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The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum

2021; Wiley; Volume: 41; Issue: 4 Linguagem: Inglês

10.1002/jum.15874

1550-9613

Radiation Dose and Imaging

Journal of Ultrasound in MedicineVolume 41, Issue 4 p. E1-E8 Practice ParameterFree Access The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum First published: 18 November 2021 https://doi.org/10.1002/jum.15874AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Introduction The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the Abdomen and/or Retroperitoneum was revised by the AIUM in collaboration with other organizations whose members use ultrasound for performing this examination(s) (see “Acknowledgments”). Recommendations for personnel requirements, the request for the examination, documentation, quality assurance, and safety may vary among the organizations and may be addressed by each separately. This practice parameter is intended to provide the medical ultrasound community with recommendations for the performance and recording of high-quality ultrasound examinations. The parameters reflect what the AIUM considers the appropriate criteria for this type of ultrasound examination but is not intended to establish a legal standard of care. Examinations performed in this specialty area are expected to follow the Parameter with the recognition that deviations may occur depending on the clinical situation. Indications Indications for ultrasound examination of the abdomen and/or retroperitoneum include, but are not limited to1: Abdominal, flank, and/or back pain Signs or symptoms that may be referred from the abdominal and/or retroperitoneal regions, such as jaundice or hematuria Palpable abnormalities, such as an abdominal mass or organomegaly Abnormal laboratory values Abnormal findings on other imaging examinations suggestive of abdominal and/or retroperitoneal pathology that require further characterization; and follow-up of known or suspected abnormalities in the abdomen and/or retroperitoneum Assessment of diseases of the biliary system and pancreas, including gallstones, cholecystitis, gallbladder dysfunction, biliary atresia, choledochal cyst, choledocholithiasis, pancreatitis, pseudocysts, pancreatic anomalies, and pancreatic neoplasms Search for metastatic disease or occult primary neoplasm complementing other cross-sectional imaging Search for source of fever and infection Evaluation of cirrhosis, portal hypertension, and transjugular intrahepatic portosystemic shunt (TIPS) stents; screening for hepatoma; evaluation of the liver in conjunction with liver elastography Abdominal trauma Evaluation of urinary tract pathology including, but not limited to, urinary tract dilation, stone disease, sequelae of infection, and postvoid residual Evaluation of hypertension and suspected renal artery stenosis Search for the presence of free or loculated peritoneal and/or retroperitoneal fluid Evaluation of suspected congenital abnormalities Evaluation of suspected hypertrophic pyloric stenosis, malrotation, and/or midgut volvulus, intussusception, necrotizing inflammatory bowel disease, appendicitis, typhlitis, as well as other bowel abnormalities Pretransplant and posttransplant evaluation Planning for and guiding an invasive procedure Lesion characterization using contrast-enhanced ultrasound (CEUS)2 Abdominal and/or retroperitoneal ultrasound should be performed when there is a valid medical reason. There are no absolute contraindications. Qualifications and Responsibilities of Personnel Physicians interpreting or performing this type of ultrasound examination should meet the specified AIUM Training Guidelines in accordance with AIUM accreditation policies. Sonographers performing the ultrasound examination should be appropriately credentialed in the specialty area in accordance with AIUM accreditation policies. Physicians not personally performing the examination must provide supervision, as defined by the Centers for Medicare and Medicaid Services Code of Federal Regulations 42 CFR §410.32. Request for the Examination The written or electronic request for an ultrasound examination must originate from a physician or other appropriately licensed healthcare provider or under the provider's direction. The clinical information provided should allow for the performance and interpretation of the appropriate ultrasound examination and should be consistent with relevant legal and local healthcare facility requirements. Specifications of the Examination Liver The examination of the liver should include long-axis and transverse views. Liver measurement may be performed on longitudinal images at the midclavicular line. The liver parenchyma should be evaluated for focal and/or diffuse abnormalities. If possible, the echogenicity of the liver should be compared with