Ultrasound

ROTATION GOALS AND OBJECTIVES
Rotation 1

Introduction to Machinery, Transducers, Color Doppler, Harmonics

Introduction to Basic Ultrasound Analysis, GB, Liver, Kidney, Free Fluid Abdomen/Pelvis, Normal Anatomy

Learn to analyze and diagnosis Hydronephrosis

Learn to analyze and Diagnose - Biliary Dilatation, Ascites, Pleural Effusion

Rotation 2

Review of work of Rotation 1 - further experience

Increased familiarity with machines and transducers

Introduction to basic OB/GYN analysis

Introduction to DVT analysis

Learn to analyze and diagnose IUP, Ectopic pregnancy, CNS fluid

Analyze and diagnose Pancreatic Mass, Liver Mass, Spleen Mass, Kidney Mass, Bladder Mass, and Ovarian Mass. Learn appropriate differential diagnoses and methods for further analysis.

Rotation 3

Review of work of Rotation 2 - further experience » mastery

Improvement in OB analysis

Improvement in DVT analysis

Learn to analyze and diagnose:

Normal OB exam and possible abnormalities

Normal lower extremity veins and rule out DVT analysis

Rotation 4

Review of work of Rotation 3 - Develop mastery, teach

Improvement in GYN, abdomen, OB ultrasound

Elective

Advanced vascular, neurosonography, prostate analysis

Be able to train junior level resident in basics

Lectures

1. Introduction to Ultrasound including techniques, transducers, and artifacts
2. Obstetrics 1 - Early obstetrical pregnancy, measurements, findings and ectopic pregnancy
3. Obstetrics 2 - 2nd and 3rd trimester fetus, normal and abnormal anatomy
4. Obstetrics 3 - 2nd and 3rd Trimester placenta, cervix, growth measurements
5. Liver and Gall Bladder - Gallstones, cholecystitis, biliary tree abnormalities, liver tumor, fatty liver, and liver transplant ultrasound
6. Spleen, pancreas and retroperitoneum
7. Kidney, Bladder
8. Vascular ultrasound
9. Pediatric hip ultrasound: synovitis, Dysplastic hips
10. Neurosonography - Including spine
11. Pediatric and adolescent gynecologic ultrasound
12. Pediatric abdominal ultrasound, Hypertrophic pylorus stenosis, gastroesophageal reflux, pylorospasm, appendicitis, intussuception, mesenteric adenitis

Elective:

Miscellaneous - Chest, pericardial, prostate, and renal transplant ultrasound

Pediatric renal, bladder and scrotal ultrasound

Diagnostic Ultrasound Curriculum

The following curriculum is based on one developed by the Curriculum Committee of the Society of Radiologists in Ultrasound and is intended as a guideline for the training of radiology residents in ultrasound. The resident should be familiar with this material as a result of hands-on clinical experience combined with formal teaching materials such as conferences, teaching files, books, etc. This material will be covered during dedicated ultrasound rotations, as well as in parts organ-based rotations and in the resident Physics coursework.

I.  Physicist Background/Technical Considerations [To Be Taught In Part By Medical Physics]:

1. Physics

   Definitions of ultrasound, relationship of sound waves used in imaging to those of higher/lower frequency with other properties

   Working knowledge of frequency, sound speed, wavelength, intensities/decibels

   Interaction of sound waves with tissues: reflection, attenuation, scattering, refraction, absorption, acoustic impedance

   Generation/detection of ultrasound waves

   Doppler phenomenon

   Pulse-echo principles

   Beam formation/focusing

2. Bioeffects/Safety

   Thermal/nonthermal effects on tissue

   Relative effects of gray scale, M-Mode, pulsed wave Doppler, color flow imaging, power imaging, harmonics

   Contrast agents

3. Imaging Applicatlons/Equipment Operation

   Transducer choice frequency: gray scale/Doppler (understand tradeoff of penetration/resolution), optimal gray scale probe may not be the optimal Doppler probe shape: linear, sector, curved approach: external, endocavitary, translabial

   Display: gray scale, M-Mode, pulsed wave Doppler, color/power imaging, 3-D

   Image orientation: standard images in different planes

   Image optimization: power output, gain, time gain compensation

   Image recording options - electronic, film, paper, videocassette

   Endocavitary imaging - vaginal, rectal, endoscopic techniques

   Interventional techniques

4. Artifacts

   Underlying principles (straight narrow sound beams, simple reflection, constant sound speed)

