USG abdomen findings in different accepts
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I now have rich data from Yamada's Textbook of Gastroenterology. Let me compile the comprehensive organ-wise USG abdomen findings.
USG Abdomen - Findings in Different Aspects (Organ-Wise)
USG (Ultrasonography) of the abdomen is a first-line imaging modality evaluating all solid abdominal organs, vascular structures, and the biliary system. Below is a structured, organ-by-organ breakdown of normal and abnormal findings.
Terminology Recap (Echogenicity)
| Term | Meaning |
|---|---|
| Anechoic | No echoes; appears black (e.g., fluid, bile, urine) |
| Hypoechoic | Darker than surrounding tissue |
| Isoechoic | Same brightness as surrounding tissue |
| Hyperechoic / Echogenic | Brighter than surrounding tissue |
| Posterior acoustic shadowing | Dark shadow behind a highly reflective structure (e.g., stone) |
| Through transmission | Increased brightness behind a fluid-filled structure (e.g., cyst) |
1. LIVER
Normal Findings
- Normal span: 14-17 cm at midclavicular line (right lobe)
- Smooth liver surface
- Homogeneous, medium-level echogenicity (slightly more echogenic than the renal cortex)
- Right lobe measured at midclavicular line (e.g., 14.7 cm is normal)
- Patent portal vein with normal hepatopetal (toward liver) flow
- Hepatic veins visible, draining into IVC at the trifurcation
- Normal portal vein caliber: <13 mm
Abnormal Findings
| Condition | USG Features |
|---|---|
| Hepatomegaly | Span >17 cm; liver tip extends below right kidney |
| Acute hepatitis | Enlarged liver, decreased parenchymal echogenicity; "starry sky" pattern (echogenic portal triads against hypoechoic parenchyma) |
| Fatty liver (steatosis) | Increased echogenicity (brighter than kidney); coarse echotexture; loss of normal vessel walls; poor deep penetration |
| Cirrhosis | Nodular surface; heterogeneous echotexture; caudate lobe hypertrophy; splenomegaly; ascites; reversed portal flow |
| Liver abscess | Hypo-/anechoic mass with irregular walls; internal echoes (debris); increased through-transmission |
| Hepatocellular carcinoma (HCC) | Ill-defined heterogeneous mass; internal vascularity on color Doppler; portal/hepatic vein invasion; arterial hypervascularity on CEUS with washout |
| Metastases (most common malignancy in non-cirrhotic liver) | Multifocal (90%); "target/bull's-eye" lesion - hyperechoic center with peripheral hypoechoic halo; heterogeneous; colorectal = hyperechoic; breast/lung/stomach = hypoechoic; mucin-producing = calcified |
| Simple cyst | Anechoic, well-defined, smooth walls, posterior acoustic enhancement |
| Hydatid cyst | "Daughter cysts within a mother cyst"; floating membrane (water lily sign); internal calcification |
| Budd-Chiari syndrome | Hepatic vein thrombosis; reversed or absent flow in hepatic veins on Doppler; caudate lobe hypertrophy |
| Portal hypertension | Portal vein >13 mm; splenomegaly; ascites; collateral vessels; reversed portal flow |
- Yamada's Textbook of Gastroenterology, 7th e
2. GALLBLADDER
Normal Findings
- Anechoic (fluid-filled), thin wall (<3 mm)
- No internal echoes
- Negative sonographic Murphy's sign
- CBD measures <6 mm (or up to 8 mm post-cholecystectomy)
Abnormal Findings
| Condition | USG Features |
|---|---|
| Cholelithiasis (stones) | Echogenic foci with posterior acoustic shadowing; mobile (change position with posture); sensitivity & specificity >90% |
| Acute cholecystitis | Stones + positive sonographic Murphy's sign (PPV 92%); GB wall thickening >3 mm; pericholecystic fluid; GB enlargement; wall hyperemia on Doppler |
| Gangrenous cholecystitis | Multilayered/striated GB wall; alternating hyperechoic-hypoechoic layers; sloughed internal membranes |
| Emphysematous cholecystitis | Air in GB wall/lumen; dirty acoustic shadowing from non-dependent area (vs. sharp shadowing of stones) |
| Porcelain gallbladder | Calcified GB wall; diffuse echogenic wall with posterior shadowing; limits internal evaluation |
| Acute acalculous cholecystitis | GB wall thickening, distension, no stones; found in critically ill patients |
