the situation, then urgent consultation with the resuscita-
pleural space, usually by leaving the needle or catheter tion team is appropriate.
open to the air after the tip is in the pleural space; Re-expansion pulmonary edema is an uncommon
(2) puncture of the lung; and (3) rupture of the vis- complication of uncertain etiology. It may be asymp-
ceral pleura because of a decrease in pleural pressure tomatic; however, it can cause various degrees of
[4,11]. If the pneumothorax is large, is symptomatic, hypoxia and can even be life-threatening [12,13]. It
or increases with time, the patient may require a chest presents as unilateral pulmonary edema, which may
tube placement. progress to bilateral edema [4,12]. Re-expansion pul-
Other significant complications of thoracentesis monary edema is believed to be more likely if a large
include pain, vasovagal reaction, bleeding, and re- volume (ie, greater than 1 L) of pleural fluid is as-
expansion pulmonary edema. Pleuritic pain may be pirated at one time. Some investigators have removed
caused by the rubbing of the visceral and parietal up to 2 L at one time, however, without adverse con-
pleural surfaces after the fluid has been removed. Pain sequences [4,7].
during the procedure may also be caused by the Bleeding is an uncommon complication. The risk
inability of the patient’s collapsed lung to re-expand is higher in patients with coagulopathies. It also may
as the fluid is removed. This may be an indication to occur with inadvertent laceration of the intercostal
stop the procedure [4,7]. artery [14]. The authors typically check platelets,
Vasovagal reactions may occur during any inter- prothrombin time and partial thromboplastin time,
ventional procedure. The patient may become tran- and International Normalized Ratio (INR) before
siently bradycardic, hypotensive, and may then lose any procedure and adjust accordingly. They prefer
consciousness. Predisposing factors include volume platelet counts over 50,000, and the prothrombin time
depletion. A quick physical examination of these pa- to be within 2 seconds of normal, or INR less than
tients shows bradycardia, diaphoresis, dilated pupils, 1.5. Fine-needle aspirations may be performed out-
and hypotension. These vasovagal reactions are usu- side of these ranges. Every case, however, should be
ally minor and temporary. Placing the patient in the individually tailored.
Trendelenburg position to improve venous return to
the heart usually resolves the problem. If the patient Ultrasound-guided chest tube insertion
improves within a few minutes, no other action is
needed. If significant, the patient may require atro- Pleural effusions can occur in a variety of settings,
pine. Typical atropine doses are as follows: adult— including pneumonia (parapneumonic effusion); ma-
1 mg intravenously; children—0.02 mg/kg to 0.60 mg lignancy; bleeding; and fluid overload. The pleural
(maximum) intravenously. The treatment interval is fluid can be classified as transudative or exudative,
every 3 to 5 minutes to a total of 3 mg for adults or depending on the laboratory analysis as described
2 mg for children. If the atropine does not improve the in Box 1. Parapneumonic effusions are generally
either radiologic or surgical. The third stage usually

Box 1. Light’s criteria for diagnosis of
requires surgical decortication, although there are
exudative effusions
some data suggesting that the pleural peels may re-
Pleural fluid protein to serum protein solve with closed-tube drainage [17].
Anechoic pleural collections or collections with
ratio > 0.5
Pleural fluid to serum L-lactate fine linear septations on ultrasound respond best to
catheter drainage, whereas those with a complex
dehydrogenase ratio > 0.6
Pleural L-lactate dehydrogenase con- honeycomb pattern usually fail catheter drainage and
require decortication. Patients showing parietal pleu-
centration more than two thirds of
ral thickness greater than 5 mm are unlikely to re-
the normal upper limit for serum
spond to catheter drainage.
L-lactate dehydrogenase
Indications for chest tubes and technique

*satisfying any one of these criteria
The primary indication for chest tube placement is
suggests exudative nature
to drain an empyema and prevent progression to the
Data from reference [16].
organized stage. This can be accomplished with
surgical drainage or closed-tube drainage. Closed-
divided into complicated and uncomplicated effu- tube drainage can be performed with blind insertion
sions. The uncomplicated effusions are transudative of a large-bore (22 – 34F catheter) chest tube placed by
effusions and small free-flowing exudative effusions. a surgeon or with image-guided chest tube placement
These effusions can resolve spontaneously with anti- using CT or ultrasound. Typically, smaller-bore, 8 to
biotic treatment. 14F catheters are used with the image-guided meth-
The complicated effusions are exudative effusions ods. The smaller tubes placed by imaging methods are
that do not respond to medical treatment and require usually better tolerated by the patients than the larger,
drainage. Empyema, hemothorax, and malignant effu- surgically placed tubes. Therapeutic options for in-
sions are all complicated effusions. Indications for fected pleural collections are summarized in Box 3.
drainage of pleural fluid are given in Box 2. Large pleural fluid collections are amenable to
Regarding parapneumonic effusions, there are single-step trocar catheters. The patient can be posi-
three stages in the evolution of empyema [15,16]. tioned either upright or in a lateral decubitus position
The first stage is a free-flowing exudative effusion. with the affected side up. As with a thoracentesis,
The second stage is the fibrinopurulent stage during initial scanning should confirm the location of the
which the cellularity and protein content of the effu- diaphragm and the overall size of the effusion. Once a
sion increase. Fibrin is deposited on the visceral and site is marked and the skin is sterilely prepared,
parietal surfaces. The third stage is the organization adequate local anesthesia should be used from the
stage; fibroblasts and capillaries grow into exudates skin surface to the pleural surface. A small incision
and form a pleural peel. If untreated, this stage can should be made with a scalpel, and the tract should be
result in lung entrapment and subsequent fluid drain- dilated with a small hemostat. An initial aspiration
age into the chest wall or into the lung. Empyema can be performed with a 19-gauge sheath needle with
requires emergent drainage to control sepsis. The first a disposable 5F tetra-fluoro-ethylene (TFE) catheter
two stages should be drained by closed-tube drainage, (Yueh centesis disposable catheter needle, Cook,
Box 2. Indications for drainage of pleural

fluid Box 3. Therapeutic options for infected
pleural collections
A very large pleural effusion causing
cardiorespiratory embarrassment Antibiotics
Grossly purulent or hemorrhagic Tube thoracotomy
pleural fluid Intrapleural fibrinolytics (urokinase)
Positive Gram stain Thoracoscopy with lysis
pH > 7.2 of adhesions
Glucose < 40 mg/dL Decortication
L-lactate dehydrogenase > 1000 U/L Open surgical drainage
Bloomington, Indiana) to determine the viscosity of able on single-step trocars, the authors have found
the fluid. A trocar – based, self-retaining catheter can that these larger catheters can be difficult to insert in a
then be inserted blindly or under ultrasound visuali- single-step procedure. If a 10F or larger catheter is
zation, depending on the size of the effusion. If the needed, the Seldinger technique can make catheter
effusion is thin, a single-step, 6 to 8F catheter (Skater, insertion easier (Fig. 4). A standard 0.035-inch
Medical Technologies, Gainesville, Florida) can be angiographic guidewire can be placed through the
placed. Although 10F and larger catheters are avail- 5F Yueh catheter and the tract can then be dilated.
Fig. 4. Complex left pleural effusion in heart transplant patient, left chest tube placement. (A) Longitudinal vector scan
demonstrates a large loculated left pleural effusion, which inverts the left hemidiaphragm. (B) Schematic representation
illustrating the procedure. Under ultrasound guidance, a 19-gauge disposable sheath needle (Yueh centesis needle) is placed into
the effusion at the level of the midaxillary line. The needle is withdrawn, a small amount of fluid is aspirated, and a standard
7.5-mm J 0.035-inch angiographic guidewire is placed. (C) The tract is sequentially dilated to 10F catheter, and a 10F catheter
self-retaining nephrostomy-type tube is placed. Arrows point to nephrostomy tube.
for such patients should not be delayed. Complica-

