Ultrasound is an essential imaging tool in modern medicine, offering visualization of soft tissues, organs, and vascular structures. However, even the most experienced sonographers encounter obstacles that can make obtaining clear images difficult. From excessive bowel gas obscuring structures to scanning patients with high body mass indexes (BMIs), these challenges require skill, adaptability, and technical adjustments. Here are some of the most common ultrasound scanning challenges and practical solutions to optimize imaging.

1.  Imaging the Aorta in Gassy Patients

Few things are as frustrating as trying to visualize the aorta when excessive bowel gas gets in the way. Gas scatters ultrasound waves, making it difficult to see vascular structures clearly.

Solutions:

• Use an Intercostal Approach: Instead of scanning anteriorly, try navigating through the intercostal spaces on the right side to bypass gas-filled loops of bowel.
  • Apply Steady, Firm Pressure: Pressing gently on the abdomen can help displace gas and improve sound wave penetration.
• Change the Frequency: A lower-frequency transducer (such as a curvilinear probe at 1–6 MHz or 2–5 MHz) allows deeper penetration, sometimes improving visibility despite gas interference.

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2.  Scanning High BMI Patients

Larger patients present challenges due to increased soft tissue thickness, which can reduce image resolution and penetration.

Solutions:

• Use a Lower Frequency Transducer: A 1–6 MHz or 2–5 MHz curvilinear transducer enhances penetration, even if it sacrifices some resolution. This is especially useful when scanning larger patients, such as when ruling out lower extremity DVTs. While linear probes are common for vascular imaging, don’t hesitate to use whatever transducer best visualizes the patient’s anatomy, whether it’s curvilinear, phased array, or another alternative.
  • Increase the Time Gain Compensation (TGC): Adjusting the TGC enhances contrast and clarity in deeper structures.
• Optimize Patient Positioning: Having the patient roll onto their side allows gravity to shift excess tissue, improving visualization. Right Lateral Decubitus (RLD) positioning works well for imaging the spleen and left kidney, while Left Lateral Decubitus (LLD) positioning is ideal for the right kidney, gallbladder, and the dome of the liver.
• Utilize Harmonic Imaging: This setting helps reduce artifacts and enhances contrast resolution for clearer imaging.

3.  Evaluating Deep or Small Vessels

Poor acoustic access can make visualizing small or deep vessels, such as the popliteal artery or small renal arteries, difficult.

Solutions:

• Use Color and Power Doppler: Increasing Doppler sensitivity helps detect slow-moving blood flow in deep or small vessels.
• Optimize the Angle of Insonation: Keeping the Doppler angle between 45 and 60 degrees improves velocity accuracy.
• Apply Gentle Compression: This technique helps differentiate veins from arteries and optimize visualization. I frequently use this when assessing ankle-brachial index (ABI) ratios in calcified arteries near the ankle.

4.  Differentiating Cysts From Solid Masses

Distinguishing between cystic and solid structures can be tricky, especially when artifacts mimic fluid-filled lesions.

Solutions:

• Use Multiple Imaging Planes: Scanning from different angles helps confirm whether a structure is truly cystic or solid. Always assess the kidneys from multiple planes—exophytic masses and cysts love to hide where you least expect them.
• Apply Color Doppler: Cysts will not show internal blood flow, while vascularized solid masses will have detectable Doppler signals.
• Adjust Gain Settings: Lowering overall gain can help differentiate hypoechoic solid structures from fluid-filled cysts.

Conclusion

Ultrasound scanning challenges are inevitable, but a skilled sonographer can overcome them with the right techniques. Adjusting transducer settings, modifying patient positioning, and using alternative scanning approaches can significantly improve image quality. By staying adaptable, sonographers can ensure optimal imaging, leading to more accurate diagnoses and better patient outcomes.

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Theresa Jenkins BS, RDMS, RVT, is a seasoned sonographer with nearly seven years of experience, having worked in top facilities nationwide. Credentialed in general, vascular, and pediatric ultrasound, she is also an educator and author with plans to become a leading voice in sonography.

This posting has been edited for length and clarity. The opinions expressed in this posting are the author’s own and do not necessarily reflect the view of their employer or the American Institute of Ultrasound in Medicine.