 We all know the advantages better resolution of superficial structures and that's why there is a drawback that depth you can't really you know you can't have a good penetration but the resolution is always better nowadays it is not just linear transducers in fact we have lot of companies coming up with convex transducers which are you know high frequency there are transducers with 2 to 9 convex also available but by and large we still are using the linear transducers 5 to 12 megahertz or 4 to 9 megahertz to get these the abdominal structures seen better so in the intra-abdominal of course we know bobble pathologies like appendicitis most common cox colitis omental and misinteric pathologies it may be just a thickening then we will lymph nodes there may be infarction then of course we can really depict pneumo peritoneum very well on ultrasound acytis if it is exudative transdative collections which are you know localized especially at some particular point will be seen better on the linear high frequency probes so typical gut signature bobble we all know there are five layers the superficial mucosa interface is ecogenic then there is muscularis mucosa which is hypoechoic then there is submucosa then there is muscularis propria and then there is a serosal interface which is again an ecogenic line so this is a typical bobble signature this is a fluid within the stomach and so you can get the better contrast there and of course when we are scanning the abdomen we usually follow one pattern you should scan the entire abdomen so you should make these exact kind of a motion so that you're not missing out on any part and then scanning the entire abdomen and then with this we come to the most common application appendicitis normal appendix rarely seen in fact sometimes in children it is less than six millimeters and whenever the appendix is inflamed typically what we see is this is the fat stranding which is seen around the inflamed appendix and that is how we tend to diagnose the appendicitis in most of the cases of course there is hypervascularity seen so a normal appendix has less than six millimeter diameter anything which is more than six millimeter is usually surrounded by hyperechoic inflamed fat and the other strongly supportive signs are presence of an appendiculate, secal apical thickening, hypervascularity as we saw in this particular patient there was little hypervascularity and on the color Doppler examination so this is the appendiculate you should see a blind ending pouch and this is typically the you know peri-appendicial fat stranding which you see so you have to identify the appendix see that it is blind ending non-compressible or peristaltic tube it has a gut signature arising from base of the cecum and diameter greater than six millimeters and supportive features are of course inflamed periantic fat pericycle collections and the appendicolates sometimes sometimes you know you can really diagnose the perforations by what? Loculated pericycle fluid or a flake monorapsis, prominent pericycle fat and circumferential loss of the submucosal layer if you can see in transverse this layer is seen very well but here there is a perforation as you can see here this is seen very well here but then there is a perforation here so this is how you will be able to diagnose so you have to look at the blind ending surface and then you will start seeing that it is perforated there in fact you can see this fluid and there is a discontinuity of the mucosal lining there so you can suspect the perforation then there is something called a perpendicular lump or a flake mon it is a large mass of non-compressible fat around the appendix and usually managed conservatively because appendicectomy in such cases is technically difficult but of course there are exceptions to rules when sometimes in children those patients with severe peritonitis which tells you that walling off process is failing then even if it is you know formed a sort of a lump these patients are operated because then otherwise they will go into septicemia so this is how typically you see a kind of a lump there is a fat there are some bowel loops which are clumped inside and there is of course the appendixial inflammation which is seen and you can see here that there is a lot of inflammation around and probably this appendix has leaked or ruptured somewhere and then these are the patients which are formed into an appendicular lump so it is important to diagnose on ultrasound whether it is perforated whether it has formed a lump or it is just an acute appendicitis and of course then we'll come to these differential diagnosis which we you know see in the RAF pain this patient again was suspected to be actually the appendicitis but as you can see here these are these linear kind of structures which are seen this is typically a tapeworm infestation and this is not actually the appendicitis which was there the another differential what needs to be considered in RAF pain is the diverticulitis so right-sided colonic diverticulitis make clinically mimic appendicitis or colisostitis in contrast to sigmoid diverticulitis in fact they are the more common ones the right-sided colonic diverticulitis usually true diverticulitis that is they have all the layers of the wall of the colon and inflammatory changes in the pericolic fat with segmental thickening of the colonic wall at the level of inflamed diverticulum that is what is the typical sign this ascending colon that will be inflamed there will be an