| GB polyp | Echogenic focus, NO posterior shadow, non-mobile (stays attached to wall) |
| GB carcinoma | Irregular wall thickening; mass replacing GB; invasion of liver; regional lymphadenopathy |
| Hydrops/Mucocele | Grossly distended GB with anechoic contents; no stones; cystic duct obstruction |
- Goldman-Cecil Medicine, International Edition
3. BILIARY TREE
Normal Findings
- CBD: <6 mm (acceptable up to 8 mm in elderly or post-cholecystectomy)
- Intrahepatic ducts not normally visible
Abnormal Findings
| Condition | USG Features |
|---|---|
| Choledocholithiasis | Echogenic foci in CBD with posterior shadowing; dilated CBD; sensitivity only 50-75% (gas may obscure) |
| Biliary obstruction | Dilated CBD (>6 mm); dilated intrahepatic ducts (parallel channel sign - "double barrel shotgun" sign) |
| Cholangiocarcinoma | Biliary ductal dilatation; hyperechoic stricture; periductal thickening |
4. PANCREAS
Normal Findings
- Often partially obscured by bowel gas
- Echogenicity equal to or slightly greater than liver
- Pancreatic duct: <3 mm
Abnormal Findings
| Condition | USG Features |
|---|---|
| Acute pancreatitis | Diffusely enlarged, hypoechoic (edema); poorly defined margins; peripancreatic fluid |
| Chronic pancreatitis | Heterogeneous; calcifications; ductal dilatation >3 mm; atrophy |
| Pancreatic carcinoma | Hypoechoic mass; ductal dilation (double duct sign); loss of normal parenchyma; vascular invasion |
| Pseudocyst | Anechoic/complex cystic lesion; thick irregular walls; internal debris |
- S. Das Manual of Clinical Surgery, 13th e
5. SPLEEN
Normal Findings
- Length: <12 cm (normal range 6-12 cm)
- Homogeneous echogenicity, similar to liver
- Smooth, convex outer margin; concave hilum
Abnormal Findings
| Condition | USG Features |
|---|---|
| Splenomegaly | Length >12 cm; associated with portal hypertension, infections, haematological disorders |
| Splenic cyst | Anechoic; well-defined; posterior enhancement |
| Splenic abscess | Hypo-/anechoic complex lesion; irregular walls; internal echoes |
| Splenic infarct | Wedge-shaped hypoechoic area; peripheral location |
| Splenic hematoma | Complex cystic/solid mass; following trauma; may be subcapsular |
6. KIDNEYS
Normal Findings
- Length: 9-12 cm (normal adult)
- Renal cortex: hypoechoic relative to liver and spleen
- Renal sinus (central echogenic complex): bright, due to fat and collecting system
- Cortex: medulla demarcation visible
- No hydronephrosis; no calculi
Abnormal Findings
| Condition | USG Features |
|---|---|
| Hydronephrosis | Anechoic dilation of renal pelvis and calyces (graded 1-4); loss of central sinus echoes |
| Nephrolithiasis (stones) | Echogenic foci with posterior shadowing in collecting system |
| Renal cyst (simple) | Anechoic; smooth walls; posterior enhancement; no internal septae |
| Polycystic kidney disease | Bilateral enlarged kidneys; multiple cysts of varying sizes replacing normal parenchyma |
| Acute pyelonephritis | Enlarged kidney; diffuse or focal decreased echogenicity; loss of corticomedullary differentiation |
| Chronic kidney disease (CKD) | Small, shrunken kidneys; increased cortical echogenicity (hyperechoic cortex - higher than liver); poor corticomedullary differentiation |
| Renal cell carcinoma | Solid mass; variable echogenicity; distortion of renal contour; Doppler vascularity |
| Nephrotic syndrome | Increased echogenicity; may show enlarged kidneys initially |
- National Kidney Foundation Primer on Kidney Diseases, 8th e; Comprehensive Clinical Nephrology, 7th e
7. ABDOMINAL AORTA & IVC
Normal Findings
- Aorta: diameter <3 cm; pulsatile
- IVC: compressible; varies with respiration
Abnormal Findings
| Condition | USG Features |
|---|---|
| Abdominal Aortic Aneurysm (AAA) | Aortic diameter >3 cm; fusiform or saccular dilation; mural thrombus (echogenic rim) |
| Aortic dissection | Intimal flap visible; two lumens - true and false; may extend into abdominal vessels |
| IVC thrombosis | Echogenic material in IVC; non-compressible; absent/reduced flow on Doppler |
8. ASCITES / PERITONEAL CAVITY
| Condition | USG Features |
|---|---|
| Ascites (free fluid) | Anechoic free fluid in Morison's pouch (hepatorenal space), splenorenal space, pelvis; shifting with position |
