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Prelims.qxd 9/15/04 6:14 AM Page i

Pediatric Ultrasound
Prelims.qxd 9/15/04 6:14 AM Page ii

For Elsevier:
Senior Commissioning Editor: Sarena Wolfaard
Project Development Manager: Mairi McCubbin
Project Manager: Derek Robertson
Designer: Judith Wright
Illustrations Manager: Bruce Hogarth
Prelims.qxd 9/15/04 6:14 AM Page iii

Pediatric Ultrasound
How, Why and When

Rose de Bruyn MBBCh DMRD FRCR

Consultant Pediatric Radiologist,

Department of Radiology,
Great Ormond Street Hospital For Children NHS Trust, London

E D I N B U R G H L O N D O N N E W YO R K O X F O R D P H I L A D E L P H I A S T L O U I S S Y D N E Y T O R O N T O 2005
Prelims.qxd 9/15/04 6:14 AM Page iv

CHURCHILL LIVINGSTONE
An imprint of Elsevier Limited

© 2005, Elsevier Limited. All rights reserved.

The right of Rose de Bruyn to be identified as author of this work has been asserted by her in
accordance with the Copyright, Designs and Patents Act 1988.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior
permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by
the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Permissions may be
sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, USA: phone: (+1)
215 238 7869, fax: (+1) 215 238 2239, e-mail: [email protected]. You may also complete
your request on-line via the Elsevier Science homepage (http://www.elsevier.com), by selecting
‘Customer Support’ and then ‘Obtaining Permissions’.

First published 2005

ISBN 0 443 07275 2

BRITISH LIBRARY CATALOGUING IN PUBLICATION DATA

A catalogue record for this book is available from the British Library

LIBRARY OF CONGRESS CATALOGING IN PUBLICATION DATA

A catalog record for this book is available from the Library of Congress

NOTICE
Medical knowledge is constantly changing. Standard safety precautions must be followed, but as new
research and clinical experience broaden our knowledge, changes in treatment and drug therapy may
become necessary or appropriate. Readers are advised to check the most current product information
provided by the manufacturer of each drug to be administered to verify the recommended dose, the
method and duration of administration, and contraindications. It is the responsibility of the practitioner,
relying on experience and knowledge of the patient, to determine dosages and the best treatment for
each individual patient. Neither the Publisher nor the author assumes any liability for any injury and/or
damage to persons or property arising from this publication.
The Publisher

The
Publisher's
policy is to use
paper manufactured
from sustainable forests

Printed in China
Prelims.qxd 9/15/04 6:14 AM Page v

Contents

Contributors vii 8. The scrotum and testes 235

Preface ix Rose de Bruyn
1. General issues of methods and equipment 1 9. The head, neck and spine 251
Rose de Bruyn Rose de Bruyn
2. Prenatal sonographic diagnosis of congenital 10. The musculoskeletal system 301
anomalies 15
Rose de Bruyn
Eva Pajkrt, Lyn S. Chitty
11. Pediatric interventional ultrasound 321
3. The urinary tract 39
Derek J. Roebuck
Rose de Bruyn
12. The chest 341
4. The adrenal glands 113
Rose de Bruyn
Rose de Bruyn
Recommended reading 353
5. The liver, spleen and pancreas 131
Glossary 355
Rose de Bruyn
Index 361
6. The abdomen and bowel 181
Rose de Bruyn
7. The female reproductive system 207
Rose de Bruyn
Prelims.qxd 9/15/04 6:14 AM Page vi

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Prelims.qxd 9/15/04 6:14 AM Page vii

vii

Contributors

Lyn S. Chitty BSc PhD MRCOG Eva Pajkrt MD PhD

Consultant and Senior Lecturer in Genetics and Clinical Fellow in Fetal and Maternal Medicine,
Fetal Medicine, Institute of Child Health and Fetal Medicine Unit, Elizabeth Garrett Anderson
University College London Hospitals NHS Trust, and Obstetric Hospital, London
London
Derek J. Roebuck FRCR FRANZCR FHKCR
Rose de Bruyn MBBCh DMRD FRCR Consultant Interventional Radiologist, Great
Consultant Pediatric Radiologist, Department of Ormond Street Hospital, London
Radiology, Great Ormond Street Hospital For
Children NHS Trust, London
Prelims.qxd 9/15/04 6:14 AM Page viii

