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1990 (Res. 7) The American College of Radiology, with more than 30,000 Revised 1993 (Res. 4) members, is the principal organization of radiologists, radiation Revised 1997 (Res. 27) oncologists, and clinical medical physicists in the United Revised 2001 (Res. 36) States. The College is a nonprofit professional society whose Effective 1/1/02 primary purposes are to advance the science of radiology, improve radiologic services to the patient, study the ACR STANDARD FOR THE socioeconomic aspects of the practice of radiology, and PERFORMANCE OF AN

encourage continuing education for radiologists, radiation ULTRASOUND EXAMINATION OF Ultrasound oncologists, medical physicists, and persons practicing in allied THE ABDOMEN OR professional fields. RETROPERITONEUM The American College of Radiology will periodically define new standards for radiologic practice to help advance the I. INTRODUCTION science of radiology and to improve the quality of service to patients throughout the United States. Existing standards will The clinical aspects of this standard (Indications/ be reviewed for revision or renewal, as appropriate, on their Contraindications, Specifications of the Individual Examinations, fifth anniversary or sooner, if indicated. and Equipment Specifications) were developed collaboratively by the American College of Radiology (ACR), and the American Each standard, representing a policy statement by the College, Institute of Ultrasound in (AIUM). has undergone a thorough consensus process in which it has These standards and guidelines have been developed to provide been subjected to extensive review, requiring the approval of assistance to practitioners performing ultrasound studies of the the Commission on Standards and Accreditation as well as abdomen or retroperitoneum. Ultrasound examination is a proven the ACR Board of Chancellors, the ACR Council Steering and useful procedure for the evaluation of many structures within Committee, and the ACR Council. The standards recognize these anatomic areas. Depending on the clinical indications, an that the safe and effective use of diagnostic and therapeutic examination may include the entirety of the abdomen and retroperitoneum, a single , or several organs. A combination radiology requires specific training, skills, and techniques, as of structures may be imaged because of location (e.g., upper described in each document. abdominal scan, right upper quadrant organs) or function (e.g., biliary system [, , and bile ducts], both kidneys). Reproduction or modification of the published standard by For some patients, more focused examinations may be appropriate those entities not providing these services is not authorized. for evaluation of specific clinical indications or to follow up a known abnormality. In some cases, additional and/or specialized examinations may be necessary (e.g., spectral, color, and/or power Doppler). While it is not possible to detect every abnormality The standards of the American College of Radiology (ACR) using ultrasound examination of the abdomen and are not rules, but are guidelines that attempt to define principles retroperitoneum, adherence to the following standards will of practice that should generally produce high-quality maximize the probability of detecting abnormalities radiologic care. The physician and medical physicist may modify an existing standard as determined by the individual Throughout this standard, references to Doppler evaluation may patient and available resources. Adherence to ACR standards include spectral, color, or power Doppler individually or in any will not assure a successful outcome in every situation. The combination. Whenever a long axis view is indicated, this could standards should not be deemed inclusive of all proper methods be either a sagittal or coronal plane. of care or exclusive of other methods of care reasonably directed to obtaining the same results. The standards are not (For specific pediatric considerations, see sections IV.A.2., IV.A.5, intended to establish a legal standard of care or conduct, and IV. B.3, and VI.) deviation from a standard does not, in and of itself, indicate or imply that such medical practice is below an acceptable II. INDICATIONS/CONTRAINDICATIONS level of care. The ultimate judgment regarding the propriety of any specific procedure or course of conduct must be made Indications for ultrasound examination of the abdomen and by the physician and medical physicist in light of all retroperitoneum include, but are not limited to: circumstances presented by the individual situation. A. Abdominal, , and/or . B. Pain that may be referred from the abdominal or retro- peritoneal regions.

