Abdominal Ultrasound

Definition

Abdominal ultrasound uses high frequency sound waves to produce two-dimensional images of the body's soft tissues, which are used for a variety of clinical applications, including diagnosis and guidance of treatment procedures. Ultrasound does not use ionizing radiation to produce images, and in comparison to other diagnostic imaging modalities, it is low cost, safe, fast, and versatile.

Purpose

Abdominal ultrasound is used in the hospital radiology department and emergency department, as well as in physician offices for a number of clinical applications. Ultrasound has a great advantage over x-ray imaging technologies in that it does not damage tissues with ionizing radiation. Ultrasound is also generally far better than plain x rays at distinguishing the subtle variations of soft tissue structures, and can be used in any of several modes, depending on the area of interest.

As an imaging tool, abdominal ultrasound generally is indicated for patients afflicted with chronic or acute abdominal pain; abdominal trauma; an obvious or suspected abdominal mass; symptoms of liver disease, pancreatic disease, gallstones, spleen disease, kidney disease and urinary blockage; or symptoms of an abdominal aortic aneurysm.

Specifically:

Abdominal pain. Whether acute or chronic, pain can signal a serious problem—from organ malfunction or injury to the presence of malignant growths. Ultrasound scanning can help doctors quickly sort through potential causes when presented with general or ambiguous symptoms. All of the major abdominal organs can be studied for signs of disease that appear as changes in size, shape, and internal structure.
Abdominal trauma. After a serious accident, such as a car crash or a fall, internal bleeding from injured abdominal organs is often the most serious life-threatening complication. Neither the injuries nor the bleeding may be immediately apparent. Ultrasound is very useful as an initial scan when abdominal trauma is suspected, and it can be used to pinpoint the location, cause, and severity of the bleeding. In the case of puncture wounds, from a bullet for example, ultrasound can locate the foreign object and provide a preliminary survey of the damage. (CT scans are sometimes used in trauma settings.)
Abdominal mass. Abnormal growths—tumors, cysts, abscesses, scar tissue, and accessory organs—can be located and tentatively identified with ultrasound. In particular, potentially malignant solid tumors can be distinguished from benign fluid-filled cysts. Masses and malformations in any organ or part of the abdomen can be found.
Liver disease. The types and underlying causes of liver disease are numerous, though jaundice tends to be a general symptom. Ultrasound can differentiate between many of the types and causes of liver malfunction, and is particularly good at identifying obstruction of the bile ducts and cirrhosis, which is characterized by abnormal fibrous growths and reduced blood flow.
Pancreatic disease. Inflammation and malformation of the pancreas are readily identified by ultrasound, as are pancreatic stones (calculi), which can disrupt proper functioning.
Gallstones. Gallstones are an extremely common cause of hospital admissions. These calculi can cause painful inflammation of the gallbladder and also obstruct the bile ducts that carry digestive enzymes from the gallbladder and liver to the intestines. Gallstones are readily identifiable with ultrasound.
Spleen disease. The spleen is particularly prone to injury during abdominal trauma. It may also become painfully inflamed when infected or cancerous.
Kidney disease. The kidneys are also prone to traumatic injury and are the organs most likely to form calculi, which can block the flow of urine and cause further systemic problems. A variety of diseases causing distinct changes in kidney morphology can also lead to complete kidney failure. Ultrasound imaging has proven extremely useful in diagnosing kidney disorders, including blockage or obstruction.
Abdominal aortic aneurysm. This is a bulging weak spot in the abdominal aorta, which supplies blood directly from the heart to the entire lower body. A ruptured aortic aneurysm is imminently life-threatening. However, it can be readily identified and monitored with ultrasound before acute complications result.
Appendicitis. Ultrasound is useful in diagnosing appendicitis, which causes abdominal pain.

Ultrasound technology can also be used for treatment purposes, most frequently as a visual aid during surgical procedures such as guiding needle placement to drain fluid from a cyst, or to guide biopsies.

Precautions

Ultrasound waves of appropriate frequency and intensity are not known to cause or aggravate any medical condition.

The value of ultrasound imaging as a medical tool, however, depends greatly on the quality of the equipment used and the skill of the medical personnel operating it. More accurate results are obtained when ultrasound is performed by a clinician skilled in sonography. Basic ultrasound equipment is relatively inexpensive to obtain, and any physician with the equipment can perform the procedure whether specifically trained in ultrasound scanning and interpretation or not. Patients should not hesitate to verify the credentials of technologists and physicians performing ultrasound scanning, as well as the quality of the equipment used and the benefits of the proposed procedure.