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Prelims.qxd 9/15/04 6:14 AM Page ix

ix

Preface

Ultrasound is one of the most widely used imaging system, together with a fundamental clinical ultra-
modalities in pediatric radiology and is set to con- sound training. The intention is to provide an
tinue to grow and develop as computing and approach to ultrasound examinations and to
equipment improves and new applications become emphasize the real value of ultrasound and its place
available. Children are ideally suited to ultrasound, in the broader perspective of the imaging modali-
since their low levels of body fat contribute to ties available.
ultrasound images of exquisite detail. Clinical expectations of the diagnostic ability of
This book is intended as a practical starting ultrasound are exceedingly high in pediatrics. The
point for radiologists, sonographers and other sonographer must strive for a good understanding
medical healthcare professionals undertaking ultra- of what is achievable and for excellence in tech-
sound examinations in children, providing all nec- nique. Working with children can be one of the
essary normative charts and guidelines on most challenging and rewarding experiences.
examining techniques. The book is not a compre- The author gratefully acknowledges the help,
hensive text on all the many different pathologies stimulation and advice of all her colleagues and
likely to be encountered in children, but it is sonographers in the ultrasound department at
intended to highlight the strengths and weaknesses Great Ormond Street Hospital for Children NHS
of ultrasound in the important conditions. The aim Trust. Also thanks to Michelle Le Maire for her
is to provide the sonographer with a framework to patience, encouragement and invaluable help in
use in diagnosis, so that the maximum amount of preparing the manuscript. This book is for all the
information can be gained from the ultrasound. sick children.
It is assumed that the sonographer has a basic R.d.B.
understanding of how to operate an ultrasound London, 2005
Prelims.qxd 9/15/04 6:14 AM Page x

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Ch01.qxd 9/14/04 5:26 PM Page 1

Chapter 1

General issues of methods and

equipment

Providing an ultrasound service for children

CHAPTER CONTENTS requires a holistic approach influenced by a variety
of considerations. It must not be forgotten that
The appointment and appointment letter 1
diagnostic examinations in children can be very
The waiting area 2
stressful both for the parents and for the child.
The examination 3
Anxiety about whether the child will be coopera-
Choosing equipment 5
tive, the findings of the test and the experience of
Use of Doppler in pediatrics 7
being in a strange clinical environment must not be
Avoidance of occupational injury 8
underestimated, and no effort should be spared to
Image recording and storage 8
make the experience a positive one.
Analogue images 9
Contributing to the success of the examination
Digital images 9
will be the provision of adequate preparatory infor-
New applications of ultrasound relevant to
mation, a child friendly waiting area and an ultra-
pediatrics 10
sound room that has familiar objects and that does
Safety of ultrasound 12
not intimidate or frighten the child. Such an ambi-
ence will help to ensure that the child and parents
are relaxed, friendly and ready for the examination.

THE APPOINTMENT AND APPOINTMENT

LETTER
It is generally good practice to provide the patient
with an appointment letter, as there are a number
of examinations that require specific preparation.
In addition, an attached information leaflet in a
format of frequently asked questions and answers is
extremely useful. Questions such as:

● What is an ultrasound scan?

