ACCURACY OF ULTRASOUND IN ACUTE AND CHRONIC ABDOMINAL

CONDITIONS.

BY

DR.SANTHOSH LAXMAN

Dissertation Submitted to the Rajiv Gandhi University of Health Sciences, Bangalore,

Karnataka, in partial fulfillments of the requirements for the degree of

M. S. (GENERAL SURGERY)

Under the guidance of

DR.GURUSHANTHAPPA YALAGACHIN. M.S.DNB. FMAS, FIAGES.

& under the co-guidance of

Dr. G.C. PATIL. MDRD

DEPARTMENT OF GENERAL SURGERY

KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI.

2011

I  

II  

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “Accuracy of Ultrasonography in

Acute and Chronic Abdominal conditions in KIMS, HUBLI” is a Bonafied and

Genuine research work carried out by me under the guidance of

Dr.GURUSHANTHAPPA YALAGACHIN.M.S.DNB.FMAS,FIAGES. Professor

Department of General Surgery, and under the co-guidance of Dr. G.C. PATIL.

MDRD Professor and Head of the Department of Radiology KIMS, HUBLI.

This dissertation has not been submitted by me on any previous occasion to any university for the award of any degree.

Date : Dr. SANTHOSH LAXMAN Place: Hubli Post Graduate student

Department Of General surgery KARNATAKA INSTITUTE OF MEDICAL SCIENCES, HUBLI.

III  

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled ““Accuracy of Ultrasonography in Acute

and Chronic Abdominal conditions in KIMS, HUBLI” is a Bonafied research work,

done by Dr.SANTHOSH LAXMAN in partial fulfillment of the requirement for the

degree of M.S. General Surgery.

DATE: Dr.GURUSHANTHAPPA YALAGACHIN M.S.DNB,FMAS, FIAGES. Place: Hubli Professor Department of General Surgery KIMS, HUBLI.

IV  

CERTIFICATE BY THE CO - GUIDE

This is to certify that the dissertation entitled ““Accuracy of Ultrasonography in Acute

and Chronic Abdominal conditions in KIMS, HUBLI” is a Bonafied research work,

done by Dr.SANTHOSH LAXMAN in partial fulfillment of the requirement for the

degree of M.S. General Surgery.

DATE: Dr. G.C. PATIL. MDRD. PLACE: Professor & Head of the Department Of Radiology,

KIMS, HUBLI.

V  

ENDORSMENT BY THE HOD, DEPARTMENT OF SURGERY

This is to certify that the dissertation entitled ““Accuracy of Ultrasonography in Acute

and Chronic Abdominal conditions in KIMS, HUBLI” is a Bonafied research work

done by Dr.SANTHOSH LAXMAN. Under the guidance of

Dr.GURUSHANTHAPPA YALAGACHIN. M.S.DNB.FMAS,FIAGES. Professor

Department of General Surgery, & under the Co- Guidance of Dr. G.C.PATIL. MDRD

Professor & Head of the Department of Radiology. KIMS,HUBLI.

DATE: Dr.B.S.MADAKATTI

PLACE : Hubli PROFESSOR AND HEAD DEPARTMENT OF GENERAL SURGERY

KIMS HUBLI.

VI  

ENDORSMENT BY THE, PRINCIPAL/HEAD OF THE INSTITUTION

This is to certify that the dissertation entitled ““Accuracy of Ultrasonography in

Acute and Chronic Abdominal conditions in KIMS, HUBLI” is a Bonafied research

work done by Dr.SANTHOSH LAXMAN under the guidance of

Dr.GURUSHANTHAPPA YALAGACHIN. M.S. FMAS,FIAGES,DNB. Professor

Department of General Surgery, & under the Co- Guidance of Dr. G.C.PATIL. MDRD

Professor & Head of the Department of Radiology KIMS, HUBLI.

Date: Dr.U.S.HUNGARGA.MD. PRINCIPAL Place: Hubli KIMS HUBLI.

VII  

COPY RIGHT

DECLARATION BY THE CANDIDATE

I hereby declare that Rajiv Gandhi University Of Health Sciences, Karnataka. Shall have

the rights to preserve, use and disseminate this dissertation/thesis in print or electronic

format for academic/research purpose.

DATE: Dr. SANTHOSH LAXMAN Post Graduate student Place: Hubli Department Of General surgery

KIMS HUBLI

© Rajiv Gandhi University of Health Sciences, Karnataka

VIII  

ACKNOWLEDGEMENT

It gives me immense pleasure to express my gratitude and respect to my

beloved teacher and guide Dr.GURUSHANTAPPA YALAGACHIN

M . S . D N B , F M A S , F I A G E S Professor, Department of General Surgery, KIMS,

Hubli,& Dr.G.C.PATIL.MDRD.Professor and Head of the Department of

Radiology,KIMS,Hubli for their priceless guidance, affection and constant

encouragement during the course of this dissertation.

I express my deepest sense of gratitude and sincere thanks to my beloved

teacher Dr. B. S. MADAKATTI M.S, Professor & Head, Department of

General Surgery, KIMS, Hubli, for his unceasing guidance, invaluable

supervision and continuous support.

I express my humble thanks to my respected teachers

Dr.M.B.BARIGIDAD.M.S,Professor, Dr.Ishwar Hosmani.M . S , Professor,

Dr.Ramesh Hosmani M . S , Associate Professor, Dr.N.I.Hebsur M.S,

Associate Professor, Dr.Ravikumar Jadhav M . S, Associate Professor ,

Dr.Suresh Hucchannavar M . S , Assistant professor , Dr.Vijay Kamath M . S ,

Assistant professor , Dr.B.P.Sanganal M . S , Assistant Professor, for their

guidance and encouragement throughout the course of this study.

I also express my sincere thanks to the rest of the Teaching Faculty and all

my friends of Department of Surgery for their valuable suggestions and kind

cooperation.

I am also thankful to Professor and Head,department of pathology,

department of Anaesthesia and department of Radiology and their respective

staff whose help in completing this work has been immense.

I am grateful to Director, Principal, Superintendent and RMO of KIMS, for

permitting to utilize resources in completion of this work.

IX  

Above all, I am eternally indebted to God, to my parents for everything they

have done, or sacrificed in shaping my career.

I express my sincere thanks to all the patients without whose consent and co-

operation, this study would not have been possible.

DATE: Dr. SANTHOSH LAXMAN Post Graduate Student PLACES: HUBLI Department of Surgery KIMS, Hubli.

X  

LIST OF ABBREVATIONS

BPH = Benign prostatic hyperplasia

Ca = Carcinoma

MHz = Mega hertz

Cps = Cycles per second

Mm = Millimeter

Cm = Centimeter

TGC = Time gain compensation

2D = Two dimensional

USG = Ultrasound

S = Seconds

GB = Gall bladder

CCK = Cholecystokinin

IHBR = Intrahepatic billary radicals

CBD = Common bike duct

PD = Pancreatic duct

Min = Minute

SMA = Superior mesenteric artery

E.Granulosis = Echinococcus granulosis

RCC = Renal cell carcinoma

TB = Tuberculosis

ICU = Intensive care unit

GOO = Gastric outlet obstruction

VUJ = Vesico ureteric junction

IVC = Inferior vena cava

XI  

ABSTRACT

BACKGROUND AND OBJECTIVES:

Abdomial pain is one of the most common conditions which calls for prompt diagnosis

and early treatment. Associated symptoms may be present but pain is the most common

symptom.

AIMS & OBJECTIVES:

1. To determine the accuracy of ultrasound in the diagnosis of acute and chronic

abdominal conditions.

2. To compare the ultrasound diagnosis with Per operative & Histopathological

diagnosis.

METHODS:

All patients presenting to KIMS Hubli with Acute non traumatic and non Gynecological

conditions. Chronic non traumatic and non gynecological conditions. During the study

period were included in the study.

RESULTS:

During the study period the total number of casesincluded in the study were 99, out of

which 50 cases were of acute abdomen and 49 cases were of chronic abdomen.

Ultrasound was performed in all the cases, and the ultrasound diagnosis was compared

with the Per Operative diagnosis and with Histopathological reports in doubtfull cases.

In the acute cases out of the 50 cases, 33 were of appendicitis and related conditions &

the ultrasound was diagnostic in 28 cases, a sensitivity of 84%. Ultrasound was

diagnostic in all the 10 cases of acute cholecystitis with a sensitivity of 100%. It was

diagnostic in one case each of ovarian cyst and ruptured psuedocyst and missed the

diagnosis in 2 cases each of perforative peritonotis and intestinal obstruction & 1 case of

ruptured liver abscess.The over all sensitivity, specificity, positive predective value &

negative predective values for acute cases were 84%,50%, 92.5% & 30% respectively.

XII  

In the chronic abdominal casesout of the 49 cases, ultrasound was diagnostic in all the 13

cases of Hepatobiliary & Pancreatic system with a sensitivity of 100%. In the

gastrointestinal system, ultrasound was diagnostic in 14 of the 22 cases with a sensitivity

of 63%. In the Genitourinary system ultrsound was diagnostic in 5 of the 6 cases

studied,a sensitivity of 84%. Ultrasound was diagnostic in 4 of the 5 cases of herniae and

was non diagonostic in 1 case of retroperitoneal tumour.

The overall sensitivity, specificity, positive predective value & negative predective value

of 76.1%, 66.67%, 97.2% & 15.4% respectively.

CONCLUSION:

In acute abdominal cases the sensitivity and the positive predective values were 84% &

92. 5% respectively indicating that USG is a good screening test in the diagnosis of acute

abdomen, whereas with low specificity & negative predective value (50% &

30%),ultrasound cannot be used as a definitive diagnostic test in the assessment of acute

abdomen. However, for Acute Appendicitis & Hepatobiliary system ultrasound is a more

accurate diagnostic modality with a sensitivity of 84% & 100% respectively, and hence

can be used as a definitive diagnostic tool. Its accuracy in assessing bowel dissorders is

limited due to less sensitivity.

In the chronic abdominal conditions, ultrasound is less sensitive and less specific, but is

good initial modality of investigation because of its easy operability and non

invasiveness. It is highly accurate in the diagnosis of hepatobiliary and genitourinry

system evaluation. But is of limited value in the assessment of bowel dissorders except

in the case of tuberculosis of abdomen which can be diagnosed with a sensitivity of upto

84%.

KEY WORDS:

USG, Acute Abdomen, chronic abdomen, sensitivity, specificity, accuracy.

XIII  

TABLE OF CONTENTS

Sl No Particulars Page no.

1. Introduction 1-2

2. Aims and objectives 3

3. Review of literature 4-59

4. Materials and Methods 60-61

5. Results 61-69

6. Discussion 69-74

7. Conclusion 75

8. Summary 76

9. Bibliography 77-83

10. Annexure

Key to master chart 84-86

Master Chart 87-90

XIV  

LIST OF TABLES

Sl No Tables Pages

1. Age distribution of cases. 62

2. List of cases. 63-64

3. Organ distribution of cases. 65

4. Cases with acute abdomen. 68

5. Cases with chronic abdomen. 69

6. Statistical analysis of acute cases. 71

7. Statistical analysis of chronic cases. 72

XV  

LIST OF CHARTS

Sl No Charts Pages

1. Sex distribution of cases. 61

2. Age distribution of cases. 62

3. Percentage distribution of age. 63

4. Organ distribution of cases. 66

5. Cases with acute abdomen. 69

6. Cases with chronic abdomen. 70

XVI  

LIST OF FIGURES

Sl No Figures Pages

1. Harmonic imaging. 5

2. A – mode trace. 6

3. M – mode trace. 6

4. Mechanical transducer. 7

5. Phased array transducer. 8

6. Linear array transducer. 9

7. Convex array transducer. 10

8. Ultrasound beam shapes. 11

9. Velocity artefact from a silicon prosthesis. 12

10. Beam width artefact. 12

11. Mirror image artefact. 13

12. Accoustic shadowing. 14

13. Increased sound transmission. 15

14. Beam dispersion by fat. 16

15. Laminar flow. 17

16. Parabolic velocity profile. 18

17. Plug flow. 19

18. Turbulance beyond a stenosis. 20

19. Common femoral artery flow ( triphasic). 20

20. Colour convention in colour flow doppler. 21

21. Power doppler display of right kidney. 22

22. Frequency aliasing. 24

23. Features of acute appendicitis. 26

24. Target sign in Acute Appendicitis. 27

25. Increased vascularity in App wall. 28

26. Appendicular Abscess. 28

27. Suppurative Appendicitis. 29

28. Acute cholecystitis. 29

29. GB stone casting an acoustic shadow. 30

30. Sludge in the Gall Bladder. 30

XVII  

31. Gangrenous Cholecystitis. 31

32. Emphysematous Cholecystitis. 32

33. The Double Arc Sign. 32

34. GB Sludge with dirty shadowing. 33

35. CBD Stone casting an acoustic shadow. 34

36. Choledochal cyst. 35

37. Acute pancreatitis. 36

38. Chronic pancreatitis with stone in the PD. 37

39. Psuedopancreatic cyst. 39

40. Carcinoma pancreas. 39

41. Liver abscess. 40

42. Portal vein thrombosis. 41

43. Honey coomb appearance in HC Liver. 42

44. Daughter cyst. 43

45. Double Rim Sign in Hydatid Cyst. 43

46. Water Lilly Sign. 44

47. Floating membranes in Hydatid cyst. 44

48. Liver Metastasis. 45

49. Target lesions in Hepatic metastasis 46

50. Portal Hypertension. 46

51. Acute Intestinal Obstruction 47

52. Peritoneal Tuberculosis. 48

53. Omental Tuberculosis. 49

54. Club sandwich sign. 50

55. TB Lymphadenitis. 50

56. Ileocecal Tuberculosis. 51

57. Pulled up cecum. 52

58. Normal kidney & Hydronephrosis. 52

59. Suprapubic US of Bladder. 53

60. Bilateral Undescended testes. 54

61. Seminoma. 55

62. Teratoma of testis 56

63. Renal calculus. 57

64. Hydronephrosis. 57

XVIII  

XIX  

INTRODUCTION

Abdominal pain is one of the most common conditions which calls for prompt diagnosis

and early treatment, associated symptoms may be present, but pain is the most common

Symptom.