Box 4. Indications for external drainage of
tions from chest tube insertion include sepsis, inap-
lung abscess
propriate pathway of chest tube, bleeding, and injury
Persistent sepsis after 5 to 7 days of to adjacent organs.
antibiotic therapy
Abscesses 4 cm or more in diameter Lung abscesses
that are under tension
Abscesses 4 cm or more in diameter Most lung abscesses are caused by oropharyngeal
aspiration of bacteria as can occur with alcoholic
that are enlarging
Failure to wean from a ventilator stupor, general anesthesia, seizures, or cerebral vas-
cular accidents [28,29]. Other causes include malig-
because of a large abscess
nancy, septic emboli, foreign bodies, and lung cysts
[28,29]. It is important to distinguish between lung
abscess and empyema because empyema requires
external drainage, whereas most lung abscesses re-
CT is the preferred method for smaller effusions or solve with medical management [30]. The distinction
effusions close to vital structures, such as the heart or between lung abscess and empyema is best made with
major vessels. When placing the chest tube, a lateral contrast-enhanced CT. A lung abscess appears round
approach is preferred rather than a direct posterior and if it contacts the pleural surface, it forms an acute
approach, if possible. The ideal site for catheter angle with the pleura. Empyema is more biconvex in
placement is usually at the level of the midaxillary shape and forms obtuse angles with the pleura. The
line; the authors try to avoid a direct posterior wall of an abscess may have thick and irregular en-
approach so that the patient does not lay on the tube. hancement, whereas the enhancing pleura with empy-
Once the tube is placed, some of the fluid should ema has a smooth curvilinear appearance (ie, the split
be withdrawn to confirm the location of the tube. pleura sign) [31].
Direct visualization with ultrasound should also doc- Indications for external drainage of lung abscess
ument the location. The tube should be secured to the [32] are summarized in Box 4.
skin and placed to a water-seal pleural drainage Relative contraindications for external drainage of
system (Pleur-Evac, Deknatel, Fall River, Massachu- lung abscess are given in Box 5.
setts) with suction at 20 cm H2O. Patients are The abscess-pleural symphysis occurs when a lung
monitored daily to ensure proper tube functioning abscess is continuous with the pleura. It is important to
and to record the amount of drained fluid. Once the have a needle traverse the abscess-pleural symphy-
fluid becomes serous, the tube output has decreased to sis to decrease the chances of complications, such as
20 mL or less per 24 hours, and the patient has leak of abscess fluid into the pleural space and bron-
defervesced, the tube may be removed. A CT scan chopleural fistula. Catheter drainage is usually per-
should be performed before tube removal to ensure formed by CT; however, ultrasound can be used in
that there are no undrained collections. Additional selected cases. If the abscess-pleural symphysis is
drainage tubes may be placed for any separate collec- small, CT is the modality of choice because it is easier
tions not being drained. to place the needle accurately under CT guidance.
Many empyemas are loculated, which can make Because lung abscesses may have fine strands of
chest tube drainage difficult. Fibrinolytic agents, such residual normal parenchyma, which can bleed, one
as streptokinase and urokinase, have been used suc- should not be too aggressive with catheter insertions or
cessfully to lyse septations [18 – 20]. Because uro- guidewire manipulations [32].
kinase is not always available, the authors have been
using streptokinase, 125,000 IU every 12 hours for up
to 2 days.
Success rates range from 70% to 94%, with a Box 5. Relative contraindications for
cumulative success rate of approximately 85% in external drainage of lung abscess
various radiologic studies [19 – 27]. Not all empyema
are amenable to percutaneous drainage. Patients who Noncompliant patient
develop a pleural peel or who have persistent fevers Lack of an abscess-pleural
and elevated white blood cell counts despite adequate symphysis
drainage and appropriate antibiotics may require sur- Coagulopathy
gical drainage and decortication. Surgical treatment
Ultrasound-guided abdominal interventions way to the parietal peritoneum. Then they perform the
aspiration with a standard 18-gauge angiocatheter. If
Paracentesis the patient is obese, the authors use a 15- or 20-cm-
long, 19-gauge sheath needle (Yueh centesis dispos-
Ultrasound-guided paracentesis is a commonly able catheter needle; Cook, Bloomington, Indiana).
performed procedure. Typically, the procedure is per- For smaller collections or collections adjacent to ma-
formed emergently in a septic patient as a diagnostic jor vessels or to the spleen, the authors use direct
procedure to evaluate for spontaneous bacterial peri- ultrasound guidance with either the freehand tech-
tonitis [33] or for hemoperitoneum in the setting of nique or the needle guide.
trauma [34]. More commonly, this procedure is per- Large-volume paracentesis provides rapid resolu-
formed urgently as a therapeutic measure for symp- tion of symptoms with minimal complications and is
tomatic relief of tense ascites. well tolerated by most patients. Complications from
Initial scanning is performed with a sector or cur- paracentesis have rarely been reported, and include
vilinear probe to find the largest pocket. Attention is inferior epigastric artery pseudoaneurysm [35], hem-
then made to the abdominal wall to ensure that there orrhage after large-volume paracentesis [36 – 38],
are no vessels at the site of subsequent needle punc- bowel perforation [38], hypotension [39], and a frag-
ture, such as the epigastric artery or collateral vessels ment of the catheter left in the abdominal wall or
in a patient with cirrhosis. In patients with malignan- peritoneum [38]. Postparacentesis circulatory dys-
cy, one should ensure that there are no peritoneal function has been reported and is characterized by
metastases at the needle insertion site. This can be hyponatremia, azotemia, and an increase in plasma
performed with a linear transducer, usually of 6 MHz renin activity. Postparacentesis circulatory dysfunc-
or greater. The preferred site for large-volume para- tion is associated with an increased mortality and may
centesis is chosen in the dependent position, such as be prevented by administration of albumin intrave-
right or left lower quadrants. The site of puncture is nously (6 to 8 g/L of ascites removed) along with large
chosen usually lateral to the rectus muscle to avoid the volume parasynthesis (LVP).
accidental puncture of the inferior epigastric artery.
The inferior epigastric artery normally travels at the Percutaneous cholecystostomy
junction of the medial two thirds and lateral one third
of the rectus or approximately 5 cm laterally from the Acute cholecystitis in high-risk patients in the
midline (Fig. 5). After standard sterile skin prepara- ICU is difficult to manage. In critically ill, oftentimes
tion, 1% lidocaine is injected into the abdominal wall septic patients with possible acalculous or gangrenous
for local anesthesia. The authors anesthetize all the cholecystitis, percutaneous cholecystostomy may be
Fig. 5. Paracentesis, epigastric artery. (A) Color Doppler transverse image of the anterior abdominal wall with a 6-MHz linear
transducer was used to localize the location of the inferior epigastric artery (arrow) before paracentesis. This is the typical
location along the lateral aspect of the rectus abdominis muscle. (B) CT scan on a different patient demonstrates the location of
the epigastric arteries (arrowheads).
both diagnostic and therapeutic. These patients are not the trocar-based catheter buckles against the liver or
suitable candidates for surgery. Percutaneous chole- gallbladder wall, the Seldinger technique can be used
cystostomy is used as a diagnostic and therapeutic (Fig. 6). The acutely inflamed gallbladder wall can be
procedure in these critically ill and difficult to manage friable and catheter and wire manipulations should not
patients [26,40 – 43]. In unstable patients with calcu- be too aggressive. If the Seldinger technique is used,
lous cholecystitis, percutaneous cholecystostomy per- the authors use a 5F catheter on a 19-gauge needle
mits stabilization so that cholecystectomy can be (Yueh centesis disposable catheter needle, Cook,
performed electively. Bloomington, Indiana) to puncture the gallbladder
lumen. They then use a standard 0.035-inch guide-
Indications wire; carefully dilate the tract to 8F catheter; and then
Percutaneous cholecystostomy may be performed place an 8F catheter, self-retaining nephrostomy tube.
in critically ill septic patients to exclude acute cho- The authors recommend not using a super-stiff guide-
lecystitis, because of the difficulties of establishing wire, such as an Amplatz, because it may perforate the
the diagnosis of acute cholecystitis in these patients gallbladder wall. If the transperitoneal approach is
[26,44,45]. The findings on the various diagnostic used, a small 8F catheter or less, single-step trocar
tests can be nonspecific. A sonographically normal catheter is recommended. The gallbladder lumen
gallbladder virtually excludes cholecystitis in an ICU should be punctured with a sharp jab, and the gall-
patient, and a positive sonographic Murphy’s sign bladder should be emptied once the catheter is within
may be the most specific finding of acute cholecystitis [49]. The Seldinger technique is not favored with this
in these patients [46]. Other findings, such as sludge, technique, because there is a theoretical risk of bile
distention, pericholecystic fluid, wall thickening, and leakage into the peritoneum.
striations, are nonspecific in this setting [46,47]. The Once the self-retaining tube is within the gallblad-
presence of gallstones, distention, and pericholecystic der, it is recommended that it remain there for at least
fluid, however, have been described as findings that 2 to 3 weeks to allow formation of a mature tract along