● Why does my child need an ultrasound scan?
● What does the ultrasound scan involve?
● Are there any risks?
● What happens before the scan?
● What happens after the scan?
Ch01.qxd 9/14/04 5:26 PM Page 2

2 PEDIATRIC ULTRASOUND

can be addressed and the answers can put the par- ● demonstrate dilated lower ureters, which other-
ents’ minds at rest. A contact telephone number wise may be missed
on the leaflet is also useful in case the parents have ● perform a pre- and post-micturition view which
any other concerns and want to speak to a member is standard for all.
of the ultrasound team.
The appointment letter should clearly state: Infants who are to undergo examinations of the
gallbladder and biliary tree should be fasted so that
● the appointment date they are scanned just before their next feed, after a
● the time of the scan (including the time at which 3–4-hour fast. Children should be booked first
the patient should arrive in the department, which thing in the morning after an overnight fast, other-
may be some time before the scan takes place) wise a minimum 6-hour fast is required.
● which examination has been booked All children who undergo pelvic examinations
● the department in which the scan will take place. should have a full bladder when scanned.
Endovaginal and endorectal scanning are not
practiced routinely in children.
Preparation
If a child is to have multiple examinations it is
Specific preparation for different scans should be best to make ultrasound the first examination.
worded simply but clearly. Examples are as follows. Cystography requires bladder catheterization which
is invasive and may render the child upset and cry-
● For ultrasound scans of the gallbladder/liver—
ing during a later ultrasound examination. Also,
‘Please ensure that your son/daughter does not
studies involving nuclear medicine or intravenous
have anything to eat or drink for at least 4–6
urography generally require an injection, which
hours before the scan appointment time. If your
may also upset the child and make him or her anx-
child is a baby then the scan should be timed for
ious and less cooperative for a later scan. After the
just before a feed.’
injection of a radioisotope the child will also be
● For renal ultrasounds—‘Please ensure that your
radioactive. Admittedly the dose is small, but this is
son/daughter arrives in the department with a
an unnecessary radiation exposure for the sonogra-
FULL BLADDER. If your child is still in nap-
pher. In addition, if a young child voids radioactive
pies, please ensure that they have a bottle of
urine while being examined, the ultrasound exam-
milk or clear fluid prior to the examination.’
ining couch and equipment may become contami-
● For pelvic/ovarian ultrasound scans
nated, delaying further examinations.
—‘Please ensure that your son/daughter arrives
in the department with a FULL BLADDER. If
your child is still in nappies, please ensure that THE WAITING AREA
they have a bottle of milk or clear fluid prior to
This is one of the most important areas of the
the examination.’
department, and every age range should be catered
—‘If your son/daughter is aged 6–11 years they
for. There should be soft play areas for the infants,
should drink at least 1 pint of water 1 hour prior
interesting activities for the children and a games
to the appointment time.’
area for the adolescents. A well-designed space
—‘If your son/daughter is aged 12–16 years
where the child can wait and be entertained hap-
they should drink at least 1 1/2 pints of water
pily is essential (Fig. 1.1). The availability of Play
1 hour prior to the appointment time.’
Specialists, who can explain the examination to the
● ‘This examination involves the use of a sound
child in a simple way with toys, is extremely help-
beam to form pictures of some of the organs
ful. Don’t forget that parents are often very anx-
within the body to help your doctor. The exami-
ious about the impending examination, and if the
nation normally takes about 30 minutes and
child is bored and unhappy then stress levels will
does not hurt.’
rise and often boil over into anger which may be
All renal tract examinations should be on a well- directed at you the sonographer. Always try to per-
hydrated child with a full bladder so as to: form the examination on time and do not keep a
Ch01.qxd 9/14/04 5:26 PM Page 3

GENERAL ISSUES 3

A B

C D
Figure 1.1 Examples of play areas. (A) A well-designed waiting area is an important part of any department
undertaking investigations on children. This is an interactive area of the department for young children where they can
draw, paint and play with many different types of toys. There are books available on the wall with mobiles on the
ceiling. A play specialist to explain the examinations to children in a friendly and gentle way helps alleviate anxiety
and fear. The area is light and welcoming with familiar objects. (B) Interactive areas are particularly good to keep
children entertained. This space station is designed for children with special needs so that they are attracted by lights
and water features. The tail of the space station allows access for children in wheelchairs. (C) All age ranges should be
catered for. This is a soft play area for babies where they can fall and not be hurt. (D) This is an area designated for
older children. There is a television, a playstation, books and activities for the older child.