CAUSES FOR ACUTE ABDOMEN

Gastro intestinal system

1. Acute intestinal obstruction

2. Acute perforative peritonitis

3. Acute appendicitis

4. Acute colonic diverticulitis

5. Acute regional enteritis

6. Ulcerative colitis

7. Acute mesenteric ischemia

Hepato-Billiary and Pancreatic system

1. Acute cholecystitis

2. Acute pancreatitis

3. Empyema of gall bladder

4. Portal vein thrombosis

5. Hepatic vein thrombosis/Budd Chiari Syndrome

6. Liver abscess

7. Subphernic/Subhepatic abscess

Genito Urinary system

1. Ureteric colic

2. Acute retention of urine

3. Perinephric abscess

4. Pyonephrosis

Retroperitoneum

1. Ruptured aortic aneurysm

2. Retroperitoneal abscess

Miscellaneous

1. Omphalitis

2. Rectus sheath hematoma

XX  

CAUSES OF CHRONIC ABDOMEN

Gastro intestinal system

1. Gastric out let obstruction

2. Abdominal kochs

3. Inflammatory bowel disease

4. Carcinoma rectum/colon

5. Small intestinal tumors

Hepato billary and Pancretic system

1. Chronic cholecystitis 2. Cholelithiasis

2. Choledocolithisis

3. Chronic Pancreatitis

4. Choledochal cysts

5. Pseudocysts of pancreas

6. Carcinoma pancreas

7. Hydatid cyst of liver

8. Hepatoma

9. Metastatic liver disease

10. Portal hypertension

Genito Urinary system:

1. Bph

2. Undescended testis.

3. Ca. Testis.

4. Vesical calculus.

Retroperitoneum.

1. Retroperitoneal tumor.

2. Aortic aneurysm.

XXI  

AIMS AND OBJECTIVES

1. To determine the Accuracy of Ultrasound in the Diagnosis of Acute and

Chronic Abdominal conditions.

2. To compare the Ultrasound Diagnosis with Per Operative and

Histopathological Diagnosis.

XXII  

REVIEW OF LITERATURE

Ultrasonography:1

General principles:

Ultrasound is simply a sound with a frequency above the limits of human

Hearing. Frequencies in the range of 2-20MHz (million cps) are used corresponding to

the wave length of 1(0.1mm in the tissue).

Ultrasonic transducers:

Ultrasound is generated by piezoelectric materials which have the property of changing

thickness when a voltage is applied across them. Lead Zirconate Titanate (PZT) is most

widely used. Piezoelectric effect is derived from movements of heavily charged lead

atoms that is loosely bound within a complex crystal. When an electric field is applied,

an atom moves and distorts the crystal.

PZT is a ceramic that is cast as a thin plate that may be disk shaped or more usually is

formed into a strip that is then sliced into several hundred tiny elements as an array with

metal electrodes on two surfaces. it is polarized by heating above the critical level and

then allowing it to cool in an electric field. When electrically pulsed, the crystal rings at

a resonant frequency that is mainly determined by its thickness. Higher frequency

crystals are thinner and thus more difficult to manufacture.

The Piezo electric effect is reversible so that a same or a similar crystal is used as the

receiver to produce small electric signals when struck by an ultrasound wave.

The crystal is mounted in a conveniently shaped holder, which contains the electrodes

and any associated electrons, as well as the lenses and the matching layers required to

improve beam shape. The whole assembly is known as a probe, transducer or head.

Propagation in tissues:

Ultrasound travels through tissues as a beam that is usually focused to improve lateral

resolution. It propagates as a sequence of compression and rarefaction waves transmitted

by the electric forces between adjacent tissue particles. The particals move in the same

direction as the wave. Thus ultrasound is a longitudinal wave. The constant speed of

ultrasound in tissues (1540m\ sec) allows the depth of reflecting structures to be

calculated by measuring the delay in return of echoes after the ultrasound pulse has been

transmitted. This is the essence of pulse echo method used in USG and Doppler. The

position of reflecting structures across the image is determined by the direction in which

ultrasound beam is transmitted.

Attenuation:

Ultrasound energy is lost to receiving transducer if it is reflected or refracted away from

the returning line of sight or if the beam diverges. Total loss from all these mechanisms

is called attenuation. High frequency ultrasonic waves give good resolution because of

its short wave length, but rapidly attenuates. Frequency upto 20MHz can be used when

only few mm of tissues are to be traversed. e.g. Eye, Skin & Intravascular Ultrasound.

For Superficial tissues 10-15MHz can be used. For Heart, Abdomen and 2nd and 3rd

Trimester Obstetrics scan 3-7MHz can be used. For Abdomen in Obese and Transcranial

Ultrasound frequency of 1-2MHz can be used.

Reflection:

Some of the transmitted energy is reflected whenever the beam crosses an interface.

Where the transmission properties change, the proportion depending on the degree of

Impedance is matched. Ultrasound that is not reflected passes through and is available

for imaging deeper tissues. 2-10% reflection occurs at each soft tissue interface. Total

reflection occurs at tissue gas interface. 2/3rd reflection occurs at tissue bone or tissue

calculus interface. aerated lung is opaque to Ultrasound.

Figure 1. Harmonic imaging. (a) Conventional grey scale image through the

gallbladder shows an echogenic mass within it. (b) Harmonic mode the image has much

higher contrast and the gallstones (arrowhead), together with the shadowing they

produce, are clearly visualized.

FIGURE 1

XXIII  

IMAGING METHODS

Pulse -Echo method:

1. A-Mode(Amplitude):

Only the depth of interface is determined.

Figure 2. A-Mode trace. Indicating echo intensity tissue with depth. There is a fluid

space (6–10 cm) from which no echoes arise. Tissues superficial and deep to this

produce echoes of varying intensities and there is a particularly strong echo from the

skin (0–5 cm). The time gain compensation (TGC) curve is also shown. FIGURE 2

2. M-Mode (Movement): Shows depth vs time. e.g 2D-Echo.

Figure 3. M-mode trace. The echo intensity is displayed as brightness and the trace is

swept across the screen so that the x-axis represents time. This is an m-mode

echocardiogram showing the rapid movement of the mitral valve apparatus within the

left ventricle (LV), with thicker proximal and distal moving bands representing the

myocardium. RV = right ventricle.

FIGURE 3

3. B-Mode (Brightness): Also known as Grey scale, it is the commonest mode used for Ultrasound imaging

XXIV  

Beam Steering:

1. Mechanical:

Used for intra cavitatory examination of Trans rectal or Trans vaginal examination.

Figure 4 Mechanical Transducer. (a) A motor rotates the transducer assembly to

sweep out a circular path. (b) Trans rectal image covering a 2.2 cm axial section showing

the layers of the rectal wall with defects of both the internal and the external sphincter

(arrowheads) anteriorly. This is a classic sphincter tear that resulted from a forceps

delivery. A = Anterior, ES = External sphincter, IS = Internal sphincter, M = mucosa, R

= right, Tx = Transducer.

FIGURE 4

XXV  

2. Electronic sector system (Phased arrays):

Figure 5. Phased array. (a) The delay lines introduce small timing differences in the

pulses driving the elements so that those at one end are fired earlier than those further

along the array. This has the effect of steering the beam away from the centre line, rather

as if the transducer face had been tilted. (b) Right lobe of the liver in a patient with a

pleural effusion imaged with a phased array ultrasound system. D = diaphragm, E=

Effusion, K = Kidney.

FIGURE 5

XXVI 

 

3. Linear array transducer: e.g. For Breast imaging.

Figure 6. Linear array. The formation of one ultrasound beam by triggering a set of

elements at one end of the probe. The next beam would be formed by the adjacent or

partially overlapping set of elements so that the beam is swept along the transducer face

to give a rectangular image. FIGURE 6

.

XXVII  

4. Convex array transducer: e.g. Trans vaginal USG.

Figure 7. Convex array. (a) Image of a fetal skull obtained using a 3.75Hz convex

array. (b) Transvaginal image of a uterus with a fibroid (arrows) obtained using a tightly

curved array at 7Hz. The convex format is a compromise between the footprint

requirements of sector and linear probes and has the advantage of giving a wide field of

view for deeper structures. M = Midline, P= Placenta, S = Skull, U = Uterus. FIGURE 7

Resolution:

Must be considered for two dimensions separately

A. Along the beam

B. Across the beam

Depth or Range of resolution is determined by the length of ultrasound pulse & is kept

as short as possible. Lateral Resolution depends on the width of Ultra sound beam

mainly controlled by mechanical and electronic lenses.

Figure 8. Ultrasound beam shapes. All are of the same frequency (3.5MHz). (a) The

beam from the 10 mm probe has a complex region close to the transducer face, then a

mid portion with near parallel sides, before the beam spreads out in the far field. The

white lines indicate the half-power limits. (b) Increasing the probe diameter improves the

overall beam width. (c) weak focusing has been added by concave shaping of the XXVIII 

 

crystal. This further improves the beam shape in the focal zone but causes it to spread

more severely further out. This would be a useful compromise for general abdominal

data acquisition. (d) Stronger focusing exaggerates these effects, producing a fine beam

but only over a short distance. This would be useful for data acquisition in superficial

structures. FIGURE 8

Artefacts:

In an USG, Ultrasound travels at a constant speed and the beam is well Behaved

Artefacts arise whenever these principles are violated. Speed of Ultrasound varies only a

few percent in water. But fat conducts 20% more slowly hence depth is over estimated,

e.g. In silicon implant there is 50% of soft tissue conduction, hence chest wall appears

twice its distance from the skin.

XXIX  

Figure 9. Velocity Artefact from a silicone prosthesis. On this breast scan, the echo

free ovoid is a prosthesis (S) inserted following removal of a tumour. The low speed of

sound within it has distorted the pleural line (P) so that it appears to lie deeper behind the

prosthesis (arrows) than to either side. FIGURE 9

Types of the artefacts:

1. Beam Width Artefact: Seen in case of gas in the Bowel with Ascites.

Figure 10. Beam Width Artefact. In this abdominal image in a patient with ascites, the

intense echoes from gas in a loop of bowel have spread across into the fluid (arrowhead).

This artefact results from the finite width of the ultrasound beam. A = Ascites, B =

Bowel.

FIGURE 10

XXX 

 

2. Linear artifact:

3. Comet tail artifact:

Seen in closely packed focuses in the bowel.

4. Mirror image artifact: Seen at air pleural interface above the diaphragm.

Figure 11. Mirror image artefact. Structures in the liver, such as cysts (arrowhead) in

this patient with dominant polycystic kidney disease, are mirrored at the air–pleura

interface and appear in the position of the lower lobe of the lung. When this surface is

absent, for example when a pleural effusion is present, the effect does not occur FIGURE 11

XXXI  

INTERPRETATIVE PRINCIPLES

Shadowing

Occurs when little or no ultrasound can penetrate an interface and results in a dark band

over the deeper tissues, bounded by the ultrasound beam lines which are parallel for a

linear transducer and radiating for a curved or sector transducer. E.g. deep to a calcific

lesion (biliary or renal stone). For stones 60% of the incident energy will be reflected

back.

For tissue gas interface almost all the incident Ultrasound is reflected and they produce

dense shadows resulting in” dirty shadows”. ‘Clean shadows’ are seen behind the

stones.

About 3/4th of the beam must be obstructed to produce a shadow; hence USG can detect

stones 5mm or more in diameter or groups of fine calcifications.

Edge shadows: these are fine dark lines extending deep to strongly curved surface. e.g.

Cysts and Fetal skull.

Figure 12. Acoustic shadowing. The dark band (arrows) deep to the gallstones (g) is an

example of shadowing produced by a combination of high absorption and reflection. L =

liver.

FIGURE 12

XXXII  

Increased through transmission:

It is the opposite of Attenuation. Shadowing echoes from deeper surface are over

amplified. E.g. Cystic spaces.

Figure 13. Increased sound transmission. The echoes (arrowheads) deep to this liver

cyst (c) appear brighter than those from the rest of the liver; this is because the cyst fluid

attenuates less than the solid liver and so signals from beyond it are relatively over

amplified.

FIGURE 13

Echogenicity

The prime determinant of strength of Ultrasound echoes is the Impedence mismatch(Z)

between adjacent tissue components. The larger the mismatch the stronger the input so

that the interface between soft tissues and bones for example gives very strong echoes.

The second important factor is the concentration of the scatterers for a given impedence

mismatch. The region that contains more scatterers is more echogenic than one where

they spread out. Commonly the dilution of scatterers is caused by high water content.

e.g. Congested liver in Right Heart Failure,.Malignant tumours untill they grow large

necrosed and calcific they tend to be echo poor.

XXXIII  

Figure 14. Beam dispersion by fat. Deep to this fatty Renal hilum, the Retroperitoneal

tissue layers (arrowheads) are less clear than adjacent tissue planes because the Hilar fat

has defocused the beam. S = Renal sinus FIGURE 14

Doppler ultrasound:

Used since 1954, it is a refinement of the technique where by regions of blood flow are

Displayed in color as an overlay on the Grey scale 2D image. Duplex is used to imply

that, two types of information are being collected simultaneously. Typically 2D imaging

and Spectral Doppler.

The Doppler Effect:

It is a change in the frequency of sound being reflected from a moving Target. It is used

to detect fetal heart sounds. With this the depth of fetal heart and the direction of

movement cannot be determined.

Theorotical basis of Doppler:

An ultrasound beam insonating a blood vessel is partly reflected by RBC’s. If these are

moving there is a change in frequency of the reflected pulse. An increase in frequency if

the flow is towards the probe and a decrease if the flow is away from the probe.

