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Differential Diagnosis in

Ultrasound Imaging

2nd Edition

Guenter Schmidt, MD

Bethesda Hospital

Freudenberg, Germany

Lucas Greiner, MD

International School for Ultrasonography Wuppertal, Germany

Dieter Nuernberg, MD

Medical Clinic B

Ruppiner Hospitals GmbH

Neuruppin, Germany

2846 illustrations

Thieme

Stuttgart · New York · Delhi · Rio

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized translation of the 3rd German edition published and copyrighted 2014 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Sonografische Differenzialdiagnose

New updated parts translated by Guenter Schmidt, MD, Kreuztal, Germany, Elisabeth Rahel Amorosa, Berlin, Germany, and Douglas Anderson, Hilchenbach, Germany. Original translation by Dietrich Herrmann, MD, Hameln, Germany, and Terry Telger, Fort Worth, Texas, USA.

Illustrators: Christiane and Michael Solodkoff,

Neckargmünd, Germany

1st Italian edition 2003

1st Portuguese edition (Brazil) 2008 1st Spanish edition (Venezuela) 2009 1st Serbian edition 2010

1st Chinese edition 2011 1st Turkish edition 2011 2nd Italian edition 2013

1st Russian edition in preparation

© 2015 by Georg Thieme Verlag KG Thieme Publishers Stuttgart

Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421 customerservice@thieme.de

Thieme Publishers New York 333 Seventh Avenue

New York, NY 10001 USA +1 800 782 3488

customerservice@thieme.com

Thieme Publishers Delhi

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Cover design: Thieme Publishing Group Typesetting by

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Printed in China by Everbest Printing Ltd

ISBN 978-3-13-131892-3

 

Also available as an e-book:

 

eISBN 978-3-13-161582-4

5 4 3 2 1

Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book. Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata will be posted at www. thieme.com on the product description page.

Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain.

This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

iv

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xi

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

xii

1 Vessels

. . . . . . . . . . . . .

. . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Aorta, Vena Cava,

 

1.2 Portal Vein and Its

and Peripheral Vessels . . .

3

Tributaries . . . 39

G. Schmidt

 

 

C. Goerg

Aorta, Arteries . . .

5

 

Enlarged Lumen Diameter . . . 41

§ Anomalies and Variant Positions . . .

5

§ Portal Hypertension . . . 41

§ Dilatation .

. . 7

 

 

 

§ Stenosis . . .

12

 

 

Intraluminal Mass . . . 48

§ Wall Thickening . .

. 19

 

§ Intraluminal Mass

22

 

§ Thrombosis . . . 48

 

§ Tumor 52

§ Perivascular Mass .

. . 25

 

Vena Cava, Veins . .

. 29

 

 

§ Anomalies .

. . 29

 

 

 

§ Dilatation . .

. 31

 

 

 

§ Intraluminal Mass .

. . 34

 

 

§ Compression, Infiltration . . . 37

 

 

2 Liver . . . . . . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

M.W.M. Brandt

 

 

 

Diffuse Changes in Hepatic

Localized Changes in Hepatic

Parenchyma . . . 70

Parenchyma . . . 86

 

§ Enlarged Liver . . . 70

§ Anechoic Masses . . .

88

§ Small Liver

. . . 76

§ Hypoechoic Masses .

. . 96

§ Homogeneous Hypoechoic

§ Isoechoic Masses . . .

101

Texture . . .

77

§ Hyperechoic Masses

. . . 107

§ Homogeneous Hyperechoic

§ Echogenic Masses . .

. 114

Texture . . .

79

§ Irregular Masses . . . 117

§ Regionally Inhomogeneous

 

 

 

Texture . .

. 80

Differential Diagnosis of Focal

§ Diffuse Inhomogeneous Texture . . . 82

 

 

Lesions . . .

119

 

 

 

§ Diagnostic Methods

. . . 119

 

 

§ Suspected Diagnosis

. . . 121

Contents

v

Contents

3 Biliary Tree and Gallbladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

3.1 Biliary Tree . . . 127

3.2 Gallbladder . . . 146

L. Greiner

C. Jakobeit

Thickening of the Bile Duct

Changes in Size . . . 148

Wall . . . 130

§ Large Gallbladder . . . 148

§ Localized and Diffuse . . . 130

§ Small/Missing Gallbladder . . . 150

Bile Duct Rarefaction . . . 132

Wall Changes . . . 151

§ Localized and Diffuse . . . 132

§ General Hypoechogenicity . . . 151

 

§ General Hyperechogenicity . . . 154

Bile Duct Dilatation and Intraductal

§ Focal Hypoechogenicity/

Hyperechogenicity . . . 155

Pressure . . . 132

§ General Tumor . . . 156

§ Intrahepatic . . . 134

§ Focal Tumor . . . 157

§ Hilar and Prepancreatic . . . 135

 