child or parents waiting. If there is a delay, take the THE EXAMINATION

time to explain this to the parents and give an
The ultrasound area
acceptable reason. Remember often parents have
taken time off work and made provision for child The ultrasound area also needs to be child friendly
care, so a lot of effort will have been made to get and welcoming (Fig. 1.2). Familiar and recogniz-
to the appointment on time. Having a box of bro- able cartoon characters at the child’s eye level,
ken toys in the corner is really not adequate, and a mobiles on the ceiling, and musical toys are very
small investment in a television playing videos or a good for distraction of the younger infant. A tele-
games console will make a world of difference. vision, placed above the examination couch, play-
Access to a drinking water fountain is extremely ing videos has proved to be one of the most
useful, and easy access to a toilet will save time for successful features of our department. Also, blow-
the post-micturition views. ing bubbles is a very effective distraction device.
Ch01.qxd 9/14/04 5:26 PM Page 4

4 PEDIATRIC ULTRASOUND

Always have a ready supply of soothers (dum-

mies) available for hungry, restless infants. If young
babies are too hungry the examination will be very
difficult, so it is generally best to wait until they
have been fed and are calmer. Diapers (nappies)
should be available for infants.
It is considerate to warm the coupling gel. Gel
warmers can be obtained at a small cost, and cold
gel is one of the major complaints from children.
Some ultrasound gel can cause irritation and sting-
ing of the eyes so make sure to check before apply-
ing it for eye examinations. Transducers should be
cleaned after each patient so as not to promote
cross-infection.
Temperature control of the examination area is
also very important. Modern ultrasound machines
and computer equipment cannot be in an environ-
ment that is too hot. By contrast, newborn infants
A need to be kept warm, as they lose heat and
become cold very quickly when exposed for the
examination.
Proper lighting should include dimmer switches
and non-glare ceiling lighting for the monitors.
Lights that cause reflections on the ultrasound
screens are not suitable.
The ultrasound area needs to be large enough to
accommodate parents, siblings and buggies. In
addition, patients on trolleys need access, and it is
best if the ultrasound couch can be temporarily
removed. Wash facilities and a toilet large enough
for wheelchair access should ideally be included in
the ultrasound area. In addition a dedicated
mother and baby room for infant feeding and
changing is essential for any pediatric environment.
Protocols for the department are good practice
when undertaking examinations. They provide a
common standard for the different sonographers.
In any case of litigation the demonstration of up-
to-date and regularly reviewed departmental pro-
B tocols is essential.
Figure 1. 2 The ultrasound room. (A) This ultrasound area
has been designed with a predominantly open plan feel, Examining the child
with brightly colored curtains screening the front of the
bays. There is wide access for beds, buggies and Children are rarely sedated for examinations.
wheelchairs. (B) An individual examining bay with lots of However, if a child is to be sedated for another
toys to entertain the child and mobiles on the ceiling. examination such as a CT scan, it is very helpful for
Video entertainment on a television above the couch has the ultrasound examination to be done around the
proved highly successful in distracting the child. For the same time. Newborns cannot be scanned when
sonographer the bed is fully adjustable and the examining
they are extremely hungry and crying, so it is best
chair can also be moved to different heights. The whole
atmosphere is warm, friendly and non-threatening.
Ch01.qxd 9/14/04 5:26 PM Page 5

