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Doctor's ultrasound clinic, Peshawar (2026)

02/06/2026

Portal Vein Thrombosis PVT on Ultrasound

Portal vein = big vein that carries blood from gut/spleen → liver. Thrombosis = blood clot inside it. On US we can see it directly + check if liver/blood flow is affected.

# # # 1. What It Is + Why It Matters

*Portal vein*: Drains intestines, spleen, pancreas → liver. Blood flow is normally toward liver = “hepatopetal”.

*PVT*: Clot blocks this vein. Consequences depend on how much is blocked + how fast it happened:

1. *Acute PVT*: Clot 60 days old. Body grows new veins = “cavernous transformation”. Leads to portal hypertension: ascites, varices, enlarged spleen.
3. *Acute-on-chronic*: Old partial clot + new clot on top.

*Urgency*: Acute PVT is medical emergency because clot can spread to mesenteric veins → bowel ischemia. Chronic PVT = long-term liver/portal hypertension problems.

# # # 2. US Findings – The 5 Signs

Doppler US is first-line test. 95% sensitive for main portal vein. No radiation.
Finding What It Means Acute vs Chronic
**1. Echogenic material in vein** Clot seen directly. Fresh clot = hypoechoic. Old clot = hyperechoic Both. Acute clot softer
**2. No flow on Color Doppler** Vein is completely blocked = “occlusive thrombus” Acute = no flow. Chronic may have slow flow around clot
**3. Absent/reversed flow** Normal = hepatopetal/toward liver. PVT = no flow or hepatofugal/away from liver Reversal = severe portal hypertension, usually chronic
**4. Cavernous transformation** Multiple small winding collateral veins at porta hepatis replacing portal vein. “Bunch of grapes” Only chronic >6 weeks. Body’s bypass
**5. Secondary signs** Enlarged spleen >12 cm, ascites, enlarged portal vein >13 mm, varices Chronic PVT causes portal hypertension
*Doppler numbers*: Normal portal vein velocity 15-40 cm/s toward liver. PVT = velocity 0 or reversed.

*POCUS rule*: If you see echogenic stuff + no Doppler color in portal vein → PVT until proven otherwise.

# # # 3. Main Causes – “Virchow’s Triad”

Blood clots when you have: slow flow + vessel injury + thick blood.
Category Examples % of Cases
**1. Cirrhosis** #1 cause worldwide. Slow flow + abnormal clotting 25-40%
**2. Local causes** Pancreatitis, abdominal surgery, trauma, malignancy compressing vein, IBD 20-30%
**3. Hypercoagulable states** JAK2 mutation, Factor V Leiden, protein C/S deficiency, antiphospholipid, OCPs, pregnancy 20-30%
**4. Idiopathic** No cause found 10-20%
*Kids*: Neonatal sepsis, umbilical catheter.
*Cancer*: Hepatocellular carcinoma HCC can invade portal vein = “tumor thrombus” not just clot.

*Key*: Everyone with PVT needs workup for cirrhosis + cancer + clotting disorders.

# # # 4. Acute vs Chronic PVT on US
Feature Acute PVT 60 days
**Portal vein** Enlarged >13 mm, filled with clot Shrunken, hard to see
**Clot echogenicity** Hypoechoic, soft Hyperechoic, organized
**Collaterals** None yet Cavernous transformation at hilum
**Spleen** Normal size Splenomegaly >12 cm
**Ascites/varices** Minimal Common
**Liver texture** Normal May be normal unless cirrhosis cause
*Tumor thrombus clue*: Clot expands vein, shows arterial flow inside clot on Doppler, adjacent liver mass. Needs contrast CT/MRI to split from bland clot.