   Beamwidth artifacts, sidelobes, slice thickness

   Multiple reflection artifacts - mirror image/reverberations

   Tissue characteristics - shadowing/enhancement

   Refractive artifacts

   Doppler artifacts - pulse wave, color imaging (includes aliasing)

5. Quality Assurance

   Equipment QA Program

   Phantoms - spatial/ contrast resolution

   Sonographer/physician based QA

II.   CLINICAL USES OF ULTRASOUND

1. General Considerations

   Examination protocols - protocols for each routine examination should be understood. Published protocols from the American Institute of Ultrasound in Medicine (AlUM) or the American College of Radiology (ACR) with or without local modification are acceptable frames of reference.

   Basic cross sectional/ultrasound anatomy/range of normal sonographic findings as related to age and sex for each of the anatomic areas included below.

   General diagnostic criteria used to evaluate tissue characteristics and distinguish normal from abnormal, cystic from solid, etc.

   General knowledge of clinical uses/limitations of ultrasound and use of other imaging studies to complement ultrasound.

   Techniques for ultrasound guided invasive procedures - aspiration (of tissue masses, fluid collections), biopsy, catheter placement (into pleural, peritoneal, other fluid collections), amniocentesis.

   Reporting skills/requirements

2. Specific Applications

   HEAD/ SPINE

   Neonatal head: hemorrhage, hydrocephalus, shunt evaluation, periventricular leukomalacia, congenital malformations

   Neonatal spine: lipoma, tethered cord, sacral skin dimple, normal anatomy, diastematomyelia

   Neurosurgical: guidance for intracranial fluid aspiration, mass localization

   NECK

   Thyroid: size, shape, multinodular goiter, benign/malignant neoplasm, associated adenopathy, localization of parathyroid mass, biopsy of thyroid/parathyroid mass or adenopathy thyroglossal duct cyst

   Vascular exams: carotid duplex exam (with Doppler spectrum analysis including normal appearance, arterial occlusion, stenosis, plaque, subclavian steal, jugular thrombosis

   CHEST

   Pleural fluid (simple vs. loculated/complex) or mass, aspiration/catheter drainage of fluid

   Vascular: subclavian vein thrombosis

   Breast: cystic vs. solid mass, malignancy, abscess, ultrasound guided needle localization/biopsy/cyst aspiration [to be taught by breast imaging group]

   Cardiac: pericardial effusion

   ABDOMEN

   Liver: normal size, shape, echotexture, Doppler and color imaging of hepatic arteries, veins, and portal veins, diffuse disease, focal mass (cyst, hemangioma, hepatocellular carcinoma, metastatic lesions), cirrhosis/portal hypertension, varices, transplant evaluation, intrahepatic porto-systemic shunt Doppler evaluation

   Gallbladder /Bile Ducts: normal gallbladder intra- and extra-hepatic duct size, gallstones, acute cholecystitis (calculus/acalculus), hyperplastic cholecystoses, sludge, polyps, carcinoma, HIV related biliary disease, biliary obstruction/dilatation, duct stones

   Pancreas: normal anatomy/size, duct size, chronic pancreatitis, pseudocyst, calcifications, cysts, masses (benign/malignant)

   Spleen: normal anatomy/size, focal lesions (cystic vs. solid), trauma, splenic varices

   Kidneys/Ureters: normal anatomy/size, cysts (simple/complex), cystic diseases, renal cell carcinoma, angiomyolipoma, hydronephrosis /hydroureter, calculi, abscess / pyeloneophritis, perinephric fluid, renal arterial Doppler (including use of resistive index), renal transplant evaluation (include Doppler)

   Adrenal Glands: focal lesion (cyst/solid), neonatal hemorrhage, normal

   Peritoneal Cavity: localization/ quantification/ aspiration of fluid (free/loculated) - including abscess, blood, omental mass, free air

   Gastroinestinal Tract: normal appearance, appendicitis, pyloric stenosis intussusception mass, inflammatory bowel disease

   Retroperitoneum/Vesse1s: adenopathy, aorta (normal/ aneurysm, including proximal and distal extent), inferior vena cava (normal I thrombosis), aortic aneurysm

   PELVIS (excluding pregnancy)

   Urinary Bladder: mass, calculi, obstruction, infection, diverticula, ureterocele, color flow imaging of ureteral jets

   Uterus: normal size, shape, echogenicity.