GENERAL ISSUES 5

to ensure that they are fed just prior to the ultra- ● the age range of the patients to be scanned—
sound so that they are quiet and sleepy. from babies to adolescents (i.e. adult size)
If children are reluctant to be scanned while ● the intended workload and types of examina-
lying supine, be adventurous and accommodating tions to be undertaken—for example, abdomi-
for the scanning position (Fig. 1.3). Sit them on nal, cranial, musculoskeletal or interventional.
mother’s lap, get her to lie down on the couch
The biggest mistake made when choosing
with the child on her tummy, but don’t give up
equipment is generally to provide too few trans-
without a good attempt. Children do not need to
ducers to be able to scan this very wide age range
be undressed; removing clothes makes them
and undertake the variety of types of examination.
unhappy and vulnerable. Usually all that is
Often equipment is bought for both adult and
required is to pull up tops and undo trousers or
pediatric use and a high quality machine is pur-
lower garments.
chased with an insufficient number of transducers.
Certificates and/or stickers to mark a successful
This is false economy, and it would be better to
examination are generally important rewards.
buy a cheaper machine.
Box 1.1 provides a summary of some aspects of
good practice in carrying out examinations.
Probes
CHOOSING EQUIPMENT
The commonest ultrasound examination in chil-
When choosing a machine for dedicated pediatric dren is the abdominal scan, so once again a good
use, the following aspects of the service need to be range of transducers is needed. Curved arrays are
considered: undoubtedly best and should be in a frequency
range suitable for newborns to adolescents, i.e. 7.5
Box 1.1 The Optimum Pediatric Examination to 3.5 MHz. A minimum of two probes is required
(Fig. 1.4).
● Ensure the examination request form For neck, eye, musculoskeletal, and soft tissue
contains sufficient information for you to be lumps and bumps, a high frequency linear trans-
able to perform an adequate scan ducer is needed such as a 15L8. This is an often
● Before starting the examination decide what neglected but essential probe. Cranial scanning can
you hope to achieve from the scan. Know generally be performed using a curved array but
what you are looking for and review the sometimes, when the fontanelle is small and access
reports and/or any prior examinations limited, the preference is for a small footprint vec-
beforehand tor transducer to enable better intracranial views
● Use the correct transducers through the anterior fontanelle. For ocular scan-
● Perform the examination quickly. Younger ning a small footprint, high frequency probe is
children only give you a small window of required.
opportunity and goodwill
● Call someone to help sooner rather than later
● Rarely, if ever, do children need to be Machine capabilities
sedated. Have adequate toys available for
The first requirement of the equipment must be to
distraction and get parents to help
produce ultrasound images safely and of the high-
immobilize the child
est quality. Generally it is false economy to invest in
● Always perform a full and thorough
a cheap machine for pediatrics, as the image qual-
examination in children. Never just look at a
ity, transducer availability and Doppler sensitivity is
single system, e.g. renal tract. Congenital
inferior. The following are features to look for in a
anomalies often involve multiple systems.
piece of equipment for pediatric scanning, where
Pathology is missed because it is not looked
the patient is often a moving target and the sono-
for
grapher has only a short period in which to do the
examination:
Ch01.qxd 9/14/04 5:27 PM Page 6

6 PEDIATRIC ULTRASOUND

A B

Figure 1.3 Scanning positions. (A) Parents are very

good at helping to immobilize children by gently holding
the legs and body and distracting their attention. (B) Get
parents to lie on the couch with their children. (C) Sit a
child on the parent’s lap to scan the back.