# # # 5. Complications US Looks For
1. *Bowel ischemia*: If clot extends to superior mesenteric vein. US shows thickened bowel wall >3 mm + no Doppler flow
2. *Portal hypertension*: Ascites, splenomegaly, varices, reversed portal flow
3. *Infarction*: Liver/spleen infarcts if multiple veins blocked
4. *Abscess*: Rare, if PVT from infection = pylephlebitis

# # # 6. Reporting Template
“Main portal vein is enlarged at 15 mm and contains echogenic material occluding 100% of lumen. No color flow detected on Doppler. Flow in intrahepatic branches is hepatofugal/reversed. Spleen enlarged at 14 cm. Small ascites present. No cavernous transformation yet. Findings consistent with acute occlusive portal vein thrombosis. Recommend urgent CT abdomen with contrast and hematology workup.”

*If chronic*:
“Main portal vein not visualized. Multiple tortuous collateral veins at porta hepatis consistent with cavernous transformation of portal vein. Spleen 16 cm. Moderate ascites. Findings of chronic portal vein thrombosis with portal hypertension.”

# # # 7. Management Based on US + Clinical
Situation Treatment
**Acute PVT

01/06/2026

HCL Measurement – Head Circumference on Ultrasound

HC = Head Circumference. Main fetal biometry used in pregnancy US to track baby’s brain/head growth. One of the 4 key measurements: BPD, HC, AC, FL → used for EFW = Estimated Fetal Weight.

# # # 1. What HC Measures + Why It Matters

*HC*: Outer perimeter of fetal skull at level of thalami + cavum septum pellucidum.

*Used for:*
1. *Gestational age*: HC is most accurate for GA 14-22 weeks. Less affected by growth restriction than AC/FL
2. *Fetal growth*: Plot HC on growth chart. Small HC = microcephaly. Large HC = macrocephaly/hydrocephalus
3. *Head shape*: HC + BPD ratio tells if head is round/dolichocephalic/brachycephalic
4. *EFW calculation*: Formula like Hadlock needs HC + AC + FL. HC is 30% of EFW formula
5. *Birth complications*: HC >95th %ile → risk of CPD. HC 97th %ile or >2 SD above mean Hydrocephalus, brain tumor, megalencephaly, Beckwith-Wiedemann. Needs neurosonogram
**Asymmetric growth** HC drops >2 percentiles on serial US Placental insufficiency, IUGR. Check Doppler, AC
**HC/AC ratio abnormal** HC/AC >1.3 at 32-34w “Brain sparing” in IUGR. Blood goes to brain, less to abdomen
**HC/FL ratio abnormal** HC/FL >23.5 after 22w Skeletal dysplasia if HC normal but FL short
*HC:BPD ratio*: Normal 1.2-1.4. 1.4 = brachycephaly/round head. Common with breech or oligohydramnios.

# # # 5. HC in Report + What Doctor Checks

*Report line*: “HC 28.4 cm, 42nd percentile for 30w2d. Consistent with GA.”

*Doctor looks at:*
1. *HC vs GA*: If HC percentile matches LMP/early US → growth on track
2. *HC vs AC*: HC > AC after 32w = normal. HC < AC = IUGR pattern
3. *HC growth velocity*: Should gain ~same percentile each scan. Drop from 50th → 10th = red flag
4. *HC + anatomy*: If HC small, doctor checks brain ventricles, corpus callosum, cerebellum

# # # 6. Factors That Affect HC Accuracy
1. *Fetal position*: Head down = easy. Deep in pelvis = hard
2. *Oligohydramnios*: No fluid around head → skull compresses
3. *Breech/molding*: Head shape changes, BPD unreliable but HC still ok
4. *Machine calipers*: Must trace outer-to-outer, not inner-to-inner

# # # 7. Key Points for Patients
1. *HC alone ≠ brain health*: Small HC can be constitutional if parents have small heads. Big HC can be normal variant. Anatomy scan + Doppler decide.
2. *Serial growth matters*: One low HC isn’t panic. 3 scans showing HC falling off curve is concerning.
3. *EFW uses HC*: If HC wrong, baby weight estimate wrong. That’s why tech spends time getting plane right.
4. *3rd trimester HC less accurate for dating*: Use HC for growth, not for GA after 22w.