that of the right kidney. In addition, the following should be imaged3-8: The major hepatic and perihepatic vessels, including the inferior vena cava (IVC), the hepatic veins, and the portal vein The hepatic lobes (right, left, and caudate) and, if possible, the right hemidiaphragm and the adjacent pleural space The liver surface may be imaged with a high-frequency transducer to evaluate for surface nodularity in patients at risk for cirrhosis For vascular examinations, color and spectral Doppler evaluation should be used to document blood flow characteristics and blood flow direction. The structures that may be examined include the main and intrahepatic arteries, hepatic veins, main and intrahepatic portal veins, intrahepatic portion of the IVC, collateral venous pathways, and TIPS stents. Transplant liver evaluation is covered in detail in the AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid Organ Transplants.9 Additionally, in patients predisposed to or suspected of having hepatic fibrosis, hepatic elastography may be performed.10 For patients at risk of hepatocellular carcinoma, recording of transverse and longitudinal cine loops through the right and left lobes may help ensure complete parenchymal visualization and improve sensitivity for detection of focal lesions11 Contrast-enhanced ultrasound may be added for the definitive characterization of focal liver lesions or assessment of the hepatic vasculature12, 13 Gallbladder and Biliary Tract Routine gallbladder examination should be conducted on an adequately distended gallbladder whenever possible. In most cases, fasting for at least 4 hours prior to elective examination will permit adequate distension of a normally functioning gallbladder. For infants and children, the fasting period should be age-appropriate. The gallbladder evaluation should include long-axis and transverse views obtained in the supine position. Decubitus imaging should be performed when feasible. Other positions, such as erect or prone imaging, may be helpful to evaluate the gallbladder and its surrounding areas completely and to differentiate mobile gallstones from impacted gallstones. Measurements in longitudinal and/or transverse planes may aid in determining gallbladder wall thickening. In adults, wall thickness of greater than 3 mm is abnormal. If the patient presents with pain, tenderness to transducer compression over the gallbladder should be assessed (eg, a sonographic Murphy sign). The intrahepatic bile ducts may be evaluated by obtaining views of the liver demonstrating the right and left branches of the portal vein. Doppler may be used to differentiate hepatic arteries and portal veins from bile ducts. The intrahepatic and extrahepatic bile ducts should be evaluated for dilatation, wall thickening, intraluminal findings, and other abnormalities. The common hepatic duct in the porta hepatis should be measured from inner wall to inner wall and documented; when possible, the common bile duct should be evaluated to its most caudal extent.14-17 Pancreas Whenever possible, all portions of the pancreas—head, uncinate process, body, and tail—should be identified. Orally administered water and changes in patient positioning or patient's maneuvers, such as upright or decubitus positions, may afford better visualization of the pancreas. The following should be assessed in the examination of the pancreas17-20: Parenchymal abnormalities, such as masses and calcifications The distal common bile duct in the region of the pancreatic head The main pancreatic duct for dilatation and any other abnormalities, with dilatation confirmed by measurement The peripancreatic region for adenopathy or collections Spleen Representative views of the spleen in long-axis and transverse planes should be obtained. Splenic length measurement and/or volume21 may be helpful in assessing enlargement. Echogenicity of the left kidney should be compared with splenic echogenicity when possible. An attempt should be made to demonstrate the left hemidiaphragm and the adjacent pleural space.22-25 Patency of the splenic hilar vasculature may be assessed with Doppler interrogation. Bowel When there is a concern for bowel pathology, the bowel may be evaluated for wall thickening, dilatation, muscular hypertrophy, masses, vascularity, adjacent inflammation or fluid collections, and other abnormalities. In the pediatric population, sonography of the pylorus and/or the superior mesenteric artery/vein may be helpful in the assessment of the vomiting infant. Graded compression sonography aids in the visualization of the appendix and other bowel loops. Doppler interrogation, evaluation of bowel wall thickening, as well as CEUS, may be helpful in the assessment of infection or inflammation of the bowel.26-40 Use of a high-frequency linear transducer allows for optimal depiction of the bowel