Lesson-AbdUS

Summary – focused ultrasonography of the abdomen Copy BUA


You have now learned how to answer the focused questions in focused ultrasonography of the abdomen relevant for perioperative medicine.

• Is the stomac full or empty?
• Is free intraperitoneal fluid visible?

If you do not feel confident, please review the topics again.

*Morten*: Billedet skal laves om til full stomac og fri væske

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Pathological images corresponding to the focused questions in focused ultrasonography of the abdomen. A: Abdominal aortic aneurism, B: Free intraperitoneal fluid in the perihepatic view

Looking for free fluid in the longitudinal pelvic view Copy BUA


Obtain the longitudinal pelvic view.

Look for free fluid around the intestines.

In men: Look for free fluid between the bladder and the rectum.

In women: Look for free fluid between the bladder and the uterus and between the uterus and the rectum.

Tilt the transducer to view the lateral side of the bladder on both sides and look for free fluid.

Looking for free fluid is a dynamic process – not a question of getting THE ONE right image – tilt the transducer and do the sweep.

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Image A: Normal pelvic view without intraperitoneal fluid
Image B: Pelvic view with intraperitoneal fluid
B: Bladder, F: Fluid, U: Uterus

Looking for free fluid in the transverse pelvic view Copy BUA


Obtain the transverse pelvic view.

Look for free fluid to the sides, below and posterior to the bladder.

Sweep the transducer from top to bottom to look for fluid at all levels.

Looking for free fluid is a dynamic process – not a question of getting THE ONE right image – move the transducer and do the sweep.

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Image A: Normal pelvic view without intraperitoneal fluid
Image B: Pelvic view with peritoneal fluid
B: Bladder, F: Fluid, U: Uterus

Video showing free fluid in the perisplenic view Copy BUA

The video shows a recording of a perisplenic examination from a trauma patient with a ruptured spleen and free fluid in the abdomen.

Free fluid is seen between the diaphragm and the spleen.

A normal perisplenic recording is shown for comparison.

The video on the left shows a recording in a trauma patient with free fluid in the perisplenic view, and the video on the right shows a similar recording in a normal patient without free fluid. Observe the discrete black area between the diaphragm and the spleen equivalent to free fluid.

Looking for free fluid in the perisplenic view Copy BUA


Obtain the perisplenic view.

Look for free fluid between the diaphragm and the spleen (subdiaphragmatic) – remember the sweep at this level.

Look for free fluid between the spleen and and the kidney (splenorenal recess) – remember the sweep at this level as well.

Intraperitoneal fluid appears as a black anechoic (black) stripe.

Looking for free fluid is a dynamic process – not a question of getting THE ONE right image – move the transducer and do the sweep.

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The bottom image shows a normal perisplenic image: The splenorenal recess is marked with a blue line, and the diaphragm is marked with a yellow line.
In the top image free fluid (marked with white arrows) is seen between the diaphragm and the spleen and around the spleen.

Video showing free fluid in the perihepatic view Copy BUA


The video shows a recording of a perihepatic examination from a trauma patient with free fluid in the abdomen.

Free fluid is seen in the hepatorenal recess (Morison’s pouch).

A normal perihepatic view recording is shown for comparison.

The video shows the recording in the trauma patient with free fluid in the perihepatic view, and the video on the right shows a similar recording in a normal patient without free fluid. Observe the black area in Morrison’s pouch and around the liver equivalent to free fluid.

Sweep of Morison BUA


To evaluate the entire area at the sub diaphragmatic level, Morison’s pouch and anterior liver tip, sweep the transducer from the anterior to posterior position.

Here exemplified at the Morison’s pouch level.

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Sweep around the right kidney

Looking for free fluid in the perihepatic view Copy BUA


Obtain the perihepatic view.

Look for free fluid between the diaphragm and the liver (subdiaphragmatic) – remember the sweep of the transducer from anterior to posterior position to evaluate the entire area of the hepato-diaphragmal area.

Look for free fluid between the liver and the kidney (Morison’s pouch) – – remember the sweep of the transducer from anterior to posterior position to evaluate the entire area of the hepato-renal recess.

Move the probe anteriorly and caudally to look for free fluid at the anterior tip of the liver and sweep again.

Intraperitoneal fluid appears as a black anechoic (black) area.

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The image shows a normal perihepatic image at the bottom.
Morison’s pouch is marked with a blue line, and the diaphragm is marked with a yellow line.

At the top free fluid (marked with white arrows) is seen in Morrison’s pouch and at the tip of the liver – the subdiaphragmatic area is not visualised in this image

Identification of free fluid Copy BUA


Free fluid is seen as anechoic (black) areas in locations where fluid is not normally found.

Free fluid often collects in specific locations in the abdomen – these include:

Perihepatic:
• The hepatorenal recess (Morrison’s pouch) between the liver and the right kidney
• The space between the liver and right diaphragm (subdiaphragmatic)
• The anterior tip of the liver

Perisplenic:
• The splenorenal recess between the spleen and the left kidney
• The space between the spleen and left diaphragm

Pelvic:
• The rectouterine pouch, vesicouterine pouch, and around intestines in the female
• The rectovesical pouch and around the intestines in the male

Peri-intestinal:
• Between the intestines

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Image showing free fluid between the liver and kidney (Morison’s pouch). The subdiaphragmatic area and the tip of the liver is not seen in this image.

Is intraperitoneal free fluid visible? Copy BUA


The original Focused Assessment with Sonography for Trauma (FAST) and the extended eFAST protocols were developed for assessment of trauma patients.

These address two concerns – pneumothorax and internal bleeding in the thorax or abdomen.

In Essential Emergency Ultrasonography we move away from the protocols towards a focused questions approach.

Ask a clinical question and answer it with all you have got – including the transducer.

We do recognise, however, that in the multi-trauma patient, the following questions your transducer can help you with are: does the patient have 1) a pneumothorax? 2) a hemothorax? 3) a hemopericardium? 4) an intraabdominal bleeding?

No. 1, 2 and 3 are covered by the previous lessons. In the following we only address no. 4 by answering the question “Is intraperitoneal free fluid visible?”

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The image shows a critically ill trauma patient arriving in the trauma center.