may predict a more favorable response to percutane- the catheter; otherwise, there may be bile leakage once
ous cholecystostomy [41,47] the catheter is removed [42,48]. It also is recom-
mended that a cholangiogram be performed before
Technique catheter removal to ensure patency of the cystic duct
Two access routes are used. The transhepatic route and common bile duct [26,48,54]. Some investigators
approaches from the right midaxillary line and aims also advise imaging the tract at the time of tube
for the ‘‘bare’’ area of the gallbladder. This route is removal [26,43,44], although other investigators dis-
preferred by most investigators and theoretically agree [41,49] even if the transperitoneal approach is
reduces the risk of bile peritonitis [26,41,42,48]. The used [49].
transperitoneal approach is from the anterior abdomen Complication rates generally range from 5% to
and is aimed at the gallbladder fundus [41,49 – 51]. 13.8% [41,43,45,49,51,55]. Complications include
Because of the risks of bile peritonitis and inadvertent bleeding, bile leakage, catheter dislodgement, and
perforation of the colon, the transperitoneal approach vasovagal events. Bile leakage has been reported with
is probably best reserved for patients with very dis- both the transhepatic and transperitoneal approaches.
tended gallbladder in which the gallbladder fundus Technical success rates (ie, adequate placement of a
abuts the anterior abdominal wall. This approach is drain in the gallbladder) are high (ie, as great as 97% –
also useful in patients with coagulopathy or underly- 100%) [26,41 – 43,45,47 – 49,56]. Overall patient re-
ing liver disease [41,43,49 – 51]. The transhepatic sponse is lower, however, because of the relatively
route for percutaneous cholecystostomy does not allow threshold of clinicians to request the procedure
ways result in a puncture of the ‘‘bare area’’ of the and the nonspecificity of the diagnostic tests; no
gallbladder and the ‘‘free’’ peritoneal surface of the clinical response to the procedure can be found in up
gallbladder may still be punctured [52]. Some inves- to 42% of the patients [26,42]. Placement of a chole-
tigators have also used simple aspiration of the gall- cystostomy tube is still helpful in these circumstances,
bladder contents without placement of a drainage tube however, because it does reassure the clinicians that
[45,53]. The authors typically use the transhepatic cholecystitis is not a cause of a patient’s sepsis.
approach and ultrasound guidance. Sometimes CT Some investigators have used simple gallbladder
guidance may be necessary, however, particularly aspiration in patients with suspected acute cholecys-
for a liver in a high subcostal location. Typically, a titis [45,53]. Simple percutaneous gallbladder aspira-
small 6F single-step trocar catheter (Skater, Medical tion does seem to be beneficial in patients with acute
Device Technologies, Gainesville, Florida) is used. If cholecystitis and comorbid conditions. Chopra’s et al
Fig. 6. Ultrasound-guided percutaneous cholecystostomy in a patient status-post recent myocardial infarction. (A) Longitudinal
vector scan demonstrates distended gallbladder with sludge and a thick wall. Initial attempts with a 6F catheter one-step trocar-
based catheter were not successful, because of the thickened gallbladder wall. The catheter buckled on the trocar. The Seldinger
technique was used. A 19-gauge disposable sheath needle (Yueh centesis needle) was used to enter the gallbladder lumen. A
standard 0.035-inch angiographic guidewire was placed, the tract was carefully dilated to 8F catheter, and a self-retaining 8F
catheter nephrostomy-type tube (arrowhead) was placed. (B) Schematic representation of the procedure described in Fig. 6A.
[45] patient population, although at high surgical risk, primary method of treatment for many patients with
consisted of noncritically ill patients. As stated in their intra-abdominal abscess [18,57 – 60]. In many hospi-
article, they excluded patients who had had prolonged tals in the United States, CT is the imaging modality of
admission to the ICU. choice to detect abscesses. Once detected, an abscess
can be drained using either CT or ultrasound guidance
Intra-abdominal abscess drainage depending on which modality best delineates the
abscess and its surrounding structures. In general,
Image-guided percutaneous abscess drainage is a CT is used for abscesses inaccessible to ultrasound,
well-established technique, which has become the such as abscesses in deep locations adjacent to vital
structures (eg, major vessels or those adjacent to abscesses, the Seldinger technique is favored unless
bone), which may block the ultrasound beam. These the abscess is very large and superficial.
abscesses include pancreatic, interloop, and deep After obtaining informed consent, the fluid is
retroperitoneal abscesses. Abscesses in more superfi- localized and the needle trajectory planned. The site
cial locations of the peritoneum or visceral organs are for needle insertion is marked, and the skin is prepared
usually amenable to ultrasound guidance. Ultrasound and draped in a sterile manner. The ultrasound probe
has many advantages, including its lower cost, its is then covered with a sterile cover, and the needle
ability to be performed portably at the patient’s bed- guide is attached unless the procedure is performed
side, and its multiplanar imaging capabilities. freehand. A skin wheal is raised with local 1% lido-
caine, and a skin nick is made with a scalpel. Using a
19-gauge sheath needle (Yueh centesis disposable
Indications catheter needle; Cook, Bloomington, Indiana), the
In general, intraperitoneal abscesses adjacent to the projected needle tract is anesthetized to the fluid
abdominal wall and abscesses in the periphery of collection. The fluid collection is then punctured with
visceral organs, such as the liver or kidney, are the 19-gauge sheath needle, the 5F disposable sheath
amenable to ultrasound-guided aspiration and drain- catheter is advanced over the needle, the sharp needle
age. The authors always avoid traversing uninvolved is then removed, and the fluid is aspirated through the
spaces or organs, such as the liver or bowel, when 5F disposable catheter sheath. If the fluid is purulent, a
performing any interventional procedure. The excep- standard 0.035-inch angiographic guidewire can be
tions are traversing the stomach for pancreatic proce- advanced into the abscess. After confirming the loca-
dures and traversing the rectum or vagina for pelvic tion of the guidewire, the tract can be dilated and an
abscess drainages. Other investigators have reported appropriate-sized, self-retaining nephrostomy tube
success without significant complications from tra- can be placed. For thin pus, 8 to 10F catheters are
versing uninvolved spaces or organs while performing usually sufficient. Catheters up to 14F can be used for
interventional procedures [61 – 63]. If a loop of bowel more viscous pus. The tube position should then be
is inadvertently traversed with a catheter, the catheter verified so that additional purulent fluid can be
should be left in place for 2 to 3 weeks so a tract can aspirated. The catheter is then secured to the skin
form. After this period the catheter can usually be either with sutures or adhesive fixation devices
removed safely without spillage of bowel contents (Percu-Stay Percutaneous Catheter Fastener, Derma
into the peritoneum [64,65]. This assumes that the Sciences, Princeton, New Jersey).
underlying bowel is otherwise normal and that there is Routine catheter care is then performed. The
no distal bowel obstruction. Relative contraindica- authors place catheters to gravity drainage. Daily tube
tions common to all percutaneous procedures include rounds are made to evaluate the drainage progress.
coagulopathy, the patient’s inability to cooperate, and Once the fluid becomes serous, the tube output has
lack of safe access to the abscess. decreased to less than 20 mL per 24 hours, the patient
has defervesced, and the white blood cell count is
normal, the tube may be removed. The authors typi-
Technique cally repeat a CT scan before tube removal to ensure
Simple, uncomplicated abscess drainage is de- that there are no residual fluid collections.
scribed next. Management of more complex abscesses,
such as infected hematomas, abscesses associated
with fistulae, and fungal abscesses, is also discussed. Liver abscess
Pelvic abscesses, particularly those caused by gyne-
cologic sources, are discussed separately. Pyogenic liver abscesses located in the periphery
Preprocedure imaging is best performed with CT are amenable to ultrasound aspiration and drainage.
because the size of the fluid collection, its location, Those located more centrally are better approached
and extent can be well-delineated. The authors typi- with CT guidance. Typically, a cuff of normal paren-
cally review the patient’s CT before the procedure and chyma should be included within the needle trajec-
if possible have a copy of the CT in the ultrasound tory to prevent spillage of the abscess contents into
suite when performing the procedure. The CT pro- the peritoneum (Fig. 7). The pleural space, loops
vides an excellent roadmap to help plan the needle of bowel, and large intrahepatic vessels should be
trajectory. The authors frequently use a commercially avoided. Multilocular abscesses may be drained;
available needle guide, although for superficial ab- however, close follow-up and additional catheters
scesses they use the freehand technique. For most may be necessary [62]. The cure rate for liver abscess
Fig. 7. Ultrasound-guided liver abscess drainage in a septic patient whose previous catheter was inadvertently pulled out. (A) CT
scan demonstrates residual abscess in the dome of the right lobe of the liver (arrows). (B) Transverse ultrasound of the liver
demonstrates the 8F pigtail catheter (arrowhead) placed by the Seldinger technique into the abscess by a subphrenic approach.
is about 80% to 90%. Causes of failures of percuta- Percutaneous nephrostomy