wall. Peritoneal Fluid Evaluation for free or loculated peritoneal fluid should include documentation of the extent and location of any fluid identified. Assessment for ascites should include limited images of the pelvis as well as both lower quadrants/paracolic gutters. Fluid localization for subsequent paracentesis can be performed by identifying an appropriate location. In the setting of trauma, particularly blunt trauma, the examination is known as focused assessment with sonography for trauma (FAST) assessment, or focused abdominal sonographic examination for trauma, may be performed.41 The objective of the abdominal portion of the FAST examination is to screen the abdomen for free fluid. Longitudinal and transverse plane images should be obtained in the right upper quadrant through the area of the liver, left upper quadrant through the area of the spleen, along the bilateral paracolic gutters, and within the pelvis to assess for free fluid. Analysis through a fluid-filled bladder (which may be filled through a catheter, when necessary) may help in the evaluation of the pelvis. The FAST examination also includes an assessment of intrathoracic structures outside of the scope of this document. Abdominal Wall When there are signs or symptoms referable to the abdominal wall, an ultrasound examination may be performed to evaluate for hernia, masses, fluid collections, or other abnormalities. The examination should include images of the abdominal wall in the location of symptoms or signs and often necessitates scanning with a high-frequency, high-resolution transducer. The relationship of any identified mass to the peritoneum should be demonstrated. Any defect in the peritoneum and abdominal wall musculature should be documented. The presence or absence of bowel, fluid, organs, or other tissues contained within any abdominal wall defect should be noted. Valsalva maneuvers in supine and upright positioning may be helpful in hernia detection and determining reducibility. The inferior epigastric vessels are an important anatomic landmark in hernia characterization.42 Doppler examination may be useful to evaluate for vascular flow in an abdominal mass. Cine clip images can be useful to further define abdominal wall hernias. Kidneys A complete examination of the kidneys need not be performed with every abdominal examination that may be targeted to other specific abdominal sites. When a complete examination of the kidneys is done, this examination should include long-axis and transverse views of the kidneys. A maximum measurement of renal length should be recorded for both kidneys. Decubitus, prone, or upright positioning may provide better images of the kidneys. When possible, renal echogenicity should be compared with the adjacent liver or spleen. The renal cortical thickness should be assessed.43 The kidneys, specifically the renal cortices, sinuses, and pelves, as well as the perirenal regions, should be assessed for abnormalities including collecting system dilatation, calculi, masses, and other abnormalities.6, 44-51 Contrast-enhanced ultrasound may be helpful in evaluating suspected focal renal lesions.52, 53 Color Doppler imaging may be helpful in detecting calculi via the twinkling artifact.54, 55 For vascular examination of the kidneys, Doppler may be used: To assess renal vasculature, please refer to the AIUM Practice Parameter for the Performance of Duplex Sonography of Native Renal Vessels.56 In the setting of renal transplant, Doppler and 2D grayscale imaging may be used; please refer to the AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid Organ Transplants.9 Contrast-enhanced ultrasound may be helpful for vascular examinations of the transplanted kidney(s); please refer to the AIUM Practice Parameter for the Performance of an Ultrasound Examination of Solid Organ Transplants.9 Urinary Bladder and Adjacent Structures When performing a complete ultrasound evaluation of the urinary tract, transverse and longitudinal images of the distended urinary bladder and its wall should be included, if possible. Bladder lumen or wall abnormalities should be noted. Dilatation or other distal ureteral abnormalities should be documented. The acquisition of ureteral jets with color Doppler imaging may be helpful when evaluating hydroureteronephrosis to evaluate for the presence of obstruction. Transvaginal ultrasound may also be a helpful tool in evaluating distal ureteral calculi in women.57 Transverse and longitudinal scans may be used to demonstrate any postvoid residual, which may be quantitated and reported. In male patients, an attempt to measure the prostate gland may be made. Incidental gynecologic abnormalities in patients with female anatomy should be noted. If there is a concern for vesicoureteral reflux, particularly in children, contrast-enhanced voiding urosonography may be