XXXIV  

Laminar flow of blood:

Blood flows in a concentric laminae at different velocities. However the flow is non

laminar near the bends, branches, junctions & near the Athermanous plaques.

Figure 15. laminar flow. Diagrammatic representation of the concentric layers of blood

flowing at different velocities with the highest velocity in the centre of the vessel.

FIGURE 15

XXXV  

Velocity profile

Parabolic flow:

Occurs if the flow is not pulsatile and the velocity is not high.

E.g. Diastolic arterial & venous flow.

Figure 16. Parabolic velocity profile. The fastest flow is in the centre of the vessel, with a

progressive reduction in velocity towards the vessel wall. FIGURE 16

XXXVI  

Plug flow: Occurs if the blood is flowing fast or is being accelerated.

E.g. Systolic flow in an artery.

Figure 17. Plug flow. The flow velocities are almost equal across the whole vessel

diameter. FIGURE 17

XXXVII  

Turbulent flow: Occurs when the complex flow disturbances that results from blood

being forced at high velocity through a small orifice.

Figure 18. Turbulence beyond a Stenosis. There is high-velocity flow beyond this

portal vein stenosis, with simultaneous forward and reverse velocities FIGURE 18

Triphasic flow pattern:

Seen in elastic arteries with high resistance beds.

e.g. Femoral flow characterized by rapid upstroke and rapid down stroke with transient

negative flow.

Figure 19. Normal Common Femoral Artery flow. There is Triphasic flow with early

diastolic flow reversal. FIGURE 19

XXXVIII  

Uniphasic flow pattern:

In this forward flow is seen throughout the Diastole. E.g. Internal Carotid, Hepatic &

Renal arteries. In an arterial stenosis, depending on the cross sectional area and the

diameter of the lumen occlusion, the following can occur.

A. Moderate spectral broadening.

B. Complete spectral broadening.

C. Turbulence beyond a stenosis.

Colour doppler:

With this form of display areas of blood flow are represented as colour within the image.

The main advantages are- vessels are detected with ease and their patency can be

confirmed. The direction of flow can be confirmed. Very small vessels can be detected.

Figure 20. Colour convention in colour doppler. Fetal circle of Willis. The flow in the

right middle cerebral artery, the left anterior communicating artery, the left posterior

communicating artery and the right posterior cerebral artery are displayed in red as the

flow is towards the transducer. The flow in the other vessels is passing away from the

transducer and is therefore represented by blue. FIGURE 20

XXXIX  

Power Doppler:

The principle is same as that of colour doppler, but velocity information and direction

information have been discarded. The colour here is modulated by the strength of the

Doppler signal, which in turn is directly proportional to the number of RBC’s moving

within the sample volume. Large vessels give high signals. Small vessels give low

signals.

Figure 21. Power Doppler display of a right Kidney. Shows the flow in the IVC,

main Renal vessels and the Intra Renal vessels right up to the capsule. The loss of

directional information prevents differentiation of arteries from veins. FIGURE 21

XL  

XLI  

DOPPLER ARTEFACTS, ERRORS & PIT FALLS Sample volume, size & position:

If the sample volume is too small or does not encompass the whole cross section of the

vessel, the resulting spectrum underestimates the range of velocities present within the

vessel. If the sample volume is small and the vessel to be studied is mobile, a

discontinuous Doppler signal results. If the range gate or beam widths are too large,

more than one vessel may lie in the beam, at the same time and give rise to a confusing

spectral display especially if the flow in both the vessels is in the same direction.

Sometimes such a feature is advantageous.

E.g. When searching for renal vein alongside a renal artery.

Velocity information:

An important source of error when attempting a velocity calculation is the effect of beam

or vessel angle. At angles >50 degrees there is a rapid increase in the error that

approaches 100% at 80 degrees.

Aliasing:

Pulse repetation frequency of the ultrasound system imposes limitations on the range of

Doppler frequency that can be measured. In order to allow time for the echoes to be

received before the next pulse is transmitted about 250 microseconds must elapse

between pulses. Thus the pulses can only be repeated at about 4000/s. The Doppler

detectors can only measure frequencies accurately if they are less than half of pulse

repetation frequency (nyquist limit) i.e. <2 kHz. Doppler shift frequencies above this

level are frequently encountered in the abdomen and are misinterpreted by the apparatus

and displayed on the wrong side of the baseline, giving rise to a characteristic

discontinuous wave form display. This is known as aliasing. It may be overcome by

measuring the vessel from a steeper angle, using lower US frequency, a high PRF or

Doppler beam or by electronic correction.

Figure 22. Frequency Aliasing. (a) The frequencies above the nyquist limit have

appeared on the wrong side of the baseline. (b) The aliased peaks have been

electronically transposed to their correct locations.

FIGURE 22

Wall filters:

The pulsating walls of the arteries give rise to high amplitude, low frequency Doppler

signal that may overload the spectrum analyzer and appear in the spectral display as high

intensity spikes. This “wall thump” can be filtered out by rejecting the very low

frequency in the Doppler. if the wall filter is set too high, true flow information may be

lost. For abdominal venous studies, a filter value as low as 25 to 50 Hz is appropriate.

Color artifacts:

If a vessel curves or bifurcates in the image plane, the flow in different segments will be

represented in different colors. The same artifact may result if a straight vessel is imaged

with a curvilinear or sector transducer. Aliasing can also occur in color flow imaging and

results in reversal of color and thus apparent flow reversal and can be identified by

noting the areas of color reversal are contiguous. If the flow reversal is genuine, the

forward and reverse flow colors are separated by a black margin.

XLII  

XLIII  

Developments in ultrasound:

3d imaging:

Used to visualise the fetal face and uterus in coronal planes for developmental

anamolies.

Elasticity imaging or Elastography:

The principle here is to obtain signals before & after applying a distorting force ( stress)

that moves the tissues by a few mm and creates an image of the tissues response(strain)

by comparing the two.

Contrast agents:

Microbubble agents- to enhance ultrasound signals. Used in heart disease.

To detect hcc in cirrhotics. Etc.

Ultrasound therapy:

Used in tissue ablative therapy particularly in oncology.

Uses the thermal effects of high power ultrasound beam that are tightly focused, so that

very small target tissue regions can be heated and coagulated.

Ultrasound findings in different condition:

1) Acute Appendicitis:

USG is the initial screening modality of choice for the evaluation of suspected acute

appendicitis.2 the sensitivity & specificity & accuracy of USG in diagnosing Acute

Appendicits are 80 to 93% , 94 to 100% & 95 to 97% respectively.3 a 5 to 9mhz4

ultrasound probe is applied with gradually increased pressure (Puylaert method of graded

compression)5 over the right iliac fossa in order to displace the bowel loops and examine

the appendix.

The following features are suggestive of the diagnosis:

Blind ending tubular structure which is- Non compressible, >7mm in diameter & non

peristaltic. The first two signs are most sensitive.6

Figure 23. Acute Appendicitis

FIGURE 23

Appendicolith casting an acoustic shadow.

If next to the inflamed appendix, a fliud collection is seen it is highly suggestive of an

appendicular abscess.High echogenicity surounding fat suggesting

omentum,secondarily thickened bowel loops attempting to seal off the abscess from

the peritoneal cavity7.

Edema of the cecal pole.

XLIV  

Figure 24. Target sign in Acute Appendicitis.

FIGURE 24

Maximum tenderness over the tip of the appendix.

Wall thickness >3mm.

Non visualasation of the appendix- normal appendix cannot be visualised most of the

time and non visualisation does not exclude appendicitis.

The presence of hyperemia in the Appendiceal wall and adjacent Mesoappendix is a

sensitive indicator of inflammation and can be well demonstrated on colour doppler8.

Figure 25 increased vascularity in the wall

FIGURE 25

XLV  

Figure 26. Appendicular abscess

FIGURE 26

False positive results are seen in- resolving appendicitis, dilated fallopian tube,

inflammatory bowel disease, inspissated stools mimicking an appendicolith.

False negative results are seen in- appendicitis involving the tip, retrocecal appendix,

gangrenous or perforated appendix becomes compressible, gas filled appendix.

Figure 27. Suppurative Appendicitis.

FIGURE 27

Mucocele of the appendix can be seen as a smooth rounded appendicular mass with a

curvilinear calcification.

XLVI  

HEPATOBILIARY & PANCREATIC SYSTEM

Figure 28. Acute cholecystitis.

FIGURE 28

1. Acute calculus cholecystitis:

It constitutes around 90 to 95% of acute cholecystitis and the sensitivity of ultrasound in

diagnosing this condition is around 80%.

USG features suggestive of acute calculus cholecystitis are:

Positive Sonographic Murphy’s sign ( sensitivity of 60% & specificity of 90% for

this sign)9

Gall bladder wall thickness >3mm.

Pericholecystic fluid.

Distended gall bladder i.e. >5cm in diameter or lumen >4cm in diameter.

Obvious wall hyperemia on Doppler examination.

Stone casting an acoustic shadow.

XLVII  

Figure 29. Gall Bladder stone casting an Accoustic shadow. FIGURE 29

Fine echoes may be seen due to sludge or pus.

Figure 30. Sludge in the Gall Bladder FIGURE 30

2. Acute Acalculus Cholecystitis:

Constitutes remaining 5 to 10% of acute cholecystitis.

The features suggesting the diagnosis are-

No calculi.

Distended gall bladder.

Gall bladder wall thickness >2mm.

Sloughed membrane or mucosa.

Pericholecystic fluid.

Positive Sonographic Murphy’s sign.

XLVIII  

Figure 31. Features of Acalculus Cholecystitis. FIGURE 31

Gangrenous Cholecystitis:

Ultrasound shows pronounced irregular or asymmetrical thickening of the gall bladder

wall.

Internal membranous echoes due to sloughed out mucosa. Pericholecystic fluid.

Figure 32. Gangrenous Cholecystitis. FIGURE 32

Gall bladder perforation:

It occurs in 5 to 10% of the patients with acute cholecystitis. Pericholecystic fluid or

features of gangrenous cholecystitis are seen. Localised disruption of gall bladder wall

seen in 40% of the cases. Generalised peritoneal fluid may be seen10.

EmphysematousCholecystitis:

Intra luminal gas will be seen appearing as a focal or diffuse bright echogenic lines in the

non dependent portion of the gall bladder with shadowing.

XLIX  

Figure 33. Emphysematous Cholecystitis showing air within GB FIGURE 33

Chronic Cholecystitis:

1. Chronic Calculus Cholecystitis:

USG shows-

Gall bladder wall thickening with fibrosis due to --chronic inflammation.

Intramural epithelial crypts.i.e. Rokitansky- aschoff sinuses may be seen.

Gall stones can be seen in upto 95% of the cases.

Failure of gall bladder to contract in response to CCK.

Chronic Acalculus Cholecystitis:

Gall bladder wall thickening with irregularity is seen.

No calculi.

Cholelithiasis or Gall stones:

The accuracy of USG in detecting gall stones is 98%11.

The features suggestive are-

They are echogenic with posterior accoustic shadowing due to their crystalline

matrix (type1).

Stones are found to lie in the dependent position.

They are freely mobile except when they are impacted in the neck or are adherent

to the wall.

Wall-Echo-Shadow or WES triad or Double Arc sign12: it is seen if the gall

bladder is contracted(type2) and completely filled with stones and also seen in

porcelain gall bladder and emphysematous gall bladder.

L  

Figure 34. The Double Arc sign.

FIGURE 34

Ultrasound classification of gall stones.

Type1 stones: Cast posterior acoustic shadow, the stones are hyper echoic, the gall

bladder is visible, ultrasound gives 100% sensitivity for this type.

Type 2 stones: Gall bladder is contracted, the stones are hyperechoic and cas t posterior

shadow, gall bladder not visualised, sensitivity is 90 to 100%.

Type 3 stones: Hyper reflective echoes originating from the anterior surface of the stone

resulting in no acoustic shadowing, gall bladder is visualjsed, sensiyivity of 50 to 80%

for this type of stones.

Types of shadows:

Clean shadow:

It is a Hypo echoic shadow with no internal echoes and is due to the stones with rough

surface, small radius of curvature, or stones with calcification.

Dirty shadow:

Appears as a comet tail with internal echoes in the shadow and is due to a stone with

smooth surface, large radius of curvature, stones with high cholesterol content or when

bowel loops were visualised instead of gall bladder.

LI  

Figure 35. Sludge with dirty shadow.

FIGURE 35

The Biliary tree:

The CBD diameter in adults is 6-7mm13. In some cases upto 12mm can be taken as

normal e.g. in post cholecystectomy patients with duct fulfilling the reservoir function or

in patient with previous obstruction. The presence of normal caliber intra hepatic ducts

does not exclude obstruction, as the dilatation can only occur if the adjacent parenchyma

is compliant. Cirrhotic or infilterated parenchyma may present duct dilatation, producing

a low volume but high pressure duct system.

e.g. If a patient with established cirrhosis develops obstructive jaundice with obstructive

LFT, it is mandatory to exclude Choledocholithiasis as a cause even if the USG shows

undilated IHBR.

Choledocholithiasis:

The sensitivity and specificity for detecting CBD stones is 95% and 50 to 80%

respectively. Accuracy 13-82%14, 15. Normally the IHBR diameter should be <2 to 3mm

centrally and just visible peripherally. CBD diameter >7mm is a predictor of obstruction.

The features of choledocholithiasis on ultrasound are-

Duct dilatation

Acoustic shadowing. These 2 signs are absent in 30% of the cases. Acoustic

shadowing is not seen if the CBD is minimally dilated or of normal caliber. Non

shadowing stones can mimic sludge or soft tissue mass.

LII  

Figure 36. CBD stone casting an acoustic shadow

FIGURE 36

Intraductal echogenic focus both in longitudinal and transverse planes suggestive of a

stone. Distal CBD stones most likely are over looked and can be detected by

scanning in the right lateral position which minimises gas in the gastric antrum and

duodenum.