   Endometrium - normal thickness (premenopausal, postmenopausal, effect of hormone replacement), physiologic variation, carcinoma, hyperplasia, polyps, endometritis, pyometra.

   Myometrium - leiomyomata, adenomyosis.

   Cervix - mass, stenosis, obstruction. Saline hysterosonography

   Ovary: normal size, shape, echogenicity, physiologic variation (follicles, corpus lutem). Torsion, infection, abscess, cystic/solid mass cystadenoma/ carcinoma, hemorrhagic cyst, dermoid, endometrioma

   Fallopian Tube: hydrosalpinx, pyosalpinx

   Prostate: normal size, shape, echogenicity, cystic/solid mass, carcinoma, abscess, biopsy

   Scrotum: normal size, shape, echogenicity of testis and epididymis, cystic/solid testicular or extratesticular mass. Testicular carcinoma, torsion, epididymitis/orchitis, varicocele, hydrocele, spermatocele, trauma, appendiceal torsion

   EXTREMITIES

   Vascular: venous thrombosis evaluation (upper and lower extremity) with compression/Doppler/color imaging, venous insufficiency, aneurysm, pseudoaneurysm/compression, arteriovenous fistula

   Musculoskeletal: mass (cystic/solid), tendon (tear, inflammation), neonatal dysplasia hip effusion, foreign body

   OBSTETRICS

   EARLY PREGNANCY
   Normal findings: gestational sac appearance, size, growth, yolk sac, embryo, cardiac activity, amnion, chorion, embryology, normal early fetal anatomy/growth, crown rump measurement, multiple gestations, correlation with hCG levels

   Abnormal findings: spontaneous abortion, embryonic death, blighted ovum, bleeding/hematoma, ectopic pregnancy, gestational trophoblastic disease, gross embryonic structural abnormalities

   2nd /3rd TRIMESTER
   Normal findings: fetal anatomy/development, placenta, biometry, amniotic: fluid, multiple gestations, umbilical cord Doppler, alphafetoprotein testing, perform complete exam according to the AIUM/ACR guidelines. Amniocentesis, chorionic villous sampling guidance

   Nonfetal abnormalities: oligohydramnios, polyhydramnios, placenta previa, placental abruption, placental masses, 2 vessel umbilical cord, cord masses, cervical shortening/ dilatation (including translabial imaging)

   Fetal abnormalities: intrauterine growth retardation, chromosomal abnormalities/ associated syndromes, hydrops, congenital infections, neural tube defects, hydrocephalus, hydranecephaly, chest masses, cardiac malformations and arrhythmias, diaphragmatic hernia, abdominal wall defects, abdominal masses, GI tract obstructions, urinary tract obstruction/cystic abnormalities, renal agenesis, ascites, limb shortening abnormalities, cleft lip/palate, twin/twin transfusion syndrome.

   Understand significance of borderline findings: choroid plexus cyst, echogenic focus in heart, echogenic bowel, borderline hydrocephalus

   PEDIATRICS [found also in earlier parts of this document]

   Brain and Spine - intraventricular hemorrhage (various grades), periventricular leukomalacia, anomalies

   Neck - thyroglososal duct cyst, branchial cleft cyst

   Chest - pleural effusion, pericardial effusion, pneumonia

   Abdominal - Non-luminal- kidney - obstruction, duplication, tumor, liver spleen, pancreas, abdomen, biliary tree, choledochal cyst, hepatocellular carcinoma, adrenal tumor.

   Abdominal - Luminal - hypertrophic pyloric stenosis, pylorospasm

   Pelvis - posterior uretheral valves, uterus, ovary, normal, anomalies, bicornuate uterus, PID, hemorrhagic cyst, TOA, ovarian cyst/follicles

   Vascular - carotid arteries, DVT, jugular vein, renal vessels, hepatic vessels, tumor or clot in vessels

   Miscellaneous/Musculoskeletal - lymph nodes, developmental hip dysplasia, hip effusion