*Bottom line*: HC measurement on US = outer skull perimeter at thalami + CSP level. Tracks baby’s head/brain growth. Percentile + trend > single number. Low HC → check for IUGR/genetics. High HC → check for hydrocephalus.💯🧠🕯️

01/06/2026

Placenta Previa on Ultrasound

Placenta previa = placenta implants in lower uterus and covers or is close to cervical opening. Main cause of 3rd trimester bleeding. US diagnosis is critical because delivery mode + timing depend on it.

# # # 1. Types of Placenta Previa

Classified by distance from placental edge to internal cervical os = ICO. Measured on transvaginal US TVUS, gold standard.
Type Definition Distance to ICO Delivery
**1. Complete/Central** Placenta fully covers ICO Covers os C-section mandatory
**2. Partial** Placenta partially covers ICO Covers part of os C-section mandatory
**3. Marginal** Edge within 2 cm of ICO, doesn’t cover 0-20 mm from os C-section if 20 mm
**4. Low-lying** Placenta in lower segment but edge >2 cm from ICO 20-25 mm from os Usually vaginal delivery ok
*Old terms “Type I-IV”*: Now avoid. Use “distance in mm” because that’s what drives management.

*Key rule*: Only TVUS can measure distance accurately. Abdominal US misses 30% of cases.

# # # 2. US Findings + How It’s Diagnosed

*Timing*: Screened at 18-22 week anatomy scan. 5-10% have “low placenta” then, but 90% migrate up = “placental migration”.

*Abdominal US first:*
1. *Placenta location*: Anterior, posterior, fundal, low-lying
2. *Placental edge*: See if it extends toward cervix
3. *Problem*: Maternal bladder + fetal head shadow cervix → can’t measure accurately

*Transvaginal US TVUS = diagnostic test:*
1. *Empty bladder*: Full bladder pushes cervix up, hides previa
2. *Measure shortest distance*: Calipers from placental edge to ICO in mm
3. *Color Doppler*: Check for “bridging vessels” crossing os = risk of vasa previa
4. *Rule out accreta*: Look for loss of retroplacental clear zone, multiple lacunae, myometrial thickness

01/06/2026

Hashimoto’s Thyroiditis on Ultrasound

Hashimoto’s = autoimmune thyroiditis. Your immune system attacks thyroid → inflammation → hypothyroidism over time. US is great at spotting it + ruling out cancer nodules hiding inside.

# # # 1. What It Is Clinically
*AKA*: Chronic lymphocytic thyroiditis, autoimmune thyroiditis
*Who*: Women 30-50yr, 10:1 female:male. Most common cause of hypothyroidism in iodine-sufficient areas
*Labs*: TSH ↑, Free T4 ↓, TPO antibodies +ve in 90%. TG antibodies +ve in 70%
*Symptoms*: Fatigue, weight gain, cold intolerance, dry skin. Early stage may be hyperthyroid = “hash*toxicosis”

# # # 2. US Features – “The 4 Patterns”

*1. Diffuse heterogeneous pattern – 60% cases* = classic
*Grayscale:*
1. *Diffuse enlargement*: Gland enlarged, but can be normal size or atrophic late-stage
2. *Coarse, heterogeneous echotexture*: Looks like “grainy sandpaper” instead of smooth. Hypoechoic compared to normal thyroid
3. *Micronodular “pseudonodules”*: Multiple 2-6 mm hypoechoic nodules throughout. They’re NOT real nodules - just lymphoid follicles. Key: no halo, ill-defined, 1 cm. These nodules need TI-RADS scoring. Cancer risk same as general population ∼5-10%, but harder to detect because background is messy.

*3. Atrophic/fibrotic pattern – late stage*
Small gland 1 cm identified. Color Doppler shows globally decreased vascularity. No suspicious cervical lymph nodes. Findings consistent with chronic autoimmune thyroiditis/Hashimoto’s thyroiditis. Correlate with TPO antibodies and TSH.”

*If nodule present*:
“Background changes of Hashimoto’s thyroiditis as above. Additionally, 1.4 cm solid hypoechoic nodule in right lobe, irregular margins, TR4. Recommend FNA per TI-RADS ≥1.5 cm threshold.”

