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Home Books The Atlas of Emergency Medicine, 5e

24-05: Left Upper Quadrant (Perisplenic View)

Jeremy S. Boyd; Myles Melton; Jordan D. Rupp; Robinson M. Ferre

Technique

  • The transducer indicator is directed toward the axilla.

  • With the indicator pointed toward the patient’s head, the transducer is oriented in a coronal section through the body in the mid to posterior axillary line extending from the 9th through 12th ribs. Start between the 11th and 12th ribs initially, then move cephalad or caudal, anterior or posterior, to complete the evaluation (Fig. 24.14). As a general rule of thumb, the perisplenic view is more posterior and cephalad than that of the RUQ view.

  • Identify and evaluate the area surrounding the spleen, including its upper and lower poles, the interface with the diaphragm, and the interface with the left kidney. Normally, the surrounding tissues of the spleen and kidney are in direct contact with one another (Fig. 24.15).

FIGURE 24.14

Left Upper Quadrant View. The transducer is oriented in a coronal section through the body in the mid to posterior axillary line extending from the 9th through 12th ribs. (Photo contributor: Lawrence B. Stack, MD.)

A patient lies in the supine position. A practitioner holds the flat side of the transducer against the lower ribs on the left side of the chest, below the armpit, to get a Left Upper Quadrant View.
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A patient lies in the supine position. A practitioner holds the flat side of the transducer against the lower ribs on the left side of the chest, below the armpit, to get a Left Upper Quadrant View.
FIGURE 24.15

Normal Left Upper Quadrant View. The region between the spleen and left kidney is a physiologic potential space (splenorenal recess); however, due to the phrenicocolic ligament (rarely seen on ultrasound but shown on illustration), free fluid is often shunted toward the subdiaphragmatic space between the diaphragm (orange line) and spleen. (Ultrasound contributor: Jeremy S. Boyd, MD; illustration contributor: Robinson M. Ferre, MD.)

An ultrasound image shows a Normal Left Upper Quadrant View. The kidney is at the center, with the spleen above it. A green dot is outside the image at the top left. An illustration depicts a Normal Left Upper Quadrant View ultrasound.
View Full Size||Download Slide (.ppt)
An ultrasound image shows a Normal Left Upper Quadrant View. The kidney is at the center, with the spleen above it. A green dot is outside the image at the top left. An illustration depicts a Normal Left Upper Quadrant View ultrasound.
An ultrasound image shows a Normal Left Upper Quadrant View. The kidney is at the center, with the spleen above it. A green dot is outside the image at the top left. An illustration depicts a Normal Left Upper Quadrant View ultrasound.
View Full Size||Download Slide (.ppt)
An ultrasound image shows a Normal Left Upper Quadrant View. The kidney is at the center, with the spleen above it. A green dot is outside the image at the top left. An illustration depicts a Normal Left Upper Quadrant View ultrasound.

Abnormal Findings

  • Hemoperitoneum: Anechoic (black) region around the spleen. This may be visible at the superior or inferior poles of the spleen, between the spleen and the diaphragm or between the spleen and left kidney. Unlike the Morison’s pouch, blood cannot flow beyond the inferior pole of the spleen down the paracolic gutter due to the phrenicocolic ligament. Blood that collects in the perisplenic space must first pass out of the lesser peritoneal sac and into the greater peritoneal sac before it will be seen collecting along the left paracolic gutter (Fig. 24.16).

  • Solid organ injury: Ultrasound is an insensitive exam for solid organ injury. Injuries such as splenic and renal lacerations as well as organ rupture have been described but are not the goal of this examination.

FIGURE 24.16

Hemoperitoneum, Left Upper Quadrant View. In this view, fluid is seen in the subdiaphragmatic space between the diaphragm and the spleen. The diagram illustrates other common potential sites for free fluid, marked by asterisks. (Ultrasound contributor: Jeremy S. Boyd, MD; illustration contributor: Robinson M. Ferre, MD.)

An ultrasound image shows the Hemoperitoneum in a Left Upper Quadrant View. The kidney is at the center with the spleen to its left. A dark space between the spleen and the diaphragm is the Hemoperitoneum layer. A green dot is outside the image at the top left. An illustration depicts the Hemoperitoneum in a Left Upper Quadrant View ultrasound.
View Full Size||Download Slide (.ppt)
An ultrasound image shows the Hemoperitoneum in a Left Upper Quadrant View. The kidney is at the center with the spleen to its left. A dark space between the spleen and the diaphragm is the Hemoperitoneum layer. A green dot is outside the image at the top left. An illustration depicts the Hemoperitoneum in a Left Upper Quadrant View ultrasound.
An ultrasound image shows the Hemoperitoneum in a Left Upper Quadrant View. The kidney is at the center with the spleen to its left. A dark space between the spleen and the diaphragm is the Hemoperitoneum layer. A green dot is outside the image at the top left. An illustration depicts the Hemoperitoneum in a Left Upper Quadrant View ultrasound.
View Full Size||Download Slide (.ppt)
An ultrasound image shows the Hemoperitoneum in a Left Upper Quadrant View. The kidney is at the center with the spleen to its left. A dark space between the spleen and the diaphragm is the Hemoperitoneum layer. A green dot is outside the image at the top left. An illustration depicts the Hemoperitoneum in a Left Upper Quadrant View ultrasound.

Pearls for RUQ and LUQ Views

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