Common Reporting Phrases for Complete Abdominal Ultrasound
In complete abdominal ultrasound, the value of the report lies less in writing long sentences for every organ and more in honestly stating the scope and limitations of the...
RadPhrases Editorial Team5 min read
REPORTING PHRASES · COMPLETE ABDOMINAL ULTRASOUND
In complete abdominal ultrasound, the value of the report lies less in writing long sentences for every organ and more in honestly stating the scope and limitations of the examination while making clinically relevant positive and critical negative findings visible.
Ultrasound is sensitive to operator technique, patient preparation, body habitus, and bowel gas. The term “normal” should therefore be used only for organs and regions that were adequately assessed. Measurement and grading fields are left as placeholders in the examples below.
| Important usage note The sentences in this article are educational examples. Prefabricated text does not replace image review or the radiologist’s clinical judgment. Laterality, level, size, technical adequacy, comparison, and impression must be reverified for every case. |
|---|
Technique, preparation, and limitations
| Scenario / purpose | Example reporting phrase and usage note |
|---|---|
| Standard technique | Complete abdominal ultrasound was performed using a curvilinear transducer with grayscale imaging and color Doppler evaluation where indicated. |
| Inadequate fasting | The gallbladder is contracted due to inadequate fasting, limiting assessment of the lumen and wall. |
| Bowel gas | The body and tail of the pancreas could not be adequately assessed because of extensive bowel gas. |
| Body habitus | Assessment of deep structures is limited by reduced acoustic penetration related to the patient’s body habitus. |
| Patient cooperation | Limited cooperation with breathing and positioning partially restricted the examination. |
Liver phrases
| Scenario / purpose | Example reporting phrase and usage note |
|---|---|
| Normal liver | The liver is normal in size and contour. Parenchymal echogenicity is homogeneous. No focal solid or cystic lesion is identified. |
| Hepatomegaly | The craniocaudal liver dimension measures ... mm and is increased. |
| Steatosis | There is diffusely increased hepatic parenchymal echogenicity, compatible with hepatic steatosis. |
| Steatosis and limitation | Assessment of the deep parenchyma and small focal lesions is limited by posterior attenuation related to marked steatosis. |
| Cirrhotic morphology | The liver has a nodular contour and heterogeneous parenchymal echotexture; clinical and laboratory correlation for chronic parenchymal liver disease is recommended. |
| Simple cyst | A thin-walled anechoic simple cyst with posterior acoustic enhancement, measuring ... mm, is present in hepatic segment .... |
| Solid lesion | A focal lesion measuring ... mm with ... echogenicity is present in hepatic segment .... When clinically indicated, characterization may be completed with contrast-enhanced cross-sectional imaging. |
Gallbladder and biliary tree
| Scenario / purpose | Example reporting phrase and usage note |
|---|---|
| Normal gallbladder | The gallbladder is adequately distended with normal wall thickness. No gallstone or sludge is identified in the lumen. |
| Cholelithiasis | Mobile calculi with posterior acoustic shadowing are present in the gallbladder lumen, the largest measuring ... mm. |
| Sludge | Layering echogenic material without acoustic shadowing in the gallbladder lumen is compatible with biliary sludge. |
| Findings suggestive of acute cholecystitis | The gallbladder wall is thickened, with pericholecystic fluid and a positive sonographic Murphy sign; findings should be evaluated for acute cholecystitis in conjunction with clinical and laboratory data. |
| Common bile duct | The common bile duct measures ... mm and is considered ... after accounting for the patient’s age and surgical history. |
| Intrahepatic ducts | No significant intrahepatic biliary ductal dilatation is identified. |
| Post-cholecystectomy | The gallbladder is surgically absent. Biliary caliber was assessed in the context of the surgical history. |
Pancreas and spleen
| Scenario / purpose | Example reporting phrase and usage note |
|---|---|
| Normal pancreas | The visualized portions of the pancreas are normal in size and echogenicity; no focal lesion is identified. |
| Limited pancreatic assessment | The pancreas is only partially visualized because of bowel gas. |
| Pancreatic duct | No significant dilatation of the main pancreatic duct is identified. |
| Normal spleen | The spleen is normal in size and parenchymal echogenicity; no focal lesion is identified. |
| Splenomegaly | The splenic long-axis dimension measures ... mm and is increased. |
| Splenic lesion | A focal lesion measuring ... mm with ... characteristics is present in the splenic parenchyma. |
Kidneys and collecting systems
| Scenario / purpose | Example reporting phrase and usage note |
|---|---|
| Normal kidneys | Both kidneys are normal in size, contour, and parenchymal thickness. No collecting-system dilatation is identified. |
| Parenchymal echogenicity | Renal parenchymal echogenicity is increased bilaterally; clinical and laboratory correlation for chronic medical renal disease is recommended. |
| Hydronephrosis | There is ... dilatation of the right renal collecting system. |
| Calculus | A ... mm calculus with posterior acoustic shadowing is present in a lower-pole calyx of the left kidney. |
| Simple cyst | A thin-walled anechoic simple cortical cyst measuring ... mm is present in the interpolar region of the right kidney. |
| Complex cystic lesion | A cystic lesion with internal septation/wall thickening/a suspected solid component is present in the left kidney. Because enhancement cannot be assessed with ultrasound, characterization with cross-sectional imaging may be recommended. |
| Caution | The Bosniak classification is based primarily on contrast-enhanced CT and MRI features. On grayscale ultrasound, it is safer to describe a complex cystic lesion than to assume a Bosniak category. |
Urinary bladder, prostate/uterus, and free fluid
| Scenario / purpose | Example reporting phrase and usage note |
|---|---|
| Urinary bladder | The urinary bladder is adequately distended, with normal wall thickness and contour. No definite intraluminal mass or calculus is identified. |
| Inadequate distention | Assessment of the urinary bladder is limited by inadequate distention. |
| Postvoid residual | Prevoid bladder volume is approximately ... mL, and postvoid residual volume is approximately ... mL. |
| Prostate | The prostate volume is approximately ... mL and is assessed as .... |
| Uterus/adnexa | The uterus and adnexal regions were assessed within the limitations of the transabdominal examination; detailed pelvic evaluation may require a separate examination depending on the indication. |
| No free fluid | No intraperitoneal free fluid is identified. |
| Free fluid | A small amount of free fluid is present in the pelvis / perihepatic region; this should be interpreted in the clinical context. |
Quick check before signing the report
- Was every organ truly assessed adequately, or should a technical limitation be stated?
- Were measurements obtained in the correct plane and documented with units?
- For a focal lesion, were laterality, segment/pole, size, and basic sonographic features described?
- Does the clinical recommendation address a question that ultrasound genuinely could not answer?
- Does the impression provide a clinically meaningful synthesis rather than repeating the findings?
References
- American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. Revised 2025. Source (opens in a new tab)
- Hartung MP, Bickle IC, Gaillard F, Kanne JP. How to Create a Great Radiology Report. RadioGraphics. 2020;40(6). Source (opens in a new tab)
- American College of Radiology. ACR–SPR–SRU Practice Parameter for the Performance and Interpretation of Diagnostic Ultrasound Examinations. Revised 2023. Source (opens in a new tab)
- Silverman SG, Pedrosa I, Ellis JH, et al. Bosniak Classification of Cystic Renal Masses, Version 2019. Radiology. 2019;292(2):475-488. Source (opens in a new tab)
Clinical use note
This content is educational and is not patient-specific medical advice. Every phrase, template, classification result, and recommendation must be verified and adapted by a physician using the complete examination, clinical context, current guidelines, and institutional protocol.
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