# # # 6. Management Based on US + Labs
Stage US + Labs Treatment
**Euthyroid Hashimoto’s** US abnormal, TSH normal, antibodies +ve No treatment. Check TSH every 12 months
**Subclinical hypo** US abnormal, TSH 4.5-10, T4 normal Treat if TSH >10, pregnant, or symptomatic
**Overt hypo** US abnormal, TSH high, T4 low Levothyroxine lifelong. Dose based on TSH
**Dominant nodule** US shows TR4/TR5 nodule FNA biopsy regardless of TSH
*Key*: Levothyroxine treats hypothyroidism, NOT Hashimoto’s itself. Antibodies stay positive forever.

# # # 7. Follow-up US
1. *No dominant nodule*: US every 2-3 years if stable, or if gland size changes
2. *Has nodule*: Follow TI-RADS schedule like any nodule. Hashimoto’s background doesn’t change FNA rules
3. *Rapid growth/new hypoechoic mass*: Urgent US + FNA to rule out lymphoma

# # # 8. Key Points for Patients
1. *US confirms diagnosis but labs diagnose*: You need TSH + TPO antibodies. US just shows damage.
2. *Goiter comes and goes*: Gland can swell during flares, shrink later. Doesn’t mean worse/better.
3. *Pregnancy*: TSH target stricter 1 cm TR4 → FNA.🧑‍💻🕯️🧠

01/06/2026

Terminal Ileitis on Ultrasound

Terminal ileitis = inflammation of the last 10-20 cm of ileum, right before it joins the cecum at the ileocecal valve. US is first-line test because it’s fast, no radiation, and sees bowel wall thickness + blood flow in real time.

# # # 1. What It Looks Like on US – “Graded Compression” Technique

Use high-freq linear probe 7-12 MHz. Press gently to push bowel gas away = “graded compression”. Terminal ileum sits in right lower quadrant, near cecum/appendix.

*Key findings:*
Finding Normal Terminal Ileitis
**Wall thickness** 6 mm = severe
**Wall layers** 5 layers visible Layers preserved early. Lost layers = severe/transmural = Crohn’s
**Lumen** Collapsible with probe Rigid, non-collapsible, narrowed
**Color Doppler** Minimal flow Markedly increased flow = “hyperemia” = active inflammation
**Mesentery** Normal fat Hyperechoic “fat proliferation”, enlarged lymph nodes
**Surrounding fluid** None Small free fluid in RLQ
**Ileocecal valve** Thin, symmetric Thickened, may gape open
*Rule*: Wall >3 mm + hyperemia on Doppler = active ileitis. Wall >6 mm + lost layers = transmural disease, think Crohn’s.

# # # 2. Main Causes of Terminal Ileitis on US

US shows inflammation, not cause. But pattern + clinical clues help:
Cause US + Clinical Clues
**1. Crohn’s disease** Segmental, asymmetric wall thickening >6 mm, lost layers, mesenteric fat proliferation, enlarged lymph nodes, strictures, fistulas. Chronic diarrhea, weight loss, perianal disease
**2. Infectious ileitis** Yersinia, Campylobacter, Salmonella, TB. Wall 4-6 mm, layers preserved, mesenteric nodes enlarged. Acute onset, fever, diarrhea, recent food. Yersinia = pseudokidney sign + huge nodes
**3. NSAID-induced** Diffuse mild thickening 3-4 mm, history of ibuprofen/naproxen use
**4. Ischemia** Elderly, AFib. Segmental thickening, poor flow on Doppler late = infarction
**5. Appendicitis** Appendix >6 mm, non-compressible. Secondary ileal thickening from nearby inflammation
**6. Eosinophilic enteritis** Marked wall thickening with hyperechoic submucosa “halo sign”
* #1 cause in developed countries*: Crohn’s. * #1 cause acutely*: Infectious/Yersinia.

