Common Reporting Phrases for Complete Abdominal Ultrasound

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Common Reporting Phrases for Complete Abdominal Ultrasound

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.

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.

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.

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.

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.

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.

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.