eMedicine Specialties > Clinical Procedures > Radiology

Ultrasonography, Abdominal: Differential Diagnoses & Workup

Author: Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Coauthor(s): Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Contributor Information and Disclosures

Updated: Nov 12, 2007

Workup

Laboratory Studies

  • A pregnancy test is invaluable in determining the etiology of abdominal pain in females of childbearing age.

Imaging Studies

  • The Murphy sign may be observed at ultrasonography. The Murphy sign is pronounced tenderness when transducer is applied directly to the gallbladder; the sign should be reproducible. With true wall thickening and/or cholelithiasis, the presence of this sign strongly suggests acute cholecystitis. Palpation with the probe is particularly helpful to the physician sonographer in differentiating right lower quadrant pain from pain of pelvic origin in female patients.
  • Ultrasonography may be indicated for the evaluation of AAA, the biliary tract, acute cholecystitis, the kidneys and urinary tract, hydronephrosis, blunt or penetrating trauma, or appendicitis.
  • Abdominal aortic aneurysm
    • The normal aorta gradually tapers; an aneurysm distorts this progressive tapering. Para-aortic nodes may anteriorly displace the aorta, causing the sensation of a pulsatile mass on physical examination. A pulsatile abdominal mass suggests an AAA; however, not every pulsatile mass is an aneurysm.
    • Abdominal lymphadenopathy can elevate the aorta, thereby simulating an AAA.
    • Aging can cause the aorta to become tortuous.
    • The normal anteroposterior diameter of the aorta is 3 cm or less when measured from outer wall to outer wall.
    • Most aneurysms are fusiform or show uniform dilatation of the entire circumference of the vessel. Aneurysms usually arise below the level of the renal arteries and are left of the midline. Their anterior expansion usually creates a good sonographic window because they push the bowel aside.
    • AAA can rupture into the retroperitoneum and adjoining viscera (eg, duodenum, left renal vein, inferior vena cava, urinary tract), causing hematuria.
  • Biliary tract
    • The gallbladder is identified as a sonolucent, oblong, pear-shaped sac that is normally posteromedial to the right lobe of the liver.
    • Gallstones usually lie in the most dependent part of gallbladder.
    • Gallstones cause characteristic shadowing; however, impacted gallstones may be difficult to visualize.
    • With biliary colic, the presence of gallstones does not, by itself, mean that pain is from the gallbladder; asymptomatic gallstones are common.
  • Acute cholecystitis
    • Cholelithiasis alone does not represent acute cholecystitis. Ultrasonographic findings that indicate acute cholecystitis are as follows:
      • Gallstones, possibly impacted
      • Gallbladder wall thickening of greater than 3 mm
      • Positive Murphy sign
      • Fluid around the gallbladder - Definite evidence (Pericholecystic fluid may represent abscess formation.)
    • The positive predictive value of gallstones and wall thickening in the diagnosis of acute cholecystitis is as high as 94%. Asymptomatic stones are common.
  • Kidney and/or urinary tract
    • The renal parenchyma has uniformly low echogenicity, which usually is less than that of the adjacent liver and spleen.
    • The renal sinus contains major branches of the renal artery, renal vein, and calyces; it lies centrally and appears brightly echogenic on sonograms.
    • Ultrasonography can help in the difficult differentiation of renal colic from an aneurysm.
    • Ultrasonography also can aid in determining the number of kidneys and the presence of anatomic anomalies.
  • Hydronephrosis
    • The kidneys are primarily evaluated to rule out hydronephrosis in patients with renal colic. The typical appearance of obstructive uropathy is a dilated caliceal system; the renal sinus is separated with anechoic fluid.
    • Severe hydronephrosis may distort the appearance of the kidney. The kidney may be obstructed without hydronephrosis.
  • Blunt or penetrating trauma
    • Ultrasonography can aid in localizing the source of life-threatening hypotension.
    • Fluid may accumulate in a number of anatomic spaces in the abdomen, including the pelvic, subphrenic, subhepatic, paracolic gutter, perinephric, and pleural spaces.
    • Free fluid appears anechoic or dark without echos. Clotted blood has a particulate, hypoechoic appearance.
    • Diaphragmatic rupture may also be evaluated with ultrasonography.
    • Ultrasonography may demonstrate a hemothorax in patients with chest trauma.
  • Appendicitis
    • The normal appendix is rarely seen. The wall of the appendix usually is no more than 6 mm thick. The normal appendix compresses when pressure is applied with the transducer.
    • In acute appendicitis, wall thickness is 7 mm or more, and the appendix is noncompressible. It should be tender when palpated with the probe.
    • A combination of transabdominal and endovaginal imaging helps to identify the source of right lower quadrant pain in female patients.
    • Ultrasonography is particularly helpful in determining the etiology of right lower quadrant pain in female patients.

More on Ultrasonography, Abdominal

Overview: Ultrasonography, Abdominal
Differential Diagnoses & Workup: Ultrasonography, Abdominal
Follow-up: Ultrasonography, Abdominal
Multimedia: Ultrasonography, Abdominal
References
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Further Reading

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Keywords

abdominal ultrasonography, abdominal ultrasound, emergency abdominal ultrasonography, endovaginal sonography, transabdominal sonography, sonography, echography, echo

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Contributor Information and Disclosures

Author

Verena T Valley, MD, Associate Professor, Director of Ultrasound, Department of Emergency Medicine, University of Mississippi School of Medicine; Consulting Staff, Department of Emergency Medicine, Singing River Hospital System, Singing River Hospital, and Ocean Springs Hospital
Verena T Valley, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia
Christopher A Fly, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eugene Hardin, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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