neous drainage of liver abscess are given in Box 6.
The main emergent indication for percutaneous
nephrostomy is pyohydronephrosis, which can occur
Renal and perinephric abscess in native or a transplant kidney. Other urgent indica-
tions include a rapidly rising creatinine level or recent
Renal and perirenal abscesses may be drained endourologic complication. Indications of percutane-
using ultrasound guidance; however, such abscesses ous nephrostomy are summarized in Box 7. Ultra-
are usually better detected and delineated by CT [66]. sound is an excellent method to guide the initial
This is particularly important for abscesses in the needle placement for percutaneous nephrostomy.
pararenal space because they can extend from the These procedures are typically performed in the
pelvis to the diaphragm. A posterolateral approach is angiography suite using a portable ultrasound unit.
preferred because it avoids the erector spinal muscles, Although the entire procedure can be performed
colon, liver, and spleen. with fluoroscopic guidance only, ultrasound is very
their numbers were small. Green [68] described suc-

Box 6. Causes of failures of percutaneous
cessful percutaneous drainage in only one of four
drainage of liver abscess
patients. Lucey et al [67] successfully drained five
of six splenic abscesses; the one failure required a
Preprocedure
splenectomy. The authors believe that splenic abscess
drainage should only be performed in rare circum-
Unable to access the abscess safely
stances and should generally be reserved for select
Improper pathway to abscess
patients. Close consultation with the surgical service
Inability to place the catheter appropri-
is recommended so that an emergent splenectomy can
ately within the abscess
be performed if needed. If percutaneous drainage of a
splenic abscess is to be attempted, the abscess ideally
Postprocedure
should be peripheral so that the least amount of nor-
mal splenic parenchyma is traversed. Thanos et al
Premature withdrawal of catheter
[69], however, have performed drainages in two pa-
Dislodged catheter
tients where the needle and catheter traversed 2.3 cm
Catheter kinked or occluded
of normal splenic parenchyma.
High-output fistula to gastrointesti-
nal tract
Fistulae
Fungal abscess
Infected necrotic tumor
Uncomplicated abscesses have gradually decreas-
Viscous pus or multiple septations,
ing output following percutaneous drainage. In those
resistant to fibrinolytic therapy
abscesses with persistently elevated output (ie, greater
Sepsis or death
than 100 mL per 24 hours) more than 3 to 4 days after
useful for obtaining initial access to the renal collect-

ing system [20,67], particularly in cases where the Box 7. Indications for percutaneous
hydronephrosis is mild, or for renal transplants where nephrostomy
the renal axis can vary. For a native kidney, the
authors target a posterior calyx using a posterolateral 1. Relief of urinary obstruction
approach to avoid most of the erector spinus muscles. Improve renal function
For transplant kidneys, the authors target an anterior Evacuate pyonephrosis
calyx. Typically, they use a 20-gauge Chiba needle for Assess recoverable renal function in
initial access, followed by instillation of contrast and a chronic obstruction
small amount of air (3 – 5 mL) to confirm the needle 2. Diversion of urine in case of urinary
position (Fig. 8). The air rises to the nondependent leakage
calices. If the needle position is satisfactory, the tract Traumatic or iatrogenic urinary
can be dilated with a micropuncture set through the tract injury
20-gauge Chiba needle. If there is a better site to Inflammatory or malignant
access the collecting system, a second needle can then urinary fistula
be placed under fluoroscopic guidance using either a 3. Provide access for urinary
20-gauge Chiba needle or 19-gauge sheath needle manipulation
(Yueh centesis needle). The tract is dilated using the Perform dynamic flow-pressure
Seldinger technique, and an 8 to 14F catheter self- studies (Whitaker test)
retaining nephrostomy tube can be placed. Biopsy
Stone therapy
Splenic abscess Benign stricture dilatation
Ureteral stent placement
Splenic abscess if untreated have a mortality rate Foreign body retrieval
of 80% to 100% and mortality rate of 14% to 30% Nephroscopic surgery
with surgical drainage. Experience with percutaneous (eg, endopyelotomy)
drainage is limited [59,68 – 70]. Although no major Administration of antifungal agents
complications were reported in these series [59,70],
Fig. 8. Ultrasound-guided percutaneous nephrostomy in a renal transplant with pyohydronephrosis caused by ureteral calculus.
(A) Initial ultrasound demonstrates complex-appearing urine within the hydronephrotic transplant, which is consistent with
pyohydronephrosis. The indwelling stent is noted (arrows). (B) Longitudinal ultrasound of the dilated distal transplant ureter
demonstrates an obstructing calculus in the cursors. Note the ‘‘twinkle’’ artifact from the calculus with the color Doppler.
(C) Longitudinal image during placement of a nephrostomy tube (arrowhead). (D) Schematic representation of the kidney and
positioning of the catheter.
twice a day-for 2 days, may improve drainage from

such hematomas.
Fungal abscess
Fungal abscesses are difficult to treat with percu-

taneous drainage and may require surgical drainage
and debridement [18,73]. This is probably caused by
the extensive tissue invasion, necrosis, and mycotic
plaque formation in the wall of the cavity [18].
Echinococcal abscess
A number of investigators have described success-

ful treatment of hydatid cysts using percutaneous
aspiration and drainage [74 – 79]. The technique is
similar to routine abscess aspiration and drainage.
Various catheter irrigants are used, such as hyperto-
nic saline [74,79], scolicidal agent [75], or alcohol
Fig. 8 (continued ). [76,77,79]. Anaphylaxis is a potential complication,
which can be severe or even fatal [78]. Many of the
patients were given prophylaxis with albendazole.
Some investigators perform single-step aspiration
initial catheter placement, especially drainage consist- [74,77], whereas others aspirate the smaller cysts
ing of bilious or enteric material, a gastrointestinal and leave catheters in larger (> 6 cm) cysts [75,78,79].
fistula is likely [71,72]. At this point a sinogram con-
firms the communication to the gastrointestinal tract. Pelvic abscesses
The cause of the fistula should then be determined so
that appropriate treatment may be initiated. Fistulae Image-guided percutaneous drainage (Fig. 9) is
caused by distal obstruction, neoplastic involvement, commonly performed for pelvic abscesses. Typically,
or ongoing infection must have these underlying pelvic abscesses arise from gastrointestinal sources,
conditions corrected or the abscess does not heal. such as diverticulitis, ruptured appendicitis, and
Low-output fistulae (ie, less than 320 mL per day) Crohn’s disease, and from postoperative fluid collec-
usually close spontaneously without additional thera- tions. In female patients, pelvic abscesses may also
py [18]. High-output fistulae may require additional arise from gynecologic sources, such as tubo-ovarian
treatment, including suction on the abscess catheter, abscess from pelvic inflammatory disease. Such pel-
and bowel rest often with nasogastric tube placement. vic abscesses are traditionally treated with medical
Hyperalimentation may be necessary, and surgical therapy and if drainage of abscess is required many
intervention may be required [18]. investigators prefer image-guided interventional tech-
niques [80 – 87]. Pelvic abscesses in a female second-
Infected hematomas ary to gynecologic causes are a special category and
usually have acute presentation.
Most infected hematomas do not drain with simple Imaging-guided pelvic abscess drainage offers
catheter placement because of their extensive amount several advantages to traditional surgical drainage.
of fibrin and the protective effects of fibrin on bacteria The imaging-directed methods are less invasive and
[18]. For patients with a suspected infected hema- do not require general anesthesia. The indications for
toma, the authors perform an initial aspiration. If surgical drainage include ruptured tubo-ovarian ab-
the fluid is bloody but not grossly infected, they only scess, when diagnosis is uncertain; pelvic abscess
take a sample for laboratory analysis and do not place secondary to appendicitis or ruptured viscus [88];
a catheter for the fear of secondary infection. If and failed percutaneous drainage. The imaging-guid-
the fluid is grossly purulent or if the cultures subse- ed methods include transabdominal, transgluteal,
quently come back positive for infection, a drainage transrectal, and transvaginal approaches. The trans-
catheter is placed. Sometimes local instillation of fi- perineal approach has also been described [89]. In
brinolytic agents, such as streptokinase, 125,000 IU general, the transabdominal approach is preferred,
Fig. 9. Ultrasound-guided pelvic abscess drainage, transabdominal, in a postsurgical patient. (A) Initial CT scan demonstrates
abscesses in the right and left lower quadrants of the pelvis (arrows). (B) Under ultrasound guidance the abscess in the right
lower quadrant was localized and punctured with a 19-gauge sheath needle. After confirming pus, a standard 0.035-inch
angiographic guidewire (Rosen) was advanced into the abscess. The tract was dilated to 10F catheter, and a self-retaining 10F
catheter nephrostomy tube (arrowhead) was placed. (C) The left lower quadrant abscess was then localized. Initial attempts were
made with a 12F one-step catheter; however, the patient complained of too much discomfort. This abscess was also punctured
with a 19-gauge sheath needle. After confirming pus, the tract was dilated and a 12F catheter nephrostomy tube was placed
(arrowhead). (D) Schematic representation of the procedure.
abscess drainage and may be a viable alternative for