outpouching scene and there will be a fat standing which is seen around that so that typically is the diverticulitis it may be right-sided left-sided it will follow the similar pattern so the ultrasound appearance will depend on the stage of the disease in the earlier stage focal wall thickening will be there it will be hyper-equate non- compressible tissue around that that is the inflamed misintree of the momentum and it is trying to seal off the imminent perforation that is the most important clue so this is how the stage one will look and once that abscess or that pus you know decompresses back into the colon then the patient feels in fact better and that is the stage of a resolution so this is how typically you will see the patient complains specifically of a pain at one side and when you use your high-frequency transducer you will see some kind of fat standing and you will see some colon inside that you know it becomes a little difficult to you know put a lot of compression and try and see these structures better because they are in extreme pain but you know is here if you can see somewhere you see that there is an outpouching from the colon and that probably is a diverticulum of course we advise it is can is typically has formed that abscess in fact there is a small amount of air which is seen there the diverticulitis can have the gut science which is segmental concentric thickening of the wall of that particular colon I mean it may be ascending colon recto sigmoid or a descending colon the inflamed diverticuli will look like an ecogenic foci within or beyond the gut wall and there will be intramural sinus tract perineventric soft tissue of course will have all the signs of inflammation that is inflammation of pericolonic fat hyper echoic mass effect thickening of the misentry or it may be abscess formation which will be seen as a localized fluid collection often with the gas component so that is what clinches the diagnosis and of course it has formed a fistula then you will have the linear tracks from the gut to the bladder or to the vagina or to the skin or to the adjacent loops and it may be hypo or hyper echoic depending on that see other differential what comes into the mind for the right iliac fossa pain will these you know inflammation of the epiploic appendages these are also small fat containing structures and these usually they can undergo torsion or it can have a secondary inflammation and that causes focal abdominal pain in the right lower quadrant so this is a self-limiting disease this does not really need any operative kind of a management and that's why it is very important to differentiate it from the appendicitis the other differential which is there is about the omen to infarction clinical presentation again is same like appendicitis or epiploic appendicitis a cake like inflamed fatty mass but which is larger than epiploic appendicitis as you can imagine the appendages are small structures so they will have a small area of hyper ecogenicity but omen infarct can have a larger area a cake like inflamed fatty mass and it may be difficult to distinguish it from the omen infarct to epiploic appendicitis but this differentiation is not of clinical importance because the management remains the same so at least you can give that if it's a smaller kind of the inflamed fat without appendicitis seen appendicular lumen seen inside we say it may be epiploic appendicitis if it is a large inflamed mass then we call it as the omen infarction of course CT is always better to confirm so this was again another young patient where you can see that there is a large kind of an hyper echoic lesion but you're not seeing any you know bobble signature in between in fact you can see these hyper echoic some strands inside and there is a many minimal perillegional fluid this was the omen infarction this is a large inflamed cake like mass so again obesity is the risk factor there is a fat accumulation in the appendages or fat deposition may outgrow the blood supply and then that's why it predisposes to ischemia heavy exercise excessive stretching and that you know sometimes cause excessive movement of the momentum and that can sometimes undergo torsion and can cause this problem so omen infarction can be primary or secondary secondary we all know it sometimes is just post surgery abdominal trauma or omen inflammation the primary one you know occurs at around the right age of the greater momentum because the arterial supply is very less in that area and that's why it tends to happen on that side there is arterial and venous compromise when it twist itself and momentum may in fact without the torsion and then this is called a primary idiopathic omen to segment infarction so again ultrasound features as you know little bit what we can differentiate between the two is it is a right lower quadrant secondary omen infarction at the site of initial insult but usually they're larger than 5 centimeter which helps to distinguish it from epiploid appendicitis ultrasound just shows you focal area of increased ecogenicity in the omen to fat and the appendicitis have a smaller area of fat standing compared to the omen infarction avoid central area of the preserved fat will be seen and hyper dense central dot is the thrombose vessel and that will be seen on a CT scan and there they are able to differentiate these better rather than ultrasound another non-specific entity what we see in the misery with especially with the high-frequency ultrasound is the misery