§ Intrapancreatic . . . 138

Intraluminal Changes . . . 160

§ Papillary . . . 140

 

§ Hyperechoic . . . 160

Abnormal Intraluminal Bile Duct

§ Hypoechoic . . . 161

 

Findings . . . 140

Nonvisualized Gallbladder . . . 163

§ Foreign Body . . . 140

 

L. Greiner

Differential Diagnosis of

§ Missing Gallbladder . . . 163

Sonographic Cholestasis . . . 142

§ Obscured Gallbladder . . . 164

§ The Seven Most Important

 

Questions . . . 142

 

4 Pancreas

. . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

G. Schmidt, A. Holle

 

 

Diffuse Pancreatic Change . . . 170

Dilatation of the Pancreatic

§ Large Pancreas . . .

170

 

Duct . . . 195

§ Small Pancreas . . .

172

 

§ Marginal/Mild Dilatation . . . 196

§ Hypoechoic Texture . . .

173

§ Marked Dilatation . . . 197

§ Hyperechoic Texture . .

. 175

 

Focal Changes . . . 179

§ Anechoic Lesion . . . 179

§ Hypoechoic Lesion . . . 182

§ Isoechoic Lesion . . . 186

§ Hyperechoic Lesion . . . 189

§Irregular (Complex Structured) Lesion . . . 191

vi

 

 

 

 

 

 

. . . . . . . . . . . . . . . . .5 Spleen

. . . . . . . . . . . . . . . . .

. . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

C. Goerg

 

 

 

 

Nonfocal Changes of the

Focal Changes of the Spleen . . .

213

Spleen . . .

206

 

§ Anechoic Mass . . . 213

 

§ Diffuse Parenchymal Changes . . . 206

§ Hypoechoic Mass . . .

215

 

§ Large Spleen . . .

208

§ Hyperechoic Mass . .

. 225

 

§ Small Spleen . . .

211

§ Splenic Calcification .

. . 228

 

6 Lymph Nodes . . . . . .

. . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231

C. Goerg

 

 

Peripheral Lymph Nodes . . . 241

Abdominal Lymph Nodes . . . 247

§ Head/Neck . . . 241

§ Porta Hepatis . .

. 247

§ Extremities (Axilla, Groin) . . . 245

§ Splenic Hilum . .

. 249

 

§ Mesentery (Celiac, Upper and Lower

 

Mesenteric Station) . . . 251

 

§ Retroperitoneum (Para-Aortic,

 

Paracaval, Aortointercaval, and

 

Iliac Station) . . .

254

7 Gastrointestinal Tract . . . . . . . . .

. . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259

M.W.M. Brandt

 

 

 

 

Stomach . . . 266

 

Small/Large Intestine . . .

274

§ Focal Wall Changes .

. . 266

§ Focal Wall Changes .

. . 274

§ Extended Wall Changes . . . 270

§ Extended Wall Changes . .

. 282

§ Dilated Lumen . . . 272

§ Dilated Lumen . . . 287

 

§ Narrowed Lumen . . .

273

§ Narrowed Lumen . . .

290

 

8 Peritoneal Cavity

. . . . . . . . . . . . . . . .

. . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

D. Nuernberg

 

 

 

 

 

Diffuse Changes . . .

298

Wall Structures . . .

312

 

§ Anechoic Structure .

. .

300

§ Smooth Margin . . .

312

 

§ Hypoechoic Structure .

. . 303

§ Irregular Margin . .

. 313

 

§ Hyperechoic Structure

. . . 307

 

 

 

Localized Changes

308

Differentiating Intraand

 

Extraluminal GI Tract Fluid

. . . 316

§ Anechoic Structure .

. .

310

§ Intragastric Processes . . . 316

§ Hypoechoic Structure .

. . 310

§ Intraintestinal Processes . . .

317

§ Hyperechoic Structure

. . . 311

 

 

 

Contents

vii

Contents

9 Kidneys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

319

G. Schmidt

Anomalies, Malformations . . . 322

§Aplasia, Hypoplasia . . . 322

§Cystic Malformation . . . 324

§Anomalies of Number, Position, or Rotation . . . 325

§Fusion Anomaly . . . 327

§Anomalies of the Renal Calices . . . 328

§Vascular Anomaly . . . 328

Diffuse Changes . . . 329

§Large Kidneys . . . 329

§Small Kidneys . . . 334

§Hypoechoic Structure . . . 337

§Hyperechoic Structure . . . 338

§Irregular Structure . . . 343

Circumscribed Changes . . . 344

§Anechoic Structure . . . 344

§Hypoechoic or Isoechoic Structure . . . 350

§Complex Structure . . . 356

§Hyperechoic Structure . . . 358

§Echogenic Structure . . . 361

10 Adrenal Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

365

D. Nuernberg

 