patients who have undergone abdominoperineal re-
section [89].
Technique
The transvaginal approach is best performed with
ultrasound guidance (Fig. 10). First, the abscess
should be localized by endovaginal ultrasound. The
abscess should be directly adjacent to the vaginal
vault with no intervening structures. The ultrasound
probe then is removed and the perineum and vagina
are prepared with a standard povidone-iodine solu-
tion. A vaginal speculum is then inserted and the
vaginal vault is prepared using sponges soaked in io-
dine-iodine solution. The speculum is then removed.
Despite the iodine-iodine preparation, the vagina is
Fig. 9 (continued ).
still semi-sterile. If the patient is not already receiving
intravenous antibiotics, she should be given an appro-
priate antibiotic before beginning the procedure. Be-
using CT or ultrasound, because it is very well- cause it can be difficult to hold the ultrasound probe
tolerated by patients. Pelvic abscesses may not be while doing the various catheter manipulations, the
accessible using the transabdominal approach, how- procedure generally requires two people.
ever, because of the presence of intervening loops of The endovaginal ultrasound probe is then fitted
bowel, urinary bladder, major blood vessels, or the with a modified guide to allow catheter insertion. The
uterus. The transgluteal approach has several disad- commercially available needle guides typically do not
vantages, including patient discomfort, injury to the allow placement of trocar-based catheters. Various
sciatic nerve, and an increased chance of catheter methods can be used [80,88], although the authors
kinking and subsequent malfunction [84,90]. Al- prefer using the plastic sheath that comes with the
though initially underused, some investigators have catheter, as described by O’Neill et al [79]. The
recently been successful using the transgluteal ap- endovaginal probe is initially placed in a sterile probe
proach [90 – 93]. The transrectal [94 – 97] and trans- cover with coupling gel. A modified guide then is
vaginal approaches are well established [60,80 – made from the plastic catheter protector. The plastic
84,88,98]. The transrectal approach can be guided protector is cut so that approximately 5 cm of the
using CT [94], ultrasound [95 – 97,99], or ultrasound catheter protrudes beyond the end of the guide; a slit is
combined with fluoroscopy [100]. The transvaginal then made along the length of the guide, which
approach is usually guided with ultrasound. facilitates subsequent removal of the guide from the
Most patients with tubo-ovarian abscesses respond catheter. This modified guide is then attached to the
to intravenous antibiotic therapy. As expected, the sterilely prepared endovaginal probe with sterile rub-
response to antibiotics is inversely related to the size ber bands along the groove intended for the metal
of the abscess [82]. In unruptured tubo-ovarian ab- probe guide. The 6 to 8F trocar-based catheter (Skater,
scesses not responding to antibiotics, image-guided Medical Device Technologies, Gainesville, Florida) is
drainage is indicated. The decision to proceed with then placed into the modified guide and a second
drainage is usually made in conjunction with the sterile probe cover is placed over the catheter and
gynecologic service. The authors prefer the trans- guide. The catheter punctures the outer sterile probe
abdominal approach, if possible, followed by the cover before puncturing the vaginal wall. One can
transrectal approach with CT guidance, and finally attempt to use local lidocaine at the vaginal wall but
the transvaginal approach with ultrasound. Female this can be difficult because there are no landmarks to
patients tolerate transrectal catheter placement better ensure that the same area is traversed with the catheter.
as compared with transvaginal placement [99]. The Before placing a catheter, an initial aspiration should
authors use the transgluteal approach only when be performed using an 18- to 20-gauge needle to
necessary (ie, a deep pelvic abscess in a patient with document infection. Initial scanning should be done
underlying rectal mucosal disease or in premenarchal to place the abscess centrally within the scan plane
or sexually inactive females). The transperineal ap- and to visualize where the catheter enters the abscess.
proach provides an additional option for deep pelvic The tip of the trocar-based catheter should indent the
Fig. 10. Ultrasound-guided transvaginal pelvic abscess drainage. (A) Photograph shows the trocar catheter advanced through the
guide and projecting approximately 5 cm past the end of the probe (arrow). Note that the guide (plastic sheath) needs to be cut to
a length such that it allows at least 5 cm of catheter advancement so that the catheter can be advanced through the vaginal vault.
(B) Photograph shows the catheter has been fed off and the pigtail has been formed. The inner needle has been removed, but the
outer metal cannula stiffener is left in the straight portion of the catheter to stiffen it and ease the peeling away of the guide from
the catheter. (C) CT scan shows a complex right adnexal fluid collection (straight arrow). An incidentally noted right-sided
fundal fibroid is noted (curved arrow). (D) Transvaginal ultrasound scan shows trocar-catheter assembly (arrow) in the right
adnexal collection along the guide. (From O’Neill MJ, Rafferty EA, Lee SI, et al. Transvaginal interventional procedures:
aspiration, biopsy, and catheter drainage. Radiographics 2001;21:657 – 72; with permission.)
wall of the abscess during light palpation. Assuming from the catheter. This is easier to perform if the metal
there are no intervening structures and the trajectory is stiffener is placed partially within the catheter. The
appropriate, the abscess wall is punctured using a stiffener is then removed and more pus is aspirated.
sharp thrust of 1 to 2 cm. This is the most difficult part Because of difficulties in penetrating the vaginal wall,
of the procedure. It is helpful to apply enough pressure the authors have found that 10F or smaller catheters
with the endovaginal ultrasound probe so that the are easier to insert.
vaginal wall is taut before being punctured with the Although the single-step trocar-based catheter is in
trocar. The sharp needle of the trocar is removed and a general easier to perform, the authors find the Sel-
diagnostic aspiration is performed. Once pus is aspi- dinger technique useful for inserting larger catheters
rated, the catheter is advanced over the metal stiffener into abscesses with thick pus [84,101,102]. For expe-
of the trocar until the self-retaining loop is formed and rienced operators, ultrasound alone can be used.
locked. The endovaginal probe is then removed care- Alternatively, a combination of ultrasound and fluo-
fully and the rubber bands and outer sterile cover roscopy can be performed. With the Seldinger tech-
gradually are cut. The modified guide is then removed nique, the abscess is punctured with a 19-gauge sheath
needle with a disposable 5F TFE catheter (Yueh not routinely flush the catheters unless they are using
centesis disposable catheter needle; Cook, Blooming- fibrinolytic agents, such as streptokinase.
ton, Inidana). After aspirating pus to confirm its Success rates for transvaginal drainage range from
location, the 19-gauge needle is removed, leaving 78% to 100% [60,81,82,84,98,106]. Similar success
the 5F catheter in the abscess, and a standard 0.035- rates are noted for the other methods (ie, transabdomi-
inch angiographic guidewire is advanced into the nal, transrectal, and transgluteal) of pelvic abscess
abscess. The 5F TFE catheter is then removed and a drainage, ranging from 94% to 100% [83,91,94,96].
standard 5F pigtail catheter is placed over the guide- Complications from transvaginal drainage are infre-
wire and coiled into the abscess. Placement should be quent and include bleeding, infection, underlying
confirmed with ultrasound. The disposable 5F TFE organ damage, and vaginal fistula formation. Catheter
catheter is not long enough to allow a guidewire to dislodgement may occur following any drainage pro-
coil within the abscess. The 0.035-inch guidewire is cedure; however, this did not adversely affect patient
removed, and a 0.035-inch Amplatz wire (Amplatz outcome in three of four patients in the study of Ryan
Super Stiff, Boston Scientific, Medi-Tech, Miami, et al [94].
Florida) is advanced into the 5F pigtail catheter. The
5F pigtail catheter is then removed, the tract can be
dilated up to 14F catheter, and an appropriate size of Summary
self-retaining nephrostomy-type tube can be placed. If
the abscess is large enough, an Amplatz wire can be The interventionist can perform many emergent
introduced initially; however, this must be done care- procedures with ultrasound guidance, because of its
fully to avoid perforating the wall of the abscess with real-time, multiplanar imaging capability and porta-
the super-stiff wire. The stiffness of the Amplatz wire bility. With the use of color Doppler, additional im-
(Amplatz Super Stiff, Boston Scientific, Medi-Tech, portant information, such as aberrant vessels, can be
Miami, Florida) allows the tract to be dilated despite ascertained to help plan needle trajectory. Ultrasound
the distance between the operator’s hands and the is also useful for nonemergent procedures, such as
point of wire insertion in the vaginal wall. Less stiff biopsies. All interventionists are encouraged to be
guidewires may kink. All of the dilatations can be facile with the use of ultrasound.
performed through the modified guide on the endo-
vaginal probe.
Some investigators perform simple needle aspi- Acknowledgment
ration of an abscess without catheter placement
[81,103 – 106]. Although large, multiloculated collec- The authors thank Elena DuPont of the radiology
tions can be treated this way, this method may be most department at University Hospitals of Cleveland for
useful for small, unilocular collections. Nelson et al the line drawings and Joe Molter for assisting in the
[80] found no correlation between the size of an preparation of images.
abscess and the success rates for simple aspiration.
The advantages of this method are that it is safe, easier
to perform than catheter drainage, and there is no
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Radiol Clin N Am 42 (2004) 479 – 486
Index
Note: Page numbers of article titles are in boldface type.
A Acalculous cholecystitis, acute, ultrasonography