Ultrasound signs of IHBR dilatation:

Color flow Doppler is absent in the dilated ducts.

Acoustic enhancement behind the dilated ducts, whereas blood attenuates the beam

due to high protein content

Double duct sign. I.e. The dilated biliary vessel accompanies portal vein.

Caliber irregularity and tortuosity of dilated ducts is seen, in contrast veins are

always smooth and taper gradually.

Spokewheel appearance can be seen at the point of conversion of ducts.

Choledochal cysts:

Ultrasound findings are-

Multiple cystic structures converging towards the porta hepatis.

Beaded appearance of intrahepatic bile ducts, most of the cysts are arranged in

branching pattern.

Central dot sign- it is a very specific sign of Caroli’s disease in which the portal

radicals are partially or completely surrounded by abnormally dilated and ectatic bile

ducts.

Sludge or calculi may be seen in the dilated ducts. Long common pancreaticobiliary

channel may be seen.

LIII  

Ultrasound reveals an anechoic cystic structure separate from gall bladder that

communicates with hepatic ducts.16,17

Figure 37 choledochal cyst

The pancreas:

The pancreas is visualised using a curved array transducer with magnifying 3.8MHz

frequency. Ingestion of 250 ml of water will act as an acoustic window. In standing

position, the pancreas which is a retroperitoneal structure remains fixed and stomach &

liver will descend and act as an acoustic window. This may allow gas and fecal matter in

the transverse colon to descend down to allow better visualisation.

Normal Anatomy:

Pancreas is visualised as a comma shaped structure draped over the anterior surface of

the Aorta, IVC or Anterior Aortic branches, the tail extends into the Splenic Hilum

which is difficult to visualise by USG due to bowel gas. There is a gradual increase in

the echogenicity of the pancreas after the age of 40 due to increased fat deposition. The

deposition is less in the ventral pancreas, and hence the difference in the echogenicity

may be visualised as a pseudo mass effect.

The pancreatic duct: the normal PD is rarely seen in its entirity in young individuals,

segments of the duct may be visualised as the duct courses in and out of the plane of

scan. They appear as short segment parallel lines measuring <1mm in diameter.

Size of PD in different age groups- 18 to 29yrs -1.5mm

40 to49yrs -1.9mm

>80yrs -2.3mm

LIV  

Acute pancreatitis:

Features suggestive of acute pancreatitis are:

In the early stages pancreas may appear normal.

Diffuse or focal enlargement of gland with reduced reflectivity due to edema,

duodenal atony and wall thicknening.

Peripancreatic fiuid may be visualised.

Underlying treatable cause such as cholelithisis can be indentified.

Enlarged pancreatic duct >2mm.

Figure 38.Features of Acute Pancreatitis.

FIGURE 38

Necrotising pancreatitis:

Liquid or semi liquid tissue may be identified spreading beyond the organ boundaries

into the retroperitoneam, pararenal space and lesser sac. Pleural effusion and ascitis may

be detected.

Recurrent Acute Pancreatitis:

Features suggestive are :

Dilatation of pancreatic duct, occasional with visualisation of truncated branches.

Mild focal or diffuse enlargement of the gland with heterogenous echo pattern.

Administration of secretin 1iu/kg can produce persistent dilatation of pancreatic

duct 20min after administration.

Demonstration of dilated pancreatic duct with dilated but truncated side branches

by endoscopic ultrasound is characteristic of Recurrant Acute Pancreatitis.

LV  

Chronic pancreatitis:

Sensitivity of 60-70%18

1. Gland size: in mild cases gland size is normal. In moderate cases there will be

mild increase in the size with irregular outline. in end stage or severe pancreatitis

gland is small due to loss of Acinar tissue.

2. Parenchyma: shows increase echogenicity due to ageing or fatty changes.

Heterogenicity of the gland.periductal fibrosis associated with early stages of

chronic pancreatitis produces centrally placed strongly reflective foci.

Focal mass can be seen in the 40% of the patients and presence of calcifications

within the mass excludes the diagnosis of neoplasm19.

3. Pancreatic duct: there is increase in the pancreas duct wall echogencity,

duct dilatation >2mm in patients younger than 20 yrs, irregularities in the duct

diameter and strictures.

4. Calculi: these are seen as highly reflective lesions with distal accoustic

shadowing seen more readily with smaller and smaller calculi as the resolution

and focussing of ultrasound equipment improves. It may be difficult to

differentiate between small calculi and peri ductal fibrosis. Calcifications or

protein plug defects can be seen in the lumen of PD.Secondary dilatation of CBD

may be seen. When duct dilatation accompanies focal enlargement of the gland,

it mimics pancreatic carcinoma. USG can also show cysts and vascular changes

like stenosis and pseudo aneurysms, fatty replacement, fibrosis, parenchymal

calcification and intraductal calculi may be seen.

Figure 39. Chronic Pancreatitis with calculi in PD.

FIGURE 39

LVI 

 

Psuedopancreatic cyst:

It presents as a large cystic mass with debris. Large cystic mass in the region of

pancreatic bed demonstrating echogenic material posteriorly represents pancreatic

necrosis. May present as a large cystic mass with septations and nodularity.

Demonstration of peripancreatic fliuid is the precursor or pancreatic pseudocyst

formation. There can be absence of internal echoes, sharp posterior margination and the

evidence of increased through transmission. There can be spontaneous regression of cyst

due to rupture. Cysts smaller than 4cm resolve spontaneously.USG is useful for the

following their progress.USG guidance will be used for per cutaneous drainage of

infected collection of persistent pseudo cysts. Internal consistency of the cystic content

may predict the success of the percutaneous technique in draining focal fluid and the size

of the catheter necessary for successful drainage.20

Figure 40. Psuedopancreatic cyst.

FIGURE 40

Carcinoma pancreas:

USG is the first investigation to be carried out in a case of Ca. Pancreas. It is highly

accurate in differentiating obstructive from non obstructive jaundice. The lesion shows

lower reflectivity than the normal parenchyma. Tumours of the head of the pancreas lead

to dilatation of the CBD and IHBR. There can be distention of gall bladder. Upstream

dilatation of the PD may be seen. Double duct sign may be seen. To visualise the liver

metastasis. To detect lymphadenopathy (pancreatic, celiac common hepatic, mesenteric

and paraaortic). To detect peritoneal metastasis indicated by ascitis. Retropancreatic

spread indicated by obliteration of fat planes around the Celiac axis and SMA. Direct

invasion of stomach or small bowel. Visualisation of the long segment indicates

LVII  

pancreatitis. Focal involvement areas are compatible with the diagnosis of tumour. USG

Doppler may make Angiography unnecessary especially with advanced tumours if

thorough evaluation for the large artery invasion is performed.21

Figure 41- Carcinoma pancreas.

FIGURE 41

Liver abscess:

Pyogenic abscess:

Ultrasound has got a sensitivity of 80 to 85 % for diagnosing pyogenic liver Abscess.

The following features lead to the diagnosis-

Double target sign-seen as wall enhancement with surrounding Hypodense zone due to

edema.30% cases contain gas within the lesion.Shows as a solid spherical lesion with an

ill defined margin and low reflectivity. As the abscess liquifies a thickened and irregular

wall becomes visible and necrotic centre often containing sparse echoes from the debris.

The contents are Anechoic in 50%, Hyper reflective in 25% and Hypo reflective in 25%.

Amebic liver abscess:

USG has a sensitivity of 90%. The cavity do not contain gas unless secondarily super

infected. Irregular shaggy borders with internal septations are seen in 30% of the cases.

Multiple abscesses are seen in 25% of the cases. Rounded lesion abutting the liver

capsule without significant rim echoes are interpreted as an abscess wall22. The contents

are Hypoechoic and non homogenous.

LVIII  

Figure 42. Liver Abscess.

FIGURE 42

Portal Vein Thrombosis:

An echogenic thrombus may be seen in the vein. The occluding thrombus frequently

dilates the main portal veins and its branches23. There will be portal vein enlargement.

Hepatofugal blood flow.

Cavernous transformation24 of the portal vein- develops in patients with complete

occlusion of portal vein, on color Doppler this looks as a rounded mass of small

collaterals with variable direction low velocity at Porta Hepatis. Because Hepatic artery

takes over the entire hepatic blood supply, high frequency arterial signals are seen at the

Porta hepatis and within the hepatic parenchyma with no demonstrable portal vein flow.

Figure 43. Portal Vein Thrombosis

FIGURE 43

LIX  

Hepatic Vein Thrombosis or Budd Chiari Syndrome:

Thrombus may be identified within the hepatic veins. Lack of colour flow within the

normal vein24. Abnormal collateral vessels may be seen wading towards the surface of

the liver.

Flow in the IVC may be reversed, turbulent, diminished or absent. Flow in the portal

vein may be reversed or diminished. Intrahepatic collateral vessels i.e. comma shaped

venovenous intra hepatic collaterals, 25, 26, 27 may be seen between major hepatic veins.

Narrowing of intrahepatic IVC. Parenchyma shows hemorrhagic infarction, appears

Hypo echoic, caudate lobe is often spared and appears enlarged. There may be damping

of the normally pulsatile hepatic vein form.

Acute Cholangitis:

There may be dilatation of the IHBR and CBD in 70% of the cases.

Pigment stones or sludge may be seen in the intrahepatic bile ducts which is a

pathognomonic sign. Biliary strictures are seen 20% and segmental hepatic atrophy in

30%. Liver abscess or pancreatitis may be detected in few cases.

Subphrenic or Subhepatic Abscess: USG is an excellent modality for the detection of

visceral abscess and is also useful for the screening of intraperitoneal abscess.28 There

will be a transonic area between liver and diaphragm with strands crossing this area

indicating loculation. Helps in draining the abscess.

Hytatid cyst of liver:

Due to E.Granulosis.

Well defined cysts, single or multiloculated (Honey Coomb appearance).

Figure 44. Honey Coomb appearance in Hydatid Cyst

FIGURE 44

LX  

Daughter cysts within the large cysts is the pathognomonic sign.

Figure 45. Daughter Cyst.

FIGURE 45

Rimlike calcification seen in 30% of the cases.

Double rim sign with endocyst and pericyst is seen.

Figure 46 Double rim sign

FIGURE 46

Snowstrom sign characterised by multiple echogenic foci due to hydatic sand, may

be seen with in the lesion by repositioning the patient, the echogenic foci quickly fall

to the most dependent portion of the cavity with forming visible strata.29

LXI 

 

Waterlilly sign due to complete detachment of the wall.30,31

Figure 47. Water lilly sign.

FIGURE 47

Floating membrane due to localised split in the wall inside the cyst.

Figure 48. Floating membranes in Hydatid cyst.

FIGURE 48

Complications of cysts like rupture can be detected by defect in the cyst wall on

ultrasound.32

Due to E.Multilocularis.

Poorly marginated multiple hypodense lesions.

Punctate and dystrophic calcification seen (not rim like).

LXII  

Hepatocellular Carcinoma:

Sensitivity of 74-94% Most small HCC’s appear hypoechoic, and the larger ones are

heterogenous. Fibrolamellar variety is heterogenous. By high velocity Doppler feeding

vessel can be visualised. Basket pattern of intralesional vessels can be detected

indicating internal vascularity and shunting may be seen in upto 15% of cases.33

Increased or decreased reflectivity of the lesion in relation to the surrounding

parenchyma. A reduced reflectivity seen in some cases represents thin fibrous capsule.

Large lesions show heterogeneity due to hemorrhage necrosis or fat. There may be

portal vein thrombosis or intravascular tumour. Doppler examination can differentiate

between the tumour and the thrombus as the presence of arterial signals within the

material occluding a portal vein indicates the presence of tumour34. High velocity

Doppler signals from within the lesion occur in majority as a result of arterioportal

shunting commonly found in HCC.

Hepatic Metastasis:

Hyper reflective lesions- are seen in colorectal and other GI malignancy. Vascular mets

from carcinoid, islet cell tumour or RCC.

Hypoechoic lesions- lymphoma& sarcoma and they are Hypovascular.

Well defined Hyperechoic lesions are seen in adenocarcinoma of lung, breast and

pancreas

Figure 49. Liver Metastasis.

FIGURE 49

LXIII  

Bull’s eye or Target lesions35: are seen in Bronchogenic carcinoma and are

characterised by hypoechoic halo around the lesion, this constitutes compressed liver

tissue and tumour fibrosis.

Figure 50- Bull’s eye/ target lesion.

FIGURE 50

Cystic Metastasis are seen in primary lesion with a cystic component as seen in

cystadenocarcinoma of ovary and pancreas.

Calcified metastasis36 is seen in all mucinous metastasis- colon thyroid, ovary, kidney&

stomach. Characterised by hyperechoic lesion with distal shadowing.

Portal hypertension:

Is diagnosed by-

Portal vein diameter >13mm.

Doppler is used to confirm the presence and direction of portal venous flow.

Mean peak velocity in main portal vein of < 12cm/s are likely to reflect significant portal

venous flow obstruction37. In severe cases flow in the portal vein becomes stationary

with an oscillating to & fro pattern related to respiration. Effective liver perfusion is

lower as calculated from flow volume in the portal trunk minus portal flow volume in the

umbilical veins38. Further progression leads to flow reversal & Hepatofugal flow. In the

presence of recanalised paraumbilical veins, unusual flow patterns like hepatopetal flow

in the right portal vein & hepatofugal flow in the left portal vein are seen, this is due to

increased blood flow through the paraumbilical veins supplied by the left portal vein

effectively stealing the blood from the right portal vein. Portosystemic shunts like, left

coronary, recanalised paraumbilical vein, splenorenal & splenogastric can be

visualised39. LXIV 

 

Figure 51- Portal Hypertension.

FIGURE 51

Gastrointestinal system Acute colonic diverticulitis: USG is helpful in minor episodes of diverticulitis with localised pain.

Graded compression over the area of tenderness, reveals the pericolic abscess as a low

reflective collection related to the bowel wall surrounded by reflective inflamed fat.