ACR STANDARDS Ultrasound of the Abdomen or Retroperitoneum / 597 C. Palpable abnormalities such as possible abdominal positions, may be necessary to evaluate the gallbladder mass or . and its surrounding area completely, particularly when D. Abnormal laboratory values suggestive of abdominal or stones and/or sludge are observed. Wall measurements retroperitoneal pathology. may aid in the determination of thickening. Tenderness E. Follow-up of known or suspected abnormalities in the to transducer compression may be assessed. abdomen or retroperitoneum. F. Search for metastatic disease or occult primary. The intrahepatic ducts can be evaluated by obtaining G. Evaluation of suspected congenital abnormalities. views of the liver demonstrating the right and left H. . branches of the portal . Doppler may be used to I. Pre- and post-transplantation evaluation. differentiate hepatic and portal from bile ducts. The intrahepatic and extrahepatic bile ducts should Abdominal or retroperitoneal ultrasound should be performed be evaluated for dilatation, wall thickening, filling when there is a valid medical reason. There are no absolute defects, and other abnormalities. The size of the contraindications. in the porta hepatis should be documented. When visualized, the distal common bile duct in the pancreatic III. QUALIFICATIONS AND RESPONSIBILITIES OF head should be evaluated. THE PHYSICIAN Routine gallbladder examination should be conducted See the ACR Standard for Performing and Interpreting Diagnostic on a filled gallbladder. Fasting for 8 hours prior to Ultrasound Examinations. examinations will permit adequate distension of a normally functioning gallbladder in adults and children. IV. SPECIFICATIONS FOR INDIVIDUAL In infants and some adults adequate distention may be EXAMINATIONS achieved in less time.

A. Abdomen 3.

1. Liver Whenever possible, all portions of the pancreas – head, uncinate process, body, and tail – should be identified The examination of the liver should include long axis in long-axis and transverse projections. Orally and transverse views. The liver parenchyma should be administered water or contrast agent may afford better evaluated for focal and/or diffuse abnormalities. If visualization of the pancreas. The following should be possible, the echogenicity of the liver should be assessed in the examination of the pancreas: compared with that of the right . In addition, the following should be imaged: a. Parenchymal abnormalities. b. The distal common bile duct in the region of the a. The major vessels in the region of the liver, including pancreatic head. the IVC, the hepatic veins, and the main, right, and c. The pancreatic duct for dilatation and any other left branches of the portal vein. abnormalities, with dilatation confirmed by b. The hepatic lobes (right, left, and caudate) and, if measurement. possible, the hepatic fissures, the right d. The peripancreatic region for adenopathy and/or hemidiaphragm, and the adjacent pleural space. fluid.

Doppler may be used to differentiate vascular from Doppler may be used to differentiate vascular from nonvascular structures. nonvascular structures.

Note: For vascular examinations of the native or 4. transplanted liver, in addition to the evaluation above, Doppler should be used to document blood flow Representative views of the spleen in long-axis and characteristics and blood flow direction in the hepatic transverse projections should be obtained. Doppler may , hepatic veins, portal veins, and intrahepatic be used to determine the presence and direction of flow portion of the IVC, as well as to identify collateral venous in the splenic vein and artery. Suspicion of splenic pathways if present. enlargement should be documented by measurement. Echogenicity of the left kidney should be compared to 2. Gallbladder and biliary tract splenic echogenicity when possible. An attempt should be made to demonstrate the left hemidiaphragm and the The gallbladder evaluation should include long-axis and adjacent pleural space. transverse views obtained in the supine position; other positions, such as left lateral decubitus, erect, or prone

598 / Ultrasound of the Abdomen or Retroperitoneum ACR STANDARDS 5. Bowel 3. Adrenal glands

The bowel may be evaluated for wall thickening, When possible, usually in the newborn or young infant, dilatation, muscular hypertrophy, masses, and other long-axis and transverse images of the adrenal glands abnormalities. Sonography of the pylorus and can be obtained. The adrenal glands are infrequently seen surrounding structures may be indicated in the evaluation in adults. When visualized, the shape and size of the of the infant. Compression sonography may gland should be documented as well as the presence of be necessary to visualize the or other bowel hemorrhage, masses, or other abnormalities. loops and also might be combined with pelvic