# # # 3. Crohn’s Disease vs Infectious Ileitis – How US Splits Them
Feature Crohn’s Infectious/Yersinia
**Pattern** Segmental, skip lesions Diffuse terminal ileum only
**Wall thickness** Often >6-8 mm, transmural 4-6 mm, mucosal/submucosal
**Layers** Lost = transmural Preserved = mucosal
**Strictures/fistulas** Common Rare
**Lymph nodes** Few, moderate size Many, huge >10 mm, especially Yersinia
**Mesenteric fat** “Fat wrapping” = hyperechoic Mild fat stranding
**Chronicity** Chronic, relapsing Acute, resolves 4-6 weeks
*If not sure*: US can’t confirm cause. Need colonoscopy + biopsies + stool studies. But US tells “active inflammation yes/no + severity”.

# # # 4. Doppler Grading of Activity
Color Doppler shows blood flow = inflammation activity.
*Grade 0*: No flow = inactive/quiescent
*Grade 1*: Mild flow in wall
*Grade 2*: Moderate flow
*Grade 3*: Marked flow = “hyperemia” = active flare

*Clinical use*: Doctor adjusts meds based on Doppler grade + wall thickness.

# # # 5. Complications US Can Detect
1. *Stricture*: Thick wall + narrowed lumen + dilated upstream loops. “To-and-fro” peristalsis
2. *Fistula/abscess*: Hypoechoic tract from ileum to bladder/skin, complex collection nearby
3. *Free perforation*: Free air, free fluid, patient peritonitis
4. *Intussusception*: “Target sign” if inflamed ileum telescopes into cecum

# # # 6. Reporting Template
“Graded compression US of RLQ shows terminal ileum segment measuring 12 cm with wall thickness 6.5 mm. Wall layers are partially preserved but submucosa appears hyperechoic. Lumen is narrowed and rigid. Marked hyperemia on color Doppler. Adjacent mesenteric fat is hyperechoic. Multiple mesenteric lymph nodes up to 9 mm. Ileocecal valve thickened. No free fluid or abscess. Findings consistent with active terminal ileitis, most suggestive of Crohn’s disease given transmural features. Recommend correlation with colonoscopy and labs.”

*If infectious pattern*:
“Terminal ileum wall thickened to 4 mm with preserved layers. Multiple enlarged mesenteric lymph nodes up to 15 mm. Moderate hyperemia. No fistula/stricture. Findings suggestive of acute infectious ileitis, consider Yersinia.”

# # # 7. Key Clinical Points
1. *US accuracy*: 80-90% sensitive for Crohn’s ileitis vs colonoscopy. Better than CT for kids/pregnancy - no radiation.
2. *Wall thickness >3 mm is abnormal*: But 3-4 mm can be infection. >6 mm + lost layers = Crohn’s.
3. *Normal US ≠ no disease*: Early Crohn’s or microscopic colitis can have normal US. If high suspicion, need colonoscopy.
4. *Monitor treatment*: US + Doppler tracks if meds are working. Wall should thin + Doppler flow drop in 6-12 weeks.
5. *RLQ pain + normal appendix*: Always scan terminal ileum. “Ileitis” explains pain when appendix normal.

# # # 8. What Comes Next After US
1. *Acute + mild*: Stool cultures, treat empirically, repeat US in 4 weeks
2. *Chronic + Crohn’s suspected*: Colonoscopy + biopsies, CRP, f***l calprotectin, MRI enterography
3. *Complications*: CT abdomen or MRI if US suggests abscess/stricture
4. *TB endemic area*: Must rule out intestinal TB - looks identical to Crohn’s on US

*Bottom line*: Terminal ileitis on US = thickened >3 mm ileum + hyperemia. Next step is finding cause. If wall >6 mm + lost layers + fat wrapping = think Crohn’s and get colonoscopy.🎉💯🌟

01/06/2026

Goiter on Ultrasound – Full Guide

Goiter = enlarged thyroid gland. US tells us if it’s diffuse, nodular, toxic, or causing compression. “Goiter” just means big, not cancer.

# # # 1. What Counts as Goiter on US

*Normal thyroid size adults:*
1. *Volume*: Female

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