Acute Regional Enteritis & Ulcerative colitis:

USG shows thickening of the bowel wall >4mm. Inflamed bowel often shows Hyper

vascularity which can be asessed by using Doppler, thus providing additional

information on the degree of disease activity40. Hydrocolonic USG allows detailed

evaluation of the bowel lumen and all the 5 anatomical layers of the colonic wall41.

Hydrogen peroxide enhanced ultrasonic fistulography injected into skin orifice enhances

visualisation of the fistula tract42.

The wall is typically stratified in UC with differentiation between submucosa and

muscularis propria. This differentiation is lost in crohn’s disease. The surrounding fat is

more reflective with acute inflammation. The ulceration is evident from focal disruption

of bowel wall layers and may be outlined by intracolonic gas.

LXV  

Acute Intestinal Obstruction:

USG is more sensitive & specific than erect x ray in the diagnosis of acute intestinal

obstruction. A bowel diameter >24mm and collapsed distal bowel loop carries a

sensitivity, specificity & accuracy of 95%, 82%& 81% respectively. It is useful for the

early recognition of strangulation with dilated bowel loops and presence of free

peritoneal fluid. The peristaltic activity of the bowel can be made out.

Figure 52. Acute Intestinal Obstruction

FIGURE 52

D) Acute perforative peritonitis:

Some studies have reported ultrasound to be the more sensitive modality than plain

radiography for the diagnosis of pneuperitoneum43.

Findings suggestive of pneumo peritoneum on USG:

Demonstration of free air as echogenic spots are lines with posterior ring down

artefact that shifts with the change in the patient position, enhancement of peritoneal

stripe echogenic free peritoneal fluid and decreased peristalsis44.

When the patient is supine the reverbarations are seen in between the anterior surface

of left lobe of liver and anterior abdominal wall.

Shifting phenomenon is seen on rolling the patient to left lateral position as free air

raises to the highest position of right hypochondrium.

Enhancement of the peritoneal stripe refers to increased echogenicity and thickening

of the peritoneal stripe due to free intraperitoneal air with associated dirty

shadowing.

LXVI 

 

Tuberculosis of the abdomen:

TB Peritonitis:

Ultrasound is recommended as an initial investigation to image very small quantities of

ascitis. Free or loculated ascites seen in 30-100% of cases USG reveals very fine,

multiple, complete or incomplete mobile strands of fibrin & debris in the ascitis in 10 to

100% of the cases. Peritoneal thickening and tiny nodules are seen45, 46, 47.

Figure 53. Peritoneal TB.

FIGURE 53

Omentum:

Omental caking is seen, which is also seen in carcinomatosis.

Omental coursing- with thin omental line suggestive of fibrous wall covering the

omentum.

Figure 54.Omental TB.

FIGURE 54

LXVII  

Mesentry:

The ultrasound features are-

Stellate sign-fixed loops of bowel and mesentry standing out as spokes radiating out

from the mesenteric root.

Club sandwich or sliced bread sign48- is due to localised or focal ascitis between

radially oriented bowel loops due to local exudation from the inflammed bowel or

ruptured lymph node.

Figure 55. Club sandwich sign.

FIGURE 55

Sclerosing Encapsulating Peritonitis or Abdominal Coccoon:

This is a thick walled mass containing bowel loops and fibrous adhesions.

TB lymphadenitis:

These lymph nodes are discrete or conglomerate masses. Enlarged nodes contain central

hypoechoic area with a mixed heterogenous ehcotexture .Dense adhesions between

nodes and adjacent structures.focal microcalcificaton may be seen.Both concretion and

fibrosis are highly specific features49,50.

LXVIII  

Figure 56. TB Lympadenitis.

FIGURE 56

Ileocecal TB:

In the early stages a few regional lymph nodes may be seen. The bowel is considered

as thickened if the wall is >5mm when not distended & >3mm when the bowel is

distended. In the later stages, the IC valve and the adjacent medial wall of the Cecum

are predominately asymmetrically distended. Psuedokidney sign-may be seen in

pulled up cecum.Mass can be visualised in the right iliac fossa. Lesion in nodes and

circumferential wall thickening of the cecum and terminal ileum may be visualised.

Jejunum and proximal ileum can be missed due to difficulty in scanning the entire

length of intestine and is also limited by the presence of the overlying gas48.51, 52.

Figure 57. Iliocecal TB.

FIGURE 57

LXIX  

Figure 58. Pulled up Cecum.

FIGURE 58

CarcinomaStomach:

The USG findings are-

A mass can be seen deep to the left lobe of the liver, the patient is given 2 to 3 glasses

of water to visualise the stomach.

The palpable mass corresponds to the area of fine echoes on the wall of the stomach.

USG is helpful to visualise the gastric disturbances and peristalsis and Doppler

technique for estimation of flow through the Pylorus.

An additional use of USG is in the asessment of gastric emptying, the swallowed

contrast is utilised which is designed to be easily seen by ultrasound transducer, the

emptying of this contrast is followed.

Carcinoma of the Colon& Rectum:

Sensitivity of sonocolonography for Ca colon is 94% and specificity 100%.

Abdominal USG requires a graded compression technique for good view of the

colon.

Gaseous distension proximally often prevents visualisation of both the walls, but

haustral pattern of anterior wall should still be seen.

Normally only low reflectivity muscularis propria and reflective submucosa are

identified. Bowel wall thickness may be measured.

Doppler flow may be assessed and pericolic tissue can be interrogated.

Endosonography shows wall layers in detail.

Pseudo kidney sign; when the bowel wall is thickened, the mucus pattern changes to

a thickened irregular bowel wall with a highly reflective irregular centre53.

LXX  

Figure 59. Psuedokidney sign.

FIGURE 59

Gastric outlet obstruction:

The stomach echoes may be visualised incomplete posteriorly due to complete reflection

of the incident beam by air in the pars media and gastric antrum.Demonstration of

stomach in the cross section as a complete circle is highly suggestive of GOO.

Genitourinary system Figure 60. A– Normal kidney, B – Hydronephrosis.

FIGURE 60

Ureteric colic & Urinary obstruction:

USG abdomen when combined with plain abdominal films will identify

approximately 95% of the patients with an obstructing stone.

Doppler USG can be used to identify functional changes caused by obstruction.

Renal resistance index (RI) is elevated in a large number of kidneys with acute high

grade ureteric obstruction and may precede the development of Hydronephrosis.

Ureteric jets: are demonstrated with colour doppler at VUJ in normal conditions, in

acute obstruction the jet is absent on the obstructed side.

LXXI  

LXXII  

Torsion of Testis:

The features on Ultrasound are-

On Colour Doppler within 4 hrs there will be absent or decresed flow. Later

peritesticular inflammation & hypervascularity is seen.

On grey scale imaging, within 4 hrs there will be enlargement and heterogenous

echogenicity.Later on reactive Hydrocele and Atrophy is seen.

BPH & Ca Prostate:

Enlarged prostate may be seen as a rounded central filling defect at the base of the

bladder. Hooking of the ureters with massive enlargement of the prostate.

Upper urinary tract changes such as reflux and dilated Ureter may be seen. The

sensitivity is 60%.

Diffusely altered heterogenous architexture. To demonstrate the size and shape of the

gland.Concommitent prostatic calculi may be seen as a bright echo casting an acoustic

shadow. Features of extra capsular extension of tumour: Contour deformity of capsule.

Irregularity.

Evidence of direct tumor extension into the the periprostatic fat. Features of bladder

outflow obstruction: Distended bladder with incomplete emptying that is post void

residual urine.Trabeculae & Diverticulum can be seen due to increased bladder pressure.

Figure 61. Suprapubic US of the Urinary Bladder with the bladder (a) distended and (b)

after voiding. When distended, the inner surface of the bladder wall is smooth and the

wall thickness measures 3 mm. The wall measures more than 5 mm on a post-voiding

image.

FIGURE 61

Undescended testis:

Sensitivity of 97% & 75% have been reported for palpable and impalpable testis

respectively.

The examination requires a high resolution linear array transducer and should begin

with an initial study of the scrotum to ensure that both the testis are absent in the

scrotum.

Testes are best demonstrated in transeverse planes.

The testis may be atrophic and hence difficult to detect.

Figure 62. Bilateral Undescended Testes, transverse US view. The testes (arrows) are

demonstrated at the level of the superior pubic rami.

FIGURE 62

Scrotal masses:

Sensitivity of USG for scrotal masses is 100%.

It is less specific to differentiate between benign and malignant tumours.

Seminoma is seen as hyporeflective mass compared to the surrounding

parenchyma and are well defined and homogenous, may be multifocal.

Embryonal cell tumours appear as less homogenous and less well defined, cystic,

heterogenous and wild.

Teratomas appear as mixed echogenecity, more likely contain cystic spaces and

calcification. It si 96% accurate in diagnosing retroperitoneal metastasis.

Lymphomas appear as diffuse or multifocal testicular enlargement.

LXXIII  

Figure 63. Seminoma: longitudinal US view. The slightly hyporeflective lesion is

almost replacing the entire testis. Microcalcifications are seen in the normal and

abnormal parenchyma. FIGURE 63

Figure 64 Teratoma of Testis. The cystic areas (arrow) within the lesion are

characteristic FIGURE 64.

Urinary tract stones:

USG shows a sensitivity of 37 to 64% for the detection of calculus & 74 to 85% for

the detection of obstruction55.

Can detect stones more than 5mm casting an acoustic shadow.

Stones at the pelviureteric junction can be readily identified.

Pelvicalyceal system can be well delineated if there is dilatation.

Bladder calculi can be seen in the dependent position casting an acoustic shadow.

Renal calculi can be detected as hyperechoic focus casting an acoustic shadow.

Stones <3mm can not be detected.

LXXIV 

 

Figure 65. Renal calculus. Ultrasound demonstrates a 1 cm calculus with a small

posterior acoustic shadow.

FIGURE 65

Polycystic kidney disease:

There will be increased renal outline. Randomly distributed asymmetrical calyceal

echoes are seen. Multiple cystic lesions can be visualised.

Hydronephrosis:

O or c sign produced by the cross sectional appearance of the dilated renal pelvis and the

collecting system.

Dilated proximal ureter in case of distal obstruction appearing as cystic tubular structure

in cross section.

Figure 66. Hydronephrosis of the kidney

FIGURE66

Renal tumours:

Appear as fine echo pattern internally without typical calyceal echoes.

Loss of normal contour of kidney.

LXXV  

LXXVI  

Retroperitoneal tumours:

Solid masses in the range of 2 to 3 cm and cystic lesions 1 to 1.5cm( especially when

surrounded by solid parenchymal organs) can be detected.

Involvement of para aortic area causes early aortic contour changes.

The changes can also be seen in IVC.

Lymph nodes are seen as variable lesions between solids and liquids.

Lymph node enlargement.

Is detected in the prevertebral area as an irregular or sausage shaped mass, often

extending from in front of one kidney to the other.

A trans sonic mass that continues in front of pre sacral area below the expected

bifurcation of the aorta is far more likely to be a lymph node mass rather than an

aneurysm.

Echo Silhoutte sign- is due to failure to delineate Aorta & IVC.

One or more subhepatic masses, rounded, discrete structures seen inferior to the

Hilum.

Non lymphoid Neoplasms:

Present as irregular masses with less well defined borders, with multiple internal

echoes indicating solid content.

Solid masses occupying areas normally free of any defined structures or displacing

the expected outline of the retroperitoneum.

LXXVII  

Materials & Methods: Source of data:

The present study is a prospective hospital based study conducted in the department of

General Surgery KIMS Hubli, during the study period of November 2008 to October

2009. A total of 99 cases admitted with Acute & Chronic abdominal conditions during

the study period were included in the study.

Method of collection of data:

Inclusion criteria:

All the patients presenting to KIMS Hubli with Acute & Chronic non traumatic & non

Gynaecological abdominal conditions in whom the clinical diagnosis has been done

already (Male or female of more than 10yrs of age) during the study period were

included in the study.

Exclusion criteria:

1) Patients with traumatic abdominal conditions.

2) Patients with Gynaecological disorders.

3) Patients with co-morbid medical conditions.

4) Patients in whom conservative management has been done.

5) Patients in whom Ultrasonography could not be done.

After the initial evaluation at the emergency department for acute cases & in the wards

for stable patients with chronic abdominal conditions, clinical diagnosis was done by

various clinical methods. The clinically diagnosed acute and chronic abdominal cases

were subjected to ultrasound examination. Informed consent was taken prior to the

examination.

Phillips IU 22 & GE Logix alpha 200 machines were used and ultrasound was

performed with high frequency linear array transducer.

Low frequency curvilinear transducer was used only in needy cases. The examination

was commenced in the right upper quadrant in the region of hepatic flexure of colon then

along the ascending colon and ended in the right lower quadrant in the region of the

Cecum. Graded compression technique was used wherever necessary. Scanning at the

point of maximum tenderness was found to be more useful in localising appendix and

that had decreased the duration of time required for examination.

For scanning of the stomach in GOO Ultrasound examination was done using a

frequency of 3 to5MHz. Patients were given water to drink for the stomach to get

LXXVIII  

distended, scan was done in longitudinal, transeverse & left sided Subcostal oblique

positions.The kidney and genitourinary system was scanned in the lateral position or

from the back.

For the other cases supine position was preferred. After the Ultrasound diagnosis has

been established, patients in the study group were subjected for Surgery. The Per

operative findings were noted and the per operative diagnosis were compared with the

clinical diagnosis and the USG diagnosis.

The Accuracy of ultrasound was asessed by comparing with per operative diagnosis.

In doubtful cases the specimen resected was sent for Histo pathological examination for

the confirmation of the diagnosis.

Results:

A total of 99 cases were included in the study.

Out of these 58 (57.42%) were males and 41(40.59) female patients.

M: F ratio was 1: 1.4.

Chart 1 – Sex distribution of cases.