sonography in the evaluation of lower abdominal/pelvic 4. Ultrasound pain. Wall measurements may aid in the determination of thickening. Transverse and longitudinal images of the should be obtained. Dimensions may be B. Retroperitoneum documented as appropriate in the proximal, mid, and distal aorta and proximal iliac arteries. Patency/stenosis 1. Kidneys may be evaluated with Doppler. If an aneurysm is present, the maximal anteroposterior (AP) and transverse The examination should include long-axis and transverse size of the aneurysm should be measured. Measurements views of the upper pole(s), mid portion(s), and lower should be from outer wall to outer wall. Surrounding pole(s). The cortex and renal pelvic regions should be soft tissues should be evaluated for any abnormality. If assessed. A maximum measurement of renal length aortic rupture or dissection is clinically suspected, should be recorded for both kidneys. Decubitus, prone ultrasound may not be the initial examination of choice. or upright positioning may provide better images of the kidney. When possible, renal echogenicity should be 5. Inferior vena cava (IVC) compared with the adjacent liver and spleen. The kidneys and perirenal regions should be assessed for Transverse and longitudinal images of the IVC should abnormalities. Doppler may be used to differentiate be obtained. Patency and abnormalities may be evaluated vascular from nonvascular structures. with Doppler. Vena cava filters, interruption devices or catheters may need to be localized with respect to the Note: For vascular examination of the kidneys, Doppler hepatic and/or renal veins. can be used as follows: V. DOCUMENTATION a. To assess renal arterial and venous patency. b. To evaluate adults suspected of having Adequate documentation is essential for high quality patient care. stenosis. For this application, detailed examination There should be a permanent record of the ultrasound examination of the intra and extra renal should be and its interpretation. Comparison with prior relevant imaging included. When possible, bilateral, angle-adjusted studies may prove helpful. Images of all appropriate areas, both measurements of the peak systolic velocity in the normal and abnormal, should be recorded. Variations from normal proximal, mid, and distal main renal arteries should size should be accompanied by measurements. Images are to be be made. Peak systolic velocity of the adjacent aorta labeled with the examination date, patient identification, and (or iliac artery in transplanted kidneys) should also image orientation. A report of the ultrasound findings should be be documented for calculation of renal aortic ratio. included in the patient’s medical record. Retention of the Within the kidney, spectral images of adequate size ultrasound examination images should be consistent both with to allow evaluation of the early systolic peak may clinical need and with relevant legal and local health-care facility be obtained from the upper and lower pole(s) of the requirements. kidney. Reporting should be in accordance with the ACR Standard for 2. and adjacent structures Communication: Diagnostic Radiology.

When performing a complete ultrasound evaluation of VI. EQUIPMENT SPECIFICATIONS the urinary tract, images of the distended urinary bladder and its wall should be included, if possible. Bladder Abdomen and retroperitoneum studies should be conducted with lumen or wall abnormalities should be noted. Dilatation real-time scanners, preferably using sector or linear (straight or or other distal ureteral abnormalities should be curved) transducers. The equipment should be adjusted to operate documented. Transverse and longitudinal scans may be at the highest clinically appropriate frequency, realizing that there used to demonstrate any post-void residual, which may is a trade-off between resolution and beam penetration. For most be quantitated and reported. preadolescent pediatric patients, mean frequencies of 5 MHz or

