ULTRASOUND

ULTRASOUND ANA QOMARIYATUN NIMAHBY dr. Sandy IstantoPENDAHULUANUltrasound merupakan salah satu modalitas radiologi untuk mendeteksi / diagnosis penyakit dengan menggunakan gelombang suara

Beberapa jenis pemeriksaan ultrasound (3) : 1. USG ABDOMEN 5,5 MHz 2. USG SMALL PART 7,5 MHZ 3. USG OBSGYNTOOLS

Transducer gel. Suara imageOperating sonographic equipment

Jenis jenis transducer

PEDOMAN DASAR SONOGRAFI

Conventinally viewed as seen from the patients right side cranial aspect left side caudal aspect right sideSagital view

Conventinally viewed as seen from the patients right side left aspect left side right aspect right side

Transversal viewedLIVER

TEKNIK SCANNING

Penilaian sonografi hepar :Ukuran < 14 15 cm ekogenisitas parenkim sama dengan korteks ginjalTepiPermukaanDuktus biliaris ( intra-ekstrahepatal ) normal tidak tervisualisasiKelainan pada parenkim misal nodulUkuran vaskuler V. hepatika : Right hepatic vein, Middle hepatic vein, Left hepatic vein PENTING dalam penentuan segmen hepar V. porta pengukuran dilakukan pada hilus

MIDCLAVICULA LINE LONGITUDINAL

HEPATIC MEASUREMENTNormal : craniocaudal 14-15 cm

Ligamentum teresVariant NormalFatty Liver peningkatan ekogenisitas hepar dibandingkan dengan ekogenisitas korteks ginjal3 grade : Grade I: Pe>> ekogenisitas dengan batas vaskuler yang masih jelas Grade II : Pe>> ek. Dengan batas vaskuler yang kabur Grade III : grade II-III + diafragma (-)

PATOLOGI HEPARMETASTASISTumor sekunder Polimorfik ekogenik : kolorektal Ca hipoekoik : Ca mammae / Ca paru Bulls eye : perihipoekoik halo / rimMultipelPendesakan struktur di sekitarnya ; vaskuler / duktus biliaris

Sirosis dan HCCTahap akhir dari penyakit hepar ; hepatitis, alkoholisme, toxin substance

hcchccHipertensi PortalSekunder terhadap sirosis / adanya massaDilatasi v. porta > 13 mm hipertensi portal

v. portaVesika Felea

Teknik scanning

Penilaian Vesika FeleaUkuranDinding menebal atau tidakBatuMassa

1. Gallstone Kolesterol / kalsium echogenic band dg acoustic shadow dipastikan dengan perubahan posisi pasien dislodge ~ polip

2. KolesistitisInflamasi di vesika felea, biasanya k/ batuAwal hanya nyeri tekan late edema ~ dinding menebal dan multipel layerDinding V F > 4 mmPerikolesistik fluid

GINJAL

AnatomyKidneys are retroperitoneal, T12 - L4Right kidney is lower than the left kidneyRight kidney is posterio-inferior to liver & gallbladderLeft kidney is inferior-medial to the spleen Adrenal glands are superior, anterior, medial to each kidneyIVCAORTACeliacaxisSMARenal arteryRenal veinHepaticVeinsRightkidneyLeft kidneyLiverSpleenAnatomy

Approach to ScanningRight kidney scanning approach: anterior, lateral, posteriorLiver is the acoustic windowLeft kidney: requires a posterior approach, through the spleenAir-filled bowel impedes anterior scanningILIVERSTOMACHSPLEENIVCAORTAKKSAnatomy9-12 cm long, 4-5 cm wide, 3-4 cm thickGerotas fascia encloses kidney, capsule, perinephric fatSinusHilum: vessels, nerves, lymphatics, ureterPelvis: major and minor calycesParenchyma surrounds the sinusCortex: site of urine formation, contains nephronsMedulla: contains pyramids that pass urine to minor calyces. Columns of Bertin separate pyramids

Renal arteryRenal veinUreterRenal capsuleCortexMedullary pyramidsMinor CalyxKidney AnatomyMedullaSinusMajor CalyxSonographic AppearanceUreters are normally not seenRenal pelvis is black when visibleRenal sinus is echogenic due to fatMedullary pyramids are hypoechoicCortex is mid-gray, less echogenic than liver or spleen. Capsule is smooth and echogenic