paniculitis chronic non-specific inflammatory process in the misery and it may lead to fibrosis and retraction so when there is fibrosis and retraction predominates then we start calling it as fibrosin misenteritis when inflammation predominates then we call it as misintric paniculitis so these are just generally the thickened misentry what we see here as just a fat which is seen there and these are sometimes you know just heterogeneous looking misintric kind of deposit of the fat and as I said sometimes the you know fibrosis predominates and retraction predominates and then these will be called as retractile or paniculitis and this is just the overall increased fat deposition there you can see the you know bowel loops pressing through it and this may be just the quarter of misintric paniculitis and then we just suggest a CT scan the another important thing is of course abdominal cox we all are good at detecting cox but the the important findings of the abdominal cox will be bowel involvement especially the IC region which gives us the pseudo kidney mucosa sub mucosa complex thickening small bowel strictures though they are difficult to see if you can you know see the focal dilatation of the bowel loop and then you can trace that bowel loop and sometimes that thickening of the wall will be seen better so that small bowel strictures can be diagnosed peritoneal misintric thickening the lymph nodes of course are better assessed by the high frequency ultrasound and asitis these are the commoner findings and as I said the misintric deposits the you know the peritoneal deposits as you can see here there will be you know some deposits on the peritoneal surface these are lymph nodes also but then there are these misintric deposits which are there this again is the typical pseudo kidney sign which we see in the cox involvement this is the bowel content the lumen and this is all the thickened kind of wall of the terminal ilium and the cecum which gives rise to that kind of an appearance and this is a terminal ilium involvement again as you can see here thickening and this was the IC cox again so most of the times we see the cervical lymph nodes getting diagnosed as cox or there is pulmonary tuberculosis these patients do come for abdominal screening so careful assessment of the bowel misintry lymph nodes free fluid is a must for follow up it is very important that you document these findings correctly because they keep coming for a follow up to see the response to the treatment abdominal wall lesions of course are important hernia fat necrosis lipomas hematomas the endometriosis this we all know it is just a mental fat which has come out to the hernia and this in fact patient feels as a lump and then comes for the ultrasound so it is always important to scan with the high frequency probe lipoma sometimes if they're big the patient can feel it there may be just a fat necrosis which gives rise to pain in the abdomen and that's why the patient comes for the ultrasound and if you don't do don't scan with the high frequency linear probe you will miss these regions a suture granuloma sometimes in fact in postoperative patients you know just gives rise to these inflammations and these kind of pus formation there and again wound complications are important cause of this healing and a lot of time patient is very worried whenever there is pain or lump kind of a feeling at the scar side patient feels that there's something went wrong while doing the surgery and then they keep coming for the ultrasound most of the times what we see are these hematomas and these are just the seromas as long as there is nothing intraabdominal these are not varism and you just need to reassure the patient this was a post-cholestectomy patient laparoscopic cholestectomy sometimes gives rise to these port hematomas where the site of port there is these properitoneal hematomas they're not in the wall they are separating just the peritoneum and the abdominal wall and sometimes they have these properitoneal wall hematomas in which you need to diagnose this is just the rectus hematoma patient continuously had the pain most of the times we see it when the patient is coughing all the time and this is typically what we see in scar endometriosis those who are post-operative they keep coming for these pain during menstrual cycle it is very important to differentiate these between if they are only in the subcutaneous tissue or if they are also involving the rectus muscle because the surgery changes the the chunk of a rectus needs to come out when it is intra muscle the endometriosis so that needs to be always mentioned in your report whenever you are especially doing it for these car endometriosis it can appear as a solid or multi-septated cystic lesion a very important site is to mention whether it is only in the subcutaneous subcutaneous with rectus extension or exclusively within the rectus muscle and that is very important to know so no ultrasound abdominal examination is complete without high frequency scanning not just intra abdominal but abdominal wall scanning is important and you respect patient symptoms even if you scan all the organs in the abdomen if the patient says I have a pain at particular site where you know that there is no organ which is going to come there and cause any symptoms you have to put your high-frequency probe at that site and then look for anything anything positive there so you should always respect the patient symptoms and scan with high-frequency probe thank you