ACR STANDARDS Ultrasound of the Abdomen or Retroperitoneum / 599 greater are preferred, and in newborns and small infants a higher 4. Bis KG, Slovis TL. Accuracy of ultrasonic bladder volume frequency transducer is often necessary. For adults, mean measurement in children. Pediatr Radiol 1990; 20:457-460. frequencies of 3.5 or 5 MHz are most commonly used. 5. Carrico CW, Fenton LZ, Taylor GA, et al. Impact of sonography on Occasionally, very large patients may require a lower frequency the diagnosis and treatment of acute lower in children transducer. When Doppler studies are performed, the Doppler and young adults. AJR 1999; 172:513-516. frequency may differ from imaging frequency. Diagnostic 6. Dodd GD, Zajko AB, Orons PD, et al. Detection of transjugular information should be optimized, while keeping total ultrasound intrahepatic portosystemic shunt dysfunction: value of duplex Doppler exposure as low as reasonably achievable. sonography. AJR 1995; 164:1119-1124. 7. Downey DB. The retroperitoneum and great vessels. In: Rumack VII. QUALITY CONTROL AND IMPROVEMENT, CM, Wilson SR, Charboneau JW, eds. Diagnostic ultrasound. 2nd SAFETY, CONTROL, AND PATIENT ed. St. Louis, Mo: Mosby, 1998; 453-486. EDUCATION CONCERNS 8. Emamian SA, Nielsen MB, Pederson JF, et al. Kidney dimensions at sonography: correlation with age, sex, and habitus in 665 adult Policies and procedures related to quality, patient education, volunteers. AJR 1993; 160:83-86. infection control, and safety should be developed and implemented 9. Grant EG, Tessler FN, Gomes AS, et al. Color Doppler imaging of in accordance with the ACR Policy on Quality Control and portosystemic shunts. AJR 1990; 154:393-397. Improvement, Safety, Infection Control, and Patient Education 10. Green D, Carroll BA. Ultrasound of renal failure. In: Hricak H, ed. Concerns appearing elsewhere in the ACR Standards Book. Clinics in ultrasound. New York, NY: Churchill Livingstone, 1986; 18:55-58. Equipment performance monitoring should be in accordance with 11. Haller JO. Sonography of the biliary tract in infants and children. the ACR Standard for Diagnostic Medical Physics Performance AJR 1991; 157:1051-1058. Monitoring of Real Time B-Mode Ultrasound Equipment. 12. Hayden CK, Swischuk LE. The gastrointestinal tract. In: Pediatric sonography. Baltimore, Md: Williams and Wilkins, 1987; 4:169- 224. ACKNOWLEDGEMENTS 13. Hayden CK, Swischuk LE. Spleen, pancreas, adrenal glands and miscellaneous retroperitoneal structures. In: Pediatric sonography. This standard was revised according to the process described in Baltimore, Md: Williams and Wilkins, 1987; 225-262. the ACR Standards Book by the Committee on Standards of the 14. House MK, Dowling RJ, King P, et al. Using Doppler sonography to Commission on Ultrasound with the collaboration of the American reveal renal artery stenosis: an evaluation of optimal imaging Institute of Ultrasound in Medicine (AIUM). parameters. AJR 1999; 173:761-765. 15. Lafortune M, Madore F, Patriquin H, et al. Segmental of Edward G. Grant, MD, Chair the liver: a sonographic approach to the Couinaud nomenclature. Lori L. Barr, MD Radiology 1991; 181:443-448. James Borgstede, MD 16. Kanterman RY, Darcy MD, Middleton WD, et al. Doppler Gretchen A.W. Gooding, MD sonography findings associated with transjugular portosystemic shunt Ulrike M. Hamper, MD malfunction. AJR 1997; 186:467-472. Barbara S. Hertzberg, MD (AIUM) 17. Laing FC. The gallbladder and bile ducts. In: Rumack CM, Wilson Mindy Horrow, MD SW, Charboneau JW, eds. Diagnostic ultrasound. 2nd ed. St. Louis, Robert A. Kane, MD Mo: Mosby, 1998; 175-223. Frederick Kremkau, PhD 18. Markisz JA, Treves ST, Davis RT. Normal hepatic and splenic size Jon W. Meilstrup, MD (AIUM) in children: scintigraphic determination. Pediatr Radiol 1987; 17:273- Laurence Needleman, MD (AIUM) 276. Catherine W. Piccoli, MD 19. Mathieson JR, Cooperberg PL. The spleen. In: Rumack CM, Wilson Ronald R. Townsend, MD SW, Charboneau JW, eds. Diagnostic ultrasound. 