LiverDiaphragmSinusCortexAnteriorPosteriorSuperiorInferiorRight Kidney Long AxisRight Kidney Short Axis

VertebralBodyR KidneyAortaRenal a.GBIVCLiverAnteriorPosteriorRightLeftLeft Kidney Long Axis

AnteriorPosteriorSuperiorInferiorSpleenKidneyRib ShadowLeft Kidney Short Axis

AnteriorPosteriorRightLeftLiverSpleenL KidneyClinical IndicationsObstructive UropathyNephrolithiasis12% of the US population Incidence of renal colic is 3% with 50% recurrence within 10 years

Manthey DE. Emerg Med Clin North Am.2001; 19(3): 633-54HydronephrosisDilatation of the urinary tract at any level secondary to intrinsic and or extrinsic obstruction to urine flow

Obstructive Uropathy Grading System - SubjectiveMildMinimal separation of calycesModerateDilation of major and minor calyceal systemSevereMarked dilation of the renal pelvis and thinning of the renal parenchymaRange of HydronephrosisNormalMildModerateSevereMild Hydronephrosis

KidneyLiverGBModerate - Severe Hydronephrosis

LiverKidneyDilated pelvisGB

Renal Pathology1. Renal CystsRenal CystsArise in the renal cortex, commonly single rather than multipleCysts do not communicate; hydronephrosis doesShape is round or ovalEcho freeSharp interface between the mass and renal tissueLarge renal cysts may be mistaken for aortic aneurysms

Renal Cysts

PANKREAS

Penilaian Pankreas

UkuranEkogenisitas parenkim KalsifikasimassaEkogenisitas parenkim >> dg bertambahnya usia

Ukuran normal kaput : < 3 mm korpus: < 2,5 mm kauda: < 2,5 mm

PANKREATITISPenyebab billiary pankreatitis ; batu di CBD alkoholismePankreatitis akut ukuran membesar ( thickness ) hipoekogenisitas parenkimPankreatitis kronis heterogenous fibrosis kalsifikasi tepi yang irreguler

Aorta & v. cava inferior

SPLEEN

Posisi RLD dengan pasien melakukan inspirasi dalam Posisi transduser sejajar dengan ICS Tervisualisasi dome diafragma dan hilus lien Normal ukuran lien < 11 cm1. Diffuse SplenomegaliHipertensi portal, infeksi, proses p>> sintesis eritrosit ( anemia hemolitik, polisitemia )Sistemik hematologi diseases leukemia Splenomegali dimulai dengan rounding dr bentuk crescentnya giant spleen kissing phenomenon >66

Vesika urinaria

Vol = A x B x C x 0,52abcPenilaian Vesika UrinariaDindingPermukaanBatumassaDinding dan lumen V U hanya dapat dievaluasi bila V U dalam keadaan penuh Pada pasien dengan kateter Foley maka diklem ter lebih dahuluV U yang penuh window uterus / prostatDinding V U tidak boleh melebihi 4 mm jika lebih dari 4 mm didiagnosa dg sistitisVesikolitiasisMassa TCCProstatPENILAIAN PROSTAT

Ukuran Normal volume < 25 ccKalsifikasiNodul?KapsulTransabdominal harus dalam keadaan V U penuh ~ menyingkirkan udara usus ke kranial dan lateral ~ acoustic windowProstat terletak pada dasar V U anterior terhadap rektumSuprapubic transversal dan longitudinal scanning

Hipertrofi ProstatMengelevasi lantai V U, dinding masih reguler, belum tampak penebalanHipertrofi lanjut stenosis urethra dinding V U tebal

Ca ProstatMuncul dari perifer Infiltrasi dinding V U Massa lobulated dalam lumen V U

Emergency UltrasoundFAST ( Focused Assesment with Sonography for Trauma ) untuk mendeteksi cairan bebas intraperitoneal maupun intratoraksIndikasi : trauma tumpul / penetrating trauma in pregnancy pediatric trauma FAST pada pasien dengan trauma tumpul abdomen : 1. pasien dengan hemodinamik tidak stabil 2. PF yang meragukan 3. unexplained hypotension

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