The age distribution of cases:

Ranged from 11- 80 years.

Mean age of presentation for acute cases was: 32.4yrs

Mean age of presentation for chronic cases was: 46.9yrs

Chart 2 – age distribution of cases.

Table 1 – Age distribution of cases.

Sl.no. Age Range Number Of cases Percentage

1 11-20 16 15.84%

2 21-30 26 25.74%

3 31-40 17 16.835

4 41-50 12 11.88%

5 51-60 11 10.89%

6 61-70 09 08.91%

7 71-80 08 07.92%

LXXIX  

Chart 3 – Percentage distribution of age group.

The cases studied included:

Table 2 – List of cases.

Sl.no Condition No. Percentage

1 Acute Appendicitis 16 15.84%

2 Stump Appendicitis 01 0.99%

3 Appendicular Abscess 04 3.965

4 Appendicular Mass 02 1.985

5 Recurrent Appendicitis 10 9.9%

6 Perforative Peritonitis 02 1.985

7 Acute Intestinal Obstruction 02 1.98%

8 Acute Cholecystitis 09 8.91%

9 Chronic Cholecystitis 05 4.95%

LXXX  

LXXXI  

10 Cholelithiasis 04 3.96%

11 Omphalitis 02 1.985

12 Liver Abscess 01 0.99%

13 Obstructive Jaundice 01 0.99%

14 Ruptured Pseudo Cyst of Pancreas 01 0.99%

15 GOO due to Ca Stomach 09 8.91%

16 GOO due to Duodenal ulcer 03 2.97%

17 LMS of Small Intestine 01 0.99%

18 Ca Colon and Rectum 04 3.965

19 Undescended Testis 01 0.99%

20 Ca Testis 01 0.99%

21 Abdominal Tuberculosis 05 4.95%

22 Chronic Pancreatitis 02 1.98%

23 Hydatid cyst of Liver 01 0.99%

24 Retroperitoneal Tumour 01 0.99%

25 BPH 04 3.96%

26 EHPHT 01 0.99%

27 Incisional Hernia 01 0.99%

28 Hiatus Hernia 01 0.99%

29 Ingunial Hernia 02 1.98%

30 APD 01 0.99%

31 Left Ureteric Colc 01 0.99%

Total 99 100

LXXXII  

Organ distribution of cases:

Of the 99 cases included in the study 59(58.4%) cases were GI system cases, 22(21.78%)

cases were Hepatobiliary cases, 3(2.97%) from the Pancreatic system, 3(2.97%)

involving the Umbilicus, 7(6.93%) from Genitourinary system, 1 (0.99%) of

Retroperitoneal tumour, 2(1.98%) of Inguinal hernia & 1 each of Incisional, Hiatus &

Umbilical hernia.

Table 3 – Organ distribution of cases.

Si.no System No.of cases Percentage

1 GIT 59 58.41%

2 Hepatobilliary 22 21.785

3 Pancreatic 03 2.97%

4 Genitourinary 07 6.93%

5 Retroperitoneal 01 0.99%

6 Others 07 6.93%

Total 99 100%

.

Chart 4 – organ distribution of cases

Results:

In the gastrointestinal cases out of the 59 cases studied, Ultrasound was diagnostic in 42

cases: Of the 17 cases of Acute Appendictis Ultrasound was diagnostic in 16 cases. Of

the 4 cases of Appendicular abscess USG was able to diagnose 3 cases correctly and in

the remaining case, it was diagnosed as Appendicular mass. Of the 2 cases of

Appendicular mass ultrasound missed the diagnosis in one case. Of the 2 cases of

Perforative Peritonitis ultrasound was non diagnostic in both the cases, however in one

case, the ultrasound diagnosis was acute appendicitis & even the HPR suggested the

same. The other case was diagnosed as Acute Intestinal Obstruction. In both the cases of

Acute Intestinal Obstruction it was non diagnostic. In GOO caused by carcinoma of the

stomach the diagnosis was picked up in 6 cases. In the 3 cases of APD, 2 causing GOO

the diagnosis was not picked up, but in the 3rd case of APD, ultrasound diagnosed it

correctly as Duodenal Diverticulosis. Out of the 4 cases of Carcinoma Rectum USG had

picked up diagnosis in only 2 cases. Ultrasound was diagnostic in all the cases of TB

abdomen. 1 case of Lieomyosarcoma of small intestine it was non diagnostic.

In Hepatobiliary & Pancreatic system: Which included 10 cases of Acute Cholecystitis, 5

cases of Chronic Cholecystitis, 4 cases of Cholelithiasis, 1 case each of liver abscess &

Hydatid cyst, 2 cases of Chronic Pancreatitis, 1 each of ruptured Psuedocyst &

Extrahepatic Portal Hypertension. Ultrasound was diagnostic in all the cases except in

the case of liver abscess which was later diagnosed as Perforative Peritonitis.

LXXXIII  

LXXXIV  

In the Genito Urinary system: Ultrasound was diagnostic in all the cases of BPH.1 case

of retroperitoneal tumor was diagnosed correctly. 1 case of Ureteric colic, the ultrasound

correctly diagnosed ovarian cyst, which was proved per operatively. One case of intra

abdominal Seminoma was missed by USG which it diagnosed as intraperitoneal

tumour.One cases of Undescended testis was diagnosed correctly.

Miscellaneous: Out of the 2 cases of Omphalitis, 1 case was diagnosed correctly & the

other was diagnosed as infraumbilical intramuscular abscess. Ultrasound was diagnostic

in all the types of Herniae included in the study i.e. 1 umbilical, 1 Incisional & 2

Inguinal hernia cases except in the case of Hiatus hernia which it diagnosed to be

normal.

Total number of Acute Abdominal cases included in the study: Table 4 – Cases with Acute Abdomen.

Sl.no Cases No of cases Percentage

1 Acute appendicitis 16 15.84%

2 Stump appendicitis 01 0.99%

3 Appendicular abscess 04 3.96%

4 Appendicular mass 02 1.98%

5 Recurrent appendicitis 10 9.90%

6 Perforative peritonitis 02 1.98%

7 Acute intestinal obstruction 02 1.98%

8 Acute cholecystitis 10 9.90%

9 Ruptured liver abscess 01 0.99%

10 Ruptured pseudocyst of pancreas 01 0.99%

11 Ureteric colic 01 0.99%

Total 50 100%

Total number of Chronic Abdominal cases included in the study

Table 5- Cases of Chronic Abdomen.

Sl.no Cases No of cases Percentage

1 Chronic Cholecystitis and Cholelithisis 09 8.91%

2 GOO 12 11.88%

3 Abdominal Tuberculosis 05 4.95%

4 BPH 04 3.96%

5 Ca Colon 04 3.96%

6 Chronic Pancreatitis 02 1.98%

7 Hydatid cyst of Liver 01 0.99%

8 Retroperitoneal Tumour 01 0.99%

9 EHPTN 01 0.99%

10 Undecended Testis 01 0.99%

11 Leiomyosarcoma of SI 01 0.99%

12 Seminoma 01 0.99%

13 Omphalitis 02 1.98%

14 Hernia 05 4.95%

Total 49 100%

LXXXV  

Chart 6 – cases 0f chronic abdomen.

DISCUSSION:

Out of the 33 Acute Appendicitis & related conditions ultrasound was diagnostic in 27

cases. With a sensitivity of 83.9%. Ultasound was diagnostic in all the 10 cases of acute

cholecystitis.Ultrasound correctly diagnosed an ovarian cyst which was diagnosed as

Ureteric colic clinically. Ultrasound correctly identified the ruptured Psuedocyst. It was

not diagnostic in 2 cases of perforative peritonitis, 2 cases of acute intestinal obstruction,

1 case of ruptured liver abscess.

In Chronic Abdominal Conditions- ultrasound was diagnostic in all the 9 cases of

Chronic Cholecystitis & Cholelithiasis, 4 of the 5 cases of TB abdomen, all the 4 cases

of BPH, 1 case each of undescended testis, retroperitoneal tumour, & Hydatid cyst &

EHPHTN, 2 cases of chronic pancreatitis. Ultrasound diagnosed 6 of the 9 cases of Ca

Stomach & was non diagnostic in 2 cases of APD leading to GOO, but in one case it

correctly diagnosed Duodenal Diverticulosis which was missed clinically, was

diagnostic in 1 of the 2 cases of Omphalitis,was nondiagnostic in 1 Seminoma, 1 TB

Abdomen & 2 of the 4 cases of Ca Colon. Ultrasound was diagnostic in 4 of the 5 cases

of hernia

LXXXVI  

LXXXVII  

Statistical analysis:

With the clinical diagnosis kept as reference, the accuracy of ultrasound was asessed by

comparing with the Per Operative diagnosis as follows:

In acute abdominal conditions out of the 50 cases studied-

37 cases were diagnosed both by the Ultrasound & Per operatively.i.e True

positives.

3 cases were falsely diagnosed by Ultrasound, but not Per Operatively.i.e False

positives.

7 cases not diagnosed by Ultrasound but were diagnosed Per operatively.i.e. False

negatives.

3 cases were not diagnosed by usg or per operatively.i.e. True negatives.

Table 6 – Statistical Analysis of Acute Cases.

PER OP DIAGNOSIS

Yes No Total

Yes 37(TP) 03(FP) 40

No 07(FN) 03(TN) 10

USG DIAGNOSIS

Total 44 06 50

Sensitivity = TP/TP+FN =37/37+7 =37/44 =84.1%.

Specificity = TN/TN+FP =3/3+3 =3/6 =50%.

Positive predictive value = TP/TP+FP = 37/37+3 = 37/40 =92.5%.

Negative predictive value = TN/TN+FN =3/3+7 = 3/10 = 30%.

It can be concluded from the above table that the Sensitivity i.e the ability to correctly

diagnose is 84.1%, the Positive Predictive value i.e the ability of ultrasound in diagnosing

Acute Abdomen is right 92.5% of the time.

Whereas the Specificity i.e the ability of ultrasound to rule out the diagnosis of acute

abdomen is only 50%, and the Negative Predictive value i.e. the ability of USG in ruling

out Acute Abdomen in only 30% of the cases.

Hence it can be concluded that the ultrasound being a sensitive test can be used as an

initial screening test in the diagnosis of Acute Abdominal conditons, but being less

specific test it cannot be used as a definitive test in the diagnosis of acute abdominal

conditions.

In Chronic abdominal conditions:

In the chronic abdominal conditions out of the 49 cases included in the study 35 cases

were diagnosed correctly by ultrasound & per operatively. (True positives).

1 case diagnosed by ultrasound was found to be negative Per operatively. (False

positives).

11 cases not picked up by Ultrasound were diagnosed Per operatively. (False

negatives).

2 cases were not diagnosed by either Ultrasound or Per operatively. (True negatives).

Table 7 – Statistical Analysis of Chronic Cases.

Sensitivity = TP/ TP+FN =35/35+11 = 35/46 = 76.1%.

Per Operative Diagnosis

Yes No Total

Yes 35(TP) 01(FP) 36

No 11(FN) 02(TN) 13

USG Diagnosis

Total 46 03 49

Specificity = TN/TN +FP =2/2+1 =2/3 = 66.67%.

Positive predictive value = TP/ TP+FP = 35/35+1 = 35/36 = 97.2%.

Negative predictive value = TN/TN+FN = 2/ 2+11 = 2/13 =15.4%.

LXXXVIII 

 

LXXXIX  

From the above table it can be concluded that ultrasound being less sensitive & less

specific investigation cannot be used in Accurately diagnosing Chronic abdominal

conditions however it is more sensitive & specific in diagnosing Hepatobiliary &

Genitourinary system, but is less sensitive & specific in diagnosing the gastrointestinal

tract.

XC  

Comparision with other studies:

S. Singh. V Chowdhury. Et al. Evaluated the efficacy of high resolution

transabdominal ultrasound in the diagnosis of fluid filled stomach in the

evaluation of Gastric carcinoma, and concluded that, High Resolution

Sonography is a supportive diagnostic modality & is supplementary diagnostic

procedure to endoscopy. In their study Sonography had diagnosed all the cases of

gastric cancer where as Endoscopy had missed the diagnosis in one case out of

17. However in our study out of the 9 cases of gastric cancer included in the

study ultrasound diagnosed only 6 cases

(Sensitivity of 66.67%).

Khanal BR, Ansari MA, Pradhan S et al. Assessed the accuracy of ultrasound in

the diagnosis of Acute Appendicitis & got a sensitivity & specificity of 85.7%

and 100% respectively and concluded that, USG has a high degree of accuracy in

the diagnosis of acute appendicitis. Whereas in our study the sensitivity of

ultrasound in the diagnosis of acute appendicitis was 94%.

S. Hollerbach, A.Geissler et al. Studied the accuracy of ultrasound in the

diagnosis of Bowel disorders & found a sensitivity of 76%, in our study overall

17 cases included in the study the sensitivity was 71%.

H. Prasad, G. Rodrigues & R. Shenoy et al studied the role of USG in non

traumatic Acute abdomen including 148 patients &found a sensitivity and

specificity as follows- acute appendicitis 66.6% & 100%, ureteric colic 84.6% &

98.4%, acute pancreatitis 73.6% & 97.7% & acute cholecystitis 92.3% & 100%

and concluded that, the accuracy of ultrasound in diagnosing Hepatobiliary

disorders & gynaecological disorders helps in reducing the negative laparotomy

XCI  

rate & is cost effective. Hence should be a part of routine surgical investigation.

In our study the sensitivity of acute appendicitis was 84% and for acute

cholecystitis sensitivity& specificity were 100% .

In a single case of ureteric colic used in the study USG was non diagnostic which

cannot be commented upon

A Lindeliun, S. Torngren et al conducted a randomized study to evaluate the

diagnostic accuracy of surgeon performed ultrasound in the emergency

department for patients presenting with abdominal pain. 800 patients were

randomized to undergo or not to undergo surgeon performed ultrasound and

found diagnostic accuracy to be significantly higher in the group examined with

ultrasound 64.7% versus 56.8% and concluded that that for patients with acute

abdominal pain higher diagnostic accuracy was achieved when the surgeons use

ultrasound as a diagnostic compliment to standard examination. The use of

bedside ultrasound should be considered in emergency departments.

