Ultrasound, the middle hepatic vein serves as a landmark for the MLF, a valuable guide to the gallbladder. As the veins converge toward the vena cava, they sometimes look like rabbit ears some have colorfully described their appearance as the “ Playboy bunny sign” ( Fig. The hepatic veins are thin, smooth-walled structures the walls themselves are almost invisible to ultrasound. The right hepatic vein divides the right lobe of the liver into anterior and posterior segments the left hepatic vein divides the left lobe of the liver into medial and lateral segments. The middle hepatic vein divides the liver into anatomical right and left lobes and courses through the MLF. Three branches of hepatic veins arise from the inferior vena cava (IVC) just after it enters the abdominal cavity near the diaphragm ( Figs. The liver is divided into anatomical lobes and segments by the hepatic veins ( Fig. If heavy shadowing is seen from the gallbladder fossa, moving the patient prone may help the stones fall forward and make the echogenic stones more visible themselves, helping distinguish the shadows of a gallbladder packed with stones from artifact created by bowel gas ( 12). This position brings the gallbladder anterior. Occasionally, it is useful to roll the patient from a left lateral decubitus position into a nearly prone position and scan from a subcostal approach. The fundus of the gallbladder lies in close proximity to the right kidney and will often pop into view with this maneuver. Once the right kidney is in view, the transducer should be angled slightly cephalad and anterior. If the anterior subcostal approach is unsuccessful, leave the patient in a left lateral decubitus position, and scan through the right flank to identify the right kidney and Morison’s pouch ( Fig. Scan again from the subcostal approach, then continue to move the transducer along the costal margin toward the right flank. This position brings the liver and gallbladder more toward the midline and closer to the transducer. If these maneuvers fail, move the patient to a left lateral decubitus position.
Have patients sit erect or semirecumbent, and instruct them to breathe deeply with their “belly out.” As the liver descends, the liver and gallbladder may be more easily imaged. Alternatively, the patient can be positioned to bring the liver down below the costal margin. In these patients, an improved image can be obtained by placing the transducer between the ribs (intercostal approach) ( Fig. In many patients, the liver is mostly intrathoracic. If it is not seen, move the transducer down the costal margin while projecting it cephalad under the rib margin to scan through the dome of the liver. In some cases, this will be sufficient to localize the gallbladder. Leaving the transducer in the midline, tilt the transducer to project the sound wave toward the patient’s right side. If there is a large left hepatic lobe, the liver may be easily seen in this position. Begin with the patient supine, and place the transducer in the midline at the epigastrium with the transducer oriented in the sagittal plane ( Fig. The subcostal approach is the most commonly used initial approach to imaging the gallbladder. Ultrasound of the RUQ is included in the list of recommended applications for emergency ultrasound and is part of the model ultrasound curriculum of emergency medicine residency training programs ( 10). The current literature verifies that emergency ultrasound of the RUQ is accurate, improves time to diagnosis and treatment, decreases ED length of stay, and improves patient satisfaction ( 7, 8, 9). Most studies can be completed in <10 minutes ( 5). With even a moderate amount of training and limited experience, emergency physicians can obtain sufficient skill to incorporate right upper quadrant (RUQ) ultrasound into their bedside exams and clinical decisions ( 1, 2, 3, 4, 5, 6).
Focused bedside ultrasound offers a valuable adjunct for the assessment of abdominal pain.
#Hepatic flexture ultrasound serial#
The evaluation of the abdomen frequently utilizes many resources, not the least of which is the time often invested in serial exams, use of consultants, and imaging procedures. Abdominal pain is a leading cause for visits to the emergency department (ED).
0 kommentar(er)