In cases where ultrasound is used as a treatment tool, patients should educate themselves about the proposed procedure with the help of their doctors—as is appropriate before any surgical procedure. Also, any abdominal ultrasound procedure, diagnostic or therapeutic, may be hampered by a patient's body type or other factors, such as the presence of excessive bowel gas (which is opaque to ultrasound). In particular, very obese people are often not good candidates for abdominal ultrasound.

Description

Ultrasound includes all sound waves above the frequency of human hearing—about 20 thousand hertz, or cycles per second. Medical ultrasound generally uses frequencies between one and 10 megahertz (1-10 MHz). Higher frequency ultrasound waves produce more detailed images, but are also more readily absorbed and so cannot penetrate as deeply into the body. Abdominal ultrasound imaging is generally performed at frequencies between 2-5 MHz.

An ultrasound scanner consists of two parts: the transducer and the data processing unit. The transducer both produces the sound waves that penetrate the body and receives the reflected echoes. Transducers are built around piezoelectric ceramic chips. (Piezoelectric refers to electricity that is produced when you put pressure on certain crystals such as quartz.) These ceramic chips react to electric pulses by producing sound waves (they are transmitting waves) and react to sound waves by producing electric pulses (receiving). Bursts of high-frequency electric pulses supplied to the transducer cause it to produce the scanning sound waves. The transducer then receives the returning echoes, translates them back into electric pulses, and sends them to the data processing unit—a computer that organizes the data into an image on a television screen.

Becausesound waves travel through all the body's tissues at nearly the same speed—about 3,400 miles per hour—the microseconds it takes for each echo to be received can be plotted on the screen as a distance into the body. The relative strength of each echo, a function of the specific tissue or organ boundary that produced it, can be plotted as a point of varying brightness. In this way, the echoes are translated into an image.

Four different modes of ultrasound are used in medical imaging:

A-mode. This is the simplest type of ultrasound in which a single transducer scans a line through the body with the echoes plotted on screen as a function of depth. This method is used to measure distances within the body and the size of internal organs.
B-mode. In B-mode ultrasound, a linear array of transducers simultaneously scans a plane through the body that can be viewed as a two-dimensional image on screen.
M-Mode. The M stands for motion. A rapid sequence of B-mode scans whose images follow each other in sequence on screen enables doctors to see and measure range of motion, as the organ boundaries that produce reflections move relative to the probe. M-mode ultrasound has been put to particular use in studying heart motion.
Doppler mode. Doppler ultrasonography includes the capability of accurately measuring velocities of moving material, such as blood in arteries and veins. The principle is the same as that used in radar guns that measure the speed of a car on the highway. Doppler capability is most often combined with B-mode scanning to produce images of blood vessels from which blood flow can be directly measured. This technique is used extensively to investigate valve defects, arteriosclerosis, and hypertension, particularly in the heart, but also in the abdominal aorta and the portal vein of the liver.

The actual procedure for a patient undergoing an abdominal ultrasound is relatively simple, regardless of the type of scan or its purpose. Fasting for at least eight hours prior to the procedure ensures that the stomach is empty and as small as possible, and that the intestines and bowels are relatively inactive. This also helps the gallbladder become more visible. Prior to scanning, an acoustic gel is applied to the skin of the patient's abdomen to allow the ultrasound probe to glide easily across the skin and also to better transmit and receive ultrasonic pulses. The probe is moved around the abdomen's surface to obtain different views of the target areas. The patient will likely be asked to change positions from side to side and to hold the breath as necessary to obtain the desired views. Usually, a scan will take from 20 to 45 minutes, depending on the patient's condition and anatomical area being scanned.

Ultrasound scanners are available in different configurations, with different scanning features. Portable units, which weigh only a few pounds and can be carried by hand, are available for bedside use, office use, or use outside the hospital, such as at sporting events and in ambulances. Portable scanners range in cost from $10,000 to $50,000. Mobile ultrasound scanners, which can be pushed to the patient bedside and between hospital departments, are the most common comfiguration and range in cost from $100,000 to over $250,000, depending on the scanning features purchased.

Preparation

A patient undergoing abdominal ultrasound will be advised by his or her physician about what to expect and how to prepare. As mentioned above, preparations generally include fasting.