In our study out of 50 cases of acute abdomen the sensitivity, specificity, PPV &

NPV were 84.1%, 50%, 92.5%& 30% respectively.

XCII  

CONCLUSION

From our study it could be concluded that, in acute abdominal conditions,

ultrasound is a more sensitive investigation and is non invasive. Hence can be

used as an initial diagnostic tool. However, its value is limited in the definitive

diagnosis of acute abdominal conditions. In acute appendicitis and hepatobiliary

and pancreatic system ultrasound is both sensitive & specific and should be the

initial modality of investigation and can be a good diagnostic tool. It has limited

role in the assessment of bowel disorders.

In the chronic abdominal conditions ultrasound is the initial modality of

investigation as it is non invasive and is more accurate in the diagnosis of

hepatobiliary, pancreatic, genitourinary & in the detection of abdominal

tuberculosis. However it is limited by its inability to detect bowel disorders.

XCIII  

SUMMARY

Early diagnosis of acute & chronic abdominal conditions is necessary to decide

about the further management of the condition. Ultrasound being a simple, non

invasive, easily operable is the most common method used for the diagnosis of

these conditions and helps in deciding the need for surgery in most of the cases

and also avoids un necessary surgical intervention preventing the patient from

surgical complications and also helps in ruling out non surgical acute abdominal

conditions. However this being operator dependent, and influenced by factors

like gas in the bowel etc needs proper preparation of the patient prior to the

examination, and high resolution ultrasound has increased the diagnostic

accuracy in diagnosing these conditions. Hence ultrasound should be an initial

diagnostic modality for assessing acute & chronic abdominal conditions.

XCIV  

Bibliography:

1.Grainger and Allisons Diagnostic radiology 5th Edition Vol. 1 Sec 1 Chapter 3 page no

55-77.

2.Rao- PM Rhea. JJ, Nomiltine RA et al Helical CT techniques for the diagnosis of

acute Appendicitis: Prospective evaluation of a focused Appendix CT examination.

Radiology 1997:140:139-144.

3.Gaitini D, Beck-Razi N, Mor–Yosef D et al. Diagnosis of acute appendicitis in adults;

Accuracy of color Doppler Sonography and MDCT compared with surgery & clinical

follow up. AJR amj roentgenology 2008;190:1300-1306.

4.Birnbaum BA, Wilson SR. Appendicitis atthe millenium. Radiology 2000;215:337-48.

5.Puylaert JB, Acute Appendicitis Ultrasound evaluation using Graded Compression.

Rad 1986;158:355-60.

6.Abu-Yousef MM, Bleicher JJ, Maher JW et al. High Resolution Sonography of Acute

Appendicitis. AJR 1987;149:53-58.

7. Juien B.C.M. Puylaert.Ultrasonography of the abdomen: Radiological Clinics N Am

2003;41:1227-1242.

8.Quillin SP, Siegel MJ, Appendicitis; efficacy of Colour Doppler Sonography

Radiology 1994;191:557-60.

9.Uggowitzer M, Kugler C, Schramayer G, et al. Sonography of Acute Cholecystitis, a

comparision of Colour & Power Doppler Sonography in detecting a Hypervascular GB

wall. AJR Amj Roentgenology 1997;168:707-12.

XCV  

10.Kim PN, Lee KS, Kim IY, Bae WK, Lee BH 1994 Gall Bladder Perforation

comparision of Ultrasound findings with CT abdomen imaging 19:239-42.

11.Hessler PC, Hill DS, Detorie FM, Rocco AF 1981, High Accuracy Sonographic

Recognition of Gall Stones AJR 136;517-520.

12.Raptopoulos V, D Orsi C, Smith E, Reuter K, Moss L, Kleinman P 1982 Dynamic

Cholecystosonography of the contracted Gall Bladder; the Double Arc Shadow Sign

AJR 138;275-278.

13.Niederan C, Muller J, Sonnenberg A et al. Extrahepatic bile ducts in healthy subjects,

in patients with Cholelithiasis and in post Cholecystectomy patients; A prospective US

study.

J Clin Ultrasonography .1983;11:23-27.

14.Koenigsberg M, Wiener SN, Walzer A.The Accuracy of Sonography in the

differential diagnosis of Obstructive Jaundice: A comparision with Cholangiography.

Radiology 1979;133:157-65.

15.Bhargava S, Vashisht S, Kakaria A. et al. Choledocholithiasis- An Ultrasound study

with comparative evaluation with ERCP/PTC. Australas Radiol 1988;32:220-226.

16.Reuter K, Raptopoulos VD, Contelmo N. et al. The diagnosis of a Choledochal cyst

by Ultrasound. Radiology 1980;136:437-38.

17.Aggarwal S, Tandon RK, Vashist S. Radiologic approach to Choledochal cyst Ind J

Gastroenterol 1989;8:107-08.

18.Bolondi L,Li Bassi S et al. Sonography of Chronic Pancreatitis. Radiol Clin North

Am 1989;27: 815- 833.

XCVI  

19.Alpern MB, Sandler MA, Kellman GM et al. Chronic Pancreatitis: Ultrasound

features. Radiology 1985;155:215-219.

20.D.E.Morgan,T.H.Baron,J.K.Smith et al. Pancreatic fluid collections prior to

interventional evaluation with MRI compared with CT & USG. Radiology 1997;

203(3):773-78.

21.Tomiyama T, Veno N, Tano S. et al, Assesment of arterial invasion in pancreatic

cancers using Colour Doppler us Amj Gastroenterol 1996;195:327-32.

22.Phillips RL. Computed Tomography and USG in the diagnosis and treatment of Liver

Abscesses. Australian Radiology 1994;38:165-69.

23.Zwiebel W.J. Vascular disorders of the liver. In Zwiebel (ed). Introduction to

Vascular USG 4th edition WB Saunders Company 2000.

24.Noguera A.M, Montserrat E, Torrubia S. et al. Doppler in Hepatic Cirrhosis and

Chronic Hepatitis. Seminars in Ultrasound, CT&MRI; 2002;23(1):19-36.

25. Arora a, sharna mp, recent trends in the diagnosis and treatment of budd chiari

syndromej assoc. Physicains of india 1992; 40:533-36.

26.Floyd JL. The Radiographic Gamut of BCS Amj Gastroenterol 1981;76:381-87.

27.Menu Y, Alison D, Lorphelin JM et al.BCS Ultrasound evaluation. Radiology 1985;

157:761-64.

28. Joseph A.E.A, Macvicar D. Ultrasound in the diagnosis of Abdominal Abscesses.

Clin Radiol 1990;42:154- 56.

29.Marti-Bonmati L,Serrano F.M. Complications of Hepatic Hydatid cysts.USG,CT

&MRI diagnosis Gastroint Radiolog 1990;15:119- 25.

XCVII  

30.Beggs I, The radiology of Hydatid disease AJR 1985;145:639-48.

31.Von Sinner, Walther N. New diagnostic sign in Hydatid disease; Radiography, USG

CT & MRI correlated to pathology. Eur J Radiol 1990;12:150-59.

32.De Diego J, KlumberriFJj, Franguart J. et al CT in Hepatic Ecchinococcosis Ajr

1998;139:699-702.

33.Brannigan M, Burns PN, Wilson ST. Blood flow pattern in focal liver lesions ay

microbubble enhanced uUSG Radiographics 2004;24:912 -35.

34.Yu S.C.H, Yeung D.T.KJ, So N.M.C. Imaging features of HCC. Clin Radiol

2004;59:145-56.

35.Ross PR, Erturk SM. Malignant tumors of the liver. In Gore RM, Levine MS (eds);

Text book of Gastroint radiol Phiedelphia, Saunders 2008;1623-62.

36.Paky MR, Ros PR. Hepatic metastasis. Hepatic imaging Radiol Clin N Am

1998;6(2): 349-64.

37.Baker EL. Kertan RK jr in Gazelle GS, Saini S, Mueller P (eds). Hepatobiliary and

Pancreatic Radiology Imaging and Intervention. Imaging of Portal HTN 1998.

38.Bolandi L, Gaiani S, Piscalylia F. et al the Portal venous system. Hylton B, Meire H,

Cosgrove D, Dewbury K, Farrant P (eds); Abdominal and General ultrasound 2nd edition

Churchill Livingstone 2001.page 69 -79.

39.Zwiebel WJ. Vascular disorders of the liver. In Zwiebel(ed) introduction to vascular

USG 4th edition WB Saunders company 2000.

40.Horsthuis K, Peter C.F Stokkers,& Stocker J. Detection of IBD. Diagnostic

performance of cross sectional imaging modalities Abd Imaging 2008;33:407-416.

XCVIII  

41.valette PJ Rioux M, pilluel F. et al USG of Chronic inflammatory Bowel diseases.

Eur Radiol 2001;11:1859-66.

42.Maconi G, Parente F, Porro G. Hydrogen Peroxide Enhanced Ultrasound

Fistulography in the assesment of Enterocutaneous fistulas complicating Crohn’s

disease.

GUT 1999;45:874-878.

43.Chen SC, Wang HP, Chen WJ. et al. Selective use of Ultrasonography for the

detection of Pnuemoperitoneum. ACAD. Emerg. Med 2002;9:643- 645.

44.Jones R. Recognition of Pneumoperitoneum using bedside ultrasound in critically ill

patients presenting with Acute Abdominal pain AMJ Emerg Med 2007;25:838-41.

45.Hulnick DH, Megibow AJ, Naidich DP, et al Abd TB: CT evaluation. Radiology

1985;157:199-204.

46.Lundstedt C, Nymon R, Brimsar J, Hugosson C, Kagevi I. Imaging of Abd TB,

abdominal manifestations in 112 patients Acta Radiol. 1996;37:489-95.

47.Malik A, Saxena NC. Ultrasound in Abd TB. Abdominal imaging 2003;29:574-579.

48.Kedar RP, Shah PP, Shivde RS. et al. Sonographic findings in GI & Peritoneal TB.

Clin Radiol 1994;49:24-29.

49.Jain R, Sawhney S, Bhargava DK.et al. diagnosis of Abd TB. Sonographic findings in

pts with early disease AJR 1995;165:1391-95.

50.Ganeshan S, Indrajeet IK. Ultrasound in abdominal lymph node TB a review of 42

cases Ind J of Radiol Imaging 1993;3:231-36.

XCIX  

51.Batra A, Gulati MS, Sarma D, Paul SB, Sonographic appearance in abdominal

Tuberculosis. J Clin USG 2000; 28:233-45.

52.Leder RA, Low VH. Tuberculosis of abdomen. Radiol Clin North Am 1995;33:691-

705.

53.Dubbins PA. The Small Bowel and Colon in abdominal and general Ultrasound.

Cosgrove D, Mere H, Dewbury K(eds) Churchill Livingstone 1993;2:765-76.

C  

KEY TO MASTER CHART

1)TABLE HEADINGS:

A = NAME

B = AGE

C = SEX

D = I.P.NO

E = CLINICAL DIAGNOSIS

F = ULTRASOUND DIAGNOSIS

F1 = DIAGNOSIS

F2 = CORRELATION WITH CLINICAL DIAGNOSIS

G = PER OP DIAGNOSIS

G1 = DIAGNOSIS

G2 = CORRELATION WITH CLINICAL DIAGNOSIS

G3 = CORRELATION WITH USG DIAGNOSIS

H = HISTOPATHOLOGICAL REPORT

H1 = DIAGNOSIS

H2 = CORRELATION WITH CLINICAL DIAGNOSIS

H3 = CORRELATION WITH USG DIAGNOSIS

H4 = CORRELATION WITH PER OP DIAGNOSIS

KEY TO ABBRAVATIONS USED:

AA = ACUTE APPENDICITIS

SA = SUBACUTE APPENDICITIS

AAb = APPENDICULAR ABSCESS

AM = APPENDICULAR MASS

RA = RECURRENT APPENDICITIS

PP = PERFORATIVE PERITONITIS

OC = OVARIAN CYST

CI  

RC = RENAL CALCULUS 

OT = OVARIAN TORSION 

ICM = ILIOCECAL MASS 

Co = COLITIS 

ChrA = CHRONIC APPENDICITIS 

AIO = ACUTE INTESTINAL OBSTRUCTION 

AC = ACUTE CHOLECYSTITIS 

ACC = ACUTE CALCULUS CHOLECYSTITIS 

OM = OMPHALITIS 

LA = LIVER ABSCESS 

EGB = EMPYEMA OF GALL BLADDER 

UC   = URETERIC COLIC 

OJ = OBSTRUCTIVE JAUNDICE 

ChrC = CHRONIC CHOLECYSTITIS  

ChrCC = CHRONIC CALCULUS CHOLECYSTITIS 

Chol  =CHOLELITHIASIS 

RPC  =RUPTURED PSUEDOPANCREATIC CYST 

Ca.S = CARCINOMA STOMACH  

GOO = GARTRIC OUTLET OBSTRUCTION 

DU=DUODENAL ULCER 

IMAb=INTRAMUSCULAR ABSCESS 

Isch  Col=ISCHENIC COLITIS 

PUD=PEPTIC ULCER DISEASE 

LMS OF SI=LEIOMYOSARCOMA OF SMALL INTESTINE 

IH=INGUINAL HERNIA 

CaR= CARCINOMA RECTUM 

CII  

Ca COL= CARCINOMA COLON 

UT= UNDECENDED TESTIS 

IC GROWTH=ILEOCECAL GROWTH 

IC TB= ILEOCECAL TUBERCULOSIS 

Chr P= CHRONIC PANCREATITIS 

HC= HYDATID CYST 

RPT=RETROPERITONEAL TUMOUR 

LUT=LEFT UNDECENDED TESTIS 

BPH=BENIGN PROSTATIC HYPERTROPHY 

VC=VESICAL CALCULUS 

EHPHTN WITH PPF=EXTRA HEPATIC PORTAL HYPERTENSION WITH PERIPORTAL FIBROSIS 

UH=UMBILICAL HERNIA 

In H= INCISIONAL HERNIA 

HH=HIATUS HERNIA 

APD=ACID PEPTIC DISEASE 

Divert= DIVERTICULOSIS 

Intra Per MASS= INTRA PERITONEAL MASS 

PPC=PSEUDO PANCREATIC CYST 

BOO= BLADDER OUT LET OBSTRUCTION 

PVT=PORTAL VEIN THROMBOSIS 

PUH= PARAUMBILICAL HERNIA 

DJ  FLEXURE=DUODENOJEJUNAL FLEXURE 

Ca T= CARCINOMA TESTIS 

CVC SPLEEN=CHRONIC VENOUS CONGESTION OF SPLEEN 

 