2nd ed. St. Louis, Mo: Mosby, 1998; 155-174. Christopher R.B. Merritt, MD, Chair, Commission 20. Millener P, Grant EG, Rose S, et al. Color Doppler imaging findings Gordon S. Perlmutter, MD, CSC in patients with Budd-Chiari syndrome: correlation with venographic findings. AJR 1993; 161:307-312. REFERENCES 21. Niederau C, Sonnenberg A, Muller JE, et al. Sonographic measurements of the normal liver, spleen, pancreas, and portal vein. 1. Abu-Yousef MM, Milam SG, Farner RM. Pulsatile portal vein flow: Radiology 1983; 149:537-540. a sign of tricuspid regurgitation on duplex Doppler sonography. AJR 22. Olin JW, Piedmonte MR, Young JR, et al. The utility of duplex 1990; 155:785-788. ultrasound scanning of the renal arteries for diagnosing significant 2. Atri M, Finnegan PW. The pancreas. In: Rumack CM, Wilson SR, renal artery stenosis. Ann Int Med 1995; 122:833-838. Charboneau JW, eds. 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600 / Ultrasound of the Abdomen or Retroperitoneum ACR STANDARDS 24. Patriquin H, Lafortune M, Burns P, et al. The duplex Doppler examination in portal hypertension: technique and anatomy. AJR 1987; 149:71-76. 25. Platt JF, Ellis JH, Rubin JM, et al. Intrarenal arterial Doppler sonography in patients with nonobstructive renal disease: correlation of resistive index with biopsy findings. AJR 1990; 154:1223-1227. 26. Radermacher J, Chavan J, Bleck J, et al. Use of Doppler ultrasonography to predict the outcome of therapy for renal artery stenosis. N Engl J Med 2001; 344:410-417. 27. Ralls PW, Mayekawa DS, Lee KP, et al. The use of color Doppler Ultrasound sonography to distinguish dilated intrahepatic ducts from vascular structures. AJR 1989; 152:291-292. 28. Ralls PW. Color Doppler sonography of the hepatic artery and portal venous system. AJR 1990; 155: 517-525. 29. Rosenberg HK, Markowitz RI, Kolberg H, et al. Normal splenic size in infants and children: sonographic measurement. AJR 1991; 157:119-121. 30. Siegel MJ. Liver. In: Pediatric sonography. 3rd ed. Philadelphia, Pa: Lippincott, Williams and Wilkins, 2001. 31. Siegel MJ. Gallbladder and biliary tract. In: Pediatric sonography. 3rd ed. Philadelphia, Pa: Lippincott, Williams and Wilkins, 2001. 32. Siegel MJ. Urinary tract. In: Pediatric sonography. 3rd ed. Philadelphia, Pa: Lippincott, Williams and Wilkins, 2001. 33. Simonovsky V. Sonographic detection of normal and abnormal appendix. Clin Radiol 1999; 54:533-539. 34. Sivit C, Siegel MJ. Gastrointestinal tract. In: Siegel MJ, ed. Pediatric sonography. 3rd ed. Philadelphia, Pa: Lippincott, Williams and Wilkins. 2001. 35. Sivit C, Siegel MJ. Spleen and . In: Siegel MJ, ed. Pediatric sonography. 3rd ed. Philadelphia, Pa: Lippincott, Williams and Wilkins. 001. 36. Stavros AT, Parker SH, Yakes WF, et al. Segmental stenosis of the renal artery: pattern recognition of tardus and parvus abnormalities with duplex sonography. Radiology 1992; 184:487-492. 37. Teele R, Share J. Recurrent abdominal pain. In: Ultrasonography of infants and children. Philadelphia, Pa: WB Saunders, 1991; 343- 345. 38. Teele R, Share J. Gastroduodenal ultrasonography. In: Ultrasonography of infants and children. Philadelphia, Pa: WB Saunders, 1991; 357-363. 39. Tessler FT, Gehring BJ, Gomes A, et al. Diagnosis of portal vein thrombosis: value of color Doppler imaging. AJR 1991; 157:293- 296. 40. Thurston W, Wilson SR. The adrenal gland. In: Rumack CM, Wilson SR, Charboneau JW, eds. Diagnostic ultrasound. 2nd ed. St. Louis, Mo: Mosby, 1998; 431-452. 41. Thurston W, Wilson SR. The urinary tract. In: Rumack CM, Wilson SR, Charboneau JW, eds. Diagnostic ultrasound. 2nd ed. St. Louis, Mo: Mosby, 1998; 329-397. 42. Withers CE, Wilson SR. The liver. In: Rumack CM, Wilson SR, Charboneau JW, eds. Diagnostic ultrasound. 2nd ed. St. Louis, Mo: Mosby, 1998; 87-154. 43. Yeh HC. Adrenal gland and nonrenal retroperitoneum. Urol Radiol 1987; 9:127-140. 44. Yeh HC, Halton KP, Shapiro RS, et al. Junctional parenchyma: revised definition of hypertrophic column of Bertin. Radiology 1992; 185:725-732.

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