Aftercare

In general, no aftercare related to the abdominal ultrasound procedure itself is required. Discomfort during the procedure is minimal.

Complications

Properly performed, ultrasound imaging is virtually without risk or side effects. Some patients report feeling a slight tingling and/or warmth while being scanned, but most feel nothing at all.

Results

As a diagnostic imaging technique, a normal abdominal ultrasound is one that indicates the absence of the suspected condition that prompted the scan. For example, symptoms such as abdominal pain radiating to the back suggest the possibility of, among other things, an abdominal aortic aneurysm. An ultrasound scan that indicates the absence of an aneurysm would rule out this life-threatening condition and point to other, less serious causes.

Because abdominal ultrasound imaging is generally undertaken to confirm a suspected condition, the results of a scan often will confirm the diagnosis, be it kidney stones, cirrhosis of the liver, or an aortic aneurysm. At that point, appropriate medical treatment as prescribed by a patient's physician is in order.

KEY TERMS

Accessory organ—A lump of tissue adjacent to an organ that is similar to it, but which serves no important purpose, if functional at all. While not necessarily harmful, such organs can cause problems if they grow too large or become cancerous.

Benign—In medical usage, benign is the opposite of malignant. It describes an abnormal growth that is stable, treatable, and generally not life-threatening.

Biopsy—The surgical removal and analysis of a tissue sample for diagnostic purposes. Usually, the term refers to the collection and analysis of tissue from a suspected tumor to establish malignancy.

Calculus—Any type of hard concretion (stone) in the body, but usually found in the gallbladder, pancreas, and kidneys. Calculi (pl.) are formed by the accumulation of excess mineral salts and other organic material such as blood or mucous. They can cause problems by lodging in and obstructing the proper flow of fluids, such as bile to the intestines or urine to the bladder.

Cirrhosis—A chronic liver disease characterized by the degeneration of proper functioning—jaundice is often an accompanying symptom. Causes of cirrhosis include alcoholism, metabolic diseases, syphilis, and congestive heart disease.

Common bile duct—The branching passage through which bile—a necessary digestive enzyme—travels from the liver and gallbladder into the small intestine. Digestive enzymes from the pancreas also enter the intestines through the common bile duct.

Computed tomography scan (CT scan)—A specialized type of x-ray imaging that uses highly focused and relatively low energy radiation to produce detailed two-dimensional images of soft tissue structures, particularly the brain. CT scans are the chief competitor to ultrasound and can yield higher quality images not disrupted by bone or gas. They are, however, more cumbersome, time consuming and expensive to perform, and they use ionizing radiation.

Doppler—The Doppler effect refers to the apparent change in frequency of sound wave echoes returning to a stationary source from a moving target. If the object is moving toward the source, the frequency increases; if the object is moving away, the frequency decreases. The size of this frequency shift can be used to compute the object's speed—be it a car on the road or blood in an artery. The Doppler effect holds true for all types of radiation, not just sound.

Frequency—Sound, whether traveling through air or the human body, produces vibrations—molecules bouncing into each other—as the shock wave travels along. The frequency of a sound is the number of vibrations per second. Within the audible range, frequency means pitch—the higher the frequency, the higher a sound's pitch.

Ionizing radiation—Radiation that can damage living tissue by disrupting and destroying individual cells at the molecular level. All types of nuclear radiation-x rays, gamma rays and beta rays-are potentially ionizing. Sound waves physically vibrate the material through which they pass, but do not ionize it.

Jaundice—A condition that results in a yellow tint to the skin, eyes and body fluids. Bile retention in the liver, gallbladder and pancreas is the immediate cause, but the underlying cause could be as simple as obstruction of the common bile duct by a gallstone or as serious as pancreatic cancer. Ultrasound can distinguish between these conditions.

Malignant—The term literally means growing worse and resisting treatment. It is used as a synonym for cancerous and connotes a harmful condition that generally is life-threatening.

Morphology—Literally, the study of form. In medicine, morphology refers to the size, shape, and structure rather than the function of a given organ. As a diagnostic imaging technique, ultrasound facilitates the recognition of abnormal morphologies as symptoms of underlying conditions.

Health care team roles

Ultrasound scanning should be performed by a registered and trained ultrasonographer, either a technologist and/or a physician (radiologist, obstetrician/gynecologist). Ultrasound scanning in the emergency department may be performed by an emergency medicine physician, who should have appropriate training and experience in ultrasonography.