C
Ch01.qxd 9/14/04 5:27 PM Page 7

GENERAL ISSUES 7

● ergonomically sound, well-positioned and acces- for example. Generally any delay in being able to
sible function keys perform a measurement prolongs the examina-
● ease of use—programmable presets for the tion for the child. Caliper measurements are
range of investigations help save time during the best done by one hand. Measurement packages,
examination and will also help produce images for example hip angles, should be standard
of diagnostic quality ● portability—examinations are often required in
● probes—ability to connect several probes simul- distant locations, and equipment needs to be
taneously, or an easy switching mechanism; readily portable and small enough to fit into
change of seating position to enable probe intensive care and bedside scenarios. Machines
transfer is not desirable used for portable examinations should be
● patient data—patient name and date of exami- lightweight and robust with moveable monitors
nation should be standard and control panels
● variable focus and number of focal zones ● DICOM compliance—new equipment should
● freeze frame with excellent static image quality now all be compliant with Digital Image
● cine replay—essential for moving children; Communications in Medicine standards
assess length and ease of replay ● a good relationship with the manufacturer—
● magnification and zoom facility—essential for essential for a reliable 24-hour service and on-
small structures; assess ease of use site maintenance. New equipment should ideally
● labeling—this needs to be achieved quickly; have remote diagnostics.
body markers are generally too time consuming
● Doppler capability—pediatric vascular structures
USE OF DOPPLER IN PEDIATRICS
are small, and Doppler of the highest sensitivity
is essential; programmable presets should be the Doppler is an integral part of any ultrasound exami-
norm nation in children. Nowadays equipment without
● simultaneous color and pulse Doppler display— the Doppler capability should not even be consid-
ability to change quickly between color power ered for routine pediatric practice. Likewise, the
Doppler (color ‘Doppler energy’) and color sonographer should expect to be using and be
Doppler is extremely useful familiar with Doppler controls in most examina-
● measuring capabilities—measuring is an essen- tions (Box 1.2).
tial part of pediatric practice; however, the pre- Power Doppler (sometimes known as Doppler
cision is less critical than in obstetric scanning, energy) is extremely useful in children, as it gives a
quick overview. Power Doppler recognizes moving
red cells but gives no information as to whether
flow is arterial or venous. It is not angle dependent
and is very sensitive. If a child is very restless and
agitated, making a conventional study difficult,
turning to the power application may allow simple
questions, such as the presence of blood flow to an
area, to be answered very quickly. It also quickly
provides a very useful sketch of the layout of blood
vessels before using the color flow imaging.
Peripheral vascular studies are often requested in
children for suspected occlusion of vessels from
catheters. When performing these studies it is
always wise to start off with the vessel on the ‘good’
side so as to standardize the controls and use the
Figure 1.4 A good range of transducers is needed for vessel as a reference. Comparison can then be made
the wide range of pediatric examinations. with the limb suspected of having pathology.
Ch01.qxd 9/14/04 5:27 PM Page 8

8 PEDIATRIC ULTRASOUND

Box 1.2 Tips for Doppler studies in children

● The examination needs to be quick—a ● Doppler receiver gain should be set so that
prolonged procedure results in a bored, noise is just visible in the background. Set it
restless and unhappy child and an too low and flow will be missed
unsuccessful examination ● Identify a vessel with color Doppler and then
● Have presets installed for all examinations to place the correct size of gate for adequate
help minimize use of the Doppler controls and spectral sampling. The gate must be
optimize the Doppler capabilities of the positioned in the center of flow parallel to the
equipment vessel walls. Slow flow will be difficult to
● When examining limbs, examine the normal detect if the gate is too large
limb first so that the settings are optimized. ● Ensure the beam steering is optimally set for
This is particularly important in neonates with the angle of incidence. The angle should be
suspected vascular occlusion and where < 60˚ for Doppler studies
vessels are small ● Keep the color box size (width) to the
● Use the correct transducer within the minimum. A large box will slow the frame rate
appropriate frequency range to obtain unacceptably in children
adequate penetration. The higher the ● Reducing the pulse repetition frequency (PRF)
frequency the higher the sensitivity. Using a will increase sensitivity at the cost of reduced
lower frequency will improve the frame rate if frame rate
too slow ● Adjust the baseline and sweep speed so that
● Magnify the image spectral information is optimally displayed

