Ultrasonography

Dr. LeeAnn Pack Dipl. ACVR

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Ultrasonography vs. Radiography

They complement each other Both have strengths and weaknesses Cost concerns correct selection All patients should receive abdominal radiographs before ultrasonography
Get all the information May eliminate need for ultrasound
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Strengths of Ultrasonography
Determining origin of an abdominal mass Evaluation of organ parenchyma
Liver, spleen, kidneys, adrenals, pancreas, intestines, prostate, bladder, heart

Fetal viability Real time scanning see movement/motion Performing fine needle aspiration/ biopsy
Cells or tissue NOT images ultimately give us the definitive diagnosis for neoplasia, etc. Ultrasound does not provide a histopathologic diagnosis www.upei.ca/~vetrad

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Weaknesses of Ultrasonography
Ultrasound cant penetrate gas or bone Difficult to evaluate liver size, kidney size in dogs Cant assess intestinal gas patterns Cant evaluate some extra abdominal structures (i.e. spine) Equipment can be expensive Diagnostic success is user dependent Must know anatomy very well
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Why do you need both?

Examples
Prostatic adenocarcinoma seen on ultrasound
Has it spread to lumbar vertebrae?

Coughing patient with mitral regurgitation on echo

Does the patient have pulmonary edema?

Enlarged liver on radiographs

Can get a guided FNA with ultrasound
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Basic Ultrasound Physics

Transducer (probe)
Piezoelectric crystal
Emit sound after electric charge applied Sound reflected from patient Returning echo is converted to electric signal- grayscale image on monitor Echo may be reflected, transmitted, or refracted Transmit 1% receive 99% of the time
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Acoustic Impedance
The velocity of sound in a tissue and tissue density = determine acoustic impedance Most soft tissues = 1400-1600m/sec Bone = 4080, Air = 330
Sound will not penetrate gets reflected or absorbed

Travel time dot depth

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Attenuation
Absorption = energy is captured by the tissue then converted to heat Reflection = occurs at interfaces between tissues of different acoustic properties Scattering = beam hits irregular interface beam gets scattered
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Basic Ultrasound Physics

Sound waves are measured in Hertz (Hz) Diagnostic ultrasound typically
1-20 MHz

As frequency increases, resolution improves As frequency increases, depth of penetration decreases

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Frequency Penetration

Examples of Ultrasound Probes

A B C A

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Transducers
Sector scanner fan shaped beam
Small surface require for contact

Linear scanner rectangle beam

Large contact area required New ones are curvi-linear
These scan heads are much smaller with wide field of view

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Basic Ultrasound Physics

Monitor and computer
Convert signal to an image/ archive Tools for image manipulation
Gain amplification of returning echoes
Overall brightness

Time gain compensation (curve)

Adjust brightness at different depths

Freeze Depth
Zoom in superficial, or zoom out for wide view Depth limited by frequency

Focal zone
Optimal resolution wherever focal zone is
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Image controls

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Modes of Display
A mode
Spikes where precise length and depth measurements are needed ophtho

B mode (brightness) used most often

2 D reconstruction of the image slice

M mode motion mode

Moving 1D image cardiac mainly
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 Improper machine settings gain Reverberation

Mirror image liver GB Comet tail gas bubble Ring down skin transducer surface

Artifacts

Acoustic shadowing Acoustic enhancement Edge enhancement

Border of kidney
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Reverb Comet Tails

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Reverb

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What Happened Here?

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Partial Mirror

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Enhancement

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Enhancement

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Enhancement

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Refraction

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Ultrasound Terminology
Never use dense, opaque, lucent Anechoic
No returning echoes= black (acellular fluid)

Echogenic
Regarding fluid--some shade of grey d/t returning echoes

Relative terms
Comparison to normal echogenicity of the same organ or other structure Hypoechoic, isoechoic, hyperechoic
Spleen should be hyperechoic to liver
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Patient Positioning - Prep

Dorsal recumbency Lateral recumbency Standing Clip hair
Be sure to check with owners

Apply ultrasound gel Alcohol can be used esp. in horses

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Image Orientation and Labeling

Must be consistent Symbol on screen ~ dot on transducer dot to head and dot to patients right dot lateral for transverse and proximal for longitudinal images Label label label
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Indications for Abdominal Ultrasonography

Same as with abdominal radiographs Should have some idea of what you are looking fornot just a fishing expedition Further investigate a radiographic finding ***If clinical signs or history indicate abdominal ultrasound, then it should be performed even if radiographs are normal!!!

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Ultrasound-guided FNA/ biopsies

NORMAL ABD U/S FINDINGS DO NOT MEAN ORGANS ARE NORMAL!!!
***Do FNA if suspect disease

Abnormal u/s findings nonspecific

Benign and malignant masses identical Bright liver may be secondary to Cushings dz or lymphoma

Aspirate abnormal structures (with few exceptions)!!!

Obtain owner approval prior to exam Warn owner of risks +/- Clotting profile

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Ultrasound-guided FNA/ biopsies

Risks of FNAs
Fatal hemorrhage Pneumothorax w/ pulmonary masses Seeding of tumors
TCC

Sepsis
Abscesses

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Ultrasound-guided FNA/ biopsies

I Routinely aspirate
Liver (masses and diffuse disease) Spleen (nodules and diffuse disease) Gastrointestinal masses Enlarged lymph nodes Enlarged prostate Pulmonary/ mediastinal masses (usually dont biopsy due to risk of pneumothorax

I Occasionally aspirate
Kidneys (esp. if enlarged) Pancreas Urinary bladder masses

I Never aspirate
Adrenals Gall bladder
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Ultrasound-guided FNA/ Fine Needle biopsies

Non-aspiration Technique
22g 1.5in needle 6 cc syringe Short jabs into organ Spray onto slide, smear, and check abd for hemorrhage

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Ultrasound-guided FNA
Aspiration technique
Same set up as with non-aspiration technique With needle in structure, pull back plunger vigorously several times Remove needle, fill syringe with air Spray onto slide and smear

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Ultrasound-guided Core Biopsies

Use a special biopsy gun
14-20g Insert thru small skin incision

Much more representative sample

Tissue not just cells Sometimes it is necessary to get the answer But. MUCH MORE LIKELY TO BLEED!

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Biopsy Bleeding???

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Catheter in Bladder

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Intro Summary
Know your limitations
Lack of expertise $15,000 vs. $150,000 machine

For abd or thx, do radiographs first If safe and reasonable, do FNAs of all suspected abnormal structures based on history, clinical signs, or the ultrasound exam
Abnormal structures can look normal Of the structures that do look abnormal, benign and malignant processes can be identical

Documentation save images in some fashion

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