Enlargement . . . 369

§ Anechoic Structure . . . 369

§ Hypoechoic Structure . . . 370

§ Complex Echo Structure . . . 374

§ Hyperechoic Structure . . . 375

11 Urinary Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

379

G. Schmidt

Malformations . . . 383

§Duplication Anomalies . . . 383

§Dilatations and Stenoses . . . 384

Dilated Renal Pelvis and

Ureter . . . 386

§Anechoic . . . 386

§Hypoechoic . . . 392

Renal Pelvic Mass, Ureteral Mass

. . . 394

§Hypoechoic . . . 394

§Hyperechoic . . . 395

Changes in Bladder Size or Shape . . . 398

§Large Bladder . . . 398

§Small Bladder . . . 400

§Altered Bladder Shape . . . 401

Intracavitary Mass . . . 402

§Hypoechoic . . . 402

§Hyperechoic . . . 406

§Echogenic . . . 408

Wall Changes . . . 410

§Diffuse Wall Thickening . . . 410

§Circumscribed Wall Thickening . . . 411

§Concavities and Convexities . . . 413

viii

12 Prostate, Seminal Vesicles, Testis, Epididymis . . . . . . 415

G. Schmidt

12.1 The Prostate . . .

417

 

12.3 Testis, Epididymis

. . . 429

Enlarged Prostate

. . . 418

 

Diffuse Change . . .

430

 

 

§ Regular . . .

418

 

 

 

§ Enlargement . . . 430

 

 

§ Irregular . .

.

421

 

 

 

§ Decreased Size . . .

431

 

 

Small Prostate . . .

422

 

 

Circumscribed Lesion .

. . 431

§ Regular . . .

422

 

 

 

§ Anechoic or Hypoechoic . . .

431

§ Echogenic .

.

. 423

 

 

 

§ Irregular/Echogenic . . .

433

 

Circumscribed Lesion . . .

423

 

Epididymal Lesion

. . . 434

 

§ Anechoic . .

.

423

 

 

 

§ Anechoic . . .

434

 

 

 

§ Hypoechoic .

. . 424

 

 

§ Hypoechoic .

. . 434

 

 

§ Echogenic .

.

. 426

 

 

 

 

 

 

 

 

12.2 Seminal Vesicles

426

Intrascrotal Mass .

. . 435

 

§ Anechoic or Hypoechoic . . .

435

Diffuse Change . .

. 426

 

 

§ Echogenic . .

. 436

 

 

 

§ Hypoechoic .

. . 426

 

 

 

 

 

 

 

Circumscribed Change . .

. 427

 

 

 

 

 

§ Anechoic . .

.

427

 

 

 

 

 

 

 

 

§ Echogenic .

.

. 428

 

 

 

 

 

 

 

 

§ Irregular . .

.

428

 

 

 

 

 

 

 

 

13 Female Genital Tract . . .

. . . . .

. . .

. . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439

B. Beuscher-Willems

Vagina . . . 442

§Masses . . . 442

§Abnormalities of Size or Shape . . . 444

Uterus . . . 444

§Abnormalities of Size or Shape . . . 446

§Myometrial Changes . . . 447

§Intracavitary Changes . . . 451

§Endometrial Changes . . . 454

Fallopian Tubes . . . 458

§ Hypoechoic Mass . . . 458

Ovaries . . . 460

§Anechoic Cystic Mass . . . 461

§Solid Echogenic or Nonhomogeneous Mass . . . 464

14 Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475

G. Schmidt

Diffuse Changes . . .

479

Circumscribed Changes . . .

489

§ Enlarged Thyroid Gland

. . . 479

§ Anechoic . . .

489

 

§ Small Thyroid Gland . . .

483

§ Hypoechoic .

. . 491

 

§ Hypoechoic Structure . .

. 487

§ Isoechoic . . .

499

 

§ Hyperechoic Structure .

. . 489

§ Hyperechoic

. . . 501

 

 

 

 

§ Irregular . . . 502

 

Differential Diagnosis of

Hyperthyroidism . . . 504

§ Types of Autonomy . . . 504

Contents

ix

Contents

 

 

 

 

 

. . . . .15 Pleura and Chest Wall

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509

C. Goerg

 

 

 

Chest Wall

. . . 513

 

Pleural Effusion . . .

523

§ Masses . . .

513

 

§ Anechoic Effusion .

. . 525

 

 

 

§ Echogenic Effusion

. . . 526

Parietal Pleura

518

§ Complex Effusion . .

. 528

 

 

§ Nodular Masses . .

. 518

 

 

§ Diffuse Pleural Thickening . . . 520

 

 

16 Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

531

C. Goerg

 

Masses . . . 533

§ Anechoic Masses . . . 534

§ Hypoechoic Masses . . . 537

§ Complex Masses . . . 546

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

553

x

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