| Exudate/complex ascites | Echogenic fluid; internal septations; loculations; debris |
| Hemoperitoneum | Complex echogenic fluid; following trauma (FAST exam) - free fluid in Morison's pouch and pelvic cul-de-sac |
9. FOCUSED ASSESSMENT with SONOGRAPHY for TRAUMA (FAST)
Four windows evaluated:
- Hepatorenal (Morison's pouch) - most sensitive for hemoperitoneum
- Splenorenal space - left upper quadrant
- Pericardium - cardiac window
- Pelvis (pouch of Douglas) - dependent pelvic free fluid
Summary: Quick Reference Card
| Organ | Key Normal Measurement | Key Abnormal Sign |
|---|---|---|
| Liver | <17 cm span | "Starry sky" in hepatitis; target lesion in mets |
| Gallbladder | Wall <3 mm, CBD <6 mm | Posterior shadow + Murphy's sign = cholecystitis |
| Pancreatic duct | <3 mm | >3 mm = chronic pancreatitis/obstruction |
| Spleen | <12 cm | >12 cm = splenomegaly |
| Kidney | 9-12 cm | Echogenic cortex = CKD; anechoic dilation = hydronephrosis |
| Aorta | <3 cm | >3 cm = AAA |
| Ascites | None | Anechoic fluid in dependent spaces |
Sources: Yamada's Textbook of Gastroenterology 7th e, Fischer's Mastery of Surgery 8th e, Schwartz's Principles of Surgery 11th e, Goldman-Cecil Medicine, National Kidney Foundation Primer on Kidney Diseases 8th e, Comprehensive Clinical Nephrology 7th e, S. Das Manual of Clinical Surgery 13th e
Can you give physical examination of renal colic
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Excellent - I now have comprehensive textbook content from Smith & Tanagho's General Urology, National Kidney Foundation Primer, and Pye's Surgical Handicraft. Here is the full physical examination breakdown:
Physical Examination in Renal Colic
General Appearance (First Impression)
The general appearance is one of the most diagnostically telling features of renal colic:
- Patient is in severe, obvious distress
- Restless and writhing - constantly changing position trying to find relief; often in "bizarre" or multiple positions
- This is a key distinguishing feature from peritonitis, where patients lie perfectly still (afraid to move)
- Diaphoresis (sweating) - visibly perspiring from pain
- Pallor - due to autonomic response and pain-related vasoconstriction
- Anxious facies
"The patient presenting with acute renal colic typically is in severe pain, often attempting to find relief in multiple, frequently bizarre, positions. This fact helps differentiate patients with this condition from those with peritonitis, who are afraid to move." - Smith & Tanagho's General Urology, 19th e
Vital Signs
| Parameter | Expected Finding | Clinical Significance |
|---|---|---|
| Pulse (HR) | Tachycardia | Reflex sympathetic response to pain |
| Blood Pressure | Normal or slightly elevated | Pain-driven sympathetic drive |
| Temperature | Usually normal (afebrile) | Fever suggests infection/urosepsis |
| RR | Mildly elevated | Pain |
| SpO2 | Normal | Usually unaffected |
Red flag: Fever + tachycardia + hypotension = urosepsis ("pus under pressure") - a urological emergency requiring urgent decompression
Systemic Signs (Head-to-Toe)
Nausea & Vomiting
- Prominent and frequent - due to shared innervation (renal pelvis and GI tract share autonomic supply via the celiac plexus)
- May produce reflex ileus (bowel sounds may be reduced or absent)
Skin
- Pallor, sweating (diaphoresis)
- Cutaneous vasodilation in urosepsis
Abdominal Examination
Inspection
- No distension (unlike bowel obstruction)
- Patient moving/writhing in discomfort
Palpation
| Sign | Finding |
|---|---|
| Tenderness | May have mild ipsilateral flank or abdominal tenderness |
| Guarding / Rigidity | Absent (unless there is co-existing pathology) |
| Rebound tenderness | Absent in uncomplicated renal colic |
| Murphy's sign | Negative (helps exclude cholecystitis) |
| Palpable mass | Rarely - only with severe longstanding hydronephrosis |
| Bladder palpation | Important - urinary retention can mimic renal colic |
Note: Uncomplicated renal colic generally has minimal abdominal signs. The pain severity far exceeds the physical findings - this mismatch is a characteristic feature.