Abdomen, interventional ultrasonography in. See of, 260
Interventional ultrasonography. Acute painful scrotum, ultrasonography of, 349 – 363
Abdominal aortic aneurysms, aortic endografting for, anatomy in, 349 – 350
372 – 373 for appendageal torsion, 356 – 357
complications of, 369 – 370 for cellulitis, 353
for epididymo-orchitis, 351 – 353
CT of, 373
for Fournier’s gangrene, 351
Ehlers-Danlos syndrome and, 370
for idiopathic varicocele, 357 – 358
risk factors for, 368
for inguinal hernia, 360 – 361
ultrasonography of, 365 – 373 for intratesticular abscess, 353 – 354
anatomy and histology in, 365 – 366 for intratesticular arteriovenous
as screening tool, 370 malformation, 359
false aneurysms, 370 – 371 for intratesticular varicocele, 358 – 359
flow characteristics in, 366 for primary orchitis, 353
for aortic dissection, 371 – 372 for secondary varicocele, 358
inflammatory aneurysms, 371 for testicular torsion, 354 – 356
limitations of, 370 for testicular trauma, 359 – 360
mycotic aneurysms, 371 for testicular tumor, 361
technique for, 350 – 351
technique for, 366 – 368
Adenomas, hepatic, ultrasonography of, 271 – 273
Abdominal ectopic pregnancy, ultrasonography
of, 333 Adnexal masses, ultrasonography of, 329 – 348
corpus luteal cysts, 329 – 331
Abdominal injuries, emergency ultrasonography cystadenocarcinoma, 342
of, 421 cystic teratomas, 341
Abdominal surgery, during pregnancy, diverticulitis, 344
ultrasonography in, 323 ectopic pregnancy, 331 – 334
abdominal, 333
Abortion, spontaneous, and first-trimester bleeding, adnexal ring sign in, 332
301 – 303, 306 cervical, 333
ultrasonography of, 322 double decidual sac sign in, 332
b-human chorionic gonadotropin in, 334
Abruption, placental, ultrasonography of, 319
interstitial, 333
Abscesses, abdominal, interventional ultrasonogra- intradecidual sign in, 331 – 332
phy for. See Interventional ultrasonography. management of, 333 – 334
intratesticular, ultrasonography of, 353 – 354 endometriomas, 339 – 340
liver, diagnosis of, 268 – 270 epiploic appendages, 345
lung, interventional ultrasonography for, 462 follicular cysts, 329
tubo-ovarian, ultrasonography of, 338 – 339 leiomyomata, 340 – 341
luteoma of pregnancy, 338
Abscess-pleural symphysis, lung abscesses and, 462 ovarian hyperstimulation syndrome, 334 – 336
doi:10.1016/S0033-8389(04)00032-6
480 Index / Radiol Clin N Am 42 (2004) 479–486
ovarian neoplasms, 341 B

ovarian torsion, 336 – 338 Barium enema examination, of intussusception, in
pelvic inflammatory disease and tubo-ovarian infants and children, 449 – 450
abscess, 338 – 339
Bell-clapper deformity, scrotal, ultrasonography
perforated appendicitis, 343 – 344
of, 354
serous and mucinous cystadenomas, 341 – 342
theca lutein cysts, 334 Biliary duct dilatation, diagnosis of, 264 – 266
Adnexal ring sign, in ectopic pregnancy, 332 Biliary obstruction, diagnosis of, 266
Amniotic sac, ultrasonography of, 301 Biopsy, renal, complications of, 406 – 407, 410
Androgens, and priapism, 430 – 431 Bleeding, first-trimester. See First-trimester bleeding.
Aneurysms, ultrasonography of, abdominal aortic. Bowel strangulation, inguinal hernias and, 360 – 361
See Abdominal aortic aneurysms. Budd-Chiari syndrome, ultrasonography of, 275
iliac artery, 377 – 379
peripheral artery, 379
popliteal, 379
splanchnic artery, 377 C
splenic artery, 377 Calf veins, ultrasonography of, for thromboembolic
in pregnancy, 325 disease, 287 – 288
Ankle-brachial index, in arterial injuries, 383 – 384 Carotid artery dissection, ultrasonography of,
389 – 390
Antipsychotic drugs, and priapism, 430
Carotid artery stenosis, and stroke, ultrasonography
Aortic dissection, ultrasonography of, 371 – 372 of, 391 – 392
Aortic endografting, for abdominal aortic aneurysms, Cellulitis, scrotal, ultrasonography of, 353
372 – 373
Cervical ectopic pregnancy, ultrasonography of, 333
Appendageal torsion, scrotal, ultrasonography of,
Chest, interventional ultrasonography in. See
356 – 357
Interventional ultrasonography.
Appendicitis, acute, in infants and children, 452 – 454 Chest injuries, emergency ultrasonography of,
ultrasonography of, 453 – 454 421 – 424
perforated, ultrasonography of, 343 – 344
Chest tube insertion, ultrasonography in, 459 – 462
Arterial embolization, for acute limb ischemia,
392 – 394 Chlorpromazine, and priapism, 430
for priapism, 436 – 437 Cholecystitis, ultrasonography of, acute, 257
Arterial injuries, ankle-brachial index in, 383 – 384 acute acalculous, 260
pathologic validation of, 383 complicated, 260 – 261
ultrasonography of, 383 – 396 emphysematous, 263 – 264
acute limb ischemia, 392 – 394 gangrenous, 261 – 262
arteriovenous fistulas, 388 – 389 Cholecystostomy, percutaneous, ultrasonography in,
craniocervical dissections, 389 – 391 463 – 465
diabetic foot, 394
hematomas, 386 – 388 Choriocarcinoma, and first-trimester bleeding, 309
pseudoaneurysms, 384 – 386 Chronic intestinal ischemia, ultrasonography of,
stroke and carotid artery stenosis, 391 – 392 373 – 377
upper limb ischemia, 394 – 395
Cirrhotic native liver, ultrasonography of. See Liver.
Arteriovenous fistulas, renal, ultrasonography of,
406 – 407 Cocaine, and priapism, 430
ultrasonography of, 388 – 389 Compression ultrasonography, of thromboembolic
disease, 281, 283, 286, 287, 291, 294
Arteriovenous malformations, and first-trimester
bleeding, 309 – 311 Computed tomography, in trauma patients, versus
intratesticular, ultrasonography of, 359 ultrasonography, 420
Index / Radiol Clin N Am 42 (2004) 479–486 481
of abdominal aortic aneurysms, 373 Empyema, chest tubes for, 460 – 462
of acute hepatic vein thrombosis, 275 versus lung abscesses, 462
of diverticulitis, 344 Endoluminal repair, of abdominal aortic aneurysms,
of intra-abdominal abscesses, 465 – 466 372 – 373
Corpus luteal cysts, ultrasonography of, 329 – 331 Endometriomas, ultrasonography of, 339 – 340
Craniocervical dissections, ultrasonography of, Endometrium, sonographic anatomy of, 297
389 – 391
Endovaginal ultrasonography, of ectopic
Crown-rump length, of embryo, 301, 305 pregnancy, 331
Cystadenocarcinoma, ultrasonography of, 342 Epididymo-orchitis, ultrasonography of, 351 – 353
Cystadenomas, ultrasonography of, 341 – 342 Epiploic appendages, ultrasonography of, 345
Cystic teratomas, ultrasonography of, 341
Cysts, corpus luteal, ultrasonography of, 329 – 331 F
follicular, ultrasonography of, 329
Fatty infiltration of liver, and liver enlargement, 270
theca lutein, ultrasonography of, 334
Fatty liver of pregnancy, and liver enlargement,
Cytotec, and spontaneous abortion, 322 270 – 271
Fibroids, uterine, ultrasonography of, 322 – 323
D First-trimester bleeding. See also Pregnancy.
Deep venous thrombosis, ultrasonography of, ultrasonography of, 297 – 314
286 – 294 anatomy in, 297 – 298
for absent intrauterine gestational sac,
Diabetic foot, ultrasonography of, 394 303 – 304
D-dimer test, for thromboembolic disease, 284, 286 for arteriovenous malformations, 309 – 311
for choriocarcinoma, 309
Diverticulitis, CT of, 344 for gestational sac with embryo, 305
ultrasonography of, 344 for gestational trophoblastic disease, 306 – 309
Double decidual sac sign, in ectopic pregnancy, 332 for hydatidiform mole, 307 – 309
in transvaginal ultrasonography, 299 for intrauterine growth restriction, 305
for retained products of conception, 306
for spontaneous abortion, 301 – 303
for subchorionic hematoma, 305 – 306
E for trophoblastic tumors, 309
Echinococcal abscesses, interventional technique for, 298
ultrasonography for, 470 versus normal ultrasonography, 298 – 301
amniotic sac in, 301
Ectopic pregnancy, ultrasonography of. See Adnexal embryo in, 300 – 301
masses. gestational sac in, 298 – 300
Edema, re-expansion pulmonary, thoracentesis yolk sac in, 300
and, 459 yolk sac criteria for, 304 – 305
Ehlers-Danlos syndrome, and abdominal aortic Fistulas, abdominal, interventional ultrasonography

aneurysms, 370 for, 468, 470
arteriovenous, renal, ultrasonography of,
Embolization, arterial, for acute limb ischemia, 406 – 407
392 – 394 ultrasonography of, 388 – 389
for priapism, 436 – 437
Focal hemorrhagic lesions, hepatic, diagnosis of,
transcatheter, for priapism, 437 – 438
271 – 274
Embryo, ultrasonography of, 300 – 301, 305
Focused abdominal sonography for trauma
Emphysematous cholecystitis, ultrasonography of, technique. See Trauma patients, emergency
263 – 264 ultrasonography in.
Follicular cysts, ultrasonography of, 329 of acute cholecystitis, 257

