eMedicine Specialties > Clinical Procedures > Radiology

Ultrasonography, Abdominal

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
Christopher A Fly, MD, Assistant Professor, Department of Emergency Medicine, Medical College of Georgia

Updated: Nov 12, 2007

Introduction

Background

Ultrasonography is an ideal clinical tool for determining the source of abdominal pain. It can simplify the differential diagnosis of abdominal pain, especially when pain and tenderness are present over the site of disease. Even if ultrasonography reveals no obvious etiology, it can facilitate diagnosis by excluding potentially life-threatening conditions. Emergency abdominal ultrasonography is indicated for the evaluation of aortic aneurysm, appendicitis, and biliary and renal colic, as well as blunt or penetrating abdominal trauma. Furthermore, patients with episodic abdominal pain may be aided by emergency physician-directed bedside ultrasonography.

Frequency

United States

Ultrasonography is gaining popularity in the examination of trauma patients.

International

Ultrasonography is widely used in European trauma centers and is a part of the surgical curriculum. In Japan, ultrasonography is used to evaluate trauma patients and to identify bowel obstruction.

Mortality/Morbidity

A primary application of ultrasonography in emergency medicine is for the rapid diagnosis of abdominal aortic aneurysm (AAA); patient survival may depend on rapid diagnosis and interdisciplinary treatment. Another important use is in blunt and penetrating trauma; the need to identify life-threatening conditions with major trauma has heralded the significance of ultrasonography in advanced trauma life support.

Clinical

History

• Abdominal aortic aneurysm
  • Elderly men with history of hypertension may present with low back pain or referred pain.
  • Patients also may report pain similar to pain that occurs with renal colic.
• Biliary colic
  • Clinical presentation is pain in the right upper quadrant or epigastric pain, which may be postprandial.
  • Pain may be referred to the right scapula.
• Renal colic
  • Patients report severe pain in the flank that may radiate toward the groin.
  • Hematuria, seen primarily in renal colic, also can be present in AAA.
• Blunt or penetrating abdominal trauma
  • Patients usually have an acute injury.
  • Patients can present with splenic injuries several days after the initial injury.
• Appendicitis: The classic presentation of right lower quadrant pain indicates appendicitis; however, the diagnosis is more difficult in female patients presenting with nonspecific right lower quadrant pain.

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.

Miscellaneous

Medicolegal Pitfalls

• Failure to rapidly diagnose AAA may affect patient survival; interdisciplinary treatment is also a factor.
• Failure to identify life-threatening conditions after blunt or penetrating trauma is a pitfall.
• The kidney may be obstructed without hydronephrosis.
• At liver function testing, liver enzyme levels may not be elevated in early obstruction of the common bile duct.
• Hematuria can be present in AAA.
• Initial ultrasonographic image in major pelvic trauma may be less accurate than in blunt trauma.

Multimedia

Media file 1: Ultrasonography, abdominal. In the right upper quadrant (RUQ), The Morison pouch between the liver and right kidney is a space in which intraperitoneal fluid can accumulate. This right upper quadrant image depicts the liver and kidney (Kid). The center of the normal kidney (renal sinus) contains dense echoes.

Media file 2: Ultrasonography, abdominal. This image of the Morison pouch (arrows) demonstrates a small layer of dark material, which is free fluid (F).

Media file 3: Ultrasonography, abdominal. This view of the gallbladder (gb) reveals a large gallstone (st), which demonstrates significant shadowing (sh). This gallstone is most likely impacted and should be surgically removed.

Media file 4: Ultrasonography, abdominal. This image of the kidney reveals hydronephrosis (Hy), grade II (bear claw sign), with separation of the renal sinus and depicts the renal parenchyma (p).

References

1. Allemann F, Cassina P, Rothlin M, Largiader F. Ultrasound scans done by surgeons for patients with acute abdominal pain: a prospective study. Eur J Surg. Oct 1999;165(10):966-70. [Medline].

2. Blaivas M, Brannam L, Hawkins M, et al. Bedside emergency ultrasonographic diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med. Nov 2004;22(7):601-4. [Medline].

3. Blaivas M, Harwood RA, Lambert MJ. Decreasing length of stay with emergency ultrasound examination of the gallbladder. Acad Emerg Med. Oct 1999;6(10):1020-3. [Medline].

4. Blaivas M, Sierzenski P, Theodoro D. Significant hemoperitoneum in blunt trauma victims with normal vital signs and clinical examination. Am J Emerg Med. May 2002;20(3):218-21. [Medline].

5. Blaivas M, Theodoro D. Intraperitoneal blood missed on a FAST examination using portable ultrasound. Am J Emerg Med. Mar 2002;20(2):105-7. [Medline].

6. Branney SW, Moore EE, Cantrill SV, et al. Ultrasound based key clinical pathway reduces the use of hospital resources for the evaluation of blunt abdominal trauma. J Trauma. Jun 1997;42(6):1086-90. [Medline].

7. Chen SC, Wang HP, Hsu HY, et al. Accuracy of ED sonography in the diagnosis of acute appendicitis. Am J Emerg Med. Jul 2000;18(4):449-52. [Medline].