CIII  

CIV  

CV  

CVI  

107  

108  

109  

  

MASTER  ‐   CHART   A  B  C  D  E  F  G  H 

SL.NO            F‐1  F‐2 G‐1  G‐2  G‐3  H‐1  H‐2 H‐3  H‐4 

1  NAZEER AHMED  30Y  MALE  8246  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

2  DIVYA  11Y  FEMALE  8027  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

3  SUNITHA  12Y  FEMALE  23125  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

4  SUDHA  25Y  FEMALE  30610  AA  AA  YES  ICM  NO  NO  CO  NO  NO  YES 

5  SHIV KUMAR  20Y  MALE  1654  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

6  MANJUNATH  23Y  MALE  7190  AA  AAB  YES  Aab  YES  YES  AA  YES  YES  YES 

7  ABDUL KHADAR  28Y  MALE  61728  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

8  SURESH  21Y  MALE  9510  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

9  AFREEN  14Y  FEMALE  3964  AA  OC  NO  AA  YES  NO  AA  YES  NO  YES 

10  PARAMESHWAR  23Y  MALE  6601  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

11  CHANDRAMMA  17Y  FEMALE  5167  AA  AA  YES  AA+OC  YES  YES  AA  YES  YES  YES 

12  BASHEER  17Y  MALE  30366  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

13  MANJUNATH  21Y  MALE  19118  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

14  MD RAFEEK  17Y  MALE  23066  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

15  NAGARAJ  18Y  MALE  16399  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

16  DAWALSAB  24Y  MALE  16380  AA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

17  SHIVANAND  35Y   MALE  7650  SA  SA  YES  SA  YES  YES  SA  YES  YES  YES 

18  GOUS SAB  18Y  MALE  5106  AAb  AAb  YES  AAb  YES  YES  Aab  YES  YES  YES 

19  REHMAN  18Y  MALE  1680  AAb  AM  NO  AAb  YES  NO  AAb  YES  NO  YES 

20  RAMANNA  50Y  MALE  484  AAb  AAb  YES  AAb  YES  YES  AA  YES  YES  YES 

21  SUSHEELA  73Y  FEMALE  16834  AAb  AAb  YES  AAb  YES  YES  AAb  YES  YES  YES 

22  NAVEEN  15Y  MALE  17339  AM  AM  YES  AM  YES  YES  AA  YES  YES  YES 

23  MANJUNATH  24Y  MALE  5729  AM  NORMAL  NO  AM  YES  NO  Chr.A  YES  NO  YES 

24  NINGAPPA  28Y  MALE  5509  RA  AAb  YES  AA  YES  YES  AA  YES  YES  YES 

25  MAHADEVAKKA  17Y  FEMALE  4885  RA  ROT  NO  AA+OC  YES  NO  AA  YES  NO  YES 

  26  MAULASAB   28Y  MALE  15834  RA  AM  YES  AA  YES  YES  AA  YES  YES  YES 

27  SUPRIYA  17Y  FEMALE  18466  RA  NORMAL  NO  AA  YES  NO  Chr.A  YES  NO  YES 

28  SARASWATHI  30Y  FEMALE  15210  RA  AM  NO  NORMAL  NO  NO  Chr.A  YES  YES  NO 

29  JYOTHIBA  24Y  MALE  7995  RA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

30  RATHNAVVA  35Y   FEMALE  6474  RA  NORMAL  NO  AA  YES  NO  Chr.A  YES  NO  YES 

31  LAKSHMI  15Y  FEMALE  30245  RA  AA  YES  AA  YES  YES  AA  YES  YES  YES 

32  DURGAPPA  30Y  MALE  32671  RA  AA  YES  AA  YES  YES  Chr.A  YES  YES  YES 

33  SUMITHRAVVA  4OY  FEMALE  27697  RA  AA  YES  AA  YES  YES  Chr.A  YES  YES  YES 

33  CHAND SAAB  60Y  MALE  8278  PP  AA  NO  PP  YES  NO  AA  NO  YES  YES 

35  SAHEBANNA  30Y  MALE  5656  PP  AIO  NO  PP  YES  NO  _  _  _  _ 

36  SHANTAPPA  35Y   MALE  22789  AIO  MILD HEP  NO  JS  YES  NO  NSPI  YES  NO  YES 

37  PARAMESHWAR GOUDA 

80Y  MALE  5633  AIO  CO  NO  ISH Chr.C  YES  NO  ISCH Chr.C 

YES  NO  YES 

38  BIBIJAN  70Y  FEMALE  20394  AC  AC  YES  AC  YES  YES  Chr.C  NO  NO  NO 

39  SUMITHRA  35Y   FEMALE  15209  AC  AC  YES  AC  YES  YES  Chr.C  NO  NO  NO 

40  SANGAPPA  66Y  MALE  3914  AC  AC  YES  AC  YES  YES  Chr.C  NO  NO  NO 

41  RENUKA  30Y  FEMALE  18465  AC  AC  YES  AC  YES  YES  ACC  YES  YES  YES 

42  RASURAMMA  60Y  FEMALE  6394  AC  AC  YES  AC  YES  YES  Chr.C  NO  NO  NO 

43  MUTHU  35Y   MALE  3278  AC  AC  YES  AC  YES  YES  ACC  YES  YES  YES 

44  KATHUMBI  75Y  FEMALE  27045  AC  AC  YES  AC  YES  YES  Chr.C  NO  NO  NO 

45  HAJARAMBI  50Y  FEMALE  18977  AC  AC  YES  EGB  YES  NO  ACC  YES  YES  YES 

46  SHANTI  34Y  FEMALE  16519  AC  AC  YES  AC  YES  YES  Chr.C  NO  NO  NO 

47  BASAMMA  60Y  FEMALE  4225  OJ+AC  OJ+AC  YES  OJ+Chr.C  YES  YES  Chr.C  YES  YES  YES 

48  DEVARAJ  32Y  MALE  28121  OM  OM  YES  OM  YES  YES  _  _  _  _ 

49  DAWALSAB  39Y  MALE  6937  OM  IMAb  YES  OM  YES  NO  OM  YES  NO  YES 

50  ARJUN  40Y  MALE  22289  LA  LA  YES  PP  NO  NO  CO  NO  NO  YES 

51  NINGAPPA  21Y  MALE  7597  RPC  RPC  YES  RPC  YES  YES  Chr.C  YES  YES  YES 

52  MANJU  21Y  FEMALE  4088  LUC  ROC  NO  ROC  NO  YES  _  _  _  _ 

53  SHAHEEN  26Y  FEMALE  24226  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

54  LAKSHMAVVA  62Y  FEMALE  6825  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

  55  CHANDBI  52Y  FEMALE  19224  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

56  FAKEERAPPA  65Y  MALE  3908  Chr.C  Chr.C  YES  NORMAL  NO  NO  Chr.C  YES  YES  NO 

57  SYEDA BEGUM  40Y  FEMALE  31253  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

58  VITTAL  38Y  MALE  22129  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

59  AMEERBI  65Y  FEMALE  27573  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

60  MALA  22Y  FEMALE  23568  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

61  PRABAVATHI  42Y  FEMALE  18262  Chr.C  Chr.C  YES  Chr.C  YES  YES  Chr.C  YES  YES  YES 

62  RAHIMBI  75Y  FEMALE  5049  Ca.S  Ca.S  YES  Ca.S  YES  YES  Ca.S  YES  YES  YES 

63  CHANDRAPPA  60Y  MALE  19796  Ca.S  NORMAL  NO  Ca.S  YES  NO  Ca.S  YES  NO  YES 

64  VIRUPAKASHAPPA  46Y  MALE  23430  Ca.S  Ca.S  YES  Ca.S  YES  YES  _  _  _  _ 

65  NASEER AHMED  45Y  MALE  8801  Ca.S  Ca.S  YES  Ca.S  YES  YES  Ca.S  YES  YES  YES 

66  BHIMAPPA  80Y  MALE  13929  Ca.S  Ca.S  YES  Ca.S  YES  YES  Ca.S  YES  YES  YES 

67  CHANNABASAPPA  40Y  MALE  9384  Ca.S  Ca.S  YES  Ca.S  YES  YES  Ca.S  YES  YES  YES 

68  YAMUNAPPA  60Y  MALE  15603  Ca.S  NORMAL  NO  Ca.S  YES  NO  Ca.S  NO  NO  YES 

69  ASTUSAB  55Y  MALE  14886  Ca.S  NORMAL  NO  Ca.S  YES  NO  Ca.S  YES  NO  YES 

70  SHIVAJI  35Y   MALE  4719  Ca.S  Ca.S  YES  Ca.S  YES  YES  Ca.S  YES  YES  YES 

71  CHAMANSAB  55Y  MALE  3366  GOO  NORMAL  NO  DU  YES  NO  PUD  YES  NO  NO 

72  RAMANNA  68Y  MALE  22030  GOO  NORMAL  NO  DU  YES  NO  _  _  _  _ 

73  SUBAMMA  70Y  FEMALE  7949  APD  DU+DIVERT  NO  DU+DIVERT  NO  YES  DU+ DIVERT 

NO  YES  YES 

74  HANUMAVVA  45Y   FEMALE  6826   LMS   RPT  NO  LMS   YES  NO  LMS  YES  NO  YES 

75  IRSHAD AHMED  26Y  MALE  10770  Ca.CR  Ca.CR  YES  Ca.CR  YES  YES  Ca.CR  YES  YES  YES 

76  KAREPPA  75Y  MALE  31469  Ca.CR  Ca.CR  YES  Ca.CR  YES  YES  Ca.CR  YES  YES  YES 

77  IRANNA  51Y  MALE  22626  Ca.CR  NORMAL  NO  Ca.CR  YES  NO  Ca.CR  YES  NO  YES 

78  PARAVVA  42Y  FEMALE  15711  Ca.CR  NORMAL  NO  Ca.CR  YES  NO  _  _  _  _ 

79  CHANDRAPPA  28Y  MALE  27679  Ca.T  IPM  NO  Ca.T  YES  NO  Ca.T  YES  NO  YES 

80  KALLAVVA  40Y  FEMALE  28566  ABD.TB  ABD.TB  YES  ABD.TB  YES  YES  ABD.TB  YES  NO  YES 

81  NASHEEMA  28Y  FEMALE  23422  ABD.TB  ABD.TB  NO  ABD.TB  YES  NO  ABD.TB  YES  NO  YES 

82  RATHNAVVA  42Y  FEMALE  19020  ABD.TB  ABD.TB  YES  ABD.TB  YES  YES  ABD.TB  YES  YES  YES 

83  SHIRIN  BANU  36Y  FEMALE  5983  ABD.TB  AA  YES  AA  NO  YES  Chr.A  NO  YES  YES 

  84  PREMA  23Y  FEMALE  7267  ABD.TB  ABD.TB  YES  ABD.TB  YES  YES  ABD.TB  YES  YES  YES 

85  GANAPATHI  37Y  MALE  7942  Chr.P  Chr.P  YES  Chr.P  YES  YES  _  _  _  _ 

86  SHARIF   32Y  MALE  30355  Chr.P  Chr.P  YES  Chr.P  YES  YES  _  _  _  _ 

87  SHANAZ  28Y  FEMALE  13918  HC  HC  YES  HC  YES  YES  HC  YES  YES  YES 

88  MAREMMA  42Y  FEMALE  5259  RPT  RPT  YES  RPT  YES  YES  RPT  YES  YES  YES 

89  KRISHNA  19Y  MALE  20370  LUT  LUT  YES  LUT  YES  YES  LUT  YES  YES  YES 

90  KHAZAMIYA  75Y  MALE  18843  BPH  BPH  YES  BPH  YES  YES  BPH  YES  YES  YES 

91  FAKEERAPPA  75Y  MALE  17219  BPH  BPH  YES  BPH  YES  YES  BPH  YES  YES  YES 

92  HANUMANTHAPPA  65Y  MALE  27823  BPH  BPH  YES  BPH  YES  YES  BPH  YES  YES  YES 

93  DYAMANNA  60Y  MALE  13941  BPH  BPH  YES  BPH  YES  YES  BPH  YES  YES  YES 

94  IRAPPA  20Y  MALE  7026  EHPT+PPF  EHPT+PPF  YES  EHPT+PPF  YES  YES  EHPT+PPF  YES  YES  YES 

95  ARJUN GOUDA  67Y  MALE  20328  IH  IH  YES  IH  YES  YES  _  _  _  _ 

96  MALAPPA  53Y  MALE  20332  IH  IH  YES  IH  YES  YES  _  _  _  _ 

97  YASHODA  24Y  FEMALE  15329  UH  PUH  YES  UH  YES  YES  _  _  _  _ 

98  SHEKAPPA  50Y  MALE  6817  InH  InH   YES  InH  YES  YES  _  _  _  _ 

99  RENUKA  43Y  FEMALE  18473  HH  NORMAL  NO  HH  YES  NO  _  _  _  _