Foot, diabetic, ultrasonography of, 394 of acute right upper quadrant pain, 276
of biliary duct dilatation, 264 – 266
Fournier’s gangrene, ultrasonography of, 351 of biliary obstruction, 266
Fungal abscesses, interventional ultrasonography of complicated cholecystitis, 260 – 261
for, 470 of emphysematous cholecystitis, 263 – 264
of focal hemorrhagic lesions, 271 – 274
of gallbladder perforation, 262 – 263
G of gallbladder wall thickening and pericholecystic
Gallbladder disease, in pregnancy, ultrasonography fluid, 260
of, 324 of gallstones, 257 – 260
of gangrenous cholecystitis, 261 – 262
Gallbladder perforation, ultrasonography of,
of hepatic artery stenosis, 398, 399
262 – 263
of hepatic artery thrombosis, 275 – 276, 398
Gallbladder wall thickening, ultrasonography of, 260 of hepatic vascular abnormalities, 274 – 276
Gallstones, ultrasonography of, 257 – 260 of hepatic vein thrombosis, 275
of hepatitis, 266 – 268
Gangrene, Fournier’s, ultrasonography of, 351 of liver abscesses, 268 – 270
Gangrenous cholecystitis, ultrasonography of, of noninfectious liver enlargement, 270 – 271
261 – 262 of portal vein thrombosis, 274 – 275, 399,
Gestational sac, ultrasonography of, 298 – 300, 401 – 402, 405
303 – 305 Hepatocellular carcinoma, ultrasonography of,
Gestational trophoblastic disease, and first-trimester 273 – 274
bleeding, 306 – 309 Hepatofugal flow, ultrasonography of, 402
Hernias, inguinal, ultrasonography of, 360 – 361
H b-Human chorionic gonadotropin, in ectopic
HELLP syndrome, ultrasonography of, 316 – 317 pregnancy, 334
in molar pregnancy, 308 – 309
Hematoceles, ultrasonography of, 359 in ovarian hyperstimulation syndrome, 334
Hematomas, infected, interventional ultrasonography in pregnancy, 299 – 300
for, 470 Hydatidiform mole, and first-trimester bleeding,
scrotal, ultrasonography of, 359 – 360 307 – 309
subchorionic, and first-trimester bleeding,
305 – 306 Hydronephrosis, in pregnancy, ultrasonography
ultrasonography of, 386 – 388 of, 325
Hemorrhage, postpartum, ultrasonography of, 321 Hydrosalpinx, ultrasonography of, 339
thoracentesis and, 459 Hypertension, in pregnancy, ultrasonography of,
Hemorrhagic lesions, hepatic, diagnosis of, 271 – 274 316 – 317
portal, ultrasonography of, 402
Hepatic abscesses, interventional ultrasonography
for, 466 – 467 Hypertrophic pyloric stenosis, in infants and children,
445 – 449
Hepatic artery stenosis, ultrasonography of, 398, 399 clinical features of, 445
Hepatic artery thrombosis, ultrasonography of, incidence of, 445
275 – 276, 398 management of, 448 – 449
Hepatic vein thrombosis, ultrasonography of, 275
Hepatic veins, ultrasonography of, 399 – 400
I
Hepatitis, diagnosis of, 266 – 268
Iliac artery aneurysms, ultrasonography of, 377 – 379
Hepatobiliary ultrasonography, 257 – 278
Inferior vena cava, ultrasonography of, 399 – 400
Murphy’s sign in, 257
of acute acalculous cholecystitis, 260 Inflammatory aneurysms, ultrasonography of, 371
Inguinal hernias, ultrasonography of, 360 – 361 K

Interstitial ectopic pregnancy, ultrasonography Kidneys, ultrasonography of, 405 – 412
of, 333 after transplantation, 405 – 409
allograft dysfunction, 408 – 409
Interventional ultrasonography, 457 – 478 arteriovenous fistulas, 406 – 407
abdominal, 463 – 474 pseudoaneurysms, 406
for echinococcal abscesses, 470 renal artery stenosis, 407
for fistulas, 468, 470 renal vein thrombosis, 408
for fungal abscesses, 470 anatomy and appearance in, 405
for hepatic abscesses, 466 – 467 during transplantation, 407
for infected hematomas, 470 native kidney, 409 – 412
for pelvic abscesses, 470, 472 – 474 for biopsy complications, 410
for renal and perinephric abscesses, 467 for pyelonephritis, 410
for splenic abscesses, 468 for renal artery stenosis, 411 – 412
in intra-abdominal abscess drainage, 465 – 466 for renal trauma, 411
in paracentesis, 463 for renal vein thrombosis, 411
in percutaneous cholecystostomy, 463 – 465 for urinary obstruction, 410
in percutaneous nephrostomy, 467 – 468
of chest, 457 – 462
for lung abscesses, 462
in chest tube insertion, 459 – 462
in thoracentesis, 457 – 459 L
Leiomyomata, ultrasonography of, 340 – 341
Intestinal ischemia, chronic, ultrasonography of,
373 – 377 Limb ischemia, ultrasonography of, 392 – 395
Intracavernosal arteries, laceration of, and
Liver, ultrasonography of, 397 – 405
priapism, 431
after transplantation, 398 – 400
Intracorporeal injection therapy, and priapism, 430 hepatic artery stenosis, 398, 399
hepatic artery thrombosis, 398
Intradecidual sign, in ectopic pregnancy, 331 – 332
hepatic veins and inferior vena cava,
in transvaginal ultrasonography, 299 399 – 400
Intratesticular abscesses, ultrasonography of, portal vein thrombosis, 399
353 – 354 pseudoaneurysms, 400
anatomy and appearance in, 397 – 398
Intratesticular arteriovenous malformations, native cirrhotic liver, 400 – 404
ultrasonography of, 359 after transjugular intrahepatic
Intratesticular varicoceles, ultrasonography of, portosystemic shunt, 400 – 404
358 – 359 for portal hypertension, 402
for portal vein aneurysmal ectasia, 404
Intrauterine growth restriction, ultrasonography for portal vein thrombosis, 401 – 402
of, 305 noncirrhotic native liver, 404 – 405
Intussusception, in infants and children, 449 – 452 Liver abscesses, diagnosis of, 268 – 270
barium enema examination for, 449 – 450 interventional ultrasonography for, 466 – 467
diagnosis of, 449 – 450
management of, 452 Liver enlargement, noninfectious, diagnosis of,
plain films of, 449 270 – 272
Lower extremities, thromboembolic disease in,

ultrasonography of, 286 – 288, 291, 293 – 294
Lung abscesses, interventional ultrasonography

J for, 462
Jugular vein, ultrasonography of, for thromboembolic
disease, 289 – 290 Luteoma of pregnancy, ultrasonography of, 338
M Percutaneous cholecystostomy, ultrasonography in,

Magnetic resonance imaging, of acute hepatic vein 463 – 465
thrombosis, 275 Percutaneous nephrostomy, interventional
Mesenteric vasculature, ultrasonography of, 373 – 377 ultrasonography in, 467 – 468
Metastatic disease, and liver enlargement, 270 Pericholecystic fluid, ultrasonography of, 260
Methotrexate, for ectopic pregnancy, 333 – 334 Perinephric abscesses, interventional ultrasonography
Mifepristone, and spontaneous abortion, 322 for, 467
Molar pregnancy, and first-trimester bleeding, Peripheral artery aneurysms, ultrasonography of, 379
307 – 309 Placentation, abnormal, ultrasonography of, 317 – 319
Mucinous cystadenomas, ultrasonography of, Plain films, in trauma patients, versus
341 – 342 ultrasonography, 422 – 424
of intussusception, in infants and children, 449
Murphy’s sign, in hepatobiliary ultrasonography, 257
Pleural effusions, chest tubes for, 459 – 462
Mycotic aneurysms, ultrasonography of, 371
emergency ultrasonography of, 421
Myometrium, sonographic anatomy of, 297
Pleuritic pain, thoracentesis and, 459
Pneumothorax, emergency ultrasonography of,
N 421 – 423
thoracentesis and, 458 – 459
Nephrostomy, percutaneous, interventional
ultrasonography in, 467 – 468 Popliteal aneurysms, ultrasonography of, 379
Neurologic disease, and priapism, 431 Popliteal vein, ultrasonography of, for
thromboembolic disease, 287
Portal hypertension, ultrasonography of, 402
O
Portal vein aneurysmal ectasia, ultrasonography
Orchitis, ultrasonography of, 353 of, 404
Ovarian hyperstimulation syndrome, ultrasonography Portal vein thrombosis, ultrasonography of,
of, 334 – 336 274 – 275, 399, 401 – 402, 405
Ovarian neoplasms, ultrasonography of, 341 Pregnancy. See also First-trimester bleeding.
Ovarian torsion, ultrasonography of, 336 – 338 ectopic, ultrasonography of. See Adnexal masses.
molar, and first-trimester bleeding, 307 – 309
Ovaries, sonographic anatomy of, 297 ultrasonography in, 315 – 327
Ovulation induction therapy, and ovarian during abdominal surgery and trauma, 323
hyperstimulation syndrome, 335 for abnormal placentation, 317 – 318
for acute renal disorders, 324 – 325
for gallbladder disease, 324
P for pelvic thrombophlebitis, 324
Paracentesis, ultrasonography in, 463 for placenta previa, 318 – 319
for placental abruption, 319
Parapneumonic effusions, chest tubes for, 459 – 460 for postpartum hemorrhage, 321
Pelvic abscesses, interventional ultrasonography for, for pregnancy-induced hypertension, 316 – 317
470, 472 – 474 for retained products of conception, 321 – 322
Pelvic inflammatory disease, ultrasonography of, for splenic artery aneurysms, 325
338 – 339 for spontaneous abortion, 322
for uterine fibroids, 322 – 323
Pelvic pain, adnexal masses and. See for uterine rupture, 317
Adnexal masses. for vasa previa, 320 – 321
Pelvic thrombophlebitis, in pregnancy, for venous thromboembolism, 323 – 324
ultrasonography of, 324 technique for, 315 – 316
Priapism, 427 – 443 Shunts, for priapism, 439