Percussion
- Mild dullness in flanks if significant hydronephrosis
- No percussion tenderness over the abdomen (unlike peritonitis)
Auscultation
- Bowel sounds: may be reduced or absent due to reflex paralytic ileus (pain-induced)
Specific Signs
1. Costovertebral Angle (CVA) Tenderness - HALLMARK SIGN
- Elicited by firm percussion/pressure over the angle between the 12th rib and the lateral border of the erector spinae (paravertebral muscles)
- Positive (tender) on the ipsilateral side of the stone
- Indicates renal or proximal ureteric pathology
- Also called "renal punch" or "kidney punch" sign
2. Loin Tenderness
- Mild tenderness along the flank (loin) on palpation
- Not as severe as would be expected from the intensity of pain
3. Radiation Pattern (guides exam location)
| Stone Location | Pain/Tenderness Radiation |
|---|---|
| Renal pelvis / Upper ureter | Loin to flank, radiates anteriorly to abdomen |
| Mid-ureter (pelvic brim) | Loin to iliac fossa |
| Lower ureter / Ureterovesical junction (UVJ) | Groin, scrotum/testis (male) or labia majora (female); mimics epididymo-orchitis |
| UVJ | Urinary frequency, urgency, dysuria (bladder irritation symptoms) |
Genital Examination
Always examine in renal colic:
- Scrotal exam (males): Exclude epididymitis, orchitis, testicular torsion - all can mimic lower ureteric colic
- Hernial orifices: Check for incarcerated inguinal hernia
- Per rectal (PR) exam: Helps exclude rectal/pelvic pathology
Examination for Complications
If Fever + Rigors Present (Infected Obstructed Kidney):
- Tachycardia, hypotension, cutaneous vasodilation
- High fever
- Signs of sepsis / septic shock
- This is a surgical emergency - requires immediate drainage (ureteric stenting or percutaneous nephrostomy) + IV antibiotics
Differential Diagnosis - Mimics to Exclude on Exam
| Condition Mimicked | Stone Location | Exam Clue to Differentiate |
|---|---|---|
| Acute cholecystitis | Right ureteropelvic junction | Murphy's sign positive in cholecystitis |
| Acute appendicitis | Right lower ureter at pelvic brim | Rebound, guarding, Rovsing's sign in appendicitis |
| Acute diverticulitis | Left lower ureter | Peritoneal signs present |
| Epididymo-orchitis | Lower ureter/UVJ | Tender, swollen epididymis; raised testis |
| Acute cystitis | UVJ stone | Suprapubic tenderness; less severe flank pain |
| Leaking AAA | Any ureteric stone | Pulsatile abdominal mass; haemodynamic instability |
| Herpes zoster | Upper ureter | Dermatomal vesicular rash |
Summary: Classic Renal Colic Presentation
| Feature | Finding |
|---|---|
| Behavior | Restless, writhing, cannot lie still |
| Vitals | Tachycardia, afebrile (unless infected) |
| Pain | Severe colicky, loin-to-groin |
| CVA tenderness | Positive (ipsilateral) |
| Abdominal signs | Minimal (no guarding/rigidity/rebound) |
| Bowel sounds | May be reduced (reflex ileus) |
| GU exam | Normal unless stone at UVJ (frequency/urgency) |
| Key mismatch | Severe pain + minimal physical signs |
Sources: Smith & Tanagho's General Urology 19th e; National Kidney Foundation Primer on Kidney Diseases 8th e; Pye's Surgical Handicraft 22nd e; Bailey & Love's Short Practice of Surgery 28th e
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