helpful.58, 59 Adrenal Glands When possible, long-axis and transverse images of the adrenal glands in the newborn or young infant may be obtained. Normal adrenal glands are less commonly seen by ultrasound in older children and adults.48 Any incidental adrenal masses detected should be documented for further characterization. Aorta Longitudinal grayscale imaging of the proximal, mid, and distal segments of the abdominal aorta should be acquired. When evaluation of the aorta is specifically requested, see the AIUM practice parameter for the performance of diagnostic and screening ultrasound of the abdominal aorta in adults.60, 61 Inferior Vena Cava Representative images of the upper IVC may be obtained. When specific evaluation of the IVC is requested, patency and abnormalities may be evaluated with Doppler. Vena cava filters, interruption devices, and catheters may need to be localized with respect to the hepatic and/or renal veins.62 Documentation Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the AIUM Practice Parameter for Documentation of an Ultrasound Examination. The initials of the operator should be accessible on the images or electronically on PACS. Equipment Specification Equipment performance monitoring should be in accordance with the AIUM Routine Quality Assurance of Clinical Ultrasound Equipment, Version 2.0.63 Quality and Safety Policies and procedures related to quality assurance and improvement, safety, infection control, and equipment performance monitoring should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. ALARA (as Low as Reasonably Achievable) Principle The potential benefits and risks of each examination should be considered. The ALARA principle should be observed for factors that affect the acoustical output and by considering transducer dwell time and total scanning time. Further details on ALARA may be found in the current AIUM publication Medical Ultrasound Safety. Infection Control Transducer preparation, cleaning, and disinfection should follow manufacturer recommendations and be consistent with the AIUM Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers Between Patients, Safe Handling, and Use of Ultrasound Coupling Gel. Equipment Performance Monitoring Monitoring protocols for equipment performance should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practice. Acknowledgments This parameter was developed by the AIUM in collaboration with the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU). We are indebted to the many volunteers who contributed their time, knowledge, and energy to developing this document. Collaborative Subcommittees ACR Helena Gabriel, MD, co-chair Christopher Fung, MD, co-chair Osama Ali, MD Baljot S. Chahal, MD, MBA, BSc Jessica Kurian, MD AIUM Shweta Bhatt, MD Nirvikar Dahiya, MD, FAIUM Nadia F. Mahmood, MD Kathryn A. Robinson, MD SPR Leanne Linam, MD HaiThuy N. Nguyen, MD Sosamma Methratta, MD SRU Paul Hill, MD Malak Itani, MD AIUM Clinical Standards Committee James M. Shwayder, MD, JD, FAIUM, chair Rachel Bo-ming Liu, MD, FAIUM, vice chair Bryann Bromley, MD, FAIUM Nirvikar Dahiya, MD, FAIUM Rob Goodman, MBBCh, MBA, BMSc Jean Spitz, MPH, CAE, RDMS, FAIUM John Stephen Pellerito, MD, FAIUM Margarita Revzin, MD, FAIUM Comment Reconciliation Committee Eve Clark, MD, chair Richard Gunderman, MD, FACR, co-chair Osama Ali, MD Javad Azadi, MD Richard A. Barth, MD, FACR Shweta Bhatt, MD Priyadarshani Ranjit Bhosale, MD Baljot S. Chahal, MD, MBA, BSc Nirvikar Dahiya, MD, FAIUM, FSRU Richard Duszak Jr., MD, FACR David T. Fetzer, MD Christopher Fung, MD Helena Gabriel, MD Lauren P. Golding, MD Paul Hill, MD Malak Itani, MD Jennifer L. Kemp, MD, FACR Jane S. Kim, MD Amy Kotsenas, MD, FACR Jessica Kurian MD David B. Larson, MD, MBA Paul A. Larson, MD, FACR Leanne Linam, MD Terry L. Levin, MD, FACR Nadia F. Mahmood, MD Sosamma Methratta, MD Mariana Meyers, MD Mary S. Newell, MD, FACR HaiThuy N. Nguyen, MD Ramon Sanchez-Jacob, MD Erick M. Remer, MD, FACR Margarita Revzin, MD, FAIUM Kathryn A. Robinson, MD Sheila Sheth, MD, FACR James Shwayder, MD, FAIUM Cicero Silva, MD William L Simpson Jr, MD, FACR Original copyright 2002; revised 2021, 2019, 2014, 2008, 2007; Renamed 2015. References 1Speets AM, Hoes AW, van der Graaf Y, et al. Upper abdominal ultrasound in general practice: indications, diagnostic yield and consequences for patient management. 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Ultrasound Quarterly 2003; 19: 106– 107. 62Wachsberg RH. Ultrasonography of the retrocrural region: normal and pathological findings. Ultrasound Q 2006; 22: 281– 290. 63 American Institute of Ultrasound in Medicine. AIUM routine quality assurance of clinical ultrasound equipment. http://aium.s3.amazonaws.com/resourceLibrary/rqa2.pdf. Accessed January 14, 2020. Volume41, Issue4April 2022Pages E1-E8 ReferencesRelatedInformation