There are a number of areas where Doppler ● The operator’s chair should be completely
examinations are an essential part of the standard adjustable so that the back-rest and chair height
examination. For example, all examinations of the can be altered. There should be lumbar support
liver, biliary tree and portal system require a and a foot rest.
Doppler examination both to show the patency ● The examination couches need to be adjustable
and direction of flow in the hepatic vasculature and so that they can be raised or lowered. This is also
to help differentiate normal anatomy in the porta particularly useful for children in wheelchairs.
hepatis. Doppler should always be used in renal ● Equipment should be ergonomically sound with
transplantation, in particular in the immediate an adjustable keypad. Elbows and wrists should
post-transplantation period and when looking for be relaxed and not in awkward positions for
arteriovenous shunts in the kidney. Vascular scanning.
anomalies are common in children. In superficial ● Monitors should be on a swivel and be at eye
skin hemangiomas Doppler can help to assess the level with no light reflection or glare.
caliber and flow in the vasculature and whether the ● Every effort must be made to schedule patients
hemangioma is suitable for treatment with sclero- appropriately so that examinations are per-
sant or embolization. formed adequately and not rushed. Sono-
graphers should have frequent breaks during the
scanning day.
AVOIDANCE OF OCCUPATIONAL INJURY
Repetitive strain injury is well recognized in sono-
IMAGE RECORDING AND STORAGE
graphers, and it is incumbent on all departments to
provide a good working environment for staff. There are many ways of storing images. The
General principles include the following. range of analogue devices includes thermal
Ch01.qxd 9/14/04 5:27 PM Page 9

GENERAL ISSUES 9

printers, videoprinters, multiformat and laser

Box 1.3 Acronyms relating to digital imagery
imagers. All vary in price and quality of image
storage.
DICOM: Digital Image Communications in
Medicine
Analogue images DIN: digital imaging network
EPI: electronic patient information
Hard copy analogue images have major disadvan-
HIS: hospital information index system
tages compared with electronic archives in this dig-
IMACS: information management and
ital age:
communications systems
LAN: local area network
● An analogue image is a static image which is
PACS: picture archiving and communication
stored on paper, film or videotape using a
system
printer, multiformat or laser imagers.
PIMS: patient information management system
● These hard copies then have to be stored either
RIS: radiology information system
in X-ray packets or on videos and require a large
amount of storage space. If these packets or
videos are lost the ability to review images and
examinations is also lost.
PACS
● Most ultrasound systems do not have an archive,
which makes review of previous examinations In this new millennium of computers and the
difficult. An archive is of particular value for internet, there is no doubt that a picture archiving
accurate reporting of examinations and compar- and communication system (PACS) is the system
ison. This is not possible if hard copy films are of the future and should be seriously considered
constantly lost or mislaid. for the present. There are major advantages to
● Images are only taken when pathology is installing one of these systems, which in the long
recognized, and there is no ability to fully run far outweigh the short term expenditure.
review the examination. There is no potential Characteristics of PACS, in which images are
to re-measure the Doppler calculations. digitally acquired and stored, are as follows.
Ultrasound is a dynamic examination which is
not fully represented in static images, and they ● Digital storage means no lost examinations and
should never be used to make a diagnosis in no need for large physical storage spaces. In
isolation. addition, time need not be wasted in looking for
● Static images are used for clinico-radiological lost packets and examinations.
meetings and for teaching and training. They ● Archiving allows immediate access to current
may also be required for medicolegal reasons. and previous examinations, and this allows more
Electronic archiving reduces film costs. accurate reporting.
● The image quality on hard copy is extremely ● Dynamic clip replay has been a feature reserved
variable and affected by many parameters such for cardiac work but is exceptionally useful in
as the camera settings and even image degrada- general ultrasound, in particular for demonstra-
tion in time if paper is used. tion to clinicians and review of previous studies.
● Hard copy images cannot be viewed by several It is extremely useful when reviewing Doppler
observers simultaneously. studies and difficult examinations.
● The ability to demonstrate examinations
dynamically improves clinical meetings as well as
Digital images
teaching and training.
Box 1.3 gives a short glossary of acronyms which ● Records of examinations can be accessed via the
may be encountered in the field of medical digital internet quickly and easily with no loss in image
imagery. quality and with simultaneous linkage to a hard
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