8. Chopra P, St-Vil D, Yazbeck S. Blunt renal trauma-blessing in disguise?. J Pediatr Surg. May 2002;37(5):779-82. [Medline].

9. Godambe SA, Boulden T. The use of an emergency physician-directed bedside ultrasound examination to clarify a diagnosis in an 8-year-old boy with chronic abdominal pain. Pediatr Emerg Care. Aug 2007;23(8):560-2. [Medline].

10. Handrigan MT, Thompson I, Foster M. Diagnostic procedures for the urogenital system. Emerg Med Clin North Am. Aug 2001;19(3):745-61. [Medline].

11. Heller M, Jehle D. Abdominal applications. In: Ultrasound in Emergency Medicine. WB Saunders; 1995:41-105, 135-65.

12. Henderson SO, Hoffner RJ, Aragona JL, et al. Bedside emergency department ultrasonography plus radiography of the kidneys, ureters, and bladder vs intravenous pyelography in the evaluation of suspected ureteral colic. Acad Emerg Med. Jul 1998;5(7):666-71. [Medline].

13. Isenhour JL, Marx J. Advances in abdominal trauma. Emerg Med Clin North Am. Aug 2007;25(3):713-33. [Medline].

14. Jehle D, Davis E, Evans T, et al. Emergency department sonography by emergency physicians. Am J Emerg Med. Nov 1989;7(6):605-11. [Medline].

15. Kuhn M, Bonnin RL, Davey MJ, et al. Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous. Ann Emerg Med. Sep 2000;36(3):219-23. [Medline].

16. Losanoff JE, Richman BW, Jones JW. Handlebar hernia: ultrasonography-aided diagnosis. Hernia. Mar 2002;6(1):36-8. [Medline].

17. Ma OJ, Kefer MP, Stevison KF, Mateer JR. Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels. Am J Emerg Med. Jul 2001;19(4):284-6. [Medline].

18. Ma OJ, Mateer JR, Ogata M, et al. Prospective analysis of a rapid trauma ultrasound examination performed by emergency physicians. J Trauma. Jun 1995;38(6):879-85. [Medline].

19. Mandavia DP, Pregerson B, Henderson SO. Ultrasonography of flank pain in the emergency department: renal cell carcinoma as a diagnostic concern. J Emerg Med. Jan 2000;18(1):83-6. [Medline].

20. Marn CS, Bree RL. Advances in pelvic ultrasound: endovaginal scanning for ectopic gestation and graded compression sonography for appendicitis. Ann Emerg Med. Dec 1989;18(12):1304-9. [Medline].

21. Mateer J, Plummer D, Heller M, et al. Model curriculum for physician training in emergency ultrasonography. Ann Emerg Med. Jan 1994;23(1):95-102. [Medline].

22. McEwan K, Thompson P. Ultrasound to detect haemothorax after chest injury. Emerg Med J. Aug 2007;24(8):581-2. [Medline].

23. McGahan JP, Richards JR, Jones CD, Gerscovich EO. Use of ultrasonography in the patient with acute renal trauma. J Ultrasound Med. Mar 1999;18(3):207-13; quiz 215-6. [Medline].

24. Nordenholz KE, Rubin MA, Gularte GG, Liang HK. Ultrasound in the evaluation and management of blunt abdominal trauma. Ann Emerg Med. Mar 1997;29(3):357-66. [Medline].

25. Ooms HW, Koumans RK, Ho Kang You PJ, Puylaert JB. Ultrasonography in the diagnosis of acute appendicitis. Br J Surg. Mar 1991;78(3):315-8. [Medline].

26. Richards JR, McGahan JP, Pali MJ, Bohnen PA. Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury. J Trauma. Dec 1999;47(6):1092-7. [Medline].

27. Richards JR, Schleper NH, Woo BD, et al. Sonographic assessment of blunt abdominal trauma: a 4-year prospective study. J Clin Ultrasound. Feb 2002;30(2):59-67. [Medline].

28. Rodgerson JD, Heegaard WG, Plummer D, et al. Emergency department right upper quadrant ultrasound is associated with a reduced time to diagnosis and treatment of ruptured ectopic pregnancies. Acad Emerg Med. Apr 2001;8(4):331-6. [Medline].

29. Sheafor DH, Hertzberg BS, Freed KS, et al. Nonenhanced helical CT and US in the emergency evaluation of patients with renal colic: prospective comparison. Radiology. Dec 2000;217(3):792-7. [Medline].

30. Shuman WP, Hastrup W, Kohler TR, et al. Suspected leaking abdominal aortic aneurysm: use of sonography in the emergency room. Radiology. Jul 1988;168(1):117-9. [Medline].

31. Sinclair D, Wilson S, Toi A, Greenspan L. The evaluation of suspected renal colic: ultrasound scan versus excretory urography. Ann Emerg Med. May 1989;18(5):556-9. [Medline].

32. Tayal VS, Nielsen A, Jones AE, Thomason MH, Kellam J, Norton HJ. Accuracy of trauma ultrasound in major pelvic injury. J Trauma. Dec 2006;61(6):1453-7. [Medline].

Keywords

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

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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