arterial embolization for, 436 – 437
Sickle cell anemia, and priapism, 430, 433, 439
definition of, 427 – 428
diagnosis of, 434 – 436 Solid organ injuries, emergency ultrasonography of,
epidemiology of, 428, 430 420 – 421
etiology of, 430 – 431 Splanchnic artery aneurysms, ultrasonography
management of, 438 – 439 of, 377
complications of, 439 – 440
pathophysiology of, 431 – 434 Splenic abscesses, interventional ultrasonography
sickle cell anemia and, 430, 433, 439 for, 468
transcatheter embolization for, 437 – 438 Splenic artery aneurysms, ultrasonography of, 377
ultrasonography of, 436, 438 in pregnancy, 325
anatomy in, 428
technique for, 428 Spontaneous abortion, and first-trimester bleeding,
301 – 303, 306
Pseudoaneurysms, hepatic, ultrasonography of, 400 ultrasonography of, 322
renal, ultrasonography of, 406
ultrasonography of, 384 – 386 Stroke, carotid artery stenosis and, ultrasonography
of, 391 – 392
Pulmonary edema, re-expansion, thoracentesis
and, 459 Subchorionic hematomas, and first-trimester
bleeding, 305 – 306
Pulmonary embolism, ultrasonography of, 294
Pyelonephritis, ultrasonography of, 410
T
Pyogenic liver abscesses, interventional
ultrasonography for, 466 – 467 Testicular torsion, ultrasonography of, 354 – 356
Testicular trauma, ultrasonography of, 359 – 360
Testicular tumors, ultrasonography of, 361
R
Raynaud’s phenomenon, ultrasonography of, Theca lutein cysts, ultrasonography of, 334
394 – 395 Thioridazine, and priapism, 430
Renal abscesses, interventional ultrasonography Thoracentesis, ultrasonography in, 457 – 459
for, 467
Thrombin injection, for pseudoaneurysms, 386
Renal artery stenosis, ultrasonography of, 407,
411 – 412 Thromboembolic disease, clinical evaluation of,
283 – 284
Renal disorders, in pregnancy, ultrasonography of, clinical features of, 279 – 281
324 – 325 D-dimer test for, 284, 286
Renal trauma, ultrasonography of, 411 ultrasonography of, 279 – 296
adjuncts to, 291
Renal vein thrombosis, ultrasonography of, 408, 411 deep venous thrombosis, 286 – 294
Retained products of conception, and first-trimester in lower extremities, 286 – 288, 293 – 294
bleeding, 306 in pregnancy, 323 – 324
ultrasonography of, 321 – 322 in upper extremities, 288 – 290, 294
pitfalls of, 291
RU 486, and spontaneous abortion, 322 pulmonary embolism, 294
Thrombophlebitis, pelvic, in pregnancy,
S ultrasonography of, 324
Scrotum, acute painful. See Acute painful scrotum. Transabdominal ultrasonography, technique for, 298
Seldinger technique, for percutaneous Transcatheter embolization, for priapism, 437 – 438
cholecystostomy, 464
Transhepatic approach, to percutaneous
Serous cystadenomas, ultrasonography of, 341 – 342 cholecystostomy, 464
Transjugular intrahepatic portosystemic shunt, of adnexal masses. See Adnexal masses.

ultrasonography after, 400 – 404 of arterial injuries. See Arterial injuries.
of first-trimester bleeding. See
Transplantation, kidney, ultrasonography after.
First-trimester bleeding.
See Kidneys.
of hypertrophic pyloric stenosis, in infants and
liver, ultrasonography after. See Liver.
children. See Hypertrophic pyloric stenosis.
Transvaginal approach, to pelvic abscess drainage, of intussusception, in infants and children.
472 – 474 See Intussusception.
Transvaginal ultrasonography, of embryo, 300 – 301 of kidneys. See Kidneys.
of liver. See Liver.
of gestational sac, 298 – 300
of mesenteric vasculature, 373 – 377
of molar pregnancy, 308 – 309
of pregnancy-related emergencies. See Pregnancy.
of yolk sac, 300
of priapism, 428, 436, 438
technique for, 298
of thromboembolic disease. See
Trauma, during pregnancy, ultrasonography of, 323 Thromboembolic disease.
renal, ultrasonography of, 411 transvaginal. See Transvaginal ultrasonography.
testicular, ultrasonography of, 359 – 360
Upper extremities, thromboembolic disease in,
Trauma patients, emergency ultrasonography in, ultrasonography of, 288 – 290, 294
417 – 425
Urinary obstruction, ultrasonography of, 410
for chest injuries, 421 – 424
for solid organ injuries, 420 – 421 Urolithiasis, in pregnancy, ultrasonography of, 325
free fluid in, 417 – 418 Uterine fibroids, ultrasonography of, 322 – 323
free fluid scoring systems in, 419 – 420
pitfalls in, 418 – 419 Uterine rupture, in pregnancy, ultrasonography
sensitivity of, 420 of, 317
versus CT, 420 Uterus, sonographic anatomy of, 297
versus plain films, 422 – 424
Trazodone, and priapism, 430
Trophoblastic tumors, and first-trimester V
bleeding, 309 Varicoceles, ultrasonography of. See Acute
Tubo-ovarian abscesses, ultrasonography of, painful scrotum.
338 – 339 Vasa previa, in pregnancy, ultrasonography of,
320 – 321
U Vasovagal reactions, thoracentesis and, 459

Ultrasonography, endovaginal, of ectopic Venous thromboembolism, in pregnancy,
pregnancy, 331 ultrasonography of, 323 – 324
hepatobiliary. See Hepatobiliary ultrasonography.
in trauma patients. See Trauma patients.
interventional. See Interventional ultrasonography.
of abdominal aortic aneurysms. See Abdominal Y
aortic aneurysms. Yolk sac, ultrasonography of, 300, 304 – 305

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Radiol Clin N Am 42 (2004) xi

Hepatobiliary imaging and its pitfalls

Diagnosis of acute cholecystitis Sonographic Murphy’s sign

Gallbladder wall thickening is defined as a wall Acute acalculous cholecystitis

and gallbladder perforation. These complications oc- Gangrenous cholecystitis

in the gallbladder wall and fossa may respond to

This is a rare complication of acute cholecystitis

Fig. 9. Gallbladder gangrene/mucosal sloughing. Longitu-

extrinsic masses with biliary duct compression and

uncertain, either CT or plain film radiography can be

The extrahepatic common duct is measured from

drink water to displace gas or by using large a

that of cholecystitis or hepatitis. On imaging, meta-

Venous protocols, techniques, and interpretations of the

Deep venous thrombosis (DVT) and pulmonary Clinical presentations

alternate diagnosis as the cause for the patient’s D-dimer

Inferior vena cava

Common iliac vein

External iliac vein

Common femoral vein

Great saphenous vein

Fig. 7. Diagrammatic representation of the veins of the lower extremity.

Internal jugular vein

Median cubital vein

Diagnosis of deep venous thrombosis of the upper Other considerations

Sonographic evaluation of first-trimester bleeding

ler US in early pregnancy, the concept of ‘‘as low as

Normal first-trimester sonography

Scanning in the first trimester may be performed

branes before 14 weeks of gestation is considered

Spontaneous abortion is defined as pregnancy

Embryo not visualized

MSD > 18MM MSD < 18MM

MSD < 10MM MSD > 10MM

Cardiac activity Cardiac activity

The most common morphologic finding in early Ultrasound findings in abortion

Failure to demonstrate intrauterine gestational sac

the viability of the gestation. The most convincing

Gestational sac with an embryo

Although visualization of a living embryo does

with that in younger women (13.8% versus 7.3%, re-

Retained products of conception

The role of ultrasound in pregnancy-related emergencies

lakes with focal lacunar flow, hypervascularity linking

Placenta previa occurs in approximately 1 in

Vasa previa of suspicion, however, vasa previa can be diagnosed

especially if it is less than 2 mm, retained blood in

Obstetric delivery has been associated with the

create loss of heart rate variability, presumably by

more frequently associated with early abortions.

Adnexal mass with pelvic pain

Fig. 1. Simple ovarian or follicular cysts. These two ovarian

Fig. 3. Atypical corpus luteal cyst. This exophytic cyst has

Fig. 4. Hemorrhagic cyst. Note lace-like or spider web

risk factors include presence of an intrauterine device,

confirm an intrauterine pregnancy. The double decid-

second trimester. A ruptured interstitial pregnancy

prevents DNA synthesis and cell multiplication. It

Box 2. Eligibility criteria for methotrexate Ovarian hyperstimulation syndrome

ovulation cycles, but only a small percentage of these

and masses spontaneously resolve several months

Disease unrelated to pregnancy

Diagnoses such as ectopic pregnancy and ovarian

Pre-existing fluid (ascites)