What should be included in a standard ultrasound (US) whole abdomen report?

Standard Ultrasound Whole Abdomen Report Format

A comprehensive whole abdomen ultrasound report should include systematic evaluation of all abdominal organs with standardized documentation of normal findings and abnormalities to ensure diagnostic accuracy and guide clinical management.

Essential Components of a Whole Abdomen Ultrasound Report

Patient Information and Technical Details

• Patient demographics (name, age, gender, ID number) 1
• Date and time of examination 2
• Clinical indication for the study 3
• Equipment used and any technical limitations encountered 2

Liver Assessment

• Size, contour, and echogenicity 4
• Evaluation of hepatic parenchyma for focal lesions 4
• Assessment of intrahepatic bile ducts 4
• Portal and hepatic venous structures 4

Biliary System

• Gallbladder size, wall thickness, and contents (presence/absence of stones) 4
• Common bile duct diameter and patency 4
• Documentation of any biliary dilatation 4

Pancreas

• Size, echogenicity, and contour 4
• Pancreatic duct assessment 4
• Peripancreatic regions for fluid collections 4

Spleen

• Size, contour, and echogenicity 1
• Documentation of any focal lesions 1

Kidneys and Adrenals

• Size, echogenicity, and cortical thickness of both kidneys 4
• Presence/absence of hydronephrosis or stones 4
• Renal parenchymal assessment 4
• Adrenal gland evaluation when visualized 1

Retroperitoneum

• Major vessels (aorta, IVC) with measurements 4
• Lymph node assessment 4
• Retroperitoneal spaces 4

Lower Abdomen/Pelvis

• Bladder wall and contents 4
• Prostate (in males) or uterus and adnexa (in females) 4
• Free fluid assessment 5

Bowel

• Bowel wall thickness when indicated 4
• Peristalsis assessment 4
• Appendix evaluation when clinically relevant 4

Peritoneal Cavity

• Presence/absence of free fluid or collections 1
• Assessment of peritoneal spaces 1

Interpretation and Conclusion

• Summary of significant findings 2
• Correlation with clinical information 3
• Differential diagnosis when appropriate 2
• Recommendations for additional imaging if needed 2

Important Considerations

Technical Approach

• Systematic scanning approach using both transverse and longitudinal planes 4
• Use of color Doppler when indicated for vascular assessment 4
• Documentation of areas with limited visualization due to body habitus or bowel gas 4

Common Pitfalls to Avoid

• Incomplete examination of organs due to patient factors 5
• Failure to document technical limitations 2
• Ambiguous terminology in reporting findings 2
• Overlooking incidental findings that may be clinically significant 3

Quality Assurance

• Clear documentation of normal and abnormal findings 2
• Use of standardized measurements and terminology 2
• Direct addressing of the clinical question that prompted the